Topical Steroid Withdrawal (TSW)

Topical is a medical term that means ‘applied directly to the skin’. Steroids are natural hormones produced in the body, which can also be made synthetically as medicines. There are two sorts of steroid: corticosteroids that reduce inflammation, and anabolic steroids that increase muscle mass. Topical Steroids (TS) contain corticosteroids and are used to treat many different inflammatory skin conditions including eczema.

Some people are able to control their eczema by careful skin care, using emollients and avoiding irritants and other things that can trigger eczema. If the eczema flares up despite these measures, NHS guidance recommends TS as the next step in treatment. TS are used to treat or prevent flare-ups, but are not a cure for eczema. For more information about TS, see our webpage here.

No, they are very different. In the UK, TS are available in four different strengths (sometimes called potencies): mild, moderate, strong and very strong. The strength prescribed depends on the patient’s age, diagnosis, severity and area of the body affected. A very strong TS is probably one hundred times as strong as a mild TS. Mild and moderate forms – hydrocortisone and clobetasone (Eumovate) – can be purchased from pharmacies, but stronger TS must be prescribed by healthcare professionals.

It is very important to know what strength TS you are using, and until recently this information was not printed on the tube or box. Following a campaign led by National Eczema Society, from June 2025 all topical steroid medicines must show the strength on the label. This will say whether the medicine is a mild strength steroid, moderate strength steroid, strong steroid or very strong steroid.

TS can be a safe and effective treatment for eczema but, like any drug, they must be prescribed and used with care to avoid adverse effects. Some people experience problems when using TS as advised. Information about side effects is included in the leaflet enclosed with every pack. TS must not be used on infected skin unless combined with an antibiotic or antifungal medicine. TS may cause redness, pimples or other rashes on delicate facial and genital skin, and medical supervision is needed if they are to be used in these areas or around the eyes.

Occasionally people develop a contact allergy to the steroid cream or ointment. Using large amounts of TS can thin the skin over time and the steroid may be absorbed into the bloodstream. Babies and children can be treated with TS, but their delicate skin is more likely to absorb steroid and therefore only milder TS should be used. If enough TS is absorbed, it acts like a steroid medicine taken orally as a tablet or by injection and can suppress the body’s natural production of corticosteroid causing serious health problems when it is discontinued. Prolonged use of stronger TS can result in TSW. These adverse effects are less likely if the strength and quantity of TS are kept to a minimum and are carefully chosen to match the person’s age, severity of eczema and body area.

Most people will only experience symptoms of their original eczema, if it doesn’t clear up or returns, after using topical steroids. If you have been using higher strength TS for some weeks, you should wean yourself off slowly (reducing the TS strength and/or frequency of application) and not stop suddenly. If you stop topical steroids and develop a skin rash different from what you had before, this may be TSW.

If you are unhappy with using the TS, even if it appears to be helping, discuss your concerns with your doctor who can check for signs of excessive TS use such as thinning of the skin, which is quite hard to detect. If your condition has cleared up with a mild or moderately strong steroid, it is reasonable for your doctor to suggest that you use it again when needed, but it is obviously your choice how you want to manage your eczema. Some alternative treatments for eczema are described below.

With all medicines, we have to balance the benefits against the risks. Millions of people have used topical steroids safely over the past 70 years, and the long clinical experience we now have with TS shows that overall the benefits outweigh the risks. There are also many research studies into the use of TS and the latest evidence on safety of TS has been reviewed recently.

People can experience problems after they stop using TS. Often the original condition comes back when the treatment stops – eczema is a long-term skin condition that comes and goes and this is a normal pattern. There is also a group of symptoms called topical steroid withdrawal (TSW) reactions, referred to variously as ‘topical steroid withdrawal’, ‘topical steroid withdrawal syndrome’, ‘red skin syndrome’ or ‘topical steroid addiction’. These are severe reactions that can occur when topical steroids, usually strong or very strong, have been used for a prolonged period, usually more than a year to treat eczema. TSW can also appear while still using the TS, but becomes much worse on stopping and more severe than the original condition. The skin becomes red (or darker than the usual skin tone, depending on skin type) often in areas where they never had eczema before. Patients can also experience swollen glands, intense itch and oozing, burning skin with excessive flaking. They can feel tired, weak and shivery and may even be bed-bound. Other symptoms include hair loss, weight loss, and sleep and mood disturbance. Dermatologists would call this state ‘erythroderma’ or ‘erythrodermic eczema’. Prolonged use of strong and very strong TS may even suppress the body’s own normal steroid production. This is called hypoadrenalism and causes severe weakness and low blood pressure, which may contribute to the symptoms of TSW. Sufferers tell us that TSW can continue for months or years: intermittent flares may be hard to distinguish from the original eczema coming back.

