Confirming the diagnosis of TSW was problematic because with an absence of diagnostic criteria, TSW could be considered the most likely diagnosis only based on history and examination findings. The differential diagnosis of TSW includes atopic dermatitis itself and allergic contact dermatitis (often to an ingredient in the vehicle of topical agents) as primary considerations. However, the full differential diagnosis of atopic dermatitis must also be invoked at times, including cutaneous T-cell lymphoma, psoriasis, scabies, and other entities, which can present with eczematous skin. Many of the symptoms seen in TSW may also be seen in severe atopic dermatitis; however, others are more typical of TSW and were thus helpful in differentiating between the 2 diagnoses. Burning pain was reported in 65%; excessive skin desquamation, in 75%; swelling, in 65%; and skin sensitivity, in 47%. Signs that have been reported commonly (but not necessarily exclusively) in TSW were seen in a number of patients: diffusely red skin, 100%; elephant wrinkles, 56%; red sleeve, 40%; and the headlight sign, 29%. Because of difficulty in accessing patch testing, exclusion of allergy to TCSs, or components of TCSs, was not possible in this population. Had it been readily available, however, patch testing would have been impractical in a number of patients because of their widespread red skin.
Suggested diagnostic criteria for TSW were devised following analysis of the 55 patient histories and clinical features (Box 1). All patients seen fulfilled the suggested essential criteria. Forty (73%) of the 55 patients met 5 or more of the key diagnostic criteria, and 48 (87%) of the 55 patients met 4 or more. Had these features been assessed prospectively and proactively, however, it is believed that significantly higher proportions of patients would have fulfilled 5 or more of the key diagnostic criteria.
The female preponderance noted elsewhere with TSW, while seen in this population, was less pronounced at 56% (31/55) of the total group. This might be because none of the patients in this sample had used TCSs for cosmetic purposes, which may be more commonly observed in women. Instead, 76% had an initial dermatological diagnosis of atopic dermatitis, whereas in Hajar and colleagues'4 systematic review of TSW, where 81% of cases were female, only 33% commenced TCS use for atopic dermatitis. The problem of TCS misuse for cosmetic purposes as reported in Africa19 and Asia20–22 (particularly India23,24) does not appear to exist in Australia.25
The numbers of children presenting with possible TSW were higher than previously reported in the literature, and younger adults were more commonly seen compared with older adults. Of the 69 cases seen over the study period, 14 (20%) were younger than 18 years (and were excluded from the analysis). This proportion was higher than the 7% found by Hajar et al.4 This could represent increasing parental internet research into TCSs over recent years and corresponding growing caretaker anxieties about long-term TCS use in children. The median age of adults presenting was 30.0 years. Younger patients have a greater propensity to seek health information online than older adults,1 and so it is possible that they are more aware and, as such, more concerned about possible TSW than their senior counterparts.
Obtaining thorough and accurate histories of TCS use was difficult; in many cases, TCS use fluctuated over the years with break periods in between, and their TCS use spanned decades. Patients were frequently unclear about the potencies and/or names of TCSs used in the past. Details of TCS use in childhood could not be determined even when their parent(s) accompanied them to their appointment (which was not an infrequent occurrence as parents were often involved in the care and support of their adult children following their cessation of TCSs). Identifying total years of TCS use was problematic as many patients reported significant periods with little or no TCS use (eg, during their teenage years or following a move overseas) before resuming and then increasing their regular TCS use. It has been reported that TSW can occur with as short as 4 to 6 weeks of frequent TCS use.2 However, the patients in this study reported much longer (but highly variable and thus difficult to quantify) periods of regular TCS use.
In Hajar and colleagues'4 systematic review, 97% of patients had a history of TCS use on the face,4 and this was a common, but not universal, finding among patients in this study as well. Eighty-four percent had used TCS on the face, and 60% of all patients reported using potent TCSs on their face. The higher incidence of TCS use on the face in Hajar and colleagues' review might reflect the larger proportion of patients with a history of using TCSs for reasons other than atopic dermatitis, as many of those conditions affect the face primarily (cosmetic/pigmentary use, “facial rash,” acne, rosacea, and perioral dermatitis were some of the initial indications for TCS use in Hajar and colleagues' study). In this Australian study, only 13 (23.6%) of the 55 patients had used TCSs for a purpose other than atopic dermatitis.
A history of prior use of oral corticosteroids for skin symptoms was commonly seen, with 42% (23/55) of the patients reporting use of oral corticosteroids for this purpose. Previous US research reported oral corticosteroid prescriptions to be “commonplace” in 5.9%26 of patients seen by a dermatologist for their atopic dermatitis. It is likely that a history of oral corticosteroid use indicates a more severe clinical picture with a consequent increased risk of TCS overuse and therefore TSW.
Topical corticosteroids were first used before the age of 13 years in 62% (34/55) of the patients, consistent with the high incidence of atopic dermatitis in childhood. However, cases still occurred in patients where TCSs were commenced in adulthood; 24% of the patients in this study reported not using TCSs until 21 years or older.
Twelve patients (22%) in this study resumed TCS use; however, 3 of them discontinued TCSs again at a later date. Twenty-two percent is likely to be an underestimate as it would be expected that some patients would not return for follow-up if they elected to recommence TCSs. This figure was higher than the 5% and 13% reported in 2 previous articles by Rapaport and Rapaport.2,14 This may be due in part to limited access to other therapies. Ten patients in this study were offered immunosuppressant therapy by their dermatologist or immunologist (5 of these reported taking it). One was given the option of participating in a trial using a biologic treatment. Another factor could be cost-of-living pressures, with many people unable to have a period of weeks (or months) off work as would be required for some patients experiencing TSW.
Although this exploratory study has a number of limitations, it does provide real-world evidence about the demographics of patients who cease long-term TCS overuse and the outcomes these patients experience. Clarifying histories of long-term TCS use is problematic. The ad hoc nature of presentations in the community makes comparisons between patients at similar stages difficult. In addition, this particular study cannot answer the most commonly asked question, “How long will TSW last for me?” Prospective studies over several years, following patients with differing TCS use histories, will be required to provide evidence-based time frame estimates for these patients.
Although there are currently no diagnostic criteria for TSW, and the symptoms and signs described in this condition are somewhat nonspecific, the combination of a typical history with characteristic features increases the likelihood of TSW. The proposed diagnostic criteria outlined in Box 1 reflect the findings from this study. A patient with a history of atopy, reporting prolonged TCS overuse, especially where such use has included the face and provided diminishing clinical benefit over time, is classic. Use of oral corticosteroids for skin symptoms appears to be a common feature on history and should be considered a risk factor for TSW. Following TCS discontinuation, patients experiencing TSW will typically report burning pain, excessive skin exfoliation, edema, and/or skin sensitivity. Widespread red skin may be seen in addition to elephant wrinkles, red sleeve, and/or the headlight sign. A significant proportion of patients in this study chose to resume TCS use. However, where an informed, competent patient with the previously mentioned clinical presentation remains motivated to eschew further TCS treatment, it would be reasonable to explore appropriate nonsteroidal options, monitor for complications, and provide (or arrange) any psychological support required.
More research into TSW is required to develop guidelines to assist with prevention, establish consensus diagnostic criteria, and recommend evidence-based management.
The author acknowledges and thanks Dr Peter Lio for his valuable suggestions, support, and assistance provided throughout this research project.
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