Topical steroid withdrawal reactions: a review of the evidence

When used correctly, topical corticosteroid medicines are safe and effective treatments for skin disorders. Correct use includes using these medicines to treat certain skin conditions for short periods of time, or with short breaks in treatment over an extended period. The MHRA received an godlyfarma enquiry from a patient representative to the Yellow Card scheme about the risk of topical steroid withdrawal reactions, which triggered this assessment. Co-treatment with CYP3A inhibitors, including cobicistat-containing products, is expected to increase the risk of systemic side-effects.

Assessment of information provided by these reports is provided in Discussion. It is intended to make information accessible, simple to use and is fully referenced.

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• They postulated that topical corticosteroids disrupt the epidermal barrier causing an initiation of cytokine cascade followed by an inflammatory response.
• 60% had used potent topical corticosteroids on the face, and 42% had a history of oral corticosteroid use for skin symptoms.
• The dose of the anti-hypertensive treatment may have to be adjusted during the treatment with dexamethasone.
• We found fungal infection (38%) was the most common reason of abuse followed by facial acne (29%) and lightening of skin colour (8.4%).

A decision on whether to continue/discontinue breast feeding or to continue/discontinue therapy with dexamethasone should be made taking into account the benefit of breast feeding to the child and the benefit of dexamethasone therapy to the woman. Aminoglutethimide can accelerate the reduction of dexamethasone and reduce its efficacy. Therefore, at the beginning of treatment, diabetics should have more frequent blood and urine tests. Prior to the use of Dexamethasone in combination with any other medicinal product, reference should be made to the Summary of Product Characteristics of that product.

Reason for the review

The main anti-inflammatory effect of GCs is based on the inhibition of the genetic transcription of numerous genes that encode proinflammatory proteins, which include numerous cytokines -interleukins (IL). These receptors act as transcription factors to regulate gene expression by recognizing palindromic hormone response elements (HRE) at the DNA after homo- or heterodimerization of the ligand-receptor complex. The activated receptor interacts with DNA and with other nuclear proteins, resulting in a change in the rate of mRNA transcription.

Topical steroids potency

This paper by Sheary reviews some individual cases and the literature, including the review by Hajar above. The author concludes that the issue is under recognised and that most cases are caused by prolonged or inappropriate use of topical corticosteroids. The table below is reported as the common features of topical steroid withdrawal reactions. There is growing evidence of topical steroid withdrawal reactions if they are used continually for a long time.

Topical steroid withdrawal reactions

Common names for these type of steroids include ‘prednisolone’, ‘hydrocortisone’ or ‘dexamethasone’ and they differ mostly in their duration of action and potency. The second is a ‘mineralocorticoid’ (controls blood pressure) and the third class are sex steroids such as testosterone or oestrogen. The dermatological side effects which were seen in our patients after application of topical steroids are listed in [Table/Fig-4].

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In a few cases, mental health problems have happened when doses are being lowered or stopped. This page is for you if you have been prescribed a high-potency topical steroid cream to treat the symptoms you have in your vulval area. Out of 2174 patients, using TC for any indication, enrolled during the study period, 256 (11.77%) patients were found to be misusing TCs and out of these 250 had clinically evident adverse effects of TCs.

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