If your rash spreads to areas that are not typical for your eczema pattern, and TS are not controlling it, then it could be TSW. If you experience a side effect(s) after using TS, we encourage you to report it to the Medicines & Healthcare products Regulatory Agency (MHRA) Yellow Card scheme.

#TSW content is widespread on social media, suggesting TSW is extremely common, although many doctors view this as rare. There are several possible explanations for this difference. People with TSW tend to avoid doctors, who can be dismissive of the idea that TS caused their problem, so it may be that doctors are simply not seeing people experiencing TSW or not recognising it. Meanwhile, doctors see hundreds of people benefitting from TS for a wide range of skin conditions, without suffering TSW. The number of social media views may be inflated by people just curious about TSW or viewing repeatedly. It could be that some of those self-diagnosing TSW may in fact have a different skin condition. It is possible that what some patients call TSW is a rebound of the eczema – we know that TS only suppresses eczema and does not cure it, so there is a natural tendency for the inflammation of eczema to bounce back when the anti-inflammatory TS is stopped. We need more research and clear diagnostic markers to better understand how common TSW is.

If you are using a TS and think it’s harming your skin, then talk to your GP and ask for a referral to see a dermatologist if necessary. You may have developed a side effect that needs different treatment.

If you think you have TSW, especially if you are feeling ill, please see your GP urgently and ask for an urgent referral to a dermatologist. Alternatively, go to a hospital emergency department. Even if the doctors do not recognise the term TSW, erythrodermic eczema and hypoadrenalism from prolonged use of steroids are medical emergencies. If you are under the care of a dermatology service, you could contact your dermatology team and ask for an emergency telephone call-back – some centres may offer this option.

We encourage open, supportive dialogue between patients and healthcare professionals over patient concerns about topical steroid use and TSW. The MHRA advises doctors to be ‘vigilant’ for the signs and symptoms of TSW reactions. Do also discuss options with friends and family, as having eczema or TSW is tough mentally, which makes it hard to advocate for yourself.

There is no consensus among healthcare professionals about correct treatment for TSW. The advice from some people – shared widely on social media – is to stop using topical steroids, suffer TSW and wait until the skin heals itself, which may take many months or longer. If someone has decided to stop using TS to treat their eczema, doctors would usually advise that this should be done under medical supervision, so that alternative treatments can be offered to manage the symptoms. The TS should be weaned gradually (reducing the TS strength and/or frequency of application) to minimise the risks of a severe withdrawal reaction and possibly hypoadrenalism.

If TSW has developed, patients will need supportive treatment to address hydration, nutritional needs and pain. It is also important to recognise the mental health impacts of TSW that can be significant and provide support for people’s psychological and social needs. Other medical therapies will likely be considered depending on the precise diagnosis, and after weighing up the risks of adverse effects. For people with severe TSW, immunosuppressant treatments and the newer biologic and JAK Inhibitor medicines can be very helpful to alleviate the condition while the body recovers. It is obviously your choice on how you decide to manage TSW, and for some that may mean not considering other drug treatments.

Unfortunately, there are unregulated practitioners offering other treatments for TSW (e.g. red light therapy, cryotherapy) with little if any evidence that they work effectively.

There is a lot of core advice on the National Eczema Society website about avoiding triggers, managing itch and keeping your skin healthy without needing medicines. These measures should always come before using TS. If these measures are not enough, some doctors will prescribe tacrolimus ointment (a non-steroid medicine known as a topical calcineurin inhibitor or TCI) as an alternative to TS. Tacrolimusis just as effective as a moderately strong TS, has fewer side effects, and is sometimes used long term to help prevent flare-ups. Another TCI, called pimecrolimus cream, is sometimes prescribed for people with less severe eczema. Zinc paste bandages can also be used for limited areas of eczema on the limbs.

If your eczema is very widespread, doesn’t clear with TS, or has been harmed by the TS, then other medicines may be needed. Patients in this situation should be referred by their GP to a hospital, where dermatologists can reassess, investigate and if necessary prescribe immuno-suppressing drugs such as methotrexate, ciclosporin and azathioprine. These can be very effective but also have side effects and patients will be told about the potential risks and benefits so that they can make an informed choice. Newer targeted drugs are now available including dupilumab and upadacitinib; these medicines can work extremely well for people with more severe eczema. Depending on the treatment, they are given by injection or taken orally as a tablet, and cream forms are also being developed for some medicines. Obviously, it will take time to understand the full effects of these new treatments but, so far, the signs are very good. Medicines like this may well help people with TSW.

