AAD（American academy of dermatology） guidelines for atopic dermatitis treatment.

AAD is now revising its guidelines for atopic dermatitis treatment. The part of topical therapy including topical corticosteroid therapy is to be published in February 2014.

http://www.aad.org/education/clinical-guidelines/current-and-upcoming-guidelines/current-guidelines-and-guidelines-in-development

However the date has been already postponed many times for the unknown reason. The last guideline expired in 2009 and a new guideline was estimates to be released soon.

The last guideline didn’t refer to TSA. In 2006 a review article entitled “Adverse effects of topical glucocorticosteroids.” was published in the journal of AAD (JAAD). The article contained an independent chapter of TSA. So I think the next guideline will contain information about TSA.

Adverse effects of topical glucocorticosteroids. Hengge UR, Ruzicka T, Schwartz RA, Cork MJ. J Am Acad Dermatol. 2006 Jan;54(1):1-15
    
Guidelines for psoriasis were revised in 2009. Though the term TSA was not adopted in it, the following description was included.
“Another possible concern with the use of topical corticosteroids in the treatment of psoriasis is rebound, wherein disease recurs worse than the pretreatment baseline after the topical corticosteroid is discontinued. Although rebound is known to occur most typically when topical corticosteroids are abruptly discontinued, its frequency and severity are poorly characterized. This is another area worthy of further investigation.”
It is a warning for TSA. 

http://www.aad.org/education/clinical-guidelines/current-and-upcoming-guidelines/current-guidelines-and-guidelines-in-development

So I believe that description of TSA will be added also in a new guideline for atopic dermatitis treatment. I really look forward to its being released. It is because Japanese guideline will be revised if AAD guideline is revised. Japan is such a country, sorry to say.

In Japan, talking or writing about TSA is a kind of taboo especially among dermatologists nowadays. Some dermatologists recognize and understand the existence of TSA but never dare to refer to it. I am a very rare exception.

In 1990s considerable patients claimed harm due to this side effect of topical steroids and some dermatologists including me agreed with them. The term TSA was not common at that time. People described it as “steroid withdrawal therapy” because patients become healed only by stopping TS. I dislike the name because it never is any therapy. It is only a rescue from the side effect.

Many baseless or folk therapists appealed the natural recovering procedure from TSA as the effect of their therapies. Such therapists radically advocated the negative side of TS to patients. So the situations became more confused.
 
A lawsuit was raised at last. One woman brought suit against dermatologists and the suit got a lot of publicity in the media. The woman brought suit against three dermatologists involved. She had visited A,B and C clinics (practitioners) ,D collage hospital and E clinic (practitioner). The record in the clinic A was old and lost. The clinic B and C prescribed considerable amount of TS for her face. The hospital D diagnosed that she suffered from steroid induced rosacea. She was introduced to the clinic E by the hospital D. The clinic E tried to reduce TS but failed to maintain her confidence. She stopped visiting any doctor and quit TS cold turkey. After overcoming severe rebound she became almost healed and raised a lawsuit against the clinic B,C and E.

Japanese dermatologists, especially authorities in JDA (Japan dermatological association), stiffened their manner. If such a lawsuit followed one by one, many Japanese dermatologists would get into trouble. Not only the doctor who prescribed TS but also the doctor who tried to reduce TS could become a target of such a lawsuit. So JDA authorities seems to have decided not to add TSA description to its guideline. If the conception of TSA remains unclear, it must be beneficial for dermatologists when they are raised lawsuit. TSA became a taboo among dermatologists in Japan.

I sometimes imagine how the situation would have changed if the woman raised lawsuit against only the clinic B and C ( not against the clinic E ). She might get some help from the hospital D and the clinic E. She lost the lawsuit at last. But she might have won it and Japan might have become an advanced country about TSA problem.

Anyway, there are many TSA sufferers still in Japan. Several conscientious dermatologists are struggling to rescue them even after I myself have retired from the battlefield. I should or must do something for my old comrades. It is one of the reasons why I am writing the blog now .

I insist that Japanese way should not be adopted in US or any other countries. Dermatologists should meet this difficult problem of TSA head-on. Please refer to TSA in the next AAD guideline. It is a start line for resolution of the difficult problem. It might save Japanese confused situations also. Japanese manner could not resolve anything. It only postponed the problem.

I never advocate that all TS users should abandon them. I am not anti-steroid fundamentalist. What I am persisting here is only that some of them are really suffering from TSA. Both dermatologists and patients could use TS more safely without anxiety after studying TSA well. Patients need dermatologists with enough knowledge about TSA. Under such dermatologists steroid-phobic patients could resume to apply TS to their eczema without fear, I believe.

Sorry, the comment column is not available now. But the author believes readers can find some hints to overcome their own situations by the previous comments.