What you need to know about Topical Steroid Withdrawal (TSW) Syndrome

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What you need to know about Topical Steroid Withdrawal (TSW) Syndrome

Topical steroid addiction (TSA), topical steroid withdrawal (TSW) or red skin syndrome (RSS) has been found to be a side effect of long term over-use or misuse of topical steroids, particularly in patients with atopic dermatitis (eczema).  Whilst the diagnosis is not broadly recognized, research into the phenomenon is growing along with social media discussions on the topic and patient inquiries into steroid-free eczema treatments.

TSW/TSA is defined as the situation where the skin becomes “resistant” to TS treatment after frequent and prolonged application to sensitive areas, including the face and genitals.  The skin becomes dependent on the TS and exhibits signs of withdrawal on cessation of treatment.   Often the skin develops a more diverse and severe presentation after withdrawal from use of topical steroids, than it had pre-treatment.

TSW/TSA of was first described by Australian researcher  Burry in 1973, where he observed that patients became increasingly unable to do without topical steroids as eczema would reappear shortly after discontinuation.  Rapaport and Lebwohl reported that this rebound reaction can affect the entire body’s surface, renaming it Red Burning Skin Syndrome2.

TSW rebound reaction can last from weeks to months and in some cases years.  The first phase typically involves the spreading of a red and burning rash throughout the body followed by weepy, itchy and scaly skin.  The skin is at heightened sensitivity making it reactive to the slightest stimulus, including seasonal change.

Research into the changes occurring in the skin during TSW has shown epidermal atrophy (skin thinning), immunological changes leading to a Th2 dominance (as often seen in atopic dermatitis), changes to expression of glucocorticoid receptors, and release of stored Nitric Oxide which leads to a dilation of blood vessels and the characteristic redness associated with the condition1.

While there is no agreed upon treatment protocol used for TSW, treatment can include tapered topical steroid use, antibiotics, antihistamines, analgesics and systemic steroids in severe cases.  Other treatments which may be effective include regular moisturising with a hypoallergenic moisturizer, cold packs/cool compresses/wet wrappings, allergen avoidance, and psychological support.  

TSW can be a serious condition and requires professional support and advice, including medical supervision.  The Psoriasis Eczema Clinic takes a holistic and integrative approach to TSW.  We work with the patient to find suitable steroid free eczema treatments, including topical and oral support, to work in safely with medical care.  

If you would like further information about the Psoriasis Eczema Clinic approach, please contact the clinic.


Fukaya, M., Sato, K., Sato, M., Kimata, H., Fujisawa, S., Dozono, H., … & Minaguchi, S. (2014). Topical steroid addiction in atopic dermatitis. Drug, healthcare and patient safety6, 131.

Hajar, T., Leshem, Y. A., Hanifin, J. M., Nedorost, S. T., Lio, P. A., Paller, A. S., … & Simpson, E. L. (2015). A systematic review of topical corticosteroid withdrawal (“steroid addiction”) in patients with atopic dermatitis and other dermatoses. Journal of the American Academy of Dermatology72(3), 541-549.

Juhász, M. L., Curley, R. A., Rasmussen, A., Malakouti, M., Silverberg, N., & Jacob, S. E. (2017). Systematic review of the topical steroid addiction and topical steroid withdrawal phenomenon in children diagnosed with atopic dermatitis and treated with topical corticosteroids. Journal of the Dermatology Nurses’ Association9(5), 233-240.

Fresh fish or fish oils: Which is best for healthy skin?

Fresh fish or fish oils

Fish oil supplements can have anti-inflammatory benefits, but is it better to take supplements or eat the real thing? Learn why we rarely prescribe fish oil

Over the years we have heard many arguments for and against the consumption of both fish and fish oil supplements for skin health.  A healthy diet rich in fresh fish would seem like the obvious way of topping up your Omega 3 stores, however fear of mercury contamination and our desire for an easy fix has meant more of us are choosing to take fish oil supplements. But when it comes to treating psoriasis and eczema, are fish oil supplements all they’re cracked up to be?

Diet Vs Supplements: What’s the evidence?

