Rebound Phenomenon

Topical Steroid Side Effects

Question 1: What is “Steroid Rebound Phenomenon?”

Answer 1:  Steroid Rebound Phenomenon is a vicious cycle that your adrenals glands play with you to keep cortisol in your body. Since you originally SHOUTED at them that you don’t need them to be producing their own cortisol, they took the lazy way out and decided to sit out the game. They figured you’ve got some other drug pusher supplying you with ‘the good stuff’  aka cortisone, and the adrenals took that as you don’t need them. Once you stop applying topical corticosteroids your ADRENALS SHOUT BACK AT YOU IN REBOUND MODE!  They are telling you to keep applying steroids because they don’t want to make their own anymore for you.

Question 2: What does the rebound look/feel like?

Answer 2: It’s like your adrenals are full of revenge and they want you to know it. Basically, they will flood your body with histamines and other itchy, obnoxious red rash types of text messages to your skin to alert you to go back and apply those cremes again.  Meanwhile, you are in a tug of war of wanting to quit those cremes, but your adrenals are so stubborn and don’t want to go back to work. So what do you do? You try and quiet their temper tantrums by applying more topical steroids. “Just this once…I promise, and then I’ll quit.” Sound familiar?  That’s the rebound phenomenon where the ball comes back to your court…again…and again.

Question 3: How do I stop playing this vicious game?

Answer 3: This is a tough call from the referee, YOU! You have to call the shots .  Quitting steroids is not easy. Timing is everything.  This is a big decision and you’ll have to do the research.

Go to ITSAN.org and chat online with some of the topical steroid withdrawal veterans that have been through the worst stages already. Start building a network of support. Start planning your life around what could be a major journey. Sometimes life gets in the way and a milestone like a wedding, birth, graduation may not be the best time to risk going into a difficult withdrawal process. You’ll need a supportive circle around you.

It may take time to educate them on what may happen and what to expect.  So while you are learning, you may need to teach others as well. This affects more than just you and it would be wise to plan with your loved ones to possibly step up and be there for you.

On the other hand, you may just breeze through it and realize your immune system is strong with or without steroids. You just may be one of the lucky ones that came through without setbacks to your hypothalamus, pituitary, adrenal (HPA) axis.

What is Topical Steroid Addiction TSA?

Topical Steroid Side Effects

Question 1: How would I know if I’m addicted to topical steroids?

Answer 1: It could be as easy as seeing if you can quit. Usually, your body will tell you within a few days or weeks.  If you have a reserve of synthetic steroids built up for a long period of time like a few years’ worth of heavy usage, it may take 1-4 months. At that point, your adrenal glands are forced to wake up and realize that they can’t take it easy anymore and they have to get back to work.

Upon stopping or reducing the use of topical steroids, the flareups begin again. With each cycle of stopping, the body communicates that it wants more. Take a long picture of your body front and back wearing minimal undergarments or nothing, if possible. This will serve a baseline as your starting point. Mark your calendar. Begin a journal of monitoring the time frame of when another flare begins to appear. Is the flare worse?

If a few weeks go by without a flare – great! Keep it up for a few more months just to be sure. If three months go by without any major flare-up and/or large red patches appear, then you may be in the clear.  It does take at least a few months or so because the body has been known to keep a reservoir of topical steroids in the most minute areas of the vascular system due to the vasoconstriction that topical steroids cause.

Remember your normal eczema patches and flare-ups are not what we are referring to, but rather a larger surface area of red skin that feels burning deeper inside and almost like the skin is wearing a red long sleeve shirt. If your skin flares up in a more angry, feverish kind of way then you may begin to see different signs and symptoms progressively.

Question 2: How will I know it’s not just another eczema flare-up?

Answer 2: TSA and RSS are different than eczema in that they encompass larger surface areas than the dry, spotty eczema patches that you may have had earlier on before starting topical steroids. There is a deeper burning sensation that goes beyond a local itching flareup.

Question 3: What kind of reaction can I expect if my body is addicted?

Answer 3: Remember in the first chapters when I mentioned those adrenal glands are like the schoolyard bullies? They get spoiled quickly and feel entitled to the slow, lazy life and they don’t like it when they actually have to do homework and work with the thyroid again rebalancing out your body’s temperature, metabolism and re-strengthening your immune system.

