Updated: Jan 31
What are Topical Steroid Creams and what do they do?
Before we cover what topical steroids are, let’s take a step back and start with the basics. Steroids are hormones produced naturally in the body by the adrenal glands located just above our kidneys. Steroids produced by the body include testosterone, oestrogen, and cortisol. Corticosteroids are a class of steroid that are involved in suppressing immune response, stress response and regulation of inflammation. Synthetic versions of Corticosteroids are used to treat a multitude of conditions, including Eczema, and are available in many forms; oral, topical, injection and inhalers.
One of the most common forms of topical corticosteroid is hydrocortisone. This is used to suppress the immune system and reduce inflammation in response to a ‘flare’ when the natural response by the body is not sufficient, for example in a person suffering from eczema. Another form of corticosteroid is Prednisone, an oral steroid. Both of these medications contain high dosages of the stress hormone Cortisol and come with an extensive list of side effects including blistering, thinning of the skin, reddening of the skin, swelling, burning, itching, peeling, acne, dizziness, migraines, insomnia, aggression, blurred vision, irregular heart rate and difficulty breathing. These are just the most common side effects. Further down the list you can find rectal bleeding, increased risk of bone fracture and vomiting a substance that resembles coffee grounds – a sign of gastric ulcers, liver disease and autoimmune disease… YIKES.
So why on earth are these steroids prescribed?
Atopic eczema is described by the NHS as “a groups of skin conditions that cause dry, irritated skin”.
Wow, pretty vague huh..?
The cause of eczema is one that hasn’t been found yet but is generally considered to be the result of an overactive immune system resulting in flares, caused by external triggers. The stress (physiologically and mentally) can cause overstimulation of cortisol production from our adrenal glands. This high intensity of fight-or-flight response over a long period of time can result in a suppressed immune system and inflammatory response, referred to as Hypothalamic-Pituitary-Adrenal (HPA) axis suppression. The body releases large amounts of cortisol and adrenaline until eventually, it has trouble producing more. When we are constantly exposing ourselves to the triggers that cause the eczema in the first place, the adrenal system becomes fatigued and will stop working efficiently.
Unfortunately, this is where topical steroids come into play. They replace the cortisol that our body would normally produce and seem to ‘clear’ the flare we’re having within days. There is much rejoicing, we put on our party shoes and forget about it. But when we use these steroids repeatedly, they send signals to our adrenal system to take a back seat as they aren’t needed anymore. As you can imagine, that doesn’t help us when we stop using the steroids creams. We continue to expose ourselves to triggers/ don’t address the underlying health issues and rely on the steroids creams to see us through each flare up. There is also the issue of these creams being over-prescribed and over-used as doctors rarely give clear concise instructions. The lack of holistic treatment and time within western medicine means doctors only have a ten minute window with a patient and tend to just send them away with steroid creams for something that could be treatable through diet or environmental considerations.
Topical steroids are absorbed through the skin; percutaneous absorption. If your skin is damaged, they are absorbed at a faster rate. The area of the body the creams are applied also affects absorption; eyelids, genitals and skin creases are high absorption areas. In ‘healthy’ individuals, peak concentrations of topical steroids were found to enter the body 12 hours after application. However, the second layer applied was found to be absorbed quicker, at around 10 hours. In patients with eczema and psoriasis, the peak concentration in the blood was found 3 hours after application. Once absorbed, steroids make their way into cells via the cell membrane where they bind to receptors. The steroid-receptor complex then makes its way into the nucleus of the cell where it has the ability to inhibit the production of pro-inflammatory mediators such as mast cells and lymphocytes. This in turn reduces inflammation and suppresses immune response.
What is a flare?
