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What Is Topical Steroid Withdrawal? If You Have Eczema, Here's What You Should Know.

Nurse Kathryn Tullos immediately noticed something was different about her youngest son's eczema symptoms. She and her three other children had all suffered from eczema, so she was well-acquainted with the condition and steroid cream used to treat it. 

At first, a stronger topical steroid treatment prescribed by a pediatric dermatologist helped, Tullos says. But then stinging red rashes started to appear all over his body, and wouldn't go away. "That's when I was kind of like, alright, this doesn't look like eczema anymore…in my mind, it looked like he's resistant to the drugs."

These symptoms, Tullos would eventually conclude, were indicative of something different than eczema—a skin condition that has been gaining traction online known as topical steroid withdrawal (TSW).

TSW refers to a severe outbreak of skin inflammation that some believe to be caused by prolonged use or abruptly discontinued use of topical steroids. First introduced in a 1979 paper, discussion of TSW has exploded online in the last decade. Graphic personal testimonials about the dangers of topical steroid addiction have gone viral on social media, bringing renewed attention to the mysterious symptoms.

Whether TSW symptoms are a flare-up of underlying skin conditions or a separate condition linked to prolonged steroid use remains poorly researched and hotly debated. Experts shed some light on what we do and don't know about the condition so far. 

Topical steroid withdrawal remains undefined

Since they were introduced in 1951, topical steroids have become the go-to treatment for inflammatory skin conditions, most commonly eczema. Usually applied as a cream, lotion, or ointment, the drug penetrates the skin and suppresses inflammation in the affected area. Topical steroids are one of the most widely prescribed drugs in dermatology. 

"They're reliable, affordable, and generally pretty safe, particularly in the short-term," says Peter Lio, a clinical assistant professor of dermatology at the Northwestern School of Medicine and board member of the National Eczema Association. Though the exact duration for using topical steroids varies by patient, he uses no more than two weeks in a row and fewer than 14 days per month as a rough rule of thumb.

In the longer-term, however, problems can start to arise. Prolonged or overuse of topical steroids can cause rosacea, skin thinning, stretch marks, says Bruce Brod, a clinical professor of dermatology at the University of Pennsylvania's Perelman School of Medicine, and some attest, an extreme and debilitating withdrawal. TSW sufferers have described widespread redness, burning, swelling far beyond their normal eczema symptoms, and in some cases, skin lesions and infection. 

A colored scanning electron micrograph (SEM) shows skin effected by eczema, in which the outer layer of the skin grows very rapidly and is easily shed—most often resulting in redness, swelling, itching and dryness, flaking, blistering, cracking, or bleeding.

Micrograph by STEVE GSCHMEISSNER, SCIENCE PHOTO LIBRARY

Leading eczema researcher Emma Guttman-Yassky says this is often the result of misusing topical steroids or stopping treatment abruptly. The medicine isn't meant to be used indefinitely because of the potential for skin damage, and as with oral steroids, patients should gradually taper off use, says Guttman-Yassky, chair of the dermatology department at Mount Sinai's Icahn School of Medicine. She typically recommends weaning patients off topicals after four weeks, "particularly the moderate to high potency" strength.

But many patients don't get this information about dose and duration, Tullos says. "I was never told any dose or, or how to use it." Only in reading the fine print on the product label and in published clinical trials did she learn about the potential side effects from using topical steroids on more than 20 percent of the body and for a prolonged period. 

Some doctors, like Brod, have begun to diagnose TSW in patients—but with difficulty. "There's a broad spectrum of presentation…That's part of the problem: There's no distinct clinical marker. There's no biomarker. There's no specific lab test." 

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The condition isn't officially recognized by the International Classification of Diseases and has no clear diagnostic criteria. Still, Lio says he's "convinced that it is a real phenomenon." He describes patients who have been off steroids for years but "continue to have terrible disease," which he believes is "fundamentally different from the eczema they started treating years prior."

Are topical steroid withdrawal symptoms a flare-up of a preexisting condition?

Aaron Drucker, a dermatologist and associate professor at the University of Toronto, says hearing stories of bad reactions to topical steroids "runs counter to our experience" that they have been used safely and effectively for decades. 

