Topical Steroid Withdrawal

Withdrawal symptoms explained

Note: Please read my first article on how topical steroids affect our skin so that you may understand fully the explanations below.

Why do we experience so many bizarre symptoms?

Most TSW symptoms are effects of the skin being damaged. Here are some explanations which I hope you’d find helpful and will bring you clarity.

Inflammation (redness, swelling, heat):
Inflammation is a general term for describing how the body reacts when it is defending itself and preparing its resources to fight. Inflammation during TSW happens:
1. Right at the very start of TSW when the skin is withdrawing
2. When it is flaring up due to falling ill, stress, monthly period, allergens/irritants, lack of sleep/rest, alcohol, heat/warmth
3. When the skin is fighting an infection:
While uncomfortable and alarming to see redness and swelling, it is your body protecting you and doing its job. When your skin is inflamed, try to identify which of the 3 above might be the cause. This will help you decide your course of action e.g. if flaring due to lack of sleep, try to rest more. If flaring due to an infection, treat the infection with antibiotics.

Care tip: Inflammation takes its own time to go away. To relieve it, you may elevate the swollen area and use ice packs if the redness/heat is causing discomfort. Cryotherapy cited to be helpful for bringing inflammation down as well.

Excessive flaking and roughness:
When the skin repairs itself, it regenerates skin cells and sheds old skin cells, causing flaking. This is the natural process of recovery and healing. As TSW skin has been damaged by the steroids, the flaking process is much more rigorous.
When skin cells are proliferating, some cells proliferate faster than others. This causes unevenness on the skin’s surface, which is observed as roughness.

Care tip: Flaking is a good sign - it is definitely frustrating and you may even be disgusted by it. But try to see it differently - your skin is working extremely hard! Keep a handheld vacuum cleaner in your house if you need to clear flakes around you regularly.

Intense itch:
When skin cells are regenerating, they send signals to each other to proliferate, causing itch. Because TSW is a process of deep and intense healing, the itch is just as intense. Skin that has been thinned needs to be repaired from deeper layers of the skin all the way to its surface layers, thus the sensation of a very deep itch.

When the skin is in the remodelling phase of recovery, the skin pulls together towards the centre of the wound. This pulling forms visible lines, and the action of pulling stimulates nerve cells, causing itch.

Care tip: Be careful with scratching; while it is extremely difficult not to scratch, deep and intense scratching can cause infections in the deeper layers of your skin, which can be tricky to fight off. Practice mindful scratching - scratch as gently as possible whenever you really need to satisfy that itch. File your nails down to avoid too much damage.
If you have had a scratch fest and are feeling guilty and frustrated, remember to be kind with yourself - do not beat yourself up about it, let it go and let your skin heal once again.
Ice packs are also helpful for numbing the itch - extreme temperatures tend to be helpful with numbing sensations out, however cold is better than hot with TSW skin. Heat tends to cause irritation/

Oozing and crusting (dried ooze forms crust):
Oozing can be because of 2 reasons:
1. Caused by leaking blood vessels and cell rupture
Ooze is also called exudate, which is made up of cellular fluid and proteins (albumin). It gives off a rancid smell when it is exposed to air and decays. Ooze is also a form of complex food/nutrient for the skin cells to heal.

In a normal case of edema, the edema is caused by fluid leakage from blood vessels.
In moderate cases, the leakage from blood vessels is high but is not high enough to split the keratin layer of the skin. These cases are presented as weeping.
In serious cases, the leakage is excessive and the keratin layer is unable to hold the pressure caused by fluid leakage. If the keratin splits down to the epidermis level, it causes epidermis cell rupture. This causes oozing but no bleeding.
If the the keratin split goes even deeper to the dermis level, it causes epidermal cell rupture and blood vessels tearing, causing oozing and bleeding.

Those who have used Class 1 to 3 steroids according to the US classification, are likely to experience oozing while those who have used Class 4 to 7 are unlikely to experience it. This is because higher potency steroids have a larger impact on our skin cells than lower potency steroids.

Note: Ooze is not a sign of detox or toxins leaving the body! That is a misconception.

Care tip: Cleanse oozy areas with saline solution and a cotton pad, dab gently. Refrain from wetting oozy areas during shower to help them dry up. Try not to wrap them up. Instead, air dry them. You may use products containing zinc oxide to help it dry up. A safe one to use is Calamine lotion (without menthol).

Please read here on how to deal with the ooze.

2. A bacteria infection
Oozing can also be caused by bacteria infection. It is usually difficult to differentiate between oozing due to reason 1 and oozing due to infection. A sign I go by is to check for any swollen lymph nodes near the oozing area. E.g. swollen lymph at the groin/hips from an infection on my feet, or swollen lymph behind the ears and on the neck from an infection on my face. Another sign is by how “angry” the skin looks - infected skin looks like it is fighting something and usually has some signs of inflammation (redness and swelling). You may or may not have a fever, but it is likely that you feel a sense of being unwell with an infection. The ooze could also be cloudy in appearance.

Care tip: Take a course of antibiotics if you are experiencing an infection. Some infections on TSW skin can persist a long time as the skin has been weakened and is less able to fight it off effectively.

Please read here on how to identify and manage infections.

Enlarged lymph nodes:
When the body is fighting an infection, the body circulates lymph fluids to bring fighter cells to the site of infection and dead cells away. Lymph nodes which hold lymph cells and fluid, can get congested during this time, and become enlarged. Lymph nodes are often enlarged for prolonged periods of time for those with TSW as TSW skin can get infected easily and is also constantly trying to repair itself.

Care tip: Do not worry about them; you may do some lymphatic draining massages or exercises to help move your lymph.

Inability to thermoregulate:
Many are confused by this symptom; it is bizarre and does not seem to follow any patterns. Most with moderate to severe TSW experience chills and feeling cold easily. Those with milder TSW tend to feel hot easily and fear the heat.

Experiencing chills, feeling hot easily, and swinging between the two, are because of our compromised skin barrier. Our skin regulates how we experience temperature as a literal barrier against the cold and the heat. When our skin is damaged, it is unable to perform this function, hence the inability to thermoregulate. When you have many open cuts and open wounds and when the skin is thin, the skin is unable to physically protect your body from temperature changes and feeling cold or hot easily is normal. Another reason for the inability to thermoregulate could be due to damaged nerve cells which are unable to signal and detect the surrounding temperature accurately.

A hot, warm or burning feeling on the skin could be due to nitric oxide levels, and/or inflammation of the skin.

Care tip: Always bring a jacket/sweater/cardigan wherever you go, and wear layers so that you may remove or put on more whenever you feel hot or cold suddenly.

Dyshidrosis/Bubbles on the palm or soles:
When bubbles appear on your palms or soles, this is a reaction to contact with an irritant or allergen. Our palms and feet touch many things and it can be extremely tricky finding out your allergen/irritant. I will be writing a checklist of allergens/irritants so that you may go through them and eliminate all possible factors.

Care tip: Eliminate all possible allergens/irritants and cleanse your hands with saline if you suspect that you have come into contact with an allergen/irritant.

Fatigue and weight loss:
Our body is using up plenty of resources to heal our skin. Skin regeneration uses up a lot of Adenosine Triphosphate (ATP). ATP are energy-carrying molecules in our cells that capture energy obtained from the breakdown of food to places where energy-consuming activities are taking place. This is why we feel fatigued easily, and in more severe cases with large areas of affected skin, lose weight. We needs lots of energy to heal and regenerate skin!

In cases which use Class 1 to 3 steroids, particularly in ointment form, topical steroids could have a systemic effect on cortisol production and thus experience more intense fatigue.

Care tip: Get LOTS of rest and do not feel guilty about it. Take care of yourself first before others. Have lots of high quality protein and lipids as that is what your skin needs! You need a lot more nutrients and nourishment than the average person, and it is best not to avoid too many foods. I have written an article on “Food, Supplements and TSW”, which you can find in the contents page.

Insomnia:
Why can’t we sleep? For our body to go into Sleep Mode, it has to feel safe, comfortable and relaxed. And our skin is definitely not that during TSW. It feels hot, sticky, itchy, painful. Some get jerking of the limbs when at rest. Not to mention the emotional and mental stress we face - anxiety of a flare up, fear of not recovering, anger at others who may not understand, grief over what you have lost. It is a lot to be going through. Our bodies are in a constant state of unrest, and it is no wonder we cannot sleep.

In cases which use Class 1 to 3 steroids, particularly in ointment form, topical steroids could have a systemic effect on cortisol production and insomnia could be more tricky to solve.

Care tip: Sleep when you can. Do not force yourself to sleep if you can’t, I find that most people feel more unsettled and frustrated when they try to sleep when they simply cannot. Watch something till you drift off to sleep, listen to calming music, use meditation apps, and check out Jacobson’s Progressive Muscle Relaxation to help your muscles relax.

Jerking and spasms:
TSW is taxing on our body and our body needs plenty of nutrients for healing. This means nutrients for other bodily functions can be depleted.

Jerking of the limbs, particularly the legs and at night/at rest, can be a sign of magnesium deficiency. Spasms and nerve pain can be due to electrolyte deficiency. Muscles need electrolytes such as potassium, chloride, sodium and magnesium in proper balance to contract and relax. An imbalance can cause issues with the body’s electrical impulses and cause muscle spasms.

Care tip: Take a magnesium citrate supplement if you are experiencing jerking of the limbs, and Neurobion supplement for the nerves if you are getting spasms.

Hair loss
It is common to experience hair loss during TSW, both on the head and on the rest of the body. Healthy skin is strong enough to hold hair follicles. When it comes to TSW skin, it is weak and unable to hold hair follicles, hence the loss of hair.

Many with TSW experience a pattern of hair loss on the head similar to alopecia areata, where the hair falls in clumps and cause round bald patches on the scalp.

Not to forget, the experience of TSW is stressful and traumatic, and this can cause temporary hair loss too!

Care tip: Do not worry about hair loss - once your skin is healthy enough, your hair will definitely grow back! For hair loss on the scalp, try not to use too many products on your hair. A simple shampoo or cleanser is enough, hair regrow tonics and creams are not necessary, your hair will grow back on its own once your scalp is healthy and trigger-free!

Hyper- and Hypopigmentation Hyperpigmentation is the darkening of the skin when it heals. The skin naturally produces more melanin when it is recovering as a protective mechanism against UV rays. This is normal and can fade with time. Hyperpigmentation tends to stay longer if the skin stays inflamed for longer. The trick for reducing hyperpigmentation quicker is to manage flare factors well so that inflammation subsides as quickly as possible.

Hypopigmentation is when the skin loses pigment and appears whiter/lighter than it usually is. This usually happens to TSW skin on bony joint areas such as the wrists, ankles, knees and elbows. Hypopigmentation on TSW skin happens from scratching too hard and too deeply. Pigment producing cells can be removed from the skin from excessive scratching. Hypopigmentation is unlikely to go away. It shows more obviously on darker skin, and can be invisible on lighter skin. It can show up when lighter skin is tanned.