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Fixing TSW (Topical Steroid Withdrawal)

EDIT: Click here to read a letter on TSW to the followers of HarlanMD.com, from Dr. Steve Harlan 

It’s a classic story repeated over and over: “I started using a topical steroid on my face for a rash, the rash got worse when I stopped using it, and my doctor then gave me a stronger topical steroid.” When the patient finally stops using their steroid, they can experience red, burning skin that sometimes lasts for years - or longer. This condition is known as Topical Steroid Withdrawal (TSW). In this article, you will learn what causes TSW, how to prevent it, and how to dramatically improve your own treatment of this condition.


Short on time? Check out our video below or continue onto our article underneath.





TSW: The Elephant In The Room


Before we begin, it’s important to address the elephant in the room. This article is featured on HarlanMD.com, where our primary product is Dr. Harlan’s SmartLotion®. As you may or may not know, one of the key ingredients in SmartLotion® is low-strength 0.75% hydrocortisone. The question that follows is obvious: How can ANY corticosteroid be used in the treatment for a condition that is literally CAUSED by corticosteroid use?

For decades, (and really, for centuries dating back to the ancient Egyptians) dermatologists have used compounded sulfur to treat minor skin rashes. Then in 1952, hydrocortisone received FDA approval and soon after followed the first cases of TSW. The Mayo Clinic scholars of dermatology at the time tried to treat TSW with their go-to, sulfur. Unfortunately,  they found that sulfur alone could not help. 

Eventually, those dermatologists tried sulfur compounded with low-strength hydrocortisone. With great intuition they decided to use low strength hydrocortisone to treat a hydrocortisone side-effect, and it worked. 


The Big Pharma Push


After that discovery, dermatologists began to use sulfur and low-strength hydrocortisone to treat not just TSW, but all types of recurring dermatitis and eczema. It was effective, and would not cause TSW or any other steroid side effects. This knowledge was passed around by dermatologists up into the 90’s, until Big Pharma started to exert more influence over the knowledge of the dermatology community.  Soon after, this knowledge of low cost treatment of TSW and many other types of dermatitis was simply “lost.”  But Dr. Harlan preserved it and developed it further to where the sulfur became part of a prebiotic strategy.  



The TSW Solution


Fully understanding what had been lost, Dr. Harlan created SmartLotion® for his patients. The reason why was twofold: First and foremost, even though SmartLotion® contains hydrocortisone, it will not cause TSW when used on the face properly for many different types of dermatitis. Dr. Harlan published a peer-reviewed study in Journal of Drugs In Dermatology about this exact issue. In 300 randomly-selected patients who had all used SmartLotion® daily, as instructed, for up to 15 years, he found zero cases of Steroid Acne, Steroid Perioral Dermatitis or Steroid Rebound Phenomenon. In dermatology, Topical Steroid Withdrawal (TSW) and Steroid Rebound Phenomenon are synonymous. 

The second reason Dr. Harlan created SmartLotion® was because it can be used as part of the cure or the “fixing” of TSW. Dr. Harlan has been teaching physicians for many years that if they treat TSW with both oral antibiotics and SmartLotion® simultaneously, the problems become dramatically better in a matter of days to a couple of weeks, instead of months or years.  For patients with mild steroid induced perioral dermatitis, they often did not need the oral antibiotics, just cool compresses and a slow tapering use of SmartLotion®. 


TSW can be seen here. Tsw is a nasty problem when you've used strong steroids

The Root-Cause of TSW


For those who are interested, strong topical steroids on the face cause three kinds of side effects:  

  1. Thinning or atrophy of the skin, which is well known and reversible.  
  2. Inflammatory and acne-like side effects caused by overgrowth of an abnormal microbiome. 
  3. The poorly understood immune dysregulation that causes burning rashes and TSW.  

Some people are relatively resistant to TSW, but others can quickly get into immune dysregulation problems with topical steroids on the face and neck.  Hydrocortisone valerate cream and mometasone cream were notorious for easily causing this immune dysregulation on the face.  On the body, this doesn’t seem to happen with topical steroids.

Physicians who know a little about TSW, know that patients must stop the topical steroid and keep the patient on oral antibiotics for months to correct the problem. However, most didn’t necessarily understand they were treating an immune dysregulation problem. That’s why Dr. Harlan has dedicated so much of his time to educating his colleagues. By adding SmartLotion®, dermatologists could attack the immune dysregulation problem directly, which dramatically improved their patients’ TSW treatment success rate and recovery speeds.




In Conclusion


If you are considering using SmartLotion® to help with your dermatitis issues and are worried that it contains hydrocortisone, fear not. SmartLotion®, when used as directed, can be used daily for years (including for seborrheic dermatitis) with no side effects. If you suffer from Topical Steroid Withdrawal (TSW), and you’re struggling with oral antibiotic therapy alone, you may consider adding SmartLotion® to your treatment routine.  Although it seems counterintuitive due to the 0.75% hydrocortisone, Dr. Harlan has treated many patients for TSW and Perioral Dermatitis with SmartLotion® over his 37-year career. 


Steven Harlan MD

Board Certified Dermatologist

Inventor of SmartLotion®


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