Guttman-Yassky believes that explaining these symptoms as "withdrawal" from steroids is inaccurate. TSW, as it's been described, is "an exaggerated concept…and many of the people that put that notion forward are not necessarily dermatologists."

A major problem is inappropriate use of topical steroids alone in cases of severe eczema, she says. In most instances, patients who have come to her with TSW symptoms see improvement through finding a new course of treatment that attacks the underlying inflammation at a systemic level.

"Topical steroids are good to suppress disease when patients have limited disease," she says. But when the condition is systemic rather than localized, meaning more than 10 percent of the body surface area is affected, liberally applying steroids will "just mask the problem" until the symptoms become too severe for the topicals alone—or flare up immediately upon stopping the drug. "If you have a patient who has multiple lesions, you're chasing your tail," she says. In that case, a different intervention is needed, such as biologics or JAK inhibitors, which mediate inflammation at the systemic level. 

Alternative treatment worked for Tullos' son. After he was taken off topical steroid treatments, his symptoms receded significantly, and after six months of ultraviolet light therapy, they disappeared altogether. "Knock on wood," Tullos says, "he's clear to this day."

The search for answers

Fear of topical steroids is hardly new; in fact, the phenomenon is so widespread it's been given an official name: corticophobia. 

That distrust has driven many to search for answers and support in online communities, which has also amplified steroid phobia and raised concerns about misinformation.

Rather than relying on unverified sources, experts recommend that patients seek professional advice from dermatologists who specialize in eczema and other inflammatory skin conditions. "There's a risk of misbranding topical steroids as something that shouldn't be used, and that's not the case at all," Brod says. "It's all about education and appropriate use."

Meanwhile, patient advocates, like Tullos, are trying to raise awareness and fund research into TSW. As a board member of the International Topical Steroid Awareness Network, she's also lobbying for adding warning labels to topical steroids (such as those published by the United Kingdom), getting an official ICD-10 code, and building a long-term patient registry. 

Many questions remain, such as how prevalent TSW-associated symptoms are, who is most likely to be affected, and how—if at all—to define the condition. New research is ongoing, including a study conducted by the National Institutes of Health looking at the tissue profiles of people who believe they're suffering from TSW. Preliminary results from the paper, which is now in preprint, suggest that TSW has clinically distinct symptoms—possibly due to a chemical irritation—and may indeed merit its own diagnosis.

For now, there's rampant confusion about whether TSW exists, among both patients and the public, Brod says. "It's a sort of a chicken or the egg theory. What comes first—the underlying condition or the topical steroid withdrawal or is it just a combination of the two?"

What To Expect From Steroid Injections For Back Pain

Steroid injections can help relieve back pain and reduce a person's need for surgery. They are typically a safe and effective treatment but do not provide a full cure for the cause of back pain.

Many people with back pain manage discomfort through over-the-counter (OTC) pain medication, stretching, or rest. However, these may not always be effective for more severe or persistent back pain. Steroid injections may help reduce inflammation and pain without the need for surgery.

Depending on a person's level of pain and the underlying cause, they might need one or several steroid injections over the course of 1 year. They may need injections into different joints or nerves depending on the underlying condition and the areas where they are experiencing pain.

This article discusses what individuals can expect from steroid injections for back pain.

A steroid injection can help people with pain that starts in the back and spreads to an arm or leg, known as radicular pain. This type of pain often occurs due to a pinched nerve.

Spinal injections do not always contain steroids and might sometimes only provide an anesthetic to numb the affected nerves. However, the injection might provide steroids such as cortisone if nearby inflammation is pressing on the nerve and causing pain.

A healthcare professional may recommend steroid injections for the following conditions and purposes:

non-specific radiculitis, which refers to symptoms of a pinched nerve

bony lumps that press on the nerve roots of the spine, known as vertebral bone spurs

thickening of ligaments and soft tissue in the spinal column

pain that can develop after a spinal surgery called laminectomy, known as postlaminectomy syndrome

a cyst on the nerve root that causes radicular pain

nerve pain after herpes or trauma

a compression fracture, in which a spinal disk, or vertebrae, partly collapses and might cause radicular pain

weakness or stress fractures in the vertebrae

degenerative conditions, such as arthritis

The site of a steroid injection depends on the type of injection, the source of pain, and the purpose of the injection.

