Your skin burns after stopping corticosteroid cream, has turned red even in areas where you never applied it, and is peeling in sheets? This may not be eczema coming back — it could be TSW syndrome. Here's how to recognise it.
What is TSW syndrome?
TSW syndrome (Topical Steroid Withdrawal syndrome) is an iatrogenic skin reaction that occurs after discontinuing long-term use of topical corticosteroids. It is also referred to as Red Skin Syndrome or corticosteroid dependency syndrome.
Crucially, TSW is not the same as eczema returning. It is a distinct condition with its own biochemical basis — a 2025 study by the US National Institutes of Health (NIH) demonstrated excess NAD+ (nicotinamide adenine dinucleotide) in the mitochondria of TSW-affected skin cells, distinguishing it from atopic dermatitis at the molecular level [1].
A 2026 narrative review in Frontiers in Medicine (Myles) summarises that TSW has gained recognition from both research and regulatory bodies — the UK's MHRA officially acknowledged TSW as an adverse effect of corticosteroids in 2021, and since June 2025, TSW risk information must appear on all corticosteroid packaging in the UK [2].
→ For a general overview of TSW, read our main article on Topical Steroid Withdrawal.
TSW syndrome symptoms
TSW symptoms typically appear within days to weeks of stopping corticosteroids, but can also manifest during use when the skin stops responding (tachyphylaxis).
Major criteria
Based on the Delphi consensus (Lio et al., 2023) and expanded diagnostic proposals (Lu et al., Journal of Clinical Medicine, 2026) [3]:
Burning skin — present in over 90% of erythematous-type TSW patients. Described as a scalding sensation. While eczema typically itches, TSW primarily burns.
Flushing — sudden, intense redness that spreads beyond the areas where corticosteroids were applied. In eczema, redness stays within original patches.
Thermodysregulation — disrupted body temperature control, sensations of heat, excessive sweating or chills. Not typical of any common dermatosis and a strong indicator of TSW.
Minor criteria
"Red sleeves" — redness covering the arms and forearms that stops sharply at the wrists. Palms are spared. An almost pathognomonic sign of TSW.
"Elephant skin" — thickened, wrinkled skin with reduced elasticity, typically on extensor surfaces and knees.
Exfoliation — extensive peeling in sheets, more pronounced than in typical eczema.
Neuropathic pain (zingers) — sharp, shooting pains in the skin with no parallel in standard dermatoses.
Metallic taste and skin odour — in the NIH case series (16 patients), 9 out of 16 reported this symptom. Not seen in eczema or other dermatitides [3].
Oozing, oedema, insomnia and secondary infections are additional common symptoms.
Diagnostic threshold: The current proposal requires at least 1 major (burning, flushing or thermodysregulation) and at least 3 minor criteria for TSW diagnosis.
Two types of TSW syndrome
The systematic review by Hajar et al. (2015), covering 1,206 patients from 34 studies, described two distinct clinical types [6].
Erythematoedematous type — more common, seen in patients who used corticosteroids for eczema. Characterised by intense redness, swelling, oozing and dominant burning. Skin is hot to touch, tense and extremely sensitive.
Papulopustular type — less common, observed in patients using corticosteroids for acne or cosmetic purposes. Features papules and pustules resembling rosacea. Spread beyond the application site is rare — 97% of patients had symptoms only at the site of application.
Women account for approximately 81% of reported cases, possibly due to more frequent corticosteroid use on the face.
Stages of TSW
Stage 1 — Acute inflammation (days to weeks after discontinuation): Skin rapidly reddens, burns and swells. Redness may spread to areas that were never treated. The most psychologically challenging stage.
Stage 2 — Exudation and oozing: Skin produces serous fluid and crusts form. High risk of secondary infection.
Stage 3 — Desquamation (peeling): Intense shedding of skin in large sheets. Skin beneath is dry but less inflamed.
Stage 4 — Remodelling and healing: Skin gradually normalises. 77% of patients see significant improvement within 3 months, though a minority may experience a prolonged course lasting years.
Stages may repeat cyclically — improvement can be followed by a flare, gradually becoming less intense.
How to tell TSW apart from eczema
| Feature | TSW syndrome | Atopic eczema |
|---|---|---|
| Dominant sensation | Burning, heat | Itching |
| Spread beyond treated area | Typical | Uncommon |
| "Red sleeves" | Characteristic | Absent |
| Thermodysregulation | Common | Absent |
| Metallic taste | Reported in ~56% (NIH) | Absent |
| Neuropathic pain | Common | Rare |
| Onset after stopping | Hours to days | Gradual |
| Biochemical marker | Elevated NAD+ | Different profile |
If your symptoms worsened dramatically after stopping, spread to new areas and burning dominates — consider TSW.
