How do oral steroids, steroid inhalers, oral immunosuppressants and biologics affect TSW skin?
Disclaimer: This does not replace professional advice.
Do they make TSW skin worse or prolong TSW?
Oral steroids, oral immunosuppressants and biologic injections suppress the symptoms of TSW via systemic suppression of inflammation but in most cases they are not the cause of TSW and do not cause it to worsen or prolong TSW.
Topical Steroid Withdrawal is caused by topical steroids/topical immunosuppressants applied directly onto the skin, causing prolonged decreased skin cell proliferation. This makes TSW skin difficult to heal and extremely sensitive.
TSW can also be developed by indirect contact with topical steroids eg transferring topical steroids from one area to another when touching your skin, or applying moisturiser over the areas with topical steroids and spreading it to other areas where they are not applied.
How can I know that oral steroids and oral immunosuppressants do not cause TSW?
Patients with conditions that require long term use of oral steroids, inhalers and oral immunosuppressants who have not used any topical steroids on their skin at all before, usually do not develop TSW. Such patients are people with conditions such as systemic lupus erythematosus, skin grafts, organ transplant receivers, rheumatoid arthritis, multiple sclerosis, people only with asthma and no skin condition etc.
In most cases, those using oral steroids and oral immunosuppressants in the long term for their conditions can experience a systemic withdrawal and other side effects not related to the skin e.g. Cushing’s Syndrome, blurred vision, cataracts, osteoporosis, high blood pressure etc.
How do oral immunosuppressants and biologics work for TSW?
Oral immunos and biologics give the person a break from the symptoms of TSW. It is not a cure for TSW, neither does it worsen or prolong it. EXAMPLE: If a person’s natural healing TSW duration were 2 years and they were on the medication for 2 years before coming off it, they will not experience TSW symptoms any more. However, if they had to stop the medication earlier due to side effects or other reasons, let’s say they came off it after a year, their TSW would still be in progress and their TSW will return. (2 years is only used as an example for the purpose of explaining the concept.)
Why do some say their TSW got worse after coming off oral steroids, oral immunosuppressants and biologics?
That is because of several reasons 1) Constant exposure to flare factors while being on the medication 2) Beginning their withdrawal while on medication 3) TSW flare continuing to progress while on medication
1) Constant exposure to flare factors while on medication
While on oral steroids or immunosuppressants, TSW symptoms are suppressed. This gives the person freedom to live their life normally, thus they are highly likely to be exposing themselves to many flare factors that affect TSW. This happens without the person knowing because symptoms are suppressed and the usual signals (inflammation) do not appear. Hence when a person comes off the medication, the TSW can be worse than before. This it is because the skin was still constantly being aggravated while being on the medication.
This is an analogy: It is akin to having a headache (TSW) and suppressing it with painkillers (oral medication/biologics), but continuing to work without rest (exposure to flare factors), then coming off the painkiller (oral medication/biologics). Your headache would have progressed and become much more painful. It was not the painkiller that caused it to worsen, it was the lack of proper care resulting in the worsening of the headache.
Hence to prevent this from happening, it is very important to continue eliminating the flare factors while on these drugs. You may read more on the 7 flare factors here.
2) Withdrawing from TS while on medication or TSW progressing while on medication
It is a common occurrence that users of oral immunosuppressants start to withdraw from TS while being on the oral medication. When they cease oral steroids or immunosuppressants, it becomes worse than their original “eczema”. That is because their TSW condition is showing after coming off oral steroids, immunosuppressants or biologic drugs.
TSW symptoms can continue to progress despite the oral steroid or immunosuppressants suppressing the symptoms. It is similar to how a headache is still there, you are just not feeling it. Once you come off it, TSW can/will return.
3) Taking oral medication at the peak of a flare
Most of the time, patients are given a course of oral steroids or oral immunos because of a flare they cannot handle. This means that the skin has already been triggered by something and the flare has already started and is worsening. They go on the oral medication which suppresses the flare, but the flare is actually continuing to develop. When they come off the medication, the flare has already progressed/worsened, thus when the oral medication is stopped, the TSW appears worse. That is not to say the oral medication caused it to worsen, but that the flare was progressing. If the oral medication was not used, it would continue to flare the same, if the trigger were not removed.
Why do I still have strange rash while on oral steroids, oral immunosuppressants and biologics?
That is because the dose or strength of the oral steroid, immunosuppressant or biologic is not strong enough to suppress all your TSW symptoms. It could mean you have more severe TSW symptoms.
Some medications have a known side effect for causing facial flares, such as Dupixent/Dupilumab.
Do steroid inhalers for my asthma make TSW worse?
In most cases they do not make TSW worse. However, steroids in inhalers are easily transferred to the skin after inhaling them. For example, touching and rubbing the nose after a puff, then touching the skin, or the particles in the puff in the air contacting the skin. This can make your TSW skin look a little better because the steroids in the inhaler have some suppressive effect. However amount of steroids affecting the skin is usually too low to cause any actual damage or harm.
Do steroid eye drops affect my skin?
It is possible for strong eye drops to affect your TSW skin and cause a flare, while weaker steroid eye drops may delay healing without causing flares.
Is it advisable to be on oral steroids, oral immunosuppressants or biologics during TSW?
Oral immunosuppressants and biologics are an option if you need a break from TSW. While it does not make TSW worse, there are other side effects of these medications on the body which require careful consideration and monitoring with your doctor. It is also worth noting that oral immunosuppressants can cause the skin to be more susceptible to bacterial, fungal and viral infections. The skin can be infected without showing any signs while on the medication, and when off the medication, symptoms on the skin start to show.
Oral steroids can be used in short courses to during TSW (at the later stages when the skin is more clear) if you have an extremely bad flare from one of the flare factors. This helps to bring down the inflammation, but you MUST eliminate the flare factors while on the course to prevent it from flaring back up badly upon stopping the medication. Your TSW will “resume” back to how it was after coming off the oral steroid, if the flare factor is eliminated.
Information in this article is based on Jay’s 15 years of treating people with TSW in Thailand and Singapore, Dr Rapaport uses oral immunosuppressants for some of his TSW patients.
Disclaimer: There could be outlier cases that experience TSW symptoms from oral steroids. It is also possible to experience a rebound from oral steroids after not using topical steroids for a long time. Further research needs to be done to understand this fully.
This is not advice to say you should be taking oral steroids or oral immunosuppressants, this article is only explaining how they affect TSW skin.
This is not intended as medical advice. Please seek advice from your doctor or medical professional for advice on your skin condition.