Acta Dermato-Venereologica 99-6CompleteContent

551 CLINICAL REPORT Topical Steroid Withdrawal: A Case Series of 10 Children Belinda SHEARY Royal Randwick Medical Centre, Randwick, Australia Concerns about topical steroid withdrawal are causing some patients to cease long-term topical corticoste- roid therapy, however, little is known about the en- suing clinical outcomes. This qualitative case series studied 10 children whose parents stopped their chro- nic topical corticosteroid use and subsequently develo- ped features typically reported in adults experiencing topical steroid withdrawal. Patients were seen in an Australian general practice between April 2014 and October 2018, with follow-up periods ranging from 18 months to 4 years. Symptoms were difficult initially for the children and their families, however, all ultima- tely improved. At the final review, 4 of the children had clear skin and another 4 had symptoms consistent with their original, pre-treatment atopic dermatitis. More research is required into long-term topical corti- costeroid use and its discontinuation, including topical steroid withdrawal, particularly in the pediatric popu- lation. Key words: topical steroid withdrawal; red skin syndrome; atopic dermatitis; topical corticosteroids; eczema. Accepted Feb 7, 2019; E-published Feb 8, 2019 Acta Derm Venereol 2019; 99: 551–556. Corr: Belinda Sheary, Royal Randwick Medical Centre, 70/73-115 Bel- more Road, Randwick NSW 2031, Australia. E-mail: belinda.sheary@ipn. com.au C oncerns about topical steroid withdrawal (TSW) are causing some parents of children with chronic dermatological conditions, particularly atopic dermati- tis (AD), to discontinue their child’s long-term topical corticosteroid (TCS) therapy. TSW is a potential adverse effect of TCS overuse (1), most commonly seen in pa- tients with a history of atopy, reporting prolonged TCS overuse, especially where such use has included the face and provided diminishing clinical benefit over time. TSW is widely discussed in social media (1) and with many patients (and parents) researching health issues online (2), discussing TSW is likely to become an increasingly common scenario for prescribers of TCSs (3). Pediatric cases of TSW have been reported in the literature infrequently (1, 4–6). The incidence and preva- lence of TSW is unknown (1, 7) and research is limited (6, 8–13), however, a systematic review (1) suggested TSW in children is uncommon with only 7% of reported cases occurring in patients under 18 years of age. In a recent study (12) examining patients ceasing long-term TCSs and subsequently developing TSW symptoms, 20% (14 out of 69) of patients were children. This paper SIGNIFICANCE Topical steroid withdrawal is discussed widely in social me- dia, and some patients with a history of long-term topi- cal steroid use are self-diagnosing this condition. There is little information in medical literature about what happens when chronic topical steroid therapy is stopped, especially in children. This study followed 10 children for between 18 months and 4 years after their parents decided to cease their topical steroid use. The children experienced typical topical steroid withdrawal symptoms for many months, however, all eventually improved. examines the histories of 10 of those 14 children. They were followed up in a general practice setting for 18 months–4 years. Little is known about what happens when children cease chronic TCS use. Patients may experience “re- bound” symptoms after stopping TCSs (14) and certainly after stopping oral steroids for skin symptoms (15). Ho- wever, it is not widely accepted there may be withdrawal symptoms associated with TCS discontinuation as it is with other medication (for example, selective serotonin reuptake inhibitors commonly prescribed for depres- sion). This may be because traditionally TCSs have been recommended intermittently for flares of symptoms and long-term frequent use has not been studied. However, in practice there are patients who use TCSs regularly for years – sometimes on a continuous daily basis (12). Confirming the diagnosis of TSW is problematic, and TSW remains controversial. Accepted diagnostic criteria for TSW do not exist (though recently some have been proposed (12)), and TCS “overuse” has never been defined. Some argue that the symptoms resulting from TCS discontinuation represent an exacerbation of the underlying skin disease, however, there are features typically reported in TSW and not in AD. On ceasing TCSs, a patient with TSW develops widespread red skin (7, 10–11) and itch, in addition to at least some of the following distinctive features: burning pain, excessive skin exfoliation, edema, skin sensitivity (1, 7, 10, 12), ‘red sleeve’ (7, 12) and/or ‘elephant wrinkles’ (12). MATERIAL AND METHODS This case series examined the histories of patients under the age of 18, who presented to an Australian general practice with concerns about TSW, and whose cases were reported to the Therapeutic Goods Administration (for inclusion in the Australian Adverse Drug Reaction Database) between January 2015 and February This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta Journal Compilation © 2019 Acta Dermato-Venereologica. doi: 10.2340/00015555-3144 Acta Derm Venereol 2019; 99: 551–556

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