We are going to skip to the punchline here, because it is pretty straightforward. If you use topical steroids, you are at risk of Topical Steroid Withdrawal (TSW), sometimes known as red skin syndrome. If you never use topical steroids, you have lessened your risk by 100%. Topical steroids are used and prescribed widely because they are very effective at temporarily reducing inflammation. But, and this is important, don’t skip over that word “temporarily”.
We aren’t trying to make something very serious and sometimes very traumatic trivial, rather, we are on a mission to educate about alternative options - especially for those who are considering using maximum strength over-the-counter (OTC) topical steroids for itch and eczema, when they may not be necessary. If we can stop even one person’s unnecessary topical steroid journey before it starts, we will have succeeded.
Are you currently using an OTC steroid? Check the ingredient labels of your products, where it says “active ingredient”. If the active ingredient is hydrocortisone, you are using a topical steroid.
In many cases, especially when your doctor or dermatologist prescribes steroids, they are necessary. Always trust your physician over a random blog article. But, the fact is that topical steroids are one of the most over-prescribed and over-used medications in the US. Between 2011 and 2015, Medicare spent $2.3 billion on topical steroids, and the government focus for change is to save money by encouraging generic versions rather than exploring alternative treatment options. (1) The vast majority of those using topical steroids have no idea that they are not meant for long-term use, and can lead to problems such as skin-thinning, worsening of skin infection, acne, rosacea, stretch marks, and excessive hair growth. (2)
Topical Steroid Facts & Figures
|# of available over-the-counter hydrocortisone brands in the US||50+|
Reported Incidence of Allergic Contact Dermatitis (8)
% increase of the search term “Topical Steroid Withdrawal” in past 10 yrs
To further illustrate this point, Cortizone-10, an over-the-counter hydrocortisone product, is consistently in Amazon’s top 3 products sold in the eczema, psoriasis, and rosacea category. (3) Even a well-known dermatologist with a large social media presence initially launched their own brand in 2021 pushing over-the-counter 1% hydrocortisone as “safe for daily use”.
Examples of over-the-counter hydrocortisone (topical steroid) creams
So, if we are supposed to lessen the use of topical steroids, or not use them at all, what can you use for skin irritation? There have been some interesting innovations in the past few years, and we present some of them here, with both pros and cons:
Dilute Bleach Baths
Pros: many patient advocacy organizations and physicians endorse this as a way of treating atopic dermatitis alone or along with prescription or emollient treatments.
Cons: conflicting data on what bleach is doing compared to water alone, and has been shown to not have an anti-bacterial effect at recommended levels.
Pros: Has been shown to be antibacterial.
Cons: non-vegan, does not address inflammation, high degree of variability, and can contain contaminants.
Endolysin & Microbiome Technology
Pros: has been shown to kill staph aureus.
Cons: does not directly address inflammation, and data is still early.
Hemp Oils & Cannabinoids
Pros: have been shown to be antibacterial, decrease dryness, reduce inflammation and itch in vitro and in some small human studies improve eczema measures.
Cons: high degree of variability between products, some have potential to be intoxicating. Here are some tested and non-intoxicating options.
Topical Sunflower Seed Oil
Pros: was shown to be helpful when used in those with eczema. (4) Sunflower seed oil is rich in linoleic acid, which has anti-inflammatory properties and helps maintain the skin’s normal barrier function. (5)
Cons: Relatively mild efficacy.
Palmitoylethanolamide (PEA or Palmitamide MEA)
Pros: Considered by some to be an endocannabinoid, it is a fatty acid amide that is naturally occurring in humans. Synthetic versions have been shown to reduce inflammation, irritation, and itch. (6)
Cons: Other studies have shown no improvement over placebo.
Other products worth considering include shea butter (7); other oils high in linoleic acid including grapeseed oil, sea buckthorn, and safflower; and non-steroidal prescription options.
Additional Resources on Topical Steroid Withdrawal:
- Song H, Adamson A, Mostaghimi A. Medicare Part D Payments for Topical Steroids: Rising Costs and Potential Savings. JAMA Dermatol. 2017;153(8):755-759. doi:10.1001/jamadermatol.2017.1130
- https://www.nhs.uk/conditions/topical-steroids/ accessed 5/3/21
- amazon data, accessed 5/3/21
- Danby SG, AlEnezi T, Sultan A, et al. Effect of olive and sunflower seed oil on the adult skin barrier: implications for neonatal skin care. Pediatr Dermatol.2013;30(1):42-50; PMID: 22995032.
- Ziboh VA, Miller CC, Cho Y. Metabolism of polyunsaturated fatty acids by skin epidermal enzymes: generation of antiinflammatory and antiproliferative metabolites. Am J Clin Nutr.2000;71(1 Suppl):361S-366S; PMID: 10617998.
- Vaia M, Petrosino S, De Filippis D, Negro L, Guarino A, Carnuccio R, Di Marzo V, Iuvone T. Palmitoylethanolamide reduces inflammation and itch in a mouse model of contact allergic dermatitis. Eur J Pharmacol. 2016 Nov 15;791:669-674. doi: 10.1016/j.ejphar.2016.10.005. Epub 2016 Oct 5. PMID: 27720681.
- Draelos ZD. A pilot study investigating the efficacy of botanical anti-inflammatory agents in an OTC eczema therapy. J Cosmet Dermatol.2016;15(2):117-119; PMID: 26596512.
- https://www.uspharmacist.com/article/appropriate-use-of-nonprescription-hydrocortisone accessed 5/4/21