Written by Dr Rinku Ratti, GP & Skin Health Specialist
TSW
Skin disease doesn’t just live on the surface.
For many patients with eczema or dermatitis, disrupted sleep, reduced confidence, lost school or work days, and anxiety are daily realities.
In recent years, an increasing number of patients have reported severe burning, redness, and “rebound” flares when stopping topical corticosteroids (TCS).
This cluster of symptoms is often referred to as Topical Steroid Withdrawal (TSW) or “Red Skin Syndrome.”
While terminology and diagnostic criteria are still evolving, it’s vital that clinicians adopt a clear, evidence-based approach that validates patient experiences, rules out dangerous mimics, and provides safe, structured care.
What Is TSW — and What Do We Actually Know?
Professional bodies acknowledge that TSW-type reactions can occur, but the condition remains not universally defined.
In 2024, the British Association of Dermatologists (BAD) — together with the National Eczema Society (NES) and others — released a joint statement and established a working group to develop expert consensus guidance.
Key points include:
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Most TCS side effects are well understood.
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TSW-type reactions are less well characterised and require careful, individualised assessment.
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Clinicians should listen, investigate, and avoid dismissive attitudes.
What Patients Commonly Report with TSW
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Burning, red or “raw” skin, often beyond the original eczema area
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Flares when TCS are tapered or stopped
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Marked skin sensitivity and stinging with moisturisers
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Intense itching that disrupts sleep and concentration
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Emotional distress and a sense of being dismissed
The National Eczema Society stresses the importance of listening and validating patient concerns, avoiding a “pro-steroid vs anti-steroid” stance. Instead, clinicians should focus on pragmatic, safe, and supportive care tailored to the individual.
GP Assessment: Rule Out Mimics, Document Clearly, Plan Safely
At The Doctor’s Practice, we follow a structured, methodical approach when TSW is suspected.
1. History of Exposure
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Potency, quantity, frequency, and duration of TCS use
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Areas applied, any occlusion, and recent escalation or tapering
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Use of other topicals (calcineurin inhibitors, keratolytics, antimicrobials, cosmetics)
2. Examination
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Distribution and pattern — is it extending beyond the initial eczema?
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Signs of warmth, oozing, or crusting
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Look for infection (bacterial, viral, fungal) or secondary changes (lichenification, excoriation)
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Consider contact allergy
3. Differentials to Consider or Exclude
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Uncontrolled atopic dermatitis
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Allergic contact dermatitis
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Seborrhoeic dermatitis
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Periorificial dermatitis
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Tinea incognito
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Scabies
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Impetiginisation
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Erythroderma
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Drug eruption
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(Rarely) systemic corticosteroid effects or adrenal suppression
4. Baseline Tests (Where Helpful)
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FBC, CRP, ESR – to check for systemic inflammation
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Vitamin D, ferritin, B12, zinc – for immune and barrier function support
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HbA1c – if recurrent infection or delayed healing
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Swabs – if oozing or secondary infection suspected
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Full allergy profile – to assess inflammatory or environmental triggers
Management: Honest Expectations, Barrier-First Care, Rational Therapy
There is no single quick cure.
At The Doctor’s Practice, we create a stepwise plan with clear, realistic goals.
1. Skin-Barrier Repair
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Use bland, fragrance-free emollients (ointments are often best tolerated)
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Take short, lukewarm baths or showers
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Avoid fragranced products and soaps
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Consider ceramide-rich formulations for barrier restoration
2. Trigger Control
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Manage sweat, heat, and friction
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Use breathable fabrics
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Address stress, anxiety, and sleep hygiene
3. Infection Strategy
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Maintain a low threshold for swabbing warm, oozing, or worsening areas
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Treat confirmed bacterial, viral, or fungal infections promptly
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Educate patients on infection warning signs
Advanced and Adjunctive Therapies- Cold Atmospheric Plasma (CAP)
Emerging dermatology research suggests CAP therapy may:
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Reduce Staphylococcus aureus bacterial load
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Support healing and tissue regeneration
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Modulate inflammatory pathways
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Improve barrier recovery
Small studies in atopic dermatitis have shown improvement in redness, itching, and bacterial balance, with excellent safety profiles.
CAP therapy is a clinic-grade medical procedure, not a salon or spa treatment, and is carried out under medical supervision.
LED / Photobiomodulation (PBM)
Clinical reviews indicate that LED light therapy can help reduce inflammation in chronic skin conditions, including eczema, by promoting mitochondrial repair and improving circulation.
While research quality varies, PBM is considered safe and effective as an adjunct when used correctly in medical settings.
At our clinic, it is offered selectively — alongside medical treatment, not in place of it.
Our Philosophy at The Doctor’s Practice
We don’t promise quick fixes — but we promise to listen.
For patients experiencing TSW-like symptoms, feeling heard and supported is the most important first step.
Our approach combines:
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Holistic doctor led skin care – addressing medical, lifestyle, and emotional aspects
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Evidence-based medicine – guided by dermatology consensus
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Long-term planning – realistic timelines and regular follow-up
The goal is not only to manage the skin but to help restore confidence, comfort, and control over daily life.
References
1.Hajar, T. et al. “Topical corticosteroid withdrawal: systematic review of clinical features.” Journal of the American Academy of Dermatology (2021).
🔗 https://www.jaad.org
- Rapaport, M. et al. “Steroid addiction and withdrawal in dermatology.” Clinical Dermatology (2022).
🔗 https://www.sciencedirect.com/journal/clinics-in-dermatology - National Eczema Association: TSW Research Summary
🔗 https://nationaleczema.org - Ohtsuki, M. et al. “Rebound phenomenon and perioral dermatitis after chronic steroid use.” British Journal of Dermatology (2023).
🔗 https://bjddom.org - International Eczema Council – Clinical guidance on TCS withdrawal
🔗 https://www.eczemacouncil.org
The Doctors Practice
Edgbaston, Birmingham
www.thedoctorspractice.co.uk
Tel: 0121 661 2366 | WhatsApp: 07388 623527
Doctor-led private GP & aesthetic clinic