Fish oil is a rich source of omega-3 essential fatty acids.  These fatty acids are referred to as “essential” because the body cannot make them and therefore we are reliant on regular dietary intake to support the body’s needs.  Omega 3 fatty acids are required for many body functions including regulating inflammation, blood pressure, clotting, platelet aggregation, brain health and reproduction.

Due to their anti-inflammatory properties, it is only natural to feel that taking fish oil tablets would benefit an inflammatory skin condition; however the evidence is mixed at best.  A recent 2018 Meta-Analysis of the use of fish oil supplements to treat psoriasis showed no clinical benefit (Yang, S., et al, 2018).  Similar results have been found with eczema. 

The strongest evidence to date appears to be in favour of the consumption of fresh fish over the use of supplementation.  A 2007 study showed that high fish consumption (more than 1-2 serves per week) during pregnancy and late infancy decreased the fish of atopic dermatitis (LISA study group, 2007).  Fish consumption as part of a Mediterranean style diet may also be beneficial for psoriasis patients due its association with reduced cardiovascular risk factors, a common comorbidity of psoriasis. 

In summary, the evidence points towards ditching the fish oil supplements from your skin care routine and replacing them with more fresh, oily fish as part of a well balanced diet. 

Which Eczema Type Are You?

Which Eczema Type Are You?

Which Eczema Type Are You?

Do you know which type of eczema you have?  Chances are the answer is no and you wouldn’t be alone.  The reason for this is that when most patients are diagnosed by their medical professional, they are simply told they have eczema – nothing more, nothing less.

The problem is the word “eczema” can be used as a very broad term to describe a number of different conditions, each with their own set of symptoms, triggers and treatments.

Let’s have a closer look:

Atopic Vs Non-Atopic – Atopic Dermatitis is an inflammatory skin condition associated with high risk of related allergies such as asthma and hay fever.   Many of us have heard the terms eczema and atopic dermatitis used interchangeably, however they are not one and the same thing.  It is important to note that not all eczema’s are atopic, which essentially means, they are not all triggered by allergies.  Therefore avoiding common allergens such as dairy, wheat, dust mites and pollens may not make any difference to the skin at all.  If you are not sure if you have atopic dermatitis, your qualified health practitioner can order tests which can confirm this for you.

Patient Age – The age of the eczema sufferer is also relevant.  Studies have shown that children under the age of 5 are more likely to have food allergies than adult patients, who are more likely to have aeroallergens such as dust and pollens.  Those with early onset eczema (from infancy) are also at a higher risk of related allergies such as asthma and hay fever, than those who developed eczema later on in life. There for your age can not only determine if you will have allergy triggers but which ones they are more likely to be.

Acute or Chronic – Research has shown that acute forms of eczema have different immunological drivers to chronic eczema and therefore, should be treated differently. Acute eczema is often very sensitive and reactive, whereas chronic eczema tend to have a higher tolerance to treatments.

Now that you understand that eczema can have many different presentations and treatments, ask yourself this…Have you been prescribed a different treatment depending on the type of eczema you have, or the stage of your flare?

If the answer is no, then you are not getting the treatment you deserve. If you would like an individualized approach to the treatment of your eczema, see here

Eczema and Psoriasis: Same same but different

cream for Eczema

Have you ever noticed that most creams available over the counter for eczema, also say that they are for psoriasis?  This can be a little confusing given they are 2 completely different skin conditions. One condition presents with a broken, fragile skin barrier and the other with dry and thickened skin.  One is dominated by an allergic immune response and the other by autoimmune processes…

So how is it so many creams claim to improve both?  The answer is, most likely, they don’t!

Many of these creams can help with symptomatic relief such as reduced itch or dryness, which are symptoms that both conditions can share.  However, a topical treatment to help heal or clear eczema or psoriasis would require completely different actions.

For instance;

Eczema responds better to gentle treatments with minimal ingredients. This reduces the likelihood of an allergic or contact irritation response.  Skin barrier supporting ingredients, including hypoallergenic fatty acids and oils that mimic the natural fatty content of the skin are often very beneficial.

