Key Points
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Topical steroids can be a powerful treatment for easing the symptoms of eczema.
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These medicines have potential side effects and should be used closely with a doctor.
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Where possible, patients should seek alternatives to topical steroid treatments.
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This article considers the side effects of topical steroids, when and how to discontinue their use, and possible alternative treatments.
Topical steroids — a.k.a. corticosteroids — can be highly effective in managing skin conditions, including eczema. However, although these medicines offer a potent treatment, they also come with the potential for severe side effects. Many eczema sufferers who are prescribed and use corticosteroids don't realize this potential or don't take it seriously.
Although these topical medicines are rubbed into the skin like any other topical treatment, steroids are anything but ordinary. This article aims to increase the understanding of these compounds among eczema sufferers.
Potential Topical Steroid Side Effects
The following is a list of steroid side effects, but remember that it isn't exhaustive. The severity of corticosteroid side effects can range from mild to life-changing and even life-threatening.
Thinning
Prolonged use of potent topical steroids can lead to skin thinning (atrophy). To minimize this risk, use the lowest potency that effectively manages your condition and follow your healthcare provider's instructions for the duration of use.
Discoloration
Topical steroids sometimes cause changes in skin color, especially in areas with repeated application. To reduce this risk, avoid overuse and consult your healthcare provider if you notice any skin changes.
Addiction and Withdrawal
Addiction and withdrawal are two of topical steroids' most serious side effects. Prolonged use can lead to a phenomenon known as "topical steroid addiction" or "topical steroid withdrawal," where the skin becomes dependent on the medication. To prevent this side effect, follow a tapering schedule when discontinuing the steroid under the guidance of your healthcare provider.
Irritation
Some individuals may experience burning, stinging, or redness when using topical steroids. If this occurs, inform your healthcare provider, who may recommend a lower potency or alternative treatment.
Infection
Prolonged topical steroid use increases the risk of skin infections. If you notice signs of infection, such as increased redness, swelling, or pus, contact your healthcare provider promptly.
Systemic Absorption
While topical steroids are primarily applied to the skin, they can be absorbed into the bloodstream, especially with prolonged use or in thinner skin areas like the face and genitals. Minimize the risk of systemic absorption by using the lowest effective dose and avoiding prolonged use. Choose the right body wash to freshen up afterward.
When and How To Wean Off Topical Steroids
Discontinuing topical steroids requires careful consideration and should be done under the guidance of your healthcare provider. Abruptly stopping topical steroids can lead to a rebound effect, where the condition worsens. Here's how to safely wean off topical steroids.
Discuss your desire to discontinue the medication with your healthcare provider. They can assess your skin's condition and develop a tapering plan. A tapering schedule involves gradually reducing the frequency and potency of the topical steroid. It may also include the use of non-steroidal alternatives.
Keep a close eye on your skin during the tapering process. If you notice a worsening condition, contact your healthcare provider for adjustments to the tapering plan. In some cases, non-steroidal treatments such as calcineurin inhibitors (e.g., tacrolimus or pimecrolimus) or non-prescription emollients may be used as alternatives to topical steroids.
Alternatives to Topical Steroids
While topical steroids are commonly prescribed for treating eczema, there are alternative approaches for managing this condition. If you're concerned about the potential side effects of corticosteroids or have experienced some firsthand, consider the following alternatives.
Topical Calcineurin Inhibitors
Topical calcineurin inhibitors (TCIs), including treatments such as tacrolimus (Protopic) and pimecrolimus (Elidel), work by modulating the immune response in the skin, addressing the underlying inflammation without causing skin thinning. This makes them especially suitable for sensitive areas like the face, neck, and eyelids, where steroids can be risky.
TCIs are generally well-tolerated and effectively manage eczema symptoms, including itching and redness. They provide a safe and reliable option for individuals seeking a non-steroidal approach to eczema treatment while preserving the integrity and health of their skin.
Emollients and Moisturizers
Emollients and moisturizers work by hydrating skin and reinforcing its natural barrier function, often compromised in eczema. These products effectively reduce dryness, itchiness, and the frequency of flare-ups. Their low risk of side effects makes them particularly appealing compared to corticosteroids. This makes them safe for long-term use, including on sensitive areas like the face and for pediatric patients.
