Understanding Topical Steroid Withdrawal Versus Atopic Dermatitis, with Brad Glick, MD

During a recent interview at the 2025 Revolutionizing Atopic Dermatitis (RAD) Conference in Nashville, Tennessee, Brad Glick, DO, MPH, spoke in a Q&A interview with the HCPLive editorial team about his conference talk titled ‘Understanding Topical Steroid Withdrawal (TSW) in Patients with Atopic Dermatitis (AD) - Spotlight Symposium.’

Glick, who is known for his role as a board-certified dermatologist and as the director of the dermatology residency training program at the Larkin Health System Palm Springs campus in Florida, touched on several important comments about topical steroid withdrawal, also known as TSW. The following is a description of his discussion:

HCPLive: Would you share some of the specifics of your topical steroid withdrawal presentation?

Glick: Let's talk about topical steroid withdrawal syndrome. First of all, what is it? Well, it's a profound inflammatory process affecting the skin that appears to happen about 2 to 4 weeks after somewhat chronic use of topical corticosteroids. That's the typical patient, but we've seen it happen in shorter periods of time. The patients can present with widespread, patchy redness, sometimes full redness.

But there are also some characteristic signs of the condition, such as what we call elephant tight skin, which we'll see on the lower parts of the thighs or near the knees, or just below the knees. The skin is very crinkly, much like elephant skin, and it's associated with some pretty significant redness. The hallmark sign is called the red sleeve sign. You know, many of our colleagues may not see this or know this, because there's no specific diagnostic criterion for TSW.

The red sleeve sign is basically redness that occurs most commonly on an upper extremity, but it can be the lower extremity, and there is a distinct sharp cut off right at that wrist area, or the ankle area, which is where it gets its name, the ‘sleeve sign,’ or the so called ‘red sleeve sign.’ So those are some of the characteristics of TSW.

HCPLive: What are some of the most important takeaways from your session regarding TSW that you hope attendees walk away with a greater awareness of?

Glick: I think it's really important, topical steroid withdrawal or ‘Red Skin Syndrome.’ There are different names for it, but I think we need to be on the lookout for it. As my colleague Peter Lio always says, it's sometimes very difficult to differentiate it from a really bad flare of atopic dermatitis, but you have to take a step back. You have to get a really good history. You have to talk about whether patients are following the instructions with the use of topical corticosteroids, because that's one of our biggest problems.

You know, we call this steroidophobia, or steroid-phobia, where sometimes we have created the scenario, as those who are providing the medication for the patient, where we urge not to overuse it. Sometimes patients may use it too little, but in this case, the patients are typically pushing through and using steroids rather chronically. Sometimes it's because in the past, that's all we had in our toolbox, of course.

Now, one of the solutions to this problem, once we recognize it, is to take advantage and utilize some of these newer, non-steroidal therapies that we have now. Actually, some of these great systemic agents that we have to treat conditions like atopic dermatitis, biologic agents like dupilumab, nemolizumab, tralokinumab, lebrikizumab, and the 2 JAK inhibitors, abrocitinib and upadacitinib. What we think, because there's no specific criteria for TSW, is that patients should respond quite well to this so-called cytokine storm that we see in these patients.

HCPLive: Outside of atopic dermatitis, what other therapeutic research are you looking forward to in other areas of dermatology?

Glick: I mean, the sky's the limit. I think right now, the hot button for me is more and more therapies for hidradenitis suppurativa. I think that we've got psoriasis down pretty well…And that's probably true because we have such effective therapies. I think we've seen a very nice wave for atopic dermatitis as well, in both systemic therapies and topical therapies. But I think for HS, it is very underdiagnosed, and there are patients floating out there who are still not receiving the care that they should be. But the tide is turning. We've got new therapeutics in the toolbox. We've got a lot of research going on, so I'm excited in that particular area

HCPLive: What would you say is the value of RAD as a disease-specific meeting?

Glick: Atopic dermatitis, up to about 7 or 8 years ago, was a disease for which we had not much. Now we do. But now that we have tools in the toolbox, we have to be able to convey those very critical messages about not even so much, how we carefully diagnose a condition like atopic dermatitis, which I think for dermatologists and our advanced practitioner dermatology colleagues, we've got that down. But now, [we have to focus on] how do we use these therapeutics and which therapies for which patients.

I think a meeting like RAD, focusing on atopic dermatitis and related disease states, is critical for all of our understanding, not only of how patients present clinically, but how we hone in on the proper therapeutic interventions for people who are suffering with this condition.

For any additional information on TSW and related topics in the atopic dermatitis space, view the latest coverage of the RAD 2025 conference.

The quotes used in this summary article were edited for clarity.