an illustration of 4 people trying different methods for red skin syndrome

Dr. Aron vs Topical Steroid Withdrawal (TSW)

Eczema can be a brutal and almost unbearable skin condition. The first response to treating the itching and associated pain is typically a combination of self-care techniques, home remedies, diet and medical therapies. In more severe cases, the next step often involves a prescription for topical steroids.

Topical steroids (TS) are most often prescribed every few weeks for an average period of 7 to 10 days. This reduces the inflammation and when the steroid therapy is complete, the inflammation quickly returns – and with it, a worsening of the red skin that is signature of severe eczema.

At this point, individuals (who we will collectively refer to as “patients” from this point forward) become more disenchanted with each application of conventional steroid therapy. Simply put, the method is ineffective in treating eczema and the resulting skin often looks worse than before the topical steroid treatment began.

Patients begin to look for solutions on their own and this had led to a hot topic debate between two modern approaches that appear to be helping where modern medicine is failing – but are they helping? Are these solutions viable? Are there risks involved? What are the benefits? This article attempts to present a fact-based comparison, regarding the pros and cons of topical steroid withdrawal and the Aron Regime in resolving red skin syndrome.

TSW

Topical Steroid Withdrawal (TSW) stems from the belief that the skin can become “addicted” to steroids. When the skin worsens after a round of steroids, it is believed that the body has become dependent on TS and this explains why a patient must keep using greater amounts of TS to achieve the same effect. As the body is now addicted, the only solution is to quit “cold turkey” – as advised by proponents of TSW.

TSW was popularized by Mototsugu Fukaya, MD JDA Certified Dermatologist, who has since retired from the field of Dermatology. Dr. Fukaya acknowledged the appearance of increasingly red skin after using TS that was becoming more commonplace among patients using TS on a routine basis. He saw the resulting red skin as an iatrogenic condition (illness caused by medical treatment) and he advised that the discontinuation of TS would eventually bring the skin to it’s former state.

Red Skin Syndrome

The red skin that results from topical steroid use has just this decade been coined “red skin syndrome” or RSS. It is characterized by red, inflamed skin that occurs after the cessation of topical steroid use. RSS is separate and distinct of atopic eczema. The process of curing RSS may or may not influence eczema.

Dr. Aron

Dr. Aron has been treating Atopic Eczema for the last four decades with a treatment plan popularly known as the “Aron Regime”. He is a Pediatric Dermatologist, based in South Africa and he is insistent that the conventional approach to treating eczema is a failure. His concern is that treating eczema only with steroids will simply reduce inflammation temporarily but it will do nothing to help heal the skin. Once the topical steroids are discontinued, the eczema will quickly return and often, it will be worse. Why?

Dr. Aron offers a published medical study as evidence that 90% of chronic eczema sufferers carry Staphylococcus aureus (staph) bacteria on their skin (and he believes the incidence to be higher). Topical steroids have no effect on bacterial infection so why are they all that is conventionally prescribed when a patient is suffering with eczema?

It gets worse. When TS are applied to the skin, they will most certainly reduce inflammation but as patients are also typically advised to moisturize during this period, this creates the perfect “breeding ground” for staph bacteria to spread. When the steroid treatment is complete, the skin can be in a worse state than just days before. Dr. Aron states that RSS isn’t an iatrogenic condition at all. It’s a condition that is perpetuated by the use of topical steroids alone, as they make conditions more favorable for massive amounts of bacteria to spread due to the reduced skin inflammation. This explains why TS are quickly blamed for the resulting red skin after treatment.

Dr. Aron believes that an antibiotic must be used in conjunction with the TS and longer than 10 days (conventionally prescribed) to heal eczematic/red skin as Staphylococcus aureus, associated with eczema, is a more severe bacterial infection than is currently recognized by doctors. Just as strep throat can worsen if an antibiotic course is not completed, Staphylococcus aureus can worsen when the prescribing dose is not sufficient. It is interesting to note that Dr. Aron’s method cures RSS in nearly every case, leaving only the underlying eczema to deal with. This gives supporting evidence to RSS not being iatrogenic, but bacterial in nature. Indeed, if it were not the case, it would be inexplicable that the Aron Regime would have such a high success rate in curing RSS, as the Aron Regime will typically increase TS applications in the beginning and then taper this frequency over the next few weeks/months until little or no TS is needed to manage eczema.

While TSW advocates attribute RSS to a reaction of using TS, Dr. Aron views RSS as a sign of untreated bacterial infection. TSW advocates often acknowledge the existence of staph but deny the role of staph as the primary culprit in dealing with RSS. It’s also of interest to