Topical Steroid Withdrawal – Case #1

                                         

                                                                                      Before pictures due not adequately reflect the actual deep red hue that the patient presented with.

Eczema complicated by Topical Steroid Withdrawal

NO INFORMATION ON THIS POST SHOULD BE USED TO DIAGNOSE, TREAT, PREVENT OR CURE ANY DISEASE OR MEDICAL CONDITION.

This patient was successfully treated for symptoms of Eczema complicated by Topical Steroid Withdrawal(TSW). Over the course of 4 months significant improvements were made with approx. 95 – 98% of lesions clearing. The main treatment was with Chinese Herbal Medicine. 

This patient has had lifelong eczema, approx. 28 years,  with eczema lesions typically appearing  behind her knees and on her hands. The patient reports that she had begun to use steroids on her hands after which when she discontinued use of the steroids she promptly developed the following symptoms which are typical of Topical Steroid Withdrawal: a red swollen face and neck at times with discharge of fluid and swollen or puffy eyes. Unfortunately, the camera reduced the redness in the Before pictures. 

The dermatitis extended down to the neck as well. In many eczematic patients suffering from TSW it is not uncommon for the neck, upper chest, and arms to also become red and inflamed. 

In this case, the patient was spared those symptoms on her arms but developed a large inflamed papular lesion extending from the left rear deltoid along the upper trapezius almost to the neck and extending down covering the upper portion of the scapula and rhomboids. This lesion exuded a lot of fluid and the patient stated that this lesion would not heal when I met her. The patient had similar smaller lesions on each side of the umbilicus over the abdominis rectus (at the acupuncture point Stomach 25). There was also a flare up behind her knees, a typical region for eczema.  

A Very Brief Review Of TSW

The diagnosis of Topical Steroid Withdrawal seems to be slightly controversial. Personally, I often see the following presentation which fits the diagnosis of Topical Steroid Withdrawal: the patient’s report that upon discontinuing use of topical steroids they state the presentation of the eczema changed  and they develop deep erythema (redness) of the entire face, neck and often the upper chest and arms.  The skin is very dry and is often complicated by fluid discharge, fissures, severe scaling, lichenification(hardening of the epidermis – top layer of skin). Other areas of the body can and often are covered with eczema. There is a lot more that can be said about TSW and I’ve come to understand that there is great interest in this topic. I plan on discussing this issue more in the future.

Treatment

The patient actually came to me for treatment of shoulder pain once before we started the treatment of Eczema and Topical Steroid Withdrawal. I knew the patient was mainly interested in TSW, but she was feeling me out. She was also hoping to just do acupuncture. Acupuncture helps everything however in order to treat skin disease Herbal Medicine is the primary treatment. So we did one acupuncture treatment. The patient reported feeling very relaxed which is great. She contacted me to let me know that she thinks believes her skin improved for a few days, which I do not doubt. However, when I saw her again approximately two weeks later, she reported that the improvements were short lived and that her skin again had deteriorated. The changes were clearly visible. 

First Herbal Medicine Visit: When the patient arrived her eyes were swollen partly closed, there was some fluid discharge from the face, mostly clear with some mild yellow crusting. The skin on the face was red. There was white and yellow scaling and crusting on the face. Aside from that all the lesions detailed above were active.

In addition to examining her skin many questions were asked to help fine tune the Chinese Medicine diagnosis and herbal formula. I asked the patient about heat and thirst and the patient reported that her face always felt very warm and she was feeling warm in general which is abnormal for her. 

I typically provide 1 – 2 weeks (usually 2 ) of herbs at the first visit. The patient was leaving town therefore I provided the following herbs, not in order of quantity, for 3 weeks. In total it was 24g of granulated herbal extracts per day which she was instructed to split into two doses with hot water every day. 