To prevent TSW, we need better understanding of how to use TS safely. What quantities, strengths and periods of use are likely to result in TSW? What skin conditions, body areas and age-groups are more susceptible? The advice provided by prescribers and with TS products generally refers to the immediate situation. But people with eczema are liable to need multiple courses of TS over their lifetime and there is currently no guidance about how much can be used safely over the longer term. Unfortunately, this leads to conflicting advice, or no advice at all, about long-term use.

Steroids do not act on the brain to cause the same sort of craving as alcohol or drugs of addiction, but they can cause dependence. TS are very effective anti-inflammatory medicines, so if they help, even just a bit, patients may feel a need to continue in order to stop the condition coming back. In most cases this is fine, and sooner or later the condition stops coming back and the need for TS stops too. This is no more addictive than needing paracetamol for a sprain. There is some evidence that the skin ‘gets used to’ the TS – a situation doctors call tachyphylaxis. The terms ‘addiction’ and ‘withdrawal’ may promote the idea (by comparison with alcohol addiction) that patients must avoid TS for ever. This is not necessarily the case and some people who have gone through TSW may subsequently tolerate short courses of TS to treat eczema flare-ups.

Most children and adults who use TS do not experience TSW and some people may worry unnecessarily. If you use a mild or moderate strength TS intermittently on limited areas of the body, TSW is unlikely and you may be able to continue treating your skin condition successfully with TS without a problem. Ideally, you would use TS for no longer than 14 days and then take a steroid break for two weeks or longer. The natural course of eczema is that it comes and goes over months or longer, and TS are used to treat flare-ups if they do happen. Therefore, if the eczema comes back some weeks after you stop using TS, it is unlikely to be TSW. But if the eczema never clears up when using a stronger TS, or comes back as soon as you stop, then this might be TSW. See above for a description of the symptoms of TSW.

Babies and children with eczema are prone to have troublesome patches and occasional flare-ups during the pre-school years but usually improve during childhood. Parents are understandably anxious to avoid treatments that may harm their child. The long experience of dermatologists is that a course of TS treatment to active areas of eczema greatly reduces inflammation and itch, enabling the skin to heal much more quickly. Untreated eczema causes pain, scarring, misery and sleeplessness with significant effects on people’s physical and emotional well-being and possibly on neurological development Eczema must be treated effectively to control itch and inflammation, and to re-establish the skin barrier to help prevent the eczema being triggered again by new allergens in the environment. It is important as well to maintain a good skincare regime using emollients to help protect the skin barrier.

If eczema is not adequately controlled by TS, or flares up immediately after stopping it, this could be TSW, but it could also mean the eczema still needs more active treatment to control it. If it flares up a week or so after stopping the TS, it is more likely the eczema is following its natural relapsing and remitting course and further short bursts of TS may be appropriate to control the flare ups.

Medical experience shows babies and children can safely continue with intermittent courses of a mild or moderate TS until their eczema clears up, as it usually does before school age. However, if their eczema cannot be controlled in this way, they should be referred to a dermatologist and other treatment approaches considered.

Yes, but doctors are bombarded with new information about the hundreds of drugs and diseases they deal with and it takes time for medical practice to change. In September 2021, the UK Medicines and Healthcare products Regulatory Agency (MHRA) recognised TSW reactions and published information for prescribers and patients which was updated in 2024. National Eczema Society contributed evidence for the MHRA review. Following the MHRA review, information about TSW reactions is now included in the patient information leaflet found in all tubes of topical steroid. The British Association of Dermatologists has recently set up a working group to review the evidence about TSW and to produce guidelines for prescribers and patients. Some other international medical websites also provide information about TSW.

Doctors receive lots of new information about the hundreds of drugs and diseases they deal with and it takes time for medical practice to change. In September 2021, the UK Medicines and Healthcare products Regulatory Agency (MHRA) recognised TSW reactions and published information for prescribers and patients, which was updated in 2024. National Eczema Society contributed evidence for these MHRA reviews and published a position statement jointly with the British Association of Dermatologists. Following the latest guidance, information about TSW reactions is now included in the patient information leaflet found in all tubes of topical steroid.

In 2024, the British Association of Dermatologists set up a working group to review the evidence about TSW and to produce guidelines for prescribers and patients in the UK. We await the recommendations of this working group. It is encouraging to see more interest in TSW at professional dermatology conferences and coverage in the medical literature. Some other international medical websites also provide information about TSW.

