Topical steroid withdrawal is recognised by the UK medicines regulator. On 15 September 2021 the Medicines and Healthcare products Regulatory Agency published a Drug Safety Update on topical corticosteroids which opens with the finding that "Rarely, severe adverse effects can occur on stopping treatment with topical corticosteroids, often after long-term continuous or inappropriate use of moderate to high potency products" (MHRA, 2021). One sentence carries both halves of the answer people are searching for. The reaction is real enough to warrant a regulatory bulletin, and it is attached to a specific pattern of use rather than to topical steroids as a class.
That position came out of a formal review. "Following concerns from patients and their families about topical steroid withdrawal reactions, the MHRA has conducted a review of the evidence and considered the need for regulatory action to minimise the risk of this side effect." The agency took advice from the Dermatology and Pharmacovigilance Expert Advisory Groups of the Commission on Human Medicines, and clinical experts in dermatology and representatives from dermatology charities took part in those discussions (MHRA, 2021). The regulatory action that followed was new information for prescribers and patients.
What the reaction looks like
The Drug Safety Update describes rebound flares of the underlying skin condition alongside "intense redness, stinging, and burning that can spread beyond the initial treatment area" (MHRA, 2021).
The MHRA's separate patient guidance is more specific. It names the leading sign as "redness of the skin which can extend beyond the area treated with the topical steroid", then adds that "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". The other listed signs are "burning or stinging, intense itching, peeling of the skin, or oozing open sores" (MHRA, Topical corticosteroids and withdrawal reactions).
The published case literature matches that picture and shows how thin it is. A systematic review by Hajar and colleagues screened 294 results and included 34 studies. Withdrawal "was reported mostly on the face and genital area (99.3%) of women (81.0%)". "Burning and stinging were the most frequently reported symptoms (65.5%)", with "erythema being the most common sign (92.3%)". The reviewers separated two presentations, papulopustular and erythematoedematous, the second with more burning and swelling. They also recorded the limitations plainly: low quality of evidence, variable data and too few rigorous studies (Hajar et al, 2015).
The pattern of use it is associated with
The MHRA attaches numbers to the phrase "long-term continuous or inappropriate use". Withdrawal reactions can develop after application of a topical corticosteroid "at least daily for longer than a year", and in children "within as little as 2 months of daily use" (MHRA, 2021). Its patient guidance puts the adult figure as a range, "longer than 6-12 months in adults", and states that "Reactions are more common after use in sensitive areas such as the face or genitals" (MHRA, Topical corticosteroids and withdrawal reactions). That last point is what the case series show as well, with 99.3% of reports on the face and genital area.
The exposure the MHRA describes combines three things: high frequency, long duration, and usually a moderate or strong product on a site where the skin is thin. A moderate potency cream used on the body for a two-week flare and then stopped is not the exposure being described. What the different potencies do and how much of them a course involves is covered in steroid creams for eczema.
The recognised long-term local effects of topical steroids are a separate category and much better documented. The British Association of Dermatologists lists them for potent and very potent products used over a long period: thinning and fragility of the skin, bruising more easily, stretch marks, folliculitis and pimples, lightening of the skin, and hair growth at the area of application (BAD, Topical corticosteroids). Those appear on treated skin during use. A withdrawal reaction, by the regulator's definition, appears after stopping and can extend past the area that was treated.
Telling it apart from the eczema
This is the hard part, and the timing is the main discriminator the regulator offers. The MHRA tells patients: "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". The same guidance puts the point again as "If you experience a return of your symptoms within days to weeks you should not re-treat the area without consulting a doctor" (MHRA, Topical corticosteroids and withdrawal reactions).
Skin that worsens while treatment is still being applied is a different problem. NICE sets a checkpoint there: if a mild or moderately potent topical corticosteroid has not controlled the eczema within 7 to 14 days, the first step is to "exclude secondary bacterial or viral infection" (NICE CG57). The signs that point that way, and the urgency attached to each, are set out in infected eczema. Beyond infection, a routine that never quite works usually fails for measurable structural reasons rather than pharmacological ones, and those are set out in why standard eczema treatments often fail.