The term flare is given when one or more symptoms of eczema or TSW appear on the skin. These symptoms can be one or many of the following: itchiness, red-brown-grey patches, dry, rough, inflamed, irritated skin, small raised bumps that ooze fluid when scratched, crusty patches of dried yellow ooze (be aware these could indicate a staph infection). Scratching whilst in a flare can further irritate and inflame the skin…easier said than done, hey. A flare is thought to be triggered by an overactive and inappropriate immune response when exposed to an irritant or allergen. Studies have found that eczema sufferer’s skin is unable to retain moisture. Stress, irritant and dry skin are the most recognised causes of flare ups. This does relate more to those suffering from eczema however, for TSW sufferers, a flare is likely to be continuous and will be exacerbated by adrenal fatigue.
Common flare triggers include chemicals found in in cleaners and detergents, rough or scratchy materials like wool and synthetic fabrics, raised body temperature from exertion, sudden drop in humidity, stress – physiological and psychological, allergies, upper respiratory infections, illness and hormones. When your body comes into contact with an irritant when it is in a hypersensitive state, a extreme reaction can occur. Antibodies, produced by white blood cells, attach themselves to the antigen (irritant). This signals other cells to release inflammatory chemicals such as histamine as part of its defence mechanism. This promotes more inflammation. A healthy adrenal system will mediate the production of histamine inflammatory responses, however in those with adrenal fatigue, this control diminishes. Unfortunately, it’s a vicious cycle of elevated histamine levels putting further strain on a depleted adrenal system which in turn pushes histamine levels higher.
What is topical steroid withdrawal?
As described by the National Eczema association, ‘topical steroid withdrawal is an effect of prolonged, frequent use of topical steroids’. The research on this condition is sorely lacking despite being needed to understand just how horrific the effects of topical steroids really are. The thousands of people suffering with topical steroid withdrawal could certainly tell you themselves just how dangerous steroid creams are. It can affect any life stage and symptoms can range from mild to severe. Unfortunately, Topical Steroid Withdrawal is not recognised as a diagnosable condition within the dermatological community nor is topical steroid addiction, meaning that sufferers are left without clear treatment options. They often feel overlooked and un-heard when practitioners try to push topical steroids as the only “cure”.
What we do know is that it seems to be very much linked to the adrenal insufficiency previously mentioned. Our adrenal glands naturally produce Cortisol while the hypothalamus-pituitary-adrenal (HPA) axis controls the regulation of its release. Production normally peaks in the morning when we first awaken in order for us to get goin’ and start the day. It plays a vital role in our physiological stress response and is involved in the fight-or-flight sympathetic nervous system response. When we repeatedly use a synthetic version of cortisol in the form of corticosteroid topical creams and oral medications, our levels of cortisol in our bodies become too high which can lead to increased risk of diabetes, insulin resistance and cardiovascular disease. Due to these high levels of cortisol, our Adrenal glands start to make less and less of the hormone themselves. This is known as tertiary adrenal insufficiency. Once this happens, our adrenals can take some time (many months) to get back up and running again. In the meantime, we can experience inflammation, fatigue, weakened immunity, depression, aching joints, tendency to feel cold and difficulty sleeping. I can confidently say that I suffered with all of these during topical steroids withdrawal, and I know many others do as well.
Ok, so I think I have topical steroid withdrawal, what can I do??
Topical steroid withdrawal is a wild ride and there’s not a lot that you have control over. There isn’t one set cure that fits all. Having said that, don’t despair! Here’s a list of things you can do to support your overall wellbeing through this difficult time.
· Adrenal health – Addressing the health of your Adrenal gland should probably be first and foremost on your list of things you have control over. Now, there is an Adrenal Fatigue Diet but having looked at it, it seems to be just following the basis of a balanced diet e.g. Good sources of protein daily, wholegrain carbohydrates and an increase in portions of vegetables daily as the B vitamins present are considered beneficial. Avoidance of white sugar, highly processed, fried foods and sugar-sweetened beverages should be followed.
· Circadian rhythm – To encourage your adrenal glands to start producing cortisol in its natural cycle, you should give attention to your wake-sleep cycle, or the Circadian rhythm. This means addressing your sleep. Winding down in the evenings with low level lighting, no screens and a calming activity such as reading can increase the quality of your sleep by increasing Melatonin production. In addition, upon waking, try to avoid looking at your phone or reaching straight away for the coffee. Instead, consider getting straight out of bed and outside to breathe in the fresh air and feel the sun on your skin (harder in winter months of course or for those who work shift patterns). That first sunlight within the first hour of waking will encourage your adrenals to start producing cortisol on their own.