Psoriasis improves with treatments which include keratolytics.  These are ingredients that help to break down the skin, reduce scale build up and shedding. By removing the surface scale, moisturising ingredients can then reach the deeper layers of the skin.  Psoriasis skin is generally much more tolerant of active ingredients including herbal extracts, which have anti-inflammatory, antioxidant and antimicrobial actions.

Customising creams for optimal results:

Having your cream customized to not only match your skin condition, but the presentation of your condition, can help ensure you are getting the most out of your daily moisturising routine.  For instance, psoriasis or eczema which presents on the feet, should be treated very differently to that which presents on the face. This is due to differences in skin thickness and absorption between the two areas.

This is why PEC practitioners compound all topical creams according to the condition AND presentation, providing you with a customized formula which recognizes these unique differences.  And best of all, helps you avoid a bathroom cabinet filled with thousands of dollars of creams which claim to treat your skin condition, but don’t! �

Eczema News: Are you steroid resistant?

Eczema News - Steroid resistant

Jessica Simonis, Practitioner Integrative Dermatology (BHScNutMed, AdDip WHM)

Chances are you are familiar with the term ‘antibiotic resistance’ but what about topical steroid resistance?  Yes, it is a thing, and here is what you need to know…

Topical steroids have been the basis of eczema treatment for over 50 years and can provide fast acting anti-inflammatory benefits.  Whilst short term use can be beneficial, long term use can be associated with various side effects, including a gradual reduction in effectiveness over time (aka topical steroid resistance).

One of the explanations for this resistance is related to the bacteria Staphylococcus aureus, a common bacteria which can become pathogenic in up to 90% of eczema cases.  Research has found S. aureus produces toxins (AKA Superantigens) which can be found in the lesions of eczema skin.  These toxins are responsible for the release of significant amounts of inflammatory cytokines which correlate with the severity of eczema, including symptoms of itch as well as a resistance to the anti-inflammatory effects of topical steroids.  Studies have shown that a combination of anti-inflammatory treatments with antibiotic therapy works better than just the anti-inflammatory on its own, suggesting that the Staphylococci bacteria and their toxins may play a role in suppressing the benefits of topical steroid treatments.  aren’t working,

So if antibiotics and steroids stop working, what’s left?

The answer lies in nature of course! New research has found that herbal bioactive ingredients, including thymol and farnesol, have demonstrated a direct action on S. aureus bacteria and superantigens, including antibiotic resistant strains.  These ingredients are found in extracts of herbs such as thyme and the peel of citrus fruits.  Topical application of these ingredients has shown great benefit in the treatment of chronic eczema presentations. Read more here

The Psoriasis Eczema Clinic specializes in the treatment of chronic skin conditions resistant to conventional therapies. Our topical treatments contain a unique combination of herbal bioactive ingredients, shown to be effective in the treatment of superantigen associated skin conditions, including eczema and psoriasis. For more information on PEC Founder, Professor Tirant’s research into Superantigens and Skin conditions, see here

How can gut health affect your immunity?

Immune Health

Immune health plays a key role in multiple skin diseases, including psoriasis and eczema, but what does gut health have to do with your immune system? 

The health of our gut plays a significant role in determining the health of our immune system.  Gut associated lymph tissue (GALT) is the largest immune organ in the body, and the primary route of exposure to pathogens.  Essentially GALT acts as the gate keeper, keeping the balance between health promoting microbes (eg.probiotics) and disease promoting microbes (eg. pathogenic bacteria, fungi, yeasts and viruses).   When we are healthy, the gate keeper is fairly tolerant, ignoring a certain amount of nasty microbes as long as the balance is in favour of probiotics.

When we experience an imbalance in the gut microbes, the gate keeper becomes intolerant and hyper responsive leading to imbalances in the immune system, including chronic inflammation, allergy, autoimmunity and vulnerability to infection.

How will I know if my gut is out of balance?

Research has shown that those with chronic skin conditions such as eczema, psoriasis and acne, demonstrate alterations in their gut bacteria.  Symptoms of an imbalanced gut microbiome are not always expressed in digestive symptoms and therefore further investigations via stool testing may be required. 

So, how can you keep your gut in balance?