What the MHRA asked prescribers and patients to do
The advice to healthcare professionals is practical rather than restrictive. The MHRA asked prescribers to consider the lowest potency needed for the condition, to advise patients on how much to apply because using too little prolongs treatment, and to say how long a course should run, particularly for sensitive areas such as the face and genitals. For people on long-term treatment it asked prescribers to consider reducing potency or how often the product is applied, to stay alert for the signs of a withdrawal reaction, and to report suspected reactions through the Yellow Card scheme, including reactions occurring after treatment has stopped (MHRA, 2021). The update also directed prescribers to a joint position statement from the National Eczema Society and the British Association of Dermatologists, which those two bodies updated in February 2024.
The advice to patients is short. The MHRA tells patients to use topical corticosteroids as instructed, to read the patient information leaflet, and to ask before applying a product to a new area of the body. And note the wording the MHRA chose for the risk itself: "Very infrequent cases of severe skin reactions have been reported in long-term users of topical corticosteroids after they stop using them" (MHRA, 2021).
How a course gets reduced
Stopping is not the only option on the table, and the reduction itself is a clinical decision. The British Association of Dermatologists describes the mechanism in its eczema leaflet: "Sometimes, your healthcare professional may suggest slowly reducing how often the topical steroid is applied or reducing its strength. This is known as weaning" (BAD, Atopic eczema).
The underlying framework is stepped rather than fixed. NICE tells clinicians to "Use the stepped approach in table 2 for managing atopic eczema in children" and states that "Emollients are the basis of management and should always be used, even when atopic eczema is clear" (NICE CG57). Stepping down is the same ladder in the other direction, with the emollient carrying the load.
Where steroids are not tolerated or not suitable for a site, there are prescription alternatives that are not steroids, covered in tacrolimus and pimecrolimus.
If you are worried about this
Nothing above is a reason to stop a prescribed treatment independently, and the MHRA's own advice is to consult a doctor before restarting after a suspected reaction rather than to act alone. The decision to change potency, change frequency or wean belongs with the prescriber, and it is easier to make with a record in front of them.
What is worth bringing to that appointment is concrete: which product and potency, which sites, how often it went on, over how many months, and what the skin did on previous occasions when it stopped. If the answer is a strong product used daily on the face for a year, that is a different conversation from a moderate cream used in short courses on the limbs. Where the question needs specialist input, when to see a dermatologist sets out the referral thresholds NICE uses and how quickly each one applies.
References
- MHRA. Topical corticosteroids: information on the risk of topical steroid withdrawal reactions. Drug Safety Update, 15 September 2021. https://www.gov.uk/drug-safety-update/topical-corticosteroids-information-on-the-risk-of-topical-steroid-withdrawal-reactions
- MHRA. Topical corticosteroids and withdrawal reactions, patient safety information. Published 15 September 2021, last updated 29 May 2024. https://www.gov.uk/guidance/topical-corticosteroids-and-withdrawal-reactions
- Hajar T, Leshem YA, Hanifin JM, et al. A systematic review of topical corticosteroid withdrawal ("steroid addiction") in patients with atopic dermatitis and other dermatoses. Journal of the American Academy of Dermatology, 2015, 72(3):541-549.e2. https://doi.org/10.1016/j.jaad.2014.11.024
- British Association of Dermatologists. Topical corticosteroids, patient information leaflet. https://www.bad.org.uk/pils/topical-corticosteroids/
- British Association of Dermatologists. Atopic eczema, patient information leaflet. https://www.bad.org.uk/pils/atopic-eczema/
- National Eczema Society and British Association of Dermatologists. Joint position statement on topical steroid withdrawal, updated February 2024. https://www.skinhealthinfo.org.uk/national-eczema-society-and-british-association-of-dermatologists-joint-position-statement-on-topical-steroid-withdrawal
- National Institute for Health and Care Excellence. Atopic eczema in under 12s: diagnosis and management. Clinical guideline CG57. https://www.ncbi.nlm.nih.gov/books/NBK571009/