· Focus on gut health – With the vast amount of research that’s recently been done on gt health and its many benefits, lots of information can be found online about how you can support your gut. Increasing the amount of fibre you’re eating e.g. increasing vegetables and wholegrains, will help to feed the bacteria that we want to keep within our guts. That’s a great place to start but if you wanted to take it further, consider eating products such as a natural yoghurt which has live bacteria, Kefir or kombucha (just be aware that there may be lots of added sugars in Kombucha so choose wisely).
· Focus on eliminating triggers – If you’re noticing a pattern where you get a case of the itchies when you’re in a certain room or you go to visit a certain person, ask yourself if there could be something in the environment that’s causing you to flare. Is it dust? Animal dander? Mould? Investing in a good quality air-purifier with an HEPA filtration system is worth doing although can be pricey. When I was suffering with TSW, we ended up having all the carpets pulled up as they were definitely contributing. If it is a beloved pet that’s flaring you, please don’t get rid of them! Just be mindful that you may have to take ani-histamines, cover your skin when interacting with them or ramp up the hoovering a little more throughout the day. Most air-purifiers do address pet hair/ dust as well.
· Protein – Protein intakes increase when our body is under physiological stress e.g. during disease or after a surgical procedure, however they also increase when addressing wound healing. Think of your skin trying to repair itself, one of the most important building blocks it needs it protein to do so. Our everyday protein needs are ~0.8g of protein per kg of body weight. So for example if we take a 60kg person, they would need 48g (0.8 x 60) of protein per day. When considering promoting wound healing, this increases to ~1.2g of protein per kg of body weight. So our 60kg person now needs 72g of protein per day in order to support their healing. Aim to include lots of different sources of protein in your day, this can include baked beans, lentils, tofu, chicken, chickpeas, fish, eggs (if you’re not allergic), other animal products, dairy/ dairy alternative products such as yoghurts, peanut butter, hummus ect. Chances are, you may even be hitting your protein goal already as even wholemeal bread contains a fair amount of protein, so it’s just something to be mindful of.
· Stressors – You would have noticed the word stress coming up a lot in this article. It goes hand in hand with TSW. Many times, in the day and night I found myself noticing horrible new symptoms of my TSW and thinking WHAT THE HELL IS HAPPENING?! So yeah, I get it, it’s hard not to get stressed during a time when everything feels like its falling apart. Try to take 5 mins for yourself each and every day whenever you are able. You can even start smaller than 5. Maybe that initial sun-hit in the mornings is spent sitting in the garden listening to the birds, counting how many colours you can see in the flowers around you. Maybe its in the evenings, listening to a pre-made chill mix on Spotify with a cup of herbal tea while you do some stretches (if your skin allows). Maybe its spent sitting in an armchair next to a low-lighting lamp, escaping the world with a good book. Maybe you find peace and calm in baking or preparing your favourite meal. Maybe it’s just 30 seconds lying in bed listening to the gentle in and out of your breathe and feeling the rhythm of your chest rising and falling. It doesn’t have to be meditation or half an hour of yoga every day. It can be whatever you want it to be as long as it’s a quiet, moment of calm that enables you to breathe just a little easier.
Ultimately there isn’t one single cure for TSW nor eczema, its about being aware of your surroundings and lifestyle whilst also maintaining complete blind trust that your body knows how to put itself back together again and you struggle to recognise the person in the mirror. You will come back to yourself and your body will remember what its supposed to be doing. The human body is an incredibly efficient machine and it will always try to return to equilibrium. For me, it took 18 months. For others it is longer and for some shorter. You are not alone in this and if you need to talk to someone, my inbox is always open. I hope you’ve found some clarity from the information in this article and maybe now understand your body a little better.