What Happens to the Body in Topical Steroid Withdrawal
Here’s an overview of the pathophysiology of Topical Steroid Withdrawal (TSW), focusing on what happens in the body and skin when topical corticosteroids are overused and then stopped.
1. Hypothalamic-Pituitary-Adrenal (HPA) Axis Suppression
Short or prolonged use of topical corticosteroids—even when applied to the skin—can lead to suppression of the HPA axis. This results in decreased endogenous cortisol production, which impairs the body’s ability to regulate inflammation naturally. When steroid application is stopped, the body cannot quickly compensate, leading to a rebound of unregulated inflammation.
2. Skin Barrier Dysfunction
Chronic steroid use thins the epidermis and impairs the skin barrier (reducing ceramide production, stratum corneum integrity, and hydration). Upon withdrawal, this weakened barrier leads to increased transepidermal water loss (TEWL), dryness, and greater susceptibility to irritants, microbes, and allergens.
3. Vascular Changes (Steroid-Induced Vasodilation)
Topical steroids cause vasoconstriction during use, but when stopped abruptly, there's a rebound vasodilation (also called "vascular hypersensitivity"). This results in:
Red, burning skin
Increased blood flow to affected areas
Flushing and skin that feels hot to the touch
4. Immune System Rebound
Short and long-term steroid use suppresses local immune responses, including T-cell function. Withdrawal causes a rebound activation of immune cells, especially Th2 cells, leading to:
Increased inflammation
Heightened histamine release
Mast cell activation
Worsening of eczema-like symptoms
5. Neurological Sensitization
Patients with TSW often report intense itching, burning, and stinging. This is thought to be due to neurological sensitization, where nerve endings in the skin become hyperresponsive due to chronic inflammation and damage.
TSW is a complex, multi-system condition involving endocrine disruption, skin barrier breakdown, vascular instability, immune dysregulation, and neurological hypersensitivity. Healing requires time and a comprehensive, root-cause approach—not just skin-deep treatments.