Regular application of emollients and moisturizer products maintains skin health and can be a fundamental part of eczema management. Plus, discontinuing these products won't lead to withdrawal or worsening symptoms beyond what might be expected without an effective treatment.
Wet Wrap Therapy
Wet wrap therapy involves applying moisturizers or prescribed medications to the affected skin and then covering it with damp clothing or bandages. This provides dual benefits: The moisture from the wraps hydrates the skin, while the occlusion enhances the absorption of topical treatments.
For many eczema sufferers, this form of treatment delivers rapid relief from itching and inflammation, which allows for a reduction in the use of topical steroids or even their complete elimination. Wet wrap therapy is particularly effective for severe flare-ups and can relieve eczema without the potential side effects of prolonged steroid use.
Phototherapy
Phototherapy for eczema, also known as light therapy, works through controlled doses of ultraviolet (UV) light to target and reduce inflammation in the skin. Two primary types of phototherapy are used for eczema: ultraviolet B (UVB) and ultraviolet A (UVA) with psoralen, known as PUVA therapy. UVB therapy involves exposing the affected skin to a specific wavelength of UVB light, which slows the inflammatory processes in the skin.
PUVA therapy combines UVA light with a light-sensitizing medication called psoralen, which makes the skin more responsive to the treatment. UVA light penetrates deeper into the skin and effectively manages severe eczema. Both types of phototherapy work by suppressing the overactive immune response in the skin and can be tailored to an individual's specific condition and needs. Phototherapy can be especially valuable for those who wish to avoid or reduce the use of topical steroids due to concerns about side effects.
Monoclonal Antibodies
Monoclonal antibody therapies, including tralokinumab and dupilumab, have emerged as effective and potentially safer alternatives to topical steroids for eczema management. Using the patient's antibodies, these biological medications target specific immune pathways involved in eczema development, addressing the root causes. Unlike topical steroids, which work by suppressing the body's immune response, monoclonal antibodies use a more targeted approach.
Tralokinumab and dupilumab specifically inhibit proteins that drive inflammation and contribute to eczema symptoms. Doing so reduces itching, redness, and skin lesions without the systemic side effects associated with long-term topical steroid use. This targeted action makes them valuable options, especially for individuals with moderate to severe eczema or those who cannot tolerate or have concerns about topical steroids. It offers effective relief while minimizing the risks of steroid-related complications.
New monoclonal antibody therapies are in continual development, and existing treatments like tralokinumab and dupilumab are under constant study and review to improve efficacy. In June 2023, the American Journal of Clinical Dermatology released a study on the effectiveness of dupilumab in pediatric patients.
Researchers Elaine C. Siegfried et al. concluded that "Treatment with dupilumab provides significant and sustained improvements within 2 weeks in AD [atopic dermatitis] signs, symptoms, and QoL [quality of life] in almost all children with severe AD, including those who did not achieve clear or almost clear skin by week 16."
Dietary Adjustments
Dietary adjustments are a valuable strategy for managing eczema, offering a potential alternative to corticosteroids, particularly for individuals who prefer non-pharmacological approaches. While diet alone may not completely replace the need for corticosteroids in some cases, it can play a significant role in managing symptoms and reducing the reliance on medication. Certain foods, such as dairy, gluten, and certain food additives, may trigger or exacerbate eczema flare-ups in some individuals.
Identifying and avoiding these triggers through dietary adjustments often leads to a reduction in inflammation and itching. Additionally, consuming a diet rich in anti-inflammatory foods like fruits, vegetables, and omega-3 fatty acids promotes skin health and overall well-being, complementing corticosteroids' effects when necessary. It's essential, however, to consult a healthcare professional or allergist to ensure any significant dietary changes align with your specific needs, treatment goals, and condition severity.
Know Your Options
For many eczema sufferers, topical steroids are a practical option for managing symptoms, but their usage and safety require careful consideration. Learn the different classes of topical steroids, proper application techniques, potential side effects, and how to wean off these medications. Exploring alternative treatments provides sufferers with more options for managing their condition while reducing potential risks.
Always consult your healthcare professional for personalized guidance on topical steroids or explore alternative treatments tailored to your needs. Your skin's health and comfort are worth a thoughtful, informed, and comprehensive approach to treatment, so do your research, pay attention to your body's signals, craft a careful treatment plan, and make adjustments as needed in collaboration with your doctor. Taking all these steps allows you to live a full life in spite of eczema.
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