In 1974 Kligman warned that topical steroid addiction is likely to occur among patients with atopic dermatitis. But the skin manifestation of topical steroid addiction described by Burry or Kligman was almost similar to steroid induced rosacea. So the significance of the problem seemed to be underestimated.
Sneddon reported one severe case of topical steroid induced adrenal cortex insufficiency in 1976. There must have been few dermatologists who noticed the relation between Burry’s or Kligman’s TSA and Sneddon’s case. Apparently the two problems are very apart from each other but connect essentially. I will refer to it here.
In Japan Enomoto reported several cases that developed erythroderma after withdrawal from topical steroids in 1991. Some of them suffered from adrenal cortex insufficiency. It is not accidental that patients with TSA were early reported in Japan. Japan was a rich country at that time and people could easily obtain much medication without their own expenses.
In US Rapaport advocated “The red burning skin syndrome” in 2003. The concept lies midway between Kligman’s TSA and Sneddon’s case and almost near to Enomoto’s. Burry, Kligman and Rapaport described their cases as “topical steroid addicted” but Enomoto and Sneddon didn’t. Apart from terminology, the cases are all related.
To understand TSA, one must know two aspects of topical steroids. One is a positive and useful aspect, that is, they suppress excessive immunological inflammation. The other is negative aspect that they thin epidermis and weaken barrier function.
The figure below will help understanding.
At first, topical steroids work well. The side effect of epidermal barrier dysfunction is not obvious. Patient is not addicted. After long continuous use of steroids, epidermal barrier dysfunction progresses gradually. The skin becomes sensitive and easily responds to various external stimuli. But because of the suppressing function of steroids, inflammation never becomes so severe as long as the patient continues to use topical steroids. If the patient discontinues steroids, eczema appears. It is not because of the patient’s original constitution but because of a side effect of topical steroid itself. The patient is TS-addicted.
If the addicted patient will not withdraw from topical steroids and continue to use more and more, the barrier function is to be destroyed completely. The skin cannot prevent inflow of topically applied steroids into the tissue. The blood concentration of steroid will increase and the patient may become adrenal cortex insufficiency. So they are series and substantially of a same phenomenon. The difference is only seriousness.
Topical drug addiction: Adverse effects of fluorinated corticosteroid creams and ointments
Burry JN.; Med J Aust. 1973 Feb 24;1(8):393-6.
http://www.ncbi.nlm.nih.gov/pubmed/4266903
Steroid addiction
Kligman AM., Frosch PJ., International Journal of Dermatology Volume 18(1974) Issue 1, Pages 23 - 31
http://www.ncbi.nlm.nih.gov/pubmed/153891
Steroid withdrawal syndrome by topical corticosteroids.
Enomoto M, Arase S, Shigemi F, Takeda K. Kousyou Journal of Japanese cosmetic science society Vol.15 No.1(1991)
http://www.jcss.jp/journal/pdf/1501/1501_17.pdf
Corticosteroid addiction and withdrawal in the atopic: the red burning skin syndrome MJ. Rapaport etc.Clinics in Dermatology Volume 21, Issue 3, May-June 2003, P201-214
http://www.ncbi.nlm.nih.gov/pubmed/12781438
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.
Dr. Fukaya,
返信削除I would like your opinion. My child is going on nearly 5 months of tsw. She has food allergies but never had hives like this very often. Just lately she has been experiencing hives mostly on the face. Sometimes many and sometimes maybe one or two. They quickly come- I cannot assume what caused it. I give an antihistamine and it goes away. I have read your blogs and your book. Can your classify this as a part of the hypersensitivity part? These hives are very localized. Only on one part of body. What does this signify? Her recent blood work shows lower eosinophils count than her initial lab work. She is also on methotrexate once weekly. I know that you have little experience with immunosuppressants. But these hives are confusing me. By the way your work with Drs Sato and others is very greatly anticipated. I took your paper to my child's doctor.
Hives and extraordinary sweating are two common signs seen in the patients at the exit of TSA. The mechanism is unknown but hives may be due to hypersensitivities and sweating may be due to functional recovery of sweating glands. Though the symptoms are unpleasant of course, please wait for a little more time. Usually they will disappear in several months.
削除Dr. Fukaya, the hives will last several months? Sometimes have you noticed patients without sweating? I have an allergy appt in a few weeks because of her food allergies will you notice false positive or very reactive response? Do you have any more information I can read on your blog regarding the hives? I thank you for your time.
返信削除I can’t say anything more about the individual case of your daughter but hives after TSW is often temporary and disappear even though the result of allergy test of the patient is positive. On the other hand, there exist patients with chronic hives caused by food allergy. Anyway, if your daughter develops hives obviously after eating some peculiar food, I suggest avoiding it. If there is no obvious food, you don’t need to look for the cause nervously. The result of the blood test is not absolute one but only a hint for you.
削除Thank you Dr. Fukaya for your time. No offending food was given. We just have to be patient and push through. Thanks for information.
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