Pediatric Steroid Withdrawal Is Rare; Counseling Is Key

By Tom Whitfield

Neither Andrew Krakowski, MD, nor Mercedes E. Gonzalez, MD, has diagnosed topical steroid withdrawal (TSW) in a child, even as social media amplifies parental fear of the condition.

On the Society for Pediatric Dermatology’s official Don’t Be Rash podcast, Krakowski hosted Gonzalez, a pediatric dermatologist in private practice in Miami, Florida. Their clinical discussion examined suspected TSW in pediatric atopic dermatitis, competing diagnoses and ways to preserve the therapeutic alliance with families.

This was an expert podcast discussion, not a pediatric case series, prevalence study or treatment trial. It offered practical diagnostic and counseling guidance rather than new efficacy data.

How rare is TSW in children?

Published reports describe TSW mostly in women, particularly on the face and genital area, after long-term inappropriate use of potent topical corticosteroids (TCS). A 2015 systematic review by Hajar and colleagues in the Journal of the American Academy of Dermatology summarized that evidence (72[3]:541-549.e2; doi:10.1016/j.jaad.2014.11.024).

Both experts said pediatric dermatologists rarely encounter TSW in children, despite viral imagery online. The only cases either recalled involved adults applying ultrapotent TCS to their faces for rosacea over many years.

Those adult histories did not involve routine, appropriately supervised treatment of childhood eczema. The distinction matters because the published pattern centers on prolonged, inappropriate potent-TCS exposure.

How does social media drive steroid phobia?

A 2023 analysis by Nickles and colleagues in Pediatric Dermatology examined steroid-phobia content across social media platforms. Much of it consisted of patients describing negative personal experiences with TCS and discouraging other users from using them (40[3]:479-482; doi:10.1111/pde.15269).

That finding matters because the podcast describes families arriving at clinics already convinced their child has TSW. Negative first-person accounts on social media can shape the diagnosis they request before a clinician evaluates the rash.

Fear may also originate in primary care. Instructions to apply TCS for only 7 days, or only during severe flares, can imply that longer use causes harm and intensify steroid phobia.

What should clinicians consider before accepting TSW?

For a child with erythroderma and shedding skin, the experts listed three alternatives to TSW:

• An undertreated atopic dermatitis flare with persistent triggers.
• Staphylococcal superinfection with crusting and oozing.
• Eczema herpeticum.

Herpes simplex virus superinfection often appears as monomorphic, punched-out circular crusts within eczematous sites. Erythema extends beyond the usual borders of the underlying eczema.

Allergic contact dermatitis to a treatment product also belongs on the differential. In one recent case, patch testing confirmed a perioral lanolin allergy.

How can counseling preserve treatment trust?

Dismissing TSW outright risks eroding trust. Effective counseling begins by validating the concern and asking families to name their specific fear.

Clinicians can then ask what the family has read online or heard in primary care. Those details identify the source of steroid phobia and allow the clinician to address the specific concern.

The experts advised explaining that appropriately supervised TCS use “carries minimal risk.” Frequent follow-up visits allow clinicians to inspect treated sites for atrophy, acne and striae.

This sequence pairs reassurance with active safety monitoring. It acknowledges the family’s concern without accepting an unsupported diagnosis, while keeping treatment decisions shared.

Which options support a steroid-sparing strategy?

Three nonsteroidal creams can support that strategy in pediatric atopic dermatitis:

• Ruxolitinib cream (Opzelura).
• Roflumilast cream (Zoryve).
• Tapinarof cream (Vtama).

The experts said these agents can serve as first-line therapy for mild to moderate disease. They can also provide active maintenance after a short TCS course achieves clearance.

The same agents can help manage flares in patients receiving systemic therapy such as dupilumab (Dupixent). That gives clinicians another nonsteroidal route during a flare, without adding topical steroid exposure.

Krakowski and Gonzalez characterized pediatric TSW as “a communication challenge more than a diagnostic one.” Their practical message was to combine careful mimic exclusion, empathetic counseling and nonsteroidal choices with supervised TCS when needed.

As nonsteroidal options widen, pairing them with appropriate topical treatment and frequent monitoring may help more families achieve clearance while staying engaged in care.