Frequent exposure to a diverse range of probiotics is important in order to keep the nasty microbes in check but also to help maintain the health of the gate itself (aka the gut barrier).  Ways to increase your microbial diversity include:

  • Increase consumption of plant based, fibrous foods (fruit, vegetables, nuts and seeds)
  • Include fermented foods, such as yoghurt and kefir (these are best kept to small amounts for those with inflammatory skin conditions due to histamine content)
  • Spend plenty of times outdoors immersed in nature (get your hands dirty!)
  • Avoid unnecessary antibiotics and opt for antibiotic-free/organic  meat and dairy products where possible
  • Avoid high sugar and high fat diets, which promote inflammation and growth of pathogenic microbes

If you would like to know more about how your gut health could be affecting your immune system, contact the Psoriasis Eczema Clinic today.


Probiotics and Eczema

What do probiotics do?

A balanced microbiome plays an important role in maintaining our immune health, including regulating allergies, autoimmunity and reducing infection.  Certain gut microbes have also been shown to influence mental health and our appetites.  With research into the microbiome now the next big thing, it seems there is a specific probiotic for almost every condition you can think of, but what does the research say about using probiotics for eczema?

Probiotics are helpful bacteria which protect us against harmful bacteria.  They occur naturally all around us and are found in particularly high amounts in fermented foods such as yoghurts, pickled foods, kombucha, kefir, Sauer Kraut and more.  For the last few decades, modern medicine has relied on antibiotics as a main stay of treatment in skin disease, with the focus on ‘killing the bad guys’ so to speak.  More recently, in the face of increasing antibiotic resistance, science is turning its attention to increasing the ‘good guys’ instead. 

Patients with eczema, as with many other skin conditions such as acne, rosacea and psoriasis, have been found to have alterations in their gut microflora when compared to healthy controls.  It is also well established that an early exposure to diverse microbes via natural birth, breast feeding, early animal exposure, and avoiding a sterile home environment are protective factors against the onset of allergic diseases.  This understanding has highlighted the importance of microbes in the regulation of allergic disease and led to multiple studies which have investigated the use of oral supplementation of probiotic bacteria as a potential eczema treatment. 

Do probiotics work?

The strongest evidence to support probiotics in eczema was from a 2015 study which found that a specific strain of probiotic helped to reduce the incidence of eczema when given to pregnant mothers towards the end of pregnancy, and directly to the infant up to 1 year of age (Rather, I., et al, 2016)

A more recent 2017 study investigated the use of the same strain of probiotic combined with oral immunotherapy in reducing anaphylactic reactions to peanuts.  Results demonstrated a significant reduction in anaphylactic and other allergic reactions to peanuts, which were maintained for at least 4 years after treatment (Hsiao, K.C., 2017).  Again, this suggests a vital role in bacterial exposure and immune regulation.

However, evidence to support the use of probiotics as a treatment of established eczema in older age groups remains elusive.   It is important to note that certain probiotic strains may also make your symptoms worse through due to their effect on the release of histamine.  Therefore, it is important to choose the right probiotic for your age and your condition.

Can eczema patients take probiotics with other medications?

At the PEC our Integrative Practitioners are trained in the field of nutritional medicine and can help you find the right dietary/nutritional solutions for your eczema.

To book an appointment, contact us at info@psoriasiseczema.com.au or call 03) 9770 5337


Hsiao, K.C., Ponsonby, A.L., Axelrad, C., Pitkin, S., Tang, M.L.K (2017).  Long-term clinical and immunological effects of probiotic and peanut oral immunotherapy after treatment cessation: 4-year follow-up of a randomized, double-blind, placebo-controlled trial.  The Lancel: Child & Adolescent Health, 1 (2), p97-105

Rather, I. A., Bajpai, V. K., Kumar, S., Lim, J., Paek, W. K., & Park, Y. H. (2016). Probiotics and Atopic Dermatitis: An Overview. Frontiers in microbiology7, 507. doi:10.3389/fmicb.2016.00507

Is ‘leaky gut’ or ‘leaky skin’ is the new culprit in eczema?

leaky gut or leaky skin is the new culprit in eczema

Many of us are now familiar with the term ‘leaky gut’ but have you heard of the term ‘leaky skin’?  Essentially both terms are referring to the same process which involves a break down in barrier function.   The function of the gut and skin barrier is to protect us against all sorts of nasties, including pathogens, chemicals, pollution and toxins.  When a break down occurs, the body is exposed to a plethora of insults, which can over-excite the immune system and cause inflammation.  

