Corticosteroid addiction and withdrawal in the atopic: the red burning skin syndrome.

We recently reported 100 patients with a chronic eyelid dermatitis that did not resolve until all topical and systemic corticosteroids had been discontinued. All of these patients had been treated with long-term topical corticosteroids, usually with escalating dosage and frequency of application. In the majority of patients, the initial symptom of pruritus commonly evolved into a characteristic, severe burning sensation. In many cases, systemic corticosteroids had also been administered to relieve the severe erythema and burning, but this only exacerbated the condition. In our opinion the continuing dermatitis resulted from “steroid addiction.” Unfortunately, the time required for corticosteroid withdrawal mirrored the time over which they had originally been applied, and was often protracted. Examination of eyelid skin usually revealed atrophy and telangiectasia. Patch testing, including four different corticosteroid allergens, demonstrated only irritant reactions but no relevant allergens. The corticosteroid antigens included budesonide, hydroxy-17-butyrate, clobetasol-17-propionate, and tixocortol. Of 100 patients, 87 were cured, but only after total cessation of corticosteroid usage. Withdrawal symptoms, manifested by angry erythema and burning, were long-lasting and severe. Although neither Cushing’s syndrome or adrenal insufficiency occurred, marked localized and systemic edema developed in some patients. Thirteen patients, unable to tolerate the severe flares on corticosteroid withdrawal, continued using these preparations and continued to exhibit skin rashes. They eventually sought medical care with other practitioners and were lost to follow-up. This paper expands our previous observations to include patients with similar syndromes localized in other body areas. These include “red face syndrome,” post-laser-peel syndrome, status cosmeticus, “red scrotum syndrome,” vulvodynia, anal atrophoderma, chronic actinic dermatitis, and “chronic eczema” in other body areas (Table 1). These conditions similarly resolved upon discontinuation of corticosteroids, suggesting that a significant proportion of these syndromes are attributable to chronic corticosteroid usage and “corticosteroid addiction.” The medical literature pertaining to these syndromes usually has implicated sun exposure, occult allergens, or psychosomatic reactions as the cause of ongoing skin eruptions. We consider “corticosteroid addiction” of the skin to be the pertinent etiologic factor in the majority of these patients.