Your doctor can record TSW as a diagnosis in your medical notes, but clinical coding systems do not yet include the term. Therefore TSW does not automatically appear in electronic medical correspondence or summaries. Currently, most doctors are reluctant to use the term TSW because it is not sufficiently precise – it covers reactions occurring both before and after stopping topical steroids, as well as the ongoing period of steroid avoidance. Also, people who consider they have TSW may actually have one of a number of conditions. We need research to define it more accurately.

You may come across the term ‘steroid phobia’. There are different views among doctors and patients about whether someone’s worries about using TS amount to a phobia (defined as an extreme or irrational fear of or aversion to something). If somebody has suffered harm from a topical steroid, it is rational to fear using TS again and this could be described as ‘steroid avoidance’. However, to avoid all topical steroids out of fear, in all circumstances could be considered a phobia. Concerns about using steroids are increasingly common and unfortunately some people, especially children, are unnecessarily deprived of their benefit because of a fear of possible side effects including TSW.

TSW has only started getting medical recognition in the last few years and many healthcare professionals remain uncertain about TSW. Medical experience over decades shows that topical steroids can be used safely and effectively, not only for eczema but also for many other conditions. TS are recommended as the first-line flare control treatment for eczema in both national and international medical guidelines. Doctors can struggle to help people with eczema who say they have TSW and prefer not to use TS, particularly GPs and others in primary care, where there are few other active treatments available.

Around 20% of all children in the UK suffer from childhood eczema. Practically all will have benefitted from topical steroids at some time and most become eczema-free over time with no adverse effects. A relatively small number continue with eczema when they are older, and that is the natural history of eczema, not necessarily a result of topical steroids. Denying patients topical steroids and making people afraid of using topical steroids has the very real potential of causing more harm than good.

No, the vast majority of doctors have no vested interest in what they prescribe. A very small number may own shares in pharmaceutical companies or are paid for consultancy advice. They are bound by tight transparency rules from the General Medical Council (GMC) and would be subject to disciplinary procedures if these rules were broken. They declare such interests online (see ABPI) and these should not influence their prescribing. UK healthcare professionals follow evidence-based guidelines published by the National Institute for Health and Care Excellence (NICE) and Scottish Medicines Consortium (SMC) in Scotland: NICE and the SMC are meticulous about this and any financial interests of their advisors are published on their website.

Eczema UK exists to make life better for people with eczema and their families. We work with a range of organisations to achieve our aims including professional and regulatory bodies, research organisations, other charities and companies. While partnership working is important, we will never compromise our independence as a patient organisation, always putting people with eczema first.

We are open and transparent about our work with pharmaceutical companies and any financial support we receive. We recognise that pharmaceutical companies produce a range of medicines to treat eczema and many people with eczema rely on these treatments, which are prescribed through the NHS. The companies we work with do not influence our activities in any way, either explicitly or implicitly. Our advice is based on clinical guidelines and research evidence and we do not recommend or endorse any specific products or treatments.

We have agreements in place for each of our company partnerships and our work with pharmaceutical companies is underpinned by our own Partnership Policy, as well as the rigorous Association of British Pharmaceutical Industries (ABPI) Code of Practice.

Doctors working in the NHS prescribe evidence-based treatments and follow guidelines approved by the regulatory bodies such as the MHRA, NICE and SMC. They are not qualified to provide alternative medicines, but some can access complementary therapies. All doctors should consider the mental health impact and psychological and social needs of people with eczema and involve other agencies if necessary and available.

Yes, a great deal. Eczema is a complex condition involving our genetic make-up, our immune system and our environment. People with atopic eczema (the most common type) are born with a genetic predisposition to develop antibodies to many and varied things in the environment. We can’t change our genetic make-up, and changing our environment is difficult, so most treatment and research focuses on ways to influence the immune system. Steroids are something of a blunt tool – they suppress ‘good immunity’ that protects us from infection, as well as ‘bad immunity’ that attacks our bodies and makes us react to otherwise harmless things in the environment. Medicines are now being developed to specifically target the bad immunity such as the newer biologics and JAK Inhibitor treatments.

Medical recognition of TSW is still developing and there has been limited research to date. Eczema UK has been encouraging more research in this area and is funding two research projects into TSW. Research is needed to define TSW more clearly, to find out how common it is, and to clarify the limits for safe use of topical steroids (e.g. the RAPID Trial Keep Control Study). We also need to find out exactly what happens to the skin with prolonged steroid use: scientists have considered various possible mechanisms, but at the moment the evidence is very limited.