The term topical steroid withdrawal (TSW) describes a distinct but poorly understood adverse effect observed after topical corticosteroid use. Reported symptoms include edema, erythema, burning pain, skin sensitivity, desquamation, oozing, exfoliation, acneiform papules, and intense pruritus.^1–4

Despite recognition by the United Kingdom and Canadian governments, TSW remains ill-defined in dermatology, contributing to a lack of diagnostic criteria and treatment options, which is further complicated by similarities between TSW symptoms and severe eczema.^5,6 Western TSW treatments mirror those for atopic dermatitis, including antibiotics, antihistamines, calcineurin inhibitors, dupilumab, emollients, and immunosuppressants.^1,7,8 Brookes et al demonstrated improvements in skin lesions, pain, dryness, and oozing with these approaches. However, a review by Tan et al found inconsistencies in treatment response and low study quality.

Rooted in pattern recognition, Traditional Chinese Medicine (TCM) utilizes a complete health history, including systemic symptoms, to guide treatment.^9,10 Published cases of TSW treated with TCM have employed herbal teas, herbal baths, and creams.^11,12 Five cases demonstrated improvement or resolution of erythroderma, thermodysregulation, oozing, and disturbed sleep, with itch/pain often persisting.¹² One case demonstrated improvements in skin lesions, sleep disturbances, pruritus, high immunoglobulin E levels, and high eosinophil count following TCM treatment.¹¹

This article expands upon the limited literature on Western and TCM TSW treatments. We highlight how four TSW cases may be approached differently from Western and TCM perspectives to illustrate considerations in treatment of these patients and learning opportunities from both approaches.

Approaching TSW from a TCM perspective facilitates personalized treatment, recognizing each patient’s unique constellation of symptoms and healing pace. Full-body physical and mental health histories guide identification of the disease etiology and guide treatment.

Assessment begins with affected body systems and associated symptoms: temperature (feeling hot/cold, fevers, chills), digestion, thirst, sleep, psychological/emotional state, bowel movements, itching, menstruation, and skin lesions. This baseline leads to pattern-identifying questions, such as, “At what skin level is heat trapped?” and “Is there dampness or dryness?” A key principle guiding conceptualization of skin disorders is the “Four Levels of Heat,” from the Huang Di Nei Jing, which helps to guide herb selection (Table 1).¹³

327191 Table 1.

Pattern identification also uses the Zang-Fu organ system. Though named like Western organs, TCM functions differ. The Lung controls circulation, skin, and hair. When imbalanced, Lung-related skin issues may manifest as wheals, papules, redness, or dryness. The Liver, associated with emotions, influences the hypochondrium, eyes, and genitals. When function of this organ is imbalanced, skin issues can manifest as pigmentation changes, lichenification, irritability, or spasms. Pattern or organ/meridian-based approaches further differentiate the causes of itching (Table 2).¹⁰

327192 Table 2.

Itch severity (“bone-deep,” superficial, “ants crawling”), lesion type (wet, dry, lichenified), exudate (color, severity), and lesion location inform treatment and determine which level is affected.

Allergies, comorbidities, and medications are reviewed for herb contraindications. Herbal formulas exclude herbs from the same families as known allergies. Herbal formulas are carefully balanced with specific properties that target the root cause. Ratios and dosages of each ingredient are adjusted as symptoms evolve, including addition and/or deletion of ingredients, ensuring treatment remains effective. To continuously reassess the condition and adjust treatment, constant communication with a patient is necessary, with frequent appointments scheduled every two-to-four weeks. TCM practitioners ask questions at each appointment about patterns, systems, and other factors to accurately assess the patient’s current condition as it evolves. Formulas are created initially, but modified throughout treatment.

The cases below illustrate various presentations of TSW, with treatment plans presented by a board-certified dermatologist (author PL) and a licensed TCM practitioner (author OHF). In all cases, only the initial TCM approach is discussed. Potential herbs listed are not exhaustive and, rather, serve as examples of what may be considered in various cases, and would not necessarily all be used at once. Determination of the ultimate constitution of herbal remedies is complex—depending on the patient’s presentation, clinical response, and tolerance. Dosages of each selected herb and the constitution of the overall formula will change as symptoms evolve.