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.

This article presents initial approaches to four TSW cases by TCM and Western providers. Despite differences, they share a foundational framework of offering personalized treatment that evolves based on response to initial therapies.

Building on shared principles, TCM and Western treatments differ in terms of scope, treatment options, extent of personalization, and regimen variation. TCM practitioners integrate symptoms across different body systems, such as thirst, bowel movements, sleep, and organ-associated channels. Rather, Western practitioners focus primarily on cutaneous symptoms; systemic symptoms serve as indications of severity or disease burden, rather than disease features that require direct treatment. Considering treatment options, TCM and Western practitioners approach the use of systemic treatments differently. In TCM, the herbal treatment often starts with an internal formula to ensure patients can tolerate herbs, under the framework that internal processes may be key to disease pathogenesis. Topical herbal formulas can be considered depending upon response to the internal formula or if a simultaneous external protocol would promote faster healing and can be tolerated, as different stages of TSW bring about varying levels of skin sensitivity. Alternatively, the Western approach employs topical or external treatments when possible, with systemic treatments reserved for widespread disease.

Furthermore, the extent of treatment personalization varies. From the Western perspective, all patients are advised basic gentle skin care, with biologics such as dupilumab used for widespread disease. Adjunctive treatments, including phototherapy and topical creams, vary in practice. From the TCM approach, the individualized treatment regimen is built based on the patient’s collection of symptoms, with each herb targeting the root cause of said symptoms. As the condition evolves, changes to formula ingredients and their ratios follow. As such, the variation, flexibility, and customizability in the treatment regimen for different patients may be greater in the TCM approach. While TCM treatment begins with exquisite personalization from the outset, Western treatment is rooted in a foundational regimen to which adjunctive therapies are added based on patient presentation. Though different, both Western and TCM approaches can relieve TSW symptoms, offering opportunities to learn from each. Several factors influence the decision to pursue one over the other, or to combine both, including patient background, preferences, and finances (Figure 5). The China Association of Chinese Medicine has published clinical practice guidelines that highlight five ways in which TCM and Western medicine can be integrated for the treatment of AD: (1) Full use of TCM and Western medicine; (2) using TCM to prevent recurrence; (3) using TCM when reducing use of Western medicine; (4) using TCM when systemic medications cannot be tolerated; (5) using TCM to treat AD and associated comorbidities.²⁸ Some studies have evaluated the efficacy of integrated Western and Chinese medicine and show potential clinical and quality of life improvements, although evidence remains weak.²⁹

Figure 5.

An important aspect for patients and providers considering TCM is to acknowledge that the strength of scientific evidence supporting its use is limited by its incompatibility to accurately assess TCM efficacy. In TCM practice, it would be unlikely for one patient to remain on the same herbal formula for the duration of their condition, thus tens or hundreds of patients with similar condition expression could only utilize “the same” formula for varying time lengths as symptom resolution is extremely individualized. As a result of this highly personalized and dynamic nature of TCM, the typical randomized controlled trial model is unfit for evaluating its efficacy. Furthermore, as each herbal ingredient is composed of many chemical constituents that are then cooked with all the other ingredients, forming different chemical bonds, herbal formulas likely have multiple mechanisms of action, which are difficult to elucidate. This dynamic nature of TCM makes its rigor of evidence for dermatitis limited with mixed results. A 2017 systematic review and meta-analysis examined 24 articles for randomized controlled trials studying the efficacy of TCM for atopic dermatitis (AD) and found no differences in clinical efficacy or SCORing Atopic Dermatitis scores, but an improvement in Eczema Area and Severity Index scores between TCM-treated patients and control.³⁰ Yet, a 2023 systematic review and meta-analysis of 17 randomized controlled trials for TCM in AD patients found a higher recovery rate and decreased recurrence rate for TCM-treated patients, but no differences in Eczema Area and Severity Index or Dermatology Life Quality.³¹ A 2023 systematic review and meta-analysis of topical TCM formulas found topical TCM to be particularly useful for mild to moderate AD, and 1.25 times more effective than the topical glucocorticoids.³² Importantly, these reviews highlight the potential of TCM as a treatment modality for atopic dermatitis, but emphasize the need for stronger clinical evidence to support the use of TCM for atopic dermatitis. This variable evidence suggests that traditional randomized controlled trials may be nonsuitable to evaluate TCM treatments, demanding a protocol that is able to assess TCM in accordance with its penchant for highly individualized treatment protocols. To better characterize the clinical efficacy of TCM, the research community must expand the definition of evidence based research to account for the inability for TCM to be accurately studied under the current rigid model of the scientific process. By doing so, more solutions may be discovered and made accessible to help patients.

For a poorly defined entity like TSW, examining how practitioners approach treatment offers insight into diverse strategies. With no TSW diagnostic criteria nor treatment guidelines, substantial treatment and knowledge gaps remain.^33–35 Learning from both Western and TCM approaches, and potentially combining them, may prove valuable. Future research to define TSW is essential to improving our ability to treat this collection of symptoms and better target treatments to its underlying pathogenesis.

This research received no funding.

Figure 1. Case 1 clinical images. (a) Widespread flaking rash on the left back and dorsal upper extremity (b) Erythematous, lichenified, and dry skin in the popliteal fossa region. (c) Erythematous, lichenified, and flaking skin on the dorsum of the hands. (d) Erythematous, lichenified, and flaking skin on the palmar aspect of the hands and wrists, with confluent areas of sparing of the palms and fingers.

Figure 2. Case 2 clinical images. a) Erythematous, lichenified, and sloughing skin on the bilateral lower extremities. b) Erythematous, flaking rash on the back and dorsal upper extremities with patchy areas of sparing. c) Erythematous rash involving the face with relative sparing of the nasal bridge, nose, philtrum, and chin.

Figure 3. Case 3 clinical images. a) Erythematous rash on the upper extremity with some skin flaking and sparing of the palms and fingers. b) Erythematous rash on the dorsal aspect of the upper extremity with some flaking and lichenification at the wrists and hands. c) Erythematous rash involving the face and neck, swelling of the eyes, fissures at the lips. d) Erythematous rash primarily involving the neck with sparing of the right cheek.

Figure 4. Case 4 clinical images. a) Extremely dry rash on the neck. b) Extremely dry rash on the face with thickening of the skin on the eyelids. c) Dry skin on the bilateral upper extremity. d) Dry skin in the popliteal fossa. e) Dry, lichenified skin on the dorsal aspect of the hands.

Figure 5. Decision tree reflecting common reasons for patients to pursue Western medicine, Traditional Chinese medicine, or integrated Chinese-Western medicine.