So…they get angry. They will definitely let you and every part of your body know. How? By causing a few reactions such as:

A body flushed with red. It may look like you are wearing a red turtleneck sweater with long sleeves. The red usually appears around the neck, chest and may be stronger in those areas and then also along your forearms right up to your wrist. For some crazy reason, the red flushing usually stops right about there. Sometimes it does cover the hands to the finger tips too.  On the legs, it will usually stop right at the ankles. Don’t be fooled into thinking that only the original areas where you applied topical steroids would be affected. Once they are in the system   the red flushing can appear anywhere, it is not specific anymore to your original eczema dry spots. You’re in the big leagues now of systemic side effects of topical steroids. 

Extreme body temperature fluctuations and hot/cold flashes.

Nausea, vomiting, lack of appetite or a voracious need to eat.

Extreme case of body itching. Some have reported itching so deep that it feels like your bones are itching. It really is that deep and intolerable.

A sudden dryness to your skin that is far worse than the original eczema or psoriasis flare-ups. Some crusting areas around lips and hands and crevices like inner elbows and knees making it virtually impossible to move or talk.

Full body dandruff with constant flaking – that’s from the extreme dry skin.

Some experience a phenomenon of oozing or the sensation of sweating a yellow or clear substance that has a pungent, sulfuric smell.

Severe insomnia and disruption to sleep quality.

Weight loss/gain. More likely it will go the opposite way of what you want.

An immune system that is generally weaker thereby allowing any cold to turn into something more dramatic that lasts longer.

Change in eyesight and/or development of cataracts and changes to the Interocular Pressure (IOP). Please get your eyesight checked 3-4 x per year if you’ve used any topical steroids on your face. 

Decreased sexual libido, fertility, and increased dysfunction.

Bone loss, weakness from mineral depletion. In children or babies, it could translate to stunted growth and lower bone density.

Symptoms of diabetes, Cushing syndrome and other auto-immune conditions.

Highest Areas of Absorption

Topical Steroid Side Effects

Question 1: Does it matter where I apply the topical steroid and how much is absorbed?

Answer 1: Oh yes! Beware of the most delicate areas around the eyelids, face, jawline, neck and thinnest skin on and around your private parts and genitals!

Question 2: Does it matter if my medication is an ointment, creme, foam, gel, shampoo, solution, lotion, compounding powder or spray for absorption?

Answer 2: Yes! They each have varying degrees of absorption and should be noted with your doctor as to when and where to apply. A diligent doctor may prescribe an ointment to skin areas that are thicker like palms of hands or psoriasis plaque areas from excessive itching and cumulative trauma to the skin with layers of dead skin piled up. Perhaps a more or less soluble ointment for other areas based on doctor’s assessment of how compromised the skin is in that specific location. A cream for the acute and subacute dermatoses that are rash prone and areas that can hold moisture. Be prepared to ask specific questions about each medication and where and when to apply.

Question 3: Are topical steroids tested on people with eczema or on people with normal skin?

Question 3: There are two types of tests. Absorption tests are conducted on healthy volunteers without atopic dermatitis.

For clinical purposes, topical steroids that go into the market are tested on diseased skin where the epidermal barrier is defective, and in those, the penetration of topical steroids is 2 to 10 times greater than that of healthy skin according to this study.

Question 4: Will only that area experience side effects or my whole body?

Answer 4: Possibly none, maybe one or all of the above. Some will only experience the most common skin atrophy and thinning locally in that localized area. Some will experience the full-body systemic effect of side effects. There’s just no way of knowing who, what, when will be the most affected and how.

In the example of the eye area, the steroids have been known to penetrate deep enough to affect interocular eye pressure and therefore, accelerate cataracts and glaucoma potential just by applying on the face and not necessarily around the eyes. So it can vary based on quantity, length of usage and the individual’s susceptibility to immune suppression therapies.

Another factor is if the person is already on another form of steroids such as inhalers for asthma and oral steroids such as prednisone for allergic reactions.  Those patients are especially reactive to eye problems.

It’s sad, but here at ELAJ, we talk to young people in their 20’s that are already suffering from eye problems such as cataracts and yet, had no idea the steroids they used on their face were the cause. They simply were not informed properly by their doctor. 

