Ian Myles, MD, MPH, is a staff clinician from the Epithelial Therapeutics Unit in NIAID’s Laboratory of Clinical Immunology and Microbiology.

Ian Myles, MD, MPH

Topical Steroid Withdrawal: Inside the Controversy Over TSW in Dermatology

Topical steroid withdrawal (TSW) is a controversial topic in the field of 

, precisely because it exposes the fault lines between patient experience and clinical consensus. Long discussed in patient communities found online, a wider acknowledgement of TSW has largely remained unseen.

TSW is often a contested diagnosis, recognized by some dermatologists as a distinct entity but dismissed by others as simply a severe or undertreated atopic dermatitis flare. Many patients who have recognized a distinction between a typical flare and a result of withdrawal from topical corticosteroids have highlighted distinct symptoms of this condition, including what is commonly referred to as ‘elephant skin.’

Additional features may be present, including sharp, “sleeve-like” demarcations at wrists and ankles, temperature dysregulation, chronic exfoliation, and neuropathic sensations described among patients reporting TSW may raise red flags for clinicians, particularly when seen alongside long-term, escalating steroid use. However, a stalemate between patient and dermatologist can arise in which patients insist steroids have impacted them, and clinicians describe their atopic dermatitis as merely uncontrolled.

In this video feature, 3 experts with recently published research on the topic of TSW were consulted on the controversy surrounding TSW, its lack of acceptance, and the ways for clinicians to recognize the condition. These experts included Peter A. Lio, MD, a clinical assistant professor of Dermatology & Pediatrics at Northwestern University Feinberg School of Medicine, Ian Myles, MD, MPH, the chief medical research officer of the US Public Health Service Commissioned Corps, and Anish Maskey, PhD, an assistant professor of Microbiology & Immunology at Touro College of Osteopathic Medicine, Montana.

The 3 dermatology experts converged on several key points in their separate interviews, noting the high efficacy of topical steroids and general safety for most patients. Additionally, prolonged and escalating use of topical corticosteroids without reassessment is a common risk factor of TSW. Lastly, they pointed to patient communities, especially those found online, as largely helpful and instrumental in highlighting TSW for clinicians who may not be aware of TSW’s distinction from eczema.

Throughout the feature, Lio, Miles, and Maskey agree on the path forward, lying not in polarization but in transparency, understanding, and new research taking patient-reported suffering seriously without discarding scientific rigor. While definitions remain imperfect, the experts agree about the existence of increasing acknowledgement of TSW and its impacts on patients. Bridging the gap between many patients’ beliefs and the views of wary physicians may be less about choosing sides than about restoring faith in the medical community’s commitment to patients while new evidence grows.

Check out the feature video posted above to discover more about the views of these 3 experts on this topic.

Lio P. Addressing Doubts About Topical Steroid Withdrawal (TSW), with Peter Lio, MD. HCPLive. June 10, 2025. Accessed December 12, 2025. 

https://www.hcplive.com/view/addressing-doubts-about-topical-steroid-withdrawal-tsw-peter-lio-md

Ahuja K, Lio P. Pediatric Topical Steroid Withdrawal Syndrome: What Is Known, What Is Unknown. Pediatr Dermatol. 2025 Mar-Apr;42(2):311-317. doi: 10.1111/pde.15799. Epub 2024 Nov 4. PMID: 39496222; PMCID: PMC11950796.

Shobnam N, Ratley G, Myles IA, et al. Topical Steroid Withdrawal Is a Targetable Excess of Mitochondrial NAD. J Invest Dermatol. 2025 Aug;145(8):1953-1968.e14. doi: 10.1016/j.jid.2024.11.026. Epub 2025 Mar 14. PMID: 40088241; PMCID: PMC12286752.

Maskey AR, Sasaki A, Li XM, et al. Breaking the cycle: a comprehensive exploration of topical steroid addiction and withdrawal. Front Allergy. 2025 Mar 31;6:1547923. doi: 10.3389/falgy.2025.1547923. PMID: 40230788; PMCID: PMC11994697.

Videos

Topical steroid withdrawal (TSW) remains a contentious issue in dermatology, with a divide between patient experiences and clinical consensus. Some dermatologists recognize TSW as distinct from atopic dermatitis flares, while others do not. Symptoms include "elephant skin," sharp demarcations, and neuropathic sensations. Experts agree on the efficacy of topical steroids but caution against prolonged use without reassessment. Patient communities play a crucial role in raising awareness. Bridging the gap between patient beliefs and clinical views requires transparency, understanding, and research that respects patient-reported experiences.

Topical steroid withdrawal remains a controversial topic in the dermatology field, given the lack of necessary data. 

 Topical Steroid Withdrawal: Inside the Controversy Over TSW in Dermatology

New findings by a team of scientists from the National Institutes of Health’s National Institute of Allergy and Infectious Diseases (NIAID) Laboratory of Clinical Immunology and Microbiology indicate that dermatitis due to topical steroid withdrawal (TSW) is distinct from 

, and they suggest that it is the result of an excess of an essential chemical compound.

This team of investigators had evaluated a prior survey involving 1,889 adults subjects with symptoms that were determined to be comparable to atopic dermatitis, or eczema. One such investigator was Ian Myles, MD, MPH, from the Epithelial Therapeutics Unit in NIAID’s Laboratory of Clinical Immunology and Microbiology, who spoke with 

 about these new data and their significance.

Findings on Topical Steroid Withdrawal Versus Eczema, with Ian Myles, MD, MPH

“The biggest [finding] is that, unlike regular atopic dermatitis, there's a mitochondrial defect in patients with topical steroid withdrawal and up-regulation of 1 of the components of the electron transport chain,” Myles said. “It basically gets revved up for reasons we do not understand, and it will not turn off for those patients. So with this overactivity, it starts producing too much niacin in the skin, which I think most of us are familiar with, from causing flushing when it used to be used for cholesterol. Then for the body to recycle niacin, it has to break down tryptophan, and so in the breaking down of tryptophan and the overactivity of niacin, those 2 things combined, we think would explain all of the symptoms that are distinct from regular eczema.”.

Myles noted that among those in the field of dermatology, many have this condition due to TSW and not eczema.

“I think what this helps is to identify who is it that you think is TSW, as it is a distinct entity and should be respected as such,” Myles said. “We did do pilot studies with interventions with metformin, and then ‘herbal metformin’ which is Berberine. They're promising. The end number is small, but I think the important thing is to establish it as a real diagnosis and give some people basic outlines of how you would go about separating who in your clinic has TSW versus who in your clinic probably has severe eczema.”

For additional information on these findings, view the full interview with Myles posted above this summary.

The quotes contained in this summary were edited for clarity. Allergy & Asthma Network received funding from Sanofi, Regeneron, Genentech, Pfizer, and Novartis for unbranded disease awareness and education; however, such funding was noted as not relevant to this research.

Learn more about the annual Revolutionizing Atopic Dermatitis (RAD) Conference

, hosted by HCPLive Dermatology Times, and our CE/CME partner Physicians’ Education Resource.

Shobnam N, Ratley G, Myles I, et al. Topical Steroid Withdrawal Is a Targetable Excess of Mitochondrial NAD+, Journal of Investigative Dermatology, 2025, ISSN 0022-202X, https://doi.org/10.1016/j.jid.2024.11.026.

This interview with Ian Myles, MD, MPH, highlights his team’s recent findings on identifying dermatitis related to topical steroid withdrawal (TSW) versus atopic dermatitis.

Ian Myles, MD, MPH

Articles