Huang Bai                  

Huang Qin                   

Huang Lian                 

Shi Gao                    

Zhi Mu                       

Zi Cao                         

Sheng Di Huang         

Zi Hua Di Ding            

Ye Ju Hua                   

Da Qing Ye               

Di Fu Zi                        

Bai Ji Li                       

This formula worked very well and progress was seen from the start. One important point – these particular herbs are very bitter, don’t necessarily taste good, and can be difficult to drink at first but they can be very effective. I bring this up because I doubt the patient has any regrets about the bad taste now that her skin is improved. Some herbs taste good, some don’t. Taste is an important hurdle to clear if you are looking to improve your health and/or avoid certain medications.

From the 2nd visit through the 4th visit I saw the patient every two weeks. The formula above was modified according to changes in her presentation.  Starting with the second visit, there were clear improvements: the shoulder and body lesions started to heal quickly. There were significant improvement on the face even at the second visit but it progressed slightly slower than the body. I find this happens often but not necessarily always in TSW cases like this. 

                                                               
Two Month Follow Up

Two months after starting, in July 2021 the patient stated that her “face is the best it’s been since the TSW started”. Up until this point the herbs had been heavily on the drying side. The fluid discharge from the face had significantly reduced after starting herbs. However, the patient continued to report occasional small amounts of mild discharge up until week 6. At week 8 there was no discharge for 2 weeks. There was still some erythema(redness) although less intense. Flaking and Scaling of the face had reduced significantly. Yellow flaking on the face stopped after the initial batch of herbs. The patient still reported heat of the face although less than previously.

At this point, while the skin had improved tremendously it was very dry. With fluid discharge having stopped completely we were free to transition the formula more toward moistening the skin while still balancing out the moistening herbs with some bitter, dry herbs initially to prevent relapse.

We returned to a 3 week period between visits and the following was given for that time, 32g of granulated extracts per day split in two doses. Total grams provided for 21 days:

Dan Zhu Ye 

Xuan Shen           

Mai Men Dong       

Tian Men Dong       

Shi Gao                                 

Zhi Ban Xia(12:1)    

Shan Yao                 

Gan Cao                

Chai Hu                    

Zhi Zi                      

Mu Dan Pi                

Ye Ju Hua                 

Da Qing Ye           

Zi Hua Di Ding          

Bai J Li                       

Huang Lian             

Two Months, Three Weeks Visit

At the next visit, the patient presented with significant improvement. When the patient initially arrived with her mask on, I had to look very closely to determine if there were any lesions present. In the dermatology treatment room, under the photography lights only then could I see some remaining lesions and erythema. Her skin had responded well to internal moisturization via the strategy of nourishing yin and fluids amongst other strategies.

The scaling had appeared to slow up and appeared to be more adherent to the skin. Despite the skin definitely having more appropriate moisture, it was still dry. Those who have experienced this can attest to how dry the skin can become leaving plenty of room for improvement. 

I modified the formula again. This time I only provided 15 days of herbs, as the patient wanted to come in before a major event otherwise we would have stayed on a 21 day schedule. The following granulated herbal extracts were provided for 15 days, 32g per day split in two doses:

Xuan Shen

Bai Mao Gen         

Tian Men Dong   

Mai Men Dong       

Shu Di Huang        

Ye Jiao Teng         

Zhi Mu                    

Dan Shen            

Huang Qi              

Bai Shao (10:1)      

Ye Ju Hua              

Da Qing Ye            

Zi Hua Di Ding       

Huang Lian              

Gan Cao                  

Three and a Half Month Visit

At the next visit at the 3.5 month mark, the patient was significantly better overall. The shoulder lesion had healed weeks prior, the abdominal lesions were 99% gone, the lesions behind the knees were 95% better, and finally her face was somewhere between 90 – 95% improved. Because she had a big event coming up I decided to leave the herbs as is and refill, just to be safe. 

When I saw the patient next her face was 95% to 98% improved or more. Currently we are treating at a reduced dosage to help the skin fully heal and to consolidate the gains achieved thus far and prevent flare up. There has not been any flare up from the 3.5 month mark to the 5 month mark.  

I do believe based on experience that TSW can be helped with Chinese Medicine. Treatment times seem to vary between a few weeks to 1 year plus. However, every case truly is different .Please consult with a specialist before preparing herbs for yourself.

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