Possible sites may include the epidural space, the facet joints, and the sacroiliac joints.

Epidural space

This is the gap outside the spinal cord's protective layer. Injections that take place here are called epidurals.

Some directly reduce inflammation in the spinal cord and relieve pressure on the nerve root. Other epidurals aim to numb a particular nerve to diagnose a specific source of pain.

Facet joints

These are joints between the vertebrae at the back of the spine. People with arthritic conditions or injury between the vertebrae who experience middle or lower back pain may benefit from a facet joint injection.

Sacroiliac joints

These joints sit between the base of the spine and the pelvic bones. People who experience lower back pain that spreads to the butt and leg might receive a steroid injection into the sacroiliac joint.

Spinal injections are often safe and effective for back pain relief. However, steroids can cause a range of mild side effects, including:

flushing and redness in the face

increase in appetite

changes to how often a person menstruates

feeling sick

diarrhea

an often temporary blood sugar increase

However, these side effects are generally rare with injections and are more common with oral or topical steroids. They usually get better without treatment.

The injection procedure may lead to direct complications, including:

bleeding

infection at the injection site

injury to the nerves

arachnoiditis — a painful condition that occurs when one of the spinal cord membranes develops inflammation

paralysis

bone tissue breakdown due to reduced blood supply

headaches

muscle weakness

increased pain

However, according to a 2023 review, spinal steroid injections have a lower risk of failure and complications than spinal surgery. The review authors recommend using spinal injections over invasive surgical procedures in the first instance.

Most people tolerate steroid injections well, but some are not suitable candidates for them. These include:

people who develop an infection at the site of injection

individuals who have a bleeding disorder

those who take medications to thin the blood

people who have high blood pressure or diabetes and do not take medications to manage either

individuals with a known allergy to anesthetics, contrast dyes, or steroids

The above individuals need to consult a doctor about alternative back pain solutions if a medical professional has recommended back pain injections.

Steroids can cause extreme mood changes and affect hormone production. Therefore, those with a history of mood disturbances or who have concerns about hormone changes may benefit from discussing these with a healthcare professional.

People often ask the following about steroid injections for back pain.

How long does a steroid shot last for back pain?

This depends on the underlying cause and severity of the back pain. According to a 2023 study, a steroid injection reaches full effect after around 2 weeks. In the study, 6.6% of people needed another injection after 2 months, and 39.6% needed their second injection after 3 months.

What should you not do after a steroid shot?

People who receive a steroid injection need to avoid receiving a vaccination with a live virus shortly after, as steroids may reduce the effects of the immune system.

People can receive injections of steroids into the epidural space, facet joints, or sacroiliac joints to relieve back pain. They can be effective for those with back pain that radiates into an arm or leg, various stress fractures, different types of nerve pain, and arthritic or degenerative conditions.

Steroid injections may cause mild, limited complications and side effects, including infection and bleeding at the injection site, flushing, increased appetite, sickness, and hormone change. Those with injection site infections, allergies to steroids, or reduced blood clotting need to avoid steroid injections and discuss alternatives with a healthcare professional.

How Are Steroids Used To Help Back Pain?

Steroids help reduce inflammation that can cause severe back pain, but steroids aren't long-term solutions. They come with a number of potential side effects and health risks.

Back pain can limit your mobility and diminish your quality of life. When certain spinal conditions, such as a bulging disk, cause back pain, a doctor may suggest steroid injections to relieve your pain.

Steroids, specifically corticosteroids, tend to provide short-term relief and are usually recommended after other treatments have been tried.

In this article, you'll learn what conditions may be treated with steroids, how these powerful medications work, as well as their possible side effects and complications.

Steroids work by reducing the inflammation that may cause your back pain. The body's immune system triggers an inflammatory response when there's illness or injury.

Inflammation is often part of the healing process. But chronic inflammation can also put pressure on nerves, which, in turn, causes pain that may linger until the inflammation is brought under control.

Steroids work by reducing levels of prostaglandins and other chemicals in the body that are part of the inflammatory process.