So is leaky gut or leaky skin the issue with eczema?

The answer is it can be both!  For many eczema patients, the skin becomes leaky due to a genetic trait which results in loss of function in the filaggrin (FLG) gene.  This gene is responsible for keeping skin cells tightly packed together.  When the FLG gene is not functioning, the skin becomes more permeable, not only letting water out but also letting uninvited guests in, including microbes and allergens.  Recent studies have shown that sensitization to allergens such as foods, dust mites and pollens may first occur through the broken skin barrier.  Furthermore, the itch-scratch cycle in Atopic dermatitis (AD) can also disturb the skin barrier due to the tears created in the skin.  This leads to a vicious cycle of re-flaring that AD sufferers are all too familiar with.

Having a leaky gut means that the intestinal barrier is compromised and substances that are not meant to penetrate the gut wall are able to, which can result in reactions to foods and immune over stimulation. Key markers of a ‘leaky gut’ have also been found in eczema sufferers and correlate with severity of the disease.  However, treatments targeting ‘leaky gut’, such as elimination diets and probiotic supplementation, have yet to demonstrate significant improvements in eczema skin. 

The good news is that treatments which target ‘leaky skin’, such as daily emollients, have shown benefit and can reduce the risk of allergen sensitization and water loss, helping to reduce inflammation and improve skin texture.

How will your PEC practitioner know if you have leaky skin or leaky gut?  Your practitioner is qualified to assess your skin condition and identify the underlying triggers causing your skin to flare.  Leaky skin can be effectively treated using our topical emollient formulations specifically compounded to suit your skin.  If leaky gut is suspected, your practitioner may refer you for further testing if required.

Practitioner – Jessica Simonis – Psoriasis Eczema Clinic

Choosing & Visiting an Integrative Dermatology Practitioner

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Choosing an Integrative Dermatology Practitioner.

Why would it suit me?

Integrative Dermatology (ID) is a health profession concerned with whole person health care, with a focus on treating both the symptoms and underlying triggers of chronic skin conditions.  Integrated Dermatology treatments combine the best of both conventional and evidence-based natural medicines, treating from the inside and the outside.  Integrative Dermatology celebrates the important relationship between practitioner and patient, ensuring a positive experience and the best outcomes for your skin.

Visiting the Integrative Dermatology Practitioner

Your Integrative Dermatology Practitioner will need a longer consultation with you to address your skin concern. The extra time is needed to listen to your story about your skin, your concerns, and for you to gain a deeper understanding of your condition and how it affects your overall health. The longer consult is also needed for the practitioner to assess Comorbidities. These are conditions which are often associated with chronic skin conditions and need to be addressed if your treatment is to be successful. This Whole Body Approach is one of the hallmarks of Integrative Dermatology, where not only the skin but the whole person is considered to shape your treatment plan.

During the consultation, your practitioner will make a detailed assessment of your skin health and identify the triggers which drive your skin condition.  Based on this information, you will be provided with a customized treatment plan, which addresses both the symptoms and triggers of your condition. 

Education forms an important focus in Integrative Dermatology and helps to empower you to make the necessary changes to better manage your skin condition and any associated comorbidities which may affect your health, or which you may be at risk for.

The result of seeing an integrative dermatology practitioner is a long-term benefit to your overall health, and an effective way to manage your chronic skin condition.

A Holistic Approach

There are many ways to help manage a chronic skin condition beyond the conventional medicine approach.  For example, the relationship between psoriasis and diet and lifestyle is clear. Moderate changes to your daily routine can make a significant difference in the health of your skin.

Important factors to consider for example are stress levels and effective stress management, body weight, and comorbidities or health conditions associated with your skin condition.

