Dr. Peter Lio discusses key points from his lecture Adverse Effects of Topical Steroids & Alternatives at the 6th Annual Elevate-Derm Alliance Conference at the JW Marriott Water Street in Tampa, Florida.

In this video

Dr. Lio makes clear that topical steroids remain "super important" and are often first-line because they're safe when used correctly, accessible, and reliable. The problem, he says, is getting "a little bit too comfortable" — telling patients to just keep using them with endless refills. Alongside familiar side effects like striae, atrophy, dyspigmentation, and increased cataract and glaucoma risk around the eyes, he focuses on topical steroid withdrawal (TSW), an entity he considers real and increasingly recognized — with over a hundred modern publications, formal recognition by the UK and Canadian governments, and patients who are "really suffering." He frames his approach in two parts: being a good steward of steroids (using them, taking a break, not endlessly escalating) and, for patients who present with TSW, avoiding steroids completely using tools that didn't exist a decade ago.

He walks through the TSW signs he sees — the sleeve pattern of confluent erythema cutting off sharply at wrists and ankles, the "elephant skin" sign, shedding and flaking, paresthesias, and temperature dysregulation — noting there's no clear dose threshold and the condition seems idiosyncratic. His "big four" management options are cyclosporine, phototherapy (for the right, not-too-severe patient), dupilumab (where he's had strong success and published a case series), and, more controversially, traditional Chinese medicine herbs. He champions an eczema action plan that splits care into a rescue phase (he uses topical steroids carefully here) and a maintenance phase with non-steroidals — TCIs, roflumilast, ruxolitinib, tapinarof — and a simple rule: if a patient is in the steroid phase more than half the month, it's time to reassess and escalate. He also shares his favorite integrative tip, the German black tea compress: a dilute second steeping, cooled in the fridge and applied by soft cloth to hot, oozing, irritated skin, followed by a good moisturizer.

  • Steroids are still first-line and safe when used correctly — the danger is getting "too comfortable" and just handing out endless refills, so be a good steward: use them, take a break, don't keep escalating on worsening skin.
  • Topical steroid withdrawal is a real entity — over a hundred modern publications, formal recognition by the UK and Canadian governments — with hallmark signs including the sleeve pattern, elephant-skin sign, shedding, paresthesias, and temperature dysregulation; there appears to be no clear dose threshold.
  • For established TSW, Dr. Lio's "big four" are cyclosporine, phototherapy, dupilumab, and traditional Chinese medicine herbs — and he aims to avoid steroids entirely in these patients.
  • Use an eczema action plan with a steroid-based rescue phase and a non-steroidal maintenance phase (TCIs, roflumilast, ruxolitinib, tapinarof); if a patient spends more than half the month flaring on steroids, stop and reassess the diagnosis or escalate to a biologic or phototherapy.
  • The black tea compress — a dilute second steeping, cooled and applied by cloth then sealed with moisturizer — is a cheap, gentle option for hot, oozing skin in severe atopic dermatitis, acute contact dermatitis, and diaper dermatitis; use plain black tea to avoid additive allergens.