A Quick History of Steroids

Topical Steroid Side Effects

Question 1: How long have steroids been around?

Answer 1: They were originally synthesized in the 1920s and used as the German army was vamping up their aggressive training programs. They pushed higher variations of testosterone into their own soldiers by pumping them up with what was then known as Anabolic-Androgenic Steroids (AAS). Anabolic means to increase and build up proteins within cells, especially in skeletal muscles. Androgenic means more development of masculine characteristics. That’s why you’ve seen the sports industry buzzing about ‘doping, juicing steroids’ abuse especially in the body-building, weight-lifting and speed sports such as swimming, bicycling and track & field. An athlete can work out and the recovery time of muscles is reduced allowing for quicker muscle build up in bigger, faster, stronger ways than previously ever possible.

In fact, there is a documentary called “Bigger, Faster, Stronger.” It is another eye-opener of the sports industry and how profoundly steroid abuse affected so many athletes that were not aware of the long-term effects they would have in their lifetime. From infertility to crippling bone density loss, these athletes expose the dark side of this parallel universe of steroid misuse.

Question 2: When were they first used in sports?

Answer 2:  Since Germany had prompted its use in the early 1930s, it had lots of experience and data on how powerful steroids can be. They continued with state-sponsored athletic training programs with estimates of 10,000 athletes using steroids.  In fact, East Germany stole the world stage of dominating sports in the Olympics for many years during the 1930s-1970s. Unfortunately, the long-term effects of doping were later realized and caused much anguish for those athletes with incalculable physical and mental scars. More tragically, many of them, male and female, did not even know they were being given such powerful drugs, nor did they have any idea of their consequences. 

Question 3: When did they become officially recognized as a medicine?

Answer 3:   The research collaboration of two American doctors from 1930-1938 is where it all started with Dr. E. C. Kendall & Dr. Phillip Hench. They identified the body’s hormone, cortisol, produced by the adrenal glands reduced arthritic symptoms and pain. The second step was realizing another hormone, adrenocorticotropic hormone ACTH, produced by the pituitary gland, worked to stimulate the adrenals to reduce rheumatoid arthritis inflammation.  These two doctors received the Noble Prize Medicine/Physiology in 1950. After seeing the glorification of steroids from the 1930s through the 1950s, there was a race in the medical world to get the hormones synthetically produced in the most cost-efficient way. President Truman even signed an Executive Order to prioritize and test over 5,000 plants to find the closest match! This was our ‘race to the moon’ but in medicine with the urgency to be the first to manufacture and distribute it worldwide!

Question 4: If hydrocortisone is considered dangerous, why is it so easily available over-the-counter with TV commercials touting it for any mysterious itchy, scratchy irritations or rashes, and even for vaginal itch?

Answer 4: Was hoping you’d ask THIS question! This article on MEDPAGE TODAY written by Alicia Ault on March 25, 2005, details how Adrenal Suppression from Topical Corticosteroids Surprisingly High.  That was the day after Dermatologic and Ophthalmic professionals met with the FDA Food & Drug Administration and had a little pow-wow discussing how high the rate of adrenal suppression was in various clinical tests. Surprise!

In 60 children, 58% of them had adrenal suppression after just two weeks of using topical steroids twice per day.  But wait…there’s more! 8 out of 10 adults treated for four weeks also had adrenal suppression. That is more than half. In fact, the FDA has been receiving reports of severe adrenal suppression since 1969!

But in that same meeting of March 2005, the discussion was about moving topical corticosteroids like the lighter version of hydrocortisone, so that it may be more easily available over-the-counter at a higher potency. Despite the FDA rejecting this back in 1957, in 1973 the FDA said topicals in the range of 0.25% to 0.5% were generally recognized as safe, and then later in 1990, the agency increased that up to 1% for drugstore sales. Yet the frequency and availability of topical steroids are increasing worldwide without prescriptions. 

Foreword thoughts

Topical Steroid Side Effects

Dr. Koushik Lahiri

Over the last nearly seven decades topical corticosteroids have meaningfully influenced the dermatologist's proficiency to efficiently treat several demanding dermatoses. The existing choice of preparations and potency gives flexibility to handle all groups of patients, different stages of disease, and diverse anatomic positions and made it almost indivisible from the practice of dermatology anywhere in the globe. But, these are assumed to be used in countless dermatological maladies based on evidence based comprehension and proficiency.

