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HEALTH MATTERS
Promoting health and wellness
Facing up to withdrawal from topical steroids
By Mary C. Smith, RN, MSN; Susan Nedorost, MD; and Brandie Tackett, MD
MANY AMERICANS have chronic skin
conditions such as seborrhea and
eczema that affect the face. These conditions can cause erythema and pruritus
and make the face look dry and scaly.
Topical corticosteroids applied to the
face to treat these symptoms can cause
steroid rosacea and steroid addiction
syndrome, resulting in new symptoms
that perpetuate the topical steroid usage.
Using topical corticosteroids on the
face for longer than 2 weeks can cause a
rosacea-like eruption, also called steroid
rosacea, or severe redness and burning
upon withdrawal of the topical medication, which is called steroid addiction syndrome. To control either condition, the
patient must cease using topical corticosteroid medication. In this article, we’ll
tell you how to recognize these conditions and how to help your patient to
withdraw from topical drugs that trigger
them.
Getting the red out
In conditions such as eczema, applying a
topical corticosteroid to the face gets the
red out immediately because of the medication’s vasoconstrictive action. Steroid
rosacea occurs only on the face and
neck; steroid addiction syndrome occurs
only on the face, neck, and genitalia.
The reason for the localization of these
responses is uncertain because regional
variation in skin physiology, including
neurocutaneous, vascular, and immunologic interactions, haven’t been fully
characterized.
When corticosteroids are withdrawn,
rosacea papules and pustules become redder and patients complain of cutaneous
burning. In response, your patient may
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apply the medication
more frequently or
switch to a higher potency steroid to relieve her
signs and symptoms.
This may give her shortterm relief, but a rebound
flare will occur with
withdrawal attempts,
resulting in even more
redness and inflammation than before1 and
requiring more medication to manage.
To prevent steroid rosacea, pictured here, teach your patient not to use steroids on her
This sets up a vicious face for longer than 2 weeks.
cycle, known as steroid
addiction syndrome. Signs and symptoms ucts. It’s a good idea to ask your patient
to bring in any medications that she’s
include erythema, a burning sensation,
used on the affected area for you to inpapules, and pustules.
spect because some products contain
Anyone who uses steroids on her face
unlabeled steroids.3
can develop steroid rosacea, but fairskinned women between the ages of 30
Stopping the cycle
and 50 who blush easily are at increased
Discontinuing all facial applications of
risk, as these are the patients most likely
steroid medications is the next step in
to develop common rosacea. Although
breaking the cycle of steroid rosacea.
no one knows exactly why, scientists
Your patient will need a clear outline
speculate that those who blush easily
of what to expect during the withhave an increased facial skin surface temdrawal period. For example, she needs
perature and oil production, which alters
to know that rebound flares will octhe type of normal microbial flora.2
cur, but that they’ll be temporary. To
Uncovering steroid rosacea
relieve withdrawal symptoms, tell her
When you perform medication reconcili- she can apply cool compresses or reation, be sure to ask specifically about
frigerated emollients such as petrotopical products; many people don’t
leum jelly (Vaseline) or glycerin and
consider creams to be medications and
rose water, which have minimal irriinadvertently omit them from the medtant and sensitization potential. Her
ication list. Ask your patient for a comhealth care provider may prescribe
plete list of topical medications that she
systemic tetracycline derivative antibicurrently uses or has used on the afotics to suppress inflammation. Your
fected areas, including steroids, herbal
patient may need support by telephone
preparations, and over-the-counter prod- follow-up because emotional distress
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often accompanies withdrawal. Warn
her that symptoms may last for many
months, proportionate to the time she
used the topical steroid.
The best time to prevent steroid
rosacea is when topical corticosteroids
are first prescribed. Tell your patient not
to use steroids on her face for longer than
2 weeks and explain adverse drug effects
such as steroid rosacea.
Patient teaching
Withdrawing from steroid use is emotionally challenging. Provide your patient with emotional support and teach
her the following:
• Stop using all steroids on the face and
eyelids. Stopping steroid use may make
the condition much worse at first, but it
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will get better.
• Use medications only as directed.
• Never use medications prescribed for
someone else.
• Never use steroids on your face for
longer than 2 weeks.
• Avoid using cosmetics and soaps during flares. Wash your face with warm
water only.
• Don’t use emollients that contain acids
such as lactic or glycolic acid.
• When you provide your health care
provider with a list of medications you
use, always include medications you apply to your skin.
• Call your health care provider with
any questions.
Learn to recognize this condition in
patients, then give them your guidance
and emotional support as they withdraw
from steroids and break the cycle. ‹›
REFERENCES
1. Rapaport MJ, Rapaport V. Eyelid dermatitis to
red face syndrome to cure: Clinical experience in
100 cases. Journal of the American Academy of Dermatology. 41(3, Pt. 1):435-442, September 1999.
2. Dahl MV, et al. Temperature regulates bacterial
protein production: Possible role in rosacea. Journal of the American Academy of Dermatology.
50(2):266-272, February 2004.
3. Beer K, Downie J. Sequelae from inadvertent
long-term use of potent topical steroids. Journal of
Drugs in Dermatology. 6(5):550-551, 2007.
RESOURCE
Arndt KA, Hsu JH. Manual of Dermatologic Therapeutics, 7th edition. Philadelphia, Pa., Lippincott
Williams & Wilkins, 2007.
Mary C. Smith is a staff nurse in the dermatology
department of University Hospitals Case Medical Center
of Cleveland, Ohio, where Susan Nedorost, a dermatologist, is director of the contact dermatitis clinic. Dr.
Nedorost is also an associate professor of dermatology
and Brandie Tackett is a recent graduate of Case
Western Reserve University Medical School in Cleveland.
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