Topical steroid withdrawal: dissecting the controversy

TL;DR

This paper reviews the controversy around topical steroid withdrawal (TSW), clarifying its clinical features, mechanisms, and the debate over its distinction from other skin conditions.

Contribution

The paper identifies and critiques flawed reasoning in TSW denial and provides updated insights into knowledge gaps and clinical implications.

Findings

TSW is increasingly recognized by regulatory agencies and clinicians, with updated warning labels on topical corticosteroids.

Three main errors in TSW denial include focusing on overlapping skin pathology, devaluing patient-reported symptoms, and circular logic in diagnostic criteria.

The paper highlights the need for better recognition of TSW to improve patient care and communication.

Abstract

In the past few years, topical steroid withdrawal (TSW) has received increasing recognition from research and regulatory agencies. Delphi protocols have solidified the clinical features and treatment options recognized by clinicians. Pilot studies elucidating the mechanisms of TSW pathology have been performed. Meanwhile, regulatory bodies have updated the topical corticosteroids (TCS) warning labels to include TSW. And yet, the idea that TSW is distinct from the underlying dermopathies which conferred the TCS exposure remains debated by some. This narrative review aims to help providers better understand the origins of, and current state of, the controversy surrounding TSW. We review the history of TSW claims and counter claims, focusing on sources found in the medical literature. Having presented the development of TSW skepticism, we next detail the errors in the three main examples of TSW denial: ignoring the syndromic nature of TSW to focus on skin pathology which overlaps with other dermopathies; systematically devaluing patient-reported symptoms; and circular logic asserting that studies into TSW cannot be conducted without first establishing diagnostic criteria requiring studies to obtain. Finally, we present an updated assessment in the knowledge gaps surrounding TSW. We hope that this report will help providers recognize TSW, especially in contrasting the disorder with the dermopathies which have similar presentations of cutaneous symptoms. Overall, we believe this report will help providers better reassure patients to whom the diagnosis of TSW should not be applied, better council patient on the risks of TCS, and better provide trauma-informed care for patients who with TSW.

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