Pathophysiology and Clinical Manifestations of Topical Steroid Withdrawal Syndrome

Authors

  • N Shobnam
  • G Ratley
  • S Saksena
  • A Sun
  • K Mccann
  • M Yadav
  • S Ganesan
  • PP Chaudhary
  • K Kanakabandi
  • S Ricklefs
  • J Lack
  • M Gadkari
  • L Franco
  • I Myles

Abstract

Background
Topical Steroid Withdrawal (TSW) occurs secondary to sudden cessation of topical steroids after a period of exposure. The resultant symptom profile has been understudied and often attributed to steroid phobia or an atopic dermatitis flare. Although evidence is limited, case reports have identified symptoms associated with TSW that are distinct from symptoms of atopic dermatitis. These include thermo-dysregulation, neurogenic pain, burning sensation, oozing with a metallic smell, and specific cutaneous signs such as the "red sleeve sign" and loose skin (“elephant wrinkles”). We propose a clinical diagnosis of TSW and have examined the possible pathophysiology underlying this disease.

Methods
This is a small pilot study with a cohort of 16 patients. Symptom profile was collected using questionnaires, limited serum analyses were performed, and skin biopsy samples were assessed. Methods of multi-omics (MALDI-TOF imaging and RNAseq) were used to identify aberrant metabolic pathways.

Results
Every member of this cohort experienced acute onset severe systemic symptoms upon cessation of steroids. Using multi-omics analysis of serum and skin samples, we identified a targetable metabolic pathway associated with TSW that has not been previously linked to AD. Directed, open-label, treatment at the source of the metabolic disturbance was associated with significant improvement in patient symptoms.

Conclusion
Topical steroid withdrawal syndrome appears to be a distinct clinical diagnosis occurring in a subset of patients who discontinue steroids after a period of sustained use. We have determined a distinct pathophysiology that offers the promise of directed therapeutic strategies.

Scientific Focus Area: Clinical Research

This page was last updated on Tuesday, August 6, 2024

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