Diet matters

Despite many patients being told that diet has nothing to do with their condition, the latest science says otherwise. For example, the link between psoriasis and metabolic diseases such as obesity and diabetes has led researchers to investigate the benefits of various dietary protocols.  Those shown to benefit psoriasis typically have a high vegetable and fruit content, are rich in polyunsaturated Omega 3 fatty acids and antioxidants and are low in calories.  Some examples include;

  • Mediterranean style diet
  • Vegetarian diet
  • Gluten Free diets (particularly in those gluten sensitive)
  • Intermittent fasting
  • Ketogenic diets

Your practitioner will guide you regarding nutrition and lifestyle adjustments which apply to your specific skin condition.

Senior Practitioner- Phillip Bayer- Psoriasis Eczema Clinic

Stress and its Effect on Nutrition

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Stress and Nutrition 

Stress and Nutrition

In modern times, Stress has become our number one health enemy. Stress has become ubiquitous, and its effects often remain hidden, manifesting only in subtle symptoms at first. But, make no mistake; it can lead to enormous health issues down the line. 

Previously I discussed ways to help manage stress by improving exercise and more passive techniques such as breathing exercises. In this blog, I’d like to talk about stress and nutrition – its effects on nutrition and how we can utilize good nutrition to counteract stress and enable our bodies to better cope with the effects of it. 

Stress, anxiety, worry and overwork can lead to unhealthy lifestyle habits, which causes more stress, leading to a very harmful cycle.  Below is a list of common bad habits people sometimes indulge in when overwhelmed, tired and worried. 

Stress-Induced Habits 

  • Drinking Too Much Coffee: Usually increased stress means longer hours and pressure at work, so you may find yourself drinking more cups of coffee through the day to keep yourself going. 
  • Eating the Wrong Foods: Stress results in cravings for foods high in fat, sugar, and salt. This occurs due partially to increased levels of cortisol, the stress hormone. This may result in increased consumption of junk foods, sweets, and unhealthy snacks. 
  • Skipping Meals: Due to the time constraints which often come with periods of higher stress, eating a healthy meal tends to drop down on our list of priorities, and you might find yourself skipping breakfast or not eating lunch because there’s just too much on your to-do list. 
  • Mindless Munching: Emotional eating may also increase when stress is high, we eat when we are not hungry but because it feels comforting or chasing the “sugar high” 
  • Forgetting Water: as with skipping meals, drinking good amounts of water tends to decrease in priority, which may lead to dehydration. This is made even worse when the consumption of soda drinks, alcohol and coffee rises during times of stress. 
  • Fast Food: Because of the convenience of quick meals, stressed people often increase their consumption of fast foods, laden with anti-nutrients which negatively affect your health. 

The Impact of the wrong foods during stress 

  • Blood Sugar Imbalances: When your food demands are not met or when foods without needed nutrients are consumed, blood sugar fluctuations may result. In the short term, these fluctuations may lead to mood swings, fatigue, poor concentration and other negative consequences which will exacerbate stress. In the long term, greater health problems such as hyperglycemia and even diabetes may be the result. 
  • Side Effects of caffeine: Caffeine in excess can lead to poor concentration, anxiety, palpitations, lower levels of productivity, and problems with sleep. An even higher level of the stress hormone cortisol is often the outcome. 
  • Poor Health Outcomes: Chronic high stress and its effects on nutrition may have significant long term effects such as decreased immunity, worsening of an existing health issue or even the start of a new one, as is often seen in psoriasis and other skin conditions. 

Healthy choices during periods of stress 

In addition to having stress reduction techniques in place and ensuring enough quality sleep, it is vital to follow a healthy eating programme during times of stress. In this way, we can ensure that our bodies have a good supply of the nutrients it needs to counteract stress, and the body’s increased demands for nutrition is met. 

A fresh, clean diet is important – lots of fresh vegetables (not overcooked), fresh fruit, ample amounts of fresh water, good quality proteins, and healthy fats are essential. Limit anti-nutrients, such as refined carbohydrates & excessive sugar consumption, excessive caffeine intake, soda drinks, alcohol, processed and smoked foods and so on. 

The practitioners at Psoriasis Eczema Clinic are well-versed in helping you to manage the triggers of your skin condition. 

Phillip Bayer, Senior Practitioner 

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