Addressing Doubts About Topical Steroid Withdrawal (TSW), with Peter Lio, MD

In another segment of his HCPLive interview at the 2025 Revolutionizing Atopic Dermatitis (RAD) Conference, Peter Lio, MD, spoke about topical steroid withdrawal at the atopic dermatitis-focused meeting.

Lio, who works at Northwestern University's Feinberg School of Medicine as a clinical assistant professor of dermatology and pediatrics, touched on the topic following his shared session about topical steroid withdrawal and its relationship to atopic dermatitis. He was asked about some of the most notable takeaways.

“There were 3 of us presenting on stage, and we got to go through different aspects of it,” Lio explained. “First, my piece was all about how we identify it? What is it? Is it a real thing? I think in this particular setting, most people, at least as far as I could tell, seem to acknowledge it as a real entity and want to understand it better. But I know that that's not true. I meet clinicians who say, ‘I don't think it's a real entity’ or ‘I think it's not different than atopic dermatitis,’ but I tried to convey some of the symptoms that are different. Some of the signs that are different and, most importantly, even if you don't acknowledge it or accept it, I think we should still hear our patient out.”

Lio added that one should still adapt to the patient and their needs related to corticosteroids.

“I wrote because I was so frustrated a couple of years ago by someone who said there's nothing else besides steroids,” Lio explained. “I wrote an entire paper about the therapeutic ladder of how we can treat atopic dermatitis without steroids at all, and I think it's pretty compelling. So when anyone says there's nothing outside of this, I'm like, ‘Here's an entire paper about the whole thing.’ We talked about that, and then the other sessions were really interesting too, about how we counsel the patients, and what we specifically do to treat it. Then finally, how do we bring all of this together?”

Lio was then asked about the doubts some physicians have related to topical steroid withdrawal.

“I hope some people who are doubtful watch it, and I hope it changes their minds,” Lio explained. “It's a powerful thing to be able to change somebody's mind. I love those moments in life when my mind gets changed, it's very exciting…I think that people feel that way for a couple of reasons. Number 1, it is relatively new. This is a bit of a controversial statement, because you can find threads in the literature for at least 20 years, and even beyond that. So it's not that new, but it's not something in the conventional canon.”

Lio noted that mainstream dermatology textbooks largely do not discuss topical steroid withdrawal.

“Part 2 is that patients often come in telling us that they have this, and that is a big reversal for dermatology,” Lio said. “We are quite used to, and I would say it's almost universal. Patients come in, or even other clinicians, even really good clinicians, come in telling us, ‘I don't know what this is, whether it's a rash, a spot, or some bumps, I don't know.’ We tell them what it is…This is backwards. The patient comes and says, ‘I think I have TSW,’ and we're not built for that. We know a lot more than the patients do, so I feel like it's a weird reaction to be threatened, but I get it. It feels threatening, like they're kind of trying to usurp you.”

Despite this initial feeling, Lio expressed that essentially all of the patients who have told him in his practice that they have TSW, he has agreed with them.

“I can reassure them ‘I see you know, you may not know this, but I'm a TSW person and I've written about it,’” Lio explained. “I say ‘I see a lot of patients with it, so I'm going to tell you very honestly, at this point, I do not think you or your child has this. We're going to treat you. We can even treat you like you have it, if you like’...Usually when I say that, their shoulders drop, they relax, and they smile."

For more from Lio and other session presenter, view our latest conference coverage.

The quotes used in this summary were edited for clarity.