Most of the time, at least primarily, family physicians and general practitioners mostly manage Dermatological disorders. Insufficient awareness about the potency based classification and insufficient understanding about the mechanism of action, indications, contraindications of topical corticosteroids has given rise to the rapid rise in incidence of improper use of these drugs which threatens to bring disrepute to the entire group of these remarkable drugs.

Benefits of rational and ethical use and the harm of overuse and misuse for non-medical, especially for cosmetic purposes, should be clearly conveyed before penning a prescription involving topical corticosteroids. Despite being the most useful drug for such treatment they are known to produce serious local, systemic and psychological side-effects when overused or misused.

This is especially true not only in countries with less than optimum effective rules and regulations but also in the most advanced and developed societies.

This treatise aims to sensitize general public about the potential side effects of this extremely useful group of medicine.

The general practitioners/Family physicians may also be benefitted from this book.

I congratulate the author Suhein Beck for her passion and commitment and sincerely hope that this book would not promote any unwarranted steroid-phobia, rather make everyone aware about the uses and misuses of topical corticosteroids.

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MBBS, DVD(CAL), FIAD, FFAADV, FRCP(Glasgow), FRCP(Edin), FRCP(London)

Vice President, International Society of Dermatology (2017-2021)

President, Association of Cutaneous Surgeons (I) (2013-2015)

Editor, Indian Journal of Dermatology (2012-2017)

Chairperson, ACSI Academy of Dermatosurgery (2017-)

Founding Chairperson of ITATSA (IADVL TASKFORCE AGAINST TOPICAL STEROID ABUSE) 2013-2015

International Fellow, American Academy of Dermatology

Honorary Board Member and Foundation Fellow, Asian Academy of Dermatology and Venereology

Member, European Academy of Dermatology

Fellow, IADVL Academy of Dermatology

Tough Eczema Decisions

Author: Suhein Beck
February 23, 2016

Imagine the day when Child Protective Services knocks on your door to take your child away because of his/her uncontrollable Eczema! Reports came from their school that you are not giving your child the necessary medications to control the horrific flare ups and you are now in the position of defending your rights as a parent to choose and treat your child as you deem fit.

These and other TRUE SKIN CONFESSIONS coming soon!
Join the discussions and share!

Cataracts and Atopic dermatitis (Eczema)

Author: Suhein Beck
February 14, 2016

What you need to know to protect your eyes.

IF you have Atopic dermatitis / Eczema – a misleading idea is to think that cataracts only affects older persons. Cataracts is the clouding of the eye’s natural lens between the iris and pupil and can cause blindness. Studies show that people that suffer with mild to moderate Atopic dermatitis (eczema) have a higher 25-50% occurrence and accelerated rate among ages 18-50 years old. Whereas the general population around the world usually reflects a prevalence of cataracts as we age after turning 40 years old.

This higher prevalence of younger people with cataracts and atopic dermatitis has not been proven to be linked to the actual clinical symptoms of eczema or eczema medications such as topical steroid use, but suspected as the same genetic factors that trigger the typical triad of problems such as eczema, asthma and allergies. This is what we can call “spillover of inflammatory response systems.”

According to the National Eye Institute, “Cataracts are sometimes linked to steroid use.” However, there seems to be contradicting information and clinical studies proving / disproving the exact relationship with corticosteroid use both systemically or topically in relation to the accelerated progression of cataracts when Atopic dermatitis is or has been present. Strangely enough, the presence of cataracts was NOT limited to those with just facial eczema, but rather cataracts had potential to develop even when the eczema was anywhere on body, and not just on / near face and eyes.

The mere diagnosis of Atopic dermatitis is enough to justify setting the alarm clocks on more frequent Opthalmologist visits. In fact, it is recommended to set up QUARTERLY OPTHAMOLOGY VISITS EVERY 3 MONTHS because of the potential of sudden and accelerated cataracts especially when the eczema condition exacerbates. Keep a health diary of symptoms and medications, especially when taking any form of corticosteroids.

Stay tuned for more info on Glaucoma and Eczema in my next article.
HINT: Topical Steroids is shown to have direct relationship in the development of Glaucoma!