→ More on safe discontinuation: How to safely taper off topical steroids
What to do if you suspect TSW
Do not stop corticosteroids abruptly without consulting a doctor. Sudden discontinuation after prolonged use on large body areas can lead to HPA axis suppression (hypothalamic-pituitary-adrenal), a potentially serious condition.
Consult a dermatologist — ideally one familiar with TSW. Prepare a summary: which corticosteroids you used, for how long, at what potency and on which areas.
Document your symptoms — photograph your skin, keep a diary. This information is crucial for diagnosis.
The Delphi consensus (Zemlok et al., 2025) recommends corticosteroid discontinuation, supportive care and psychosocial support as the first line [4].
Supportive care during TSW
During TSW recovery, gentle skin care is essential. The Betuldiol® complex in EPIDERMA® products combines CBD with betulin — CBD helps soothe the skin while betulin supports skin barrier repair. This is not a cure for TSW, but supportive care that may help relieve symptoms.
DermBalance Complex® — a dietary supplement containing zinc, which contributes to the maintenance of normal skin, and vitamin D3, which contributes to the normal function of the immune system.
Learn more about DermBalance Complex®→ Full overview of scientific evidence: TSW scientific studies: research overview
Frequently asked questions
Key distinguishing features of TSW include: dominant burning (not itching), spread of symptoms beyond areas of corticosteroid application, thermodysregulation, "red sleeves" and neuropathic pain. If symptoms worsened dramatically within days of stopping and affect new areas, it is likely TSW.
TSW typically develops after more than 2–3 months of daily use of medium- to high-potency corticosteroids. The risk is very low with short-term use at low potency as directed by a doctor. Rare cases have been reported after shorter use, particularly on the face.
It varies — from several months to several years. Most patients see significant improvement within 6 to 12 months. A study by Fukaya et al. showed that 80% of adolescents and adults improved after stopping corticosteroids. Recovery duration usually correlates with the length and intensity of prior use.
There is no specific approved treatment yet. The 2025 Delphi consensus recommends corticosteroid discontinuation, dupilumab as first-line systemic treatment, and supportive care. A pilot NIH study with berberine and metformin showed promising results but these are preliminary data.
Gradual tapering under medical supervision is the safer approach. Abrupt discontinuation can lead to dramatic symptoms and, with prolonged use on large areas, potential adrenal insufficiency. More in our article How to safely taper off topical steroids.
Yes, paediatric cases are documented. Children's skin is thinner and absorbs more active ingredient. Fukaya et al. found that 75% of infants improved after discontinuation. More in our article TSW in children: what parents should know.
ITSAN (International Topical Steroid Awareness Network) unites patients worldwide. On Reddit, the r/TS_Withdrawal community has tens of thousands of members.
References
[1] Shobnam N, Ratley G, Saksena S et al. Topical Steroid Withdrawal is a Targetable Excess of Mitochondrial NAD+. J Invest Dermatol, 2025. doi:10.1016/j.jid.2024.11.026
[2] Myles IA. Topical steroid withdrawal: dissecting the controversy. Front Med, 2026. doi:10.3389/fmed.2026.1786331
[3] Lu MY et al. Examining the Unanswered Questions in TSW: A Case Series of 16 Patients. J Clin Med, 2026; 15:361. doi:10.3390/jcm15010361
[4] Zemlok SK et al. Initial Consensus for the Management of TSW: A Delphi Study. J Cutan Med Surg, 2025. doi:10.1177/17103568251388635
[5] Maskey AR et al. Breaking the cycle. Front Allergy, 2025; 6:1547923. doi:10.3389/falgy.2025.1547923
[6] Hajar T et al. A systematic review of topical corticosteroid withdrawal. J Am Acad Dermatol, 2015; 72(3):541-549.
[7] Blakely K et al. Topical steroid withdrawal and steroid phobia. JAAD Reviews, 2026; 7:52-57. doi:10.1016/j.jdrv.2025.12.001
[8] Moon Y, Lio P. Therapeutic Update on TSW. J Cutan Med Surg, 2026. doi:10.1177/17103568251413232
MUDr. Jiří Skalický
Founder of EPIDERMA®
This article is for educational purposes and does not replace medical advice. If you suspect TSW, please consult your dermatologist.