Topical Steroid Withdrawal: Inside the Controversy Over TSW in Dermatology

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

References:

1. 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.

2. 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.

3. 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.

4. 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.