My patients are concerned about the safety of topical corticosteroids – should they be?

For the management of eczema, beyond the daily use of moisturisers, topical corticosteroids (TCS) are the mainstay for the management of flares. They can be used safely and effectively. However, concerns about the safety of TCS are widespread on social media, and sometimes reinforced by legacy and inconsistent advice from health professionals. Stories about topical steroid withdrawal are difficult to put into context for both consumers and health professionals. The outcome is that many consumers are avoiding using TCS, which in many cases, makes it harder to manage conditions such as eczema. So what can health professionals do to address this concerning trend?

Understanding patient perspectives and making shared decisions

Good shared decision-making requires discussing with patients and carers what works and what doesn’t work for them as well as informing them of the potential benefits and harms from treatment. However, by the time that a consultation occurs, patients may already have strong views on treatment options.

The foundations of eczema management are patient education and support, the use of regular moisturisers and, where possible, the avoidance of triggers, irritants and allergens. For active flares, the use of TCS is first-line. 

While in theory management is simple, there are a multitude of options to choose from, and choosing what is effective and feasible for an individual and their circumstances takes time and persistence.

Addressing concerns about topical corticosteroid safety

Patients are increasingly turning to the internet and social media rather than their health professional to find out about their condition and its treatment. So, before a consultation occurs, they may be well-prepped from a range of sources of information regarding the treatment options for eczema, and in particular, TCS. 

If asked about the safety of TCS, many health professionals may think of adverse effects, such as skin thinning and hypopigmentation. In line with that, we may be inclined to advise to apply sparingly to avoid such problems. However such advice runs counter to best practice and when used appropriately, TCS are unlikely to cause adverse effects such as these. 

For patients, many sources exaggerate the potential harms of TCS such as skin thinning and hypopigmentation. On top of that, some media influencers tell alarming stories about topical steroids being addictive and that stopping them caused them to have an extreme reaction referred to as ‘topical steroid withdrawal’. The information is very challenging and creates profound concerns, often leading to fears and avoidance of TCS. Addressing patient concerns about this requires time.

The rare phenomenon of topical steroid withdrawal

The incidence and causes of what is known as topical steroid withdrawal are contentious. However, it is described as a rare adverse reaction typically resulting from prolonged and inappropriate use of more potent TCS applied primarily on the face and genital areas. It is characterised by burning, itch, redness and papulopustular rashes. 

Sometimes it is confused with undertreated eczema or rebound eczema flares. 

Putting information in context for patients

GPs and pharmacists are increasingly seeing patients that are very concerned about using TCS, becoming dependent on them and whether, if they start then stop using them, they will be at risk of having topical steroid withdrawal. Here are some points that could be helpful in discussions with patients:

• The incidence of topical steroid withdrawal is believed to be extremely rare. Far more people with eczema benefit from topical steroids than experience a reaction.
• It is most likely that a disease flare following the cessation of steroid treatment is not topical steroid withdrawal, but a resurgence of eczema.
• Topical steroids are safe and effective when used as prescribed, and are vital in providing relief, alongside moisturisers and avoiding triggers.
• If the topical steroid you are using is not working well it will be important to review your treatment to determine what changes are needed.

Health professionals should explain to people how to use TCS (considering the potency, amount, age of the patient, site on the skin of application and duration of use) and inform them of the potential benefits and risks. 

The above is illustrative of why the Quality Use of Medicines Alliance decided to develop resources and educational activities on eczema. Management is not as simple as it seems.

In-consultation resources:

• Eczema Management Algorithm
• Eczema Care Plan

Educational activities and CPD:

• Podcast – Beyond Skin Deep: Unravelling the challenges of managing eczema
• Webinar –  The Eczema Equation: Burden of disease and challenges in management
• Virtual Educational Visiting

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