How do you prevent topical corticosteroid withdrawal? Prevention and treatment of any secondary infection.Calcineurin inhibitors and tetracycline antibiotics for the papulopustular subtype.Dupilumab may be considered in atopic dermatitis patients.Abrupt cessation vs tapering is debated.Discontinuation of topical corticosteroids is the mainstay of treatment but it is important to monitor for rebound reactions.Cold compresses, ice, and gabapentin for burning pain.Many different treatments are available, however they are not associated with a reduced time to resolution. What is the treatment for topical corticosteroid withdrawal? What is the differential diagnosis for topical corticosteroid withdrawal? Histology is not useful in the diagnosis of topical corticosteroid withdrawal due to its non-specific histological features of epidermal atrophy, spongiosis, and parakeratosis. Patch testing can be useful in excluding contact dermatitis to the topical corticosteroid or cream excipients, or other topical agents (eg, emollients), although this may be difficult if there are insufficient areas of normal skin. One of the challenges is determining whether the skin reaction observed is due to the stopping of topical corticosteroids, or a worsening of the underlying skin disease for which the steroids were prescribed. ‘Elephant wrinkles’ of the posterior elbows and anterior knees (extensors).Swelling (oedema), especially of the eyelids or ankles.History of oral prednisone use for skin symptoms.History of atopy, especially atopic dermatitis.Confluent redness (erythema) within days to weeks of topical steroid cessation.Frequent and prolonged topical steroid use on the facial or genital region.Frequent and prolonged topical steroid use on the area of initial eruption.There is a lack of consensus on diagnostic criteria for topical corticosteroid withdrawal however, in recent literature, the key features are: How is topical corticosteroid withdrawal diagnosed? Suicidal ideation (16%) from prolonged debilitation.Flare of pre-treatment skin disorder, particularly atopic dermatitis.What are the complications of topical corticosteroid withdrawal? How do clinical features vary in differing types of skin?ĭarker or grey skin changes, rather than redness, may feature in more pigmented skin types. This subtype is less commonly affected by burning, stinging, or swelling. Papulopustular subtype: commonly seen after steroid use for pigmentation changes or other cosmetic reasons, characterised by papules, pustules, and erythema.Erythematoedematous subtype: commonly seen in patients with chronic atopic dermatitis, characterised by burning sensation, erythema, oedema, and scaling.Headlight sign: erythema of the face, sparing the nose and perioral skin.Red sleeve sign: erythema of limbs, sparing the palms and soles.‘Elephant wrinkles’: thickened skin with reduced elasticity, usually affecting extensor surfaces.The recovery process may take weeks to years. Skin recovers to the state prior to topical corticosteroid cessation.Skin starts to recover but has increased sensitivity and intermittent flares may occur.Skin becomes dry and itchy with shedding ( desquamation).A few days (usually) after discontinuation, there is an acute eruption of burning red, exudative skin which may extend to untreated areas.Withdrawal typically occurs in four stages. The onset of withdrawal from the time of discontinuation ranges from 48 hours to over 3 months. Prior to stopping the steroid, the skin often appears normal or near-normal, although patients with atopic dermatitis may have itching or prurigo-like nodules. What are the clinical features of topical corticosteroid withdrawal? Barrier disruption induces a rebound cytokine cascade once the anti- inflammatory effects from topical corticosteroids are withdrawn.Topical corticosteroids cause vasoconstriction, but on withdrawal rebound vasodilation occurs from increased nitric oxide release, leading to skin erythema.Keratinocytes have continued suppression of self- cortisol production after topical steroid cessation.Upregulation of glucocorticoid receptor b in atopic dermatitis patients with poor response to topical steroids.Tachyphylaxis (reduced response) with continued application, leading to usage of higher doses.The following mechanisms may explain the pathogenesis of topical steroid withdrawal: What causes topical corticosteroid withdrawal? Topical corticosteroid treatment duration of 6 months or more (63%).Topical corticosteroid of medium (69%) or high (21%) potency.
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