Steroids are sometimes recommended to treat acute back pain that results from an injury. The fast-acting nature of steroids can reduce pain and inflammation while the injury heals.

Other back conditions that may be treated with steroids include:

Steroids are also sometimes used to treat spinal stenosis, a condition in which the space inside the vertebrae narrows and puts pressure on the spinal cord and nerves. But a 2022 analysis of 13 clinical trials suggests that, while steroids may be helpful for some conditions, they're not particularly effective for relieving spinal stenosis pain.

Steroids for back pain include oral tablets and injectable medications.

One of the most common oral steroids is prednisone (Deltasone), which is also taken for conditions ranging from asthma to various autoimmune disorders, such as lupus and multiple sclerosis.

Other oral steroids sometimes prescribed for back pain include methylprednisolone (Medrol) and dexamethasone (Maxidex, Ozurdex, DexPak).

An injectable form of dexamethasone (Decadron) is also used to treat back pain. Other injectable steroids commonly used to treat back pain include:

The choice of which steroid to use depends on several factors, including your previous reaction to a particular steroid and the region of the spine to be injected.

Oral and injectable steroids share some common side effects, such as insomnia. Most potential side effects of steroids are specific to the type of medication used.

Because oral steroids affect the entire body, some common side effects include:

changes in your heart rate (faster, slower, irregular)

elevated blood pressure

leg swelling

mood shifts

weight gain

Receiving steroid injections can lead to minor pain at the injection site and a temporary increase in back pain. You may also experience some flushing of your skin and a brief increase in your blood sugar levels. These side effects tend to disappear after a few days.

One of the main concerns with steroid injections for back pain is that the steroids can weaken the bones of the spine and the surrounding muscles. The National Institutes of Health notes that the general guideline is to limit spinal injections to no more than 3–4 per year.

Individuals rarely experience heavy bleeding or infection at the injection site. Allergic reactions to steroid injections are also uncommon.

Serious complications related to oral steroids are also uncommon, but there are some potential risks. A 2017 study suggests that short-term use of oral steroids may increase the risk of fractures and upper respiratory tract infections.

Oral steroids are taken daily but should only be used for 1–2 weeks. It can take several days before they provide significant relief. Steroid use is usually tapered. For example, you may take 6 tablets the first day, and then 6 the next day, and then 5, and so on until there are no more tablets left.

Injectable steroids are much more concentrated. After receiving one injection, you may not need one for a few months or longer.

Before receiving an injection of steroids, you'll receive a local anesthetic to numb the injection site. You'll lie face down, and you may have an X-ray taken of your spine to confirm the location of the injection.

After you receive your shot, you should be able to sit up and walk around. Before going home, you may be observed in the doctor's office for 10 or 20 minutes to check for any adverse reactions.

A 2022 study suggests that steroids may be most effective for short-term back pain relief and delaying surgery, but there still isn't enough data to show that there are many long-term benefits.

The best use of steroids for back pain may be as part of a combination of treatments that include heat and cold packs, physical therapy, and complementary treatments, such as massage or acupuncture.

Surgery is usually considered a last resort, though, in cases of severe spinal conditions, it may be necessary.

How quickly do steroids help back pain?

You should begin to experience back pain relief within 2–3 days after starting oral steroids.

Injectable steroids also may begin to work within a couple of days, though the pain may temporarily increase the first day or so after the injection. The timeline for steroids to work also depends on what's causing your back pain.

What is the most common steroid for pain?

Prednisone is one of the most common oral steroids for back pain. Among the most common injectable steroids are dexamethasone and betamethasone.

What is the biggest side effect of prednisone?

Weight gain is an especially common side effect of prednisone, but mood shifts and changes in your heart rate are also common.

Steroids are generally well-tolerated medications that can provide short-term and fast-acting relief for various types of back pain, but they aren't meant to be used regularly for a long time or as substitutes for more lasting treatments, such as physical therapy.

If you experience back pain, get an accurate diagnosis of your condition and discuss your treatment options with a healthcare team. Steroids may be a helpful piece of the puzzle in relieving your back pain and restoring your mobility and quality of life.

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