Guidance

Topical corticosteroids and withdrawal reactions

Safety leaflet on topical corticosteroids and withdrawal reactions to help patients and their carers to use these medicines safely.

From:
Medicines and Healthcare products Regulatory Agency
Published
15 September 2021
Last updated
29 May 2024 — See all updates

This safety information will help you to understand topical steroids and Topical Steroid Withdrawal reactions (TSW). You should always use your medicines as instructed by your doctor or healthcare professional and you should bookmark this page as you may need to read it again.

A PDF version is also available: Topical corticosteroids and withdrawal reactions (PDF, 153 KB, 4 pages).

For further information on using topical steroids safely, and a full list of possible side effects, read the Patient Information Leaflet that came with your medicine, and keep it handy. Patient Information Leaflets for each medicine are also available on the MHRA’s product website.

Key messages

  • Topical steroids are medicines used on the skin to reduce inflammation
  • When used correctly, topical steroid medicines are safe and effective treatments for skin disorders
  • Different topical steroids have different strengths (known as potencies) and your prescriber will decide on the correct potency for you
  • Using too little of the cream or ointment can prolong treatment time and increase the risk of certain side effects
  • If you’ve been using these medicines continually for a long time, consider asking your prescriber for a treatment review
  • If you experience a recurrence of your condition shortly after stopping treatment, within 2 weeks, do not restart using the cream/ointment without consulting your prescriber unless your prescriber has previously advised you to do so.
  • If your condition has resolved and on recurrence the redness extends beyond the initial treatment area and you experience a burning sensation, please seek medical advice before restarting. If you have been using topical steroids for a long time you may be experiencing TSW which can sometimes be severe
  • Contact your doctor if you experience any of the following after stopping treatment:
    • redness or darkening of skin colour, or greying of the skin in darker complexions, which can extend beyond the initial area treated
    • burning, stinging, itching or peeling of the skin, or oozing open sores

1. About Topical Steroids

Steroids are natural chemicals produced by the body and also are manufactured to be used as medicines. There are different types of steroids. The most common type used to treat skin problems are topical steroids which are medicines applied directly to the skin.

Steroids treat skin conditions such as eczema and psoriasis by reducing inflammation. Steroid creams, ointments and other topical preparations come in four different potencies or strengths. These are known as mild, moderately potent, potent and very potent. Your doctor will usually refer to topical steroid potency rather than strength. A potent or strong steroid has a much stronger effect than a mild steroid when using the same amount of steroid.

Your doctor (or another prescriber) will decide on the correct strength for you based on your condition, your age, and the area of your body to be treated. Your doctor may prescribe more than one topical steroid. These may be of different potencies and for you to apply to different body areas. Some body areas are more prone to side effects from steroids than others. These areas include the face, especially the eyelids, the groin and under the arms or breasts. Only mild potency products should be used in these areas. This is why it is important that you don’t treat a new body area with your existing topical steroid unless your doctor has told you to do so. Remember that the percentage concentration stated on the tube only applies to that particular steroid.

2. Safe Use of Topical Steroids

When used correctly, topical steroids are a safe and effective treatment. You should follow your doctor’s instructions on how to use your medicine. Your doctor will explain where, how often and for how long to use your topical steroid. You will need to use enough of the preparation to cover the area treated. Finger-tip application units can help with this, you can also find a factsheet from the National Eczema Society.

Topical steroids are usually applied once or twice a day, and your doctor will tell you what is best for your skin condition. If your skin condition gets worse or does not get better, it is important that you return to your doctor for advice. You might have developed a different condition, which may need a different treatment.

Most people prescribed topical steroids will also be prescribed an emollient, which is a moisturiser that hydrates and soothes the skin. You can use the topical steroid and the emollient at the same time of day. However, you should wait 20 to 30 minutes between applying each treatment, otherwise the emollient could dilute the topical steroid and reduce the steroid’s effectiveness. Your doctor will discuss with you the order in which your treatments should be used. Emollients can be used several times a day, as needed during a flare and can be used long term to help maintain your skin.

3. Special Considerations for Children

Topical steroids can be used safely in children if recommended by a healthcare professional. However, children, especially infants, are particularly susceptible to side effects of steroids.

This means it is important to use only the amount advised by a doctor and for a short amount of time. If your patient information leaflet does not specify fingertip applications for children by age, please confirm with your child’s doctor the correct amount to apply.

Be careful not to use too little. This can mean that the steroid needs to be used for longer than necessary. Seek medical advice if your child’s eczema or skin condition does not improve or worsens with treatment. If a stronger topical steroid is prescribed and there is still no improvement, discuss with your child’s doctor or a healthcare professional as soon as possible.

4. Topical Steroid Withdrawal Reactions

It is not unusual for skin conditions to flare or return shortly after stopping topical steroids. However, if you experience a return of your symptoms within days to weeks you should not re-treat the area without consulting a doctor. Sometimes a severe type of reaction referred to as topical steroid withdrawal reaction (TSW) can occur.

It is not currently known how common these reactions are, however they are thought to be rare.

TSW is usually seen after very frequent or long-term use of strong topical steroids, for example, longer than 6-12 months in adults. Although, it has also been seen after as little as 2 months of continual use in children. Reactions are more common after use in sensitive areas such as the face or genitals.

TSW has not been reported when topical steroids are used to treat suitable conditions for short periods of time or with breaks in treatment over an extended period. It is very important that you follow your doctor’s instructions. You should also read the Patient Information Leaflet included with your medicine.

Signs of TSW include redness of the skin which can extend beyond the area treated with the topical steroid. Redness can be on a spectrum of pink to purple which may show as darkening/greying of the normal skin tone and can vary depending on the skin tone of the individual. Other signs include burning or stinging, intense itching, peeling of the skin, or oozing open sores. These signs may occur days or weeks after stopping treatment.

5. Other Effects of Over-Use

 Over-using topical steroids can also lead to other possible side effects during treatment. These include colour changes or thinning of the skin. Thinned skin appears translucent with visible tiny blood vessels and may be more fragile and more susceptible to stretch marks than normal skin. This can be very difficult to see in brown or black skin.

Over-use can also cause adrenal suppression which can result in low blood pressure, dizziness and fainting.

Another rare side effect associated with over-use of topical steroids is Cushing’s syndrome, a disorder that can lead to a range of symptoms including red, puffy and rounded face, high blood pressure, weight gain, stretch marks, slower healing wounds, acne, excessive facial hair and body hair, muscle weakness, fatigue, emotional changes including anxiety, irritability, and depression, frequent infections, irregular periods in women, erectile dysfunction, loss of sexual interest or infertility in men and slower rate of growth in children.

If you experience any of the reactions described, you should speak to your doctor or pharmacist.

6. Help and Advice on Managing Your Condition

Your GP, dermatologist, or another healthcare professional can provide further information, including help and advice on managing your condition. The following charities or organisations also have resources:

The BAD, NES and British Dermatological Nursing Group have published a statement on topical steroid withdrawal.

Please report medicine side effects directly to the MHRA on the Yellow Card website, or via the free apps (Android, iOS), or by phoning the free phoneline (0800 731 6789).

Updates to this page

Published 15 September 2021
Last updated 29 May 2024 + show all updates

  1. Major update of advice following further review of topical steroid withdrawal reactions and the introduction of new potency labelling.

  2. First published.

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