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Topical Steroid

Addiction in Atopic
Dermatitis
Journal
28th November, 2015

Coach : dr. Eko Krisnanto


Sp.KK

Meiria
Sari
03011186

Topical Steroid Addiction


in Atopic Dermatitis
Author : Mototsugu Fukaya, Kenji Sato,
Mitsuko Sato, Hajime Kimata,
Shigeki Fujisawa, Haruhiko
Dozono,
Jun Yoshizawa, Satoko
Minaguchi
Published :
Date
: 14 October 2014

Abstract

The American Academy of Dermatology


new guideline May 2014
Topical steroid addiction or red burning skin
syndrome 2006 Journal of the American
Academy of Dermatology controversies
Purpose:
Better understand the illness
To spur discussion regarding topical steroid
addiction or red burning skin syndrome.
Keywords: topical steroid addiction, atopic
dermatitis, red burning skin syndrome, rebound,
corticosteroid, eczema

Introduction
(TSA) or
(RBSS).

simple fear,
patient
ignorance

National Eczema Association (NEA) assembled


a task force to elucidate the realities of the illness

1. How do you define steroid addiction?


TSA not referred to steroid addiction topical
corticosteroid addiction.
topical steroid topical corticosteroids (TCS)
dermatological
steroid topical and systemic steroid
addiction frequently and uniquely with the
topical form,
TCS was first used by Burry
in Australia in 1973.
Patients become unable to do without the TCS
eczema
Burrys directed more toward expressing
patients behavior.
Kligman and Frosch dermatological or
morphological

2. What are the clinical findings of


steroid addiction?
Before
withdraw
al
normal or
wellcontrolled
Itching
more
TCS do not
work as
well
Prurigo-like
eruptions
(Fig 1A)

acute
phase

After
withdraw
al
erythema
eczema
thickened
(+
prurigo )
(Fig 1B).
rebound
eruption

thickened
and
desquamat
ive skin

Mild
rebou
nd

flushing or
erythema
with or
without
exudative
edema

myriad of skin
(papules,
pustules, or
erosions )(Fig
2)
high fever
(102F)
skin
gradually
depressed
improves
and
(very
pessimistic
sensitive)
(Fig3)

Severe
rebou
nd

Figure
1
A.A typical appearance
of TSA, with prurigolike eruption before
withdrawal.
B.Appearance just after
trial of decreasing the
amount of potent
topical steroids. The
severity of addiction
is so intense that the
patient cannot safely
withdraw by a
gradual-decrease
method.
C. The rebound
erythema is
spreading after
complete cessation of

Figure
2
The

procedures of
withdrawal in
a severe case
of TSA.

A. Before withdrawal
B. 2 weeks after
withdrawal
C.3 months after
withdrawa
D.13 months after
withdrawal.

Figure
3A case presenting hypersensitivity after topical steroid
withdrawal.

The skin where a band-aid was placed and detached


(yellow arrows) shows an irritated appearance in the left

3. What do the skin lesions look like,


and how are they different to eczema?
Atopic
dermatit
is
neck,
knees, or
elbows
(flexor
parts of
the body)

Original skin disease


Distribution

TSA
not limited (not in
palms and soles)
Rebound eruption
central to
extremities (Fig4)
thin and pale
after withdrawal,
thickened

Figure
4An example of typical demarcation around
the wrists seen in the rebound eruption.

(A) at the peak of


rebound

(B) 1 month later

(C) 2 months later

4. Where on the body does


it usually occur?

Face (special ,
rosacea )

Armpit, genital
(thin )

Other areas
(latently,
difficult)

No original
lesion, no TCS
were ever
applied

Soles and palms


(rarely, Hand
eczema/housewi
ves eczema)

Whole-body
(potent TCS,
senile xerosis)

5. What strength of steroid and usage


pattern leads to steroid addiction?
not have a
longer periods of application
record of
applied
potent strength of the TCS the TCS

Histologically atrophy
after 6 weeks
(within 2 weeks) (Fig5)

After the
interruption
skin may
recover

TCS can be
resumed no
evidence really
prevents

Figure
5The result of immunohistochemical staining, using an antibody
against PCNA

2 weeks application of 0.05% clobetasol propionate twice a day, on


a healthy adult forearm.
Note: The epidermis became obviously thinner, and PCNA-positive
nuclei
(brown) decreased.
before

after

6. How is steroid addiction treated?

Switch to other medications


Paradoxically, systemic steroids
Abrupt withdrawal
Gradual or intermittent decrease
Time may be the most beneficial
medication

7.How common is steroid addiction


syndrome?
JAPAN 2000

Poorly Controlled Disease


19%
53%
28%

Adults
Children
Infants

3 Problems From the Viewpoint of Preventing


TSA or RBSS in the new AAD guidelines
The proactive
approach has
covert meanings

potent TCS
proactive approach
reactive approach

Tachyphylaxis and
TSA are different
problems

With repeated use same


agent

Undertreatment
should not always
be regarded as
inadequacy

steroid-phobic patients
short-term observation
effective

Is it also effective from a more longterm viewpoint?


Did the number of patients with
adulthood atopic dermatitis increase
after dermatologists began to
prescribe TCS several decades ago?
Why do patients with atopic
dermatitis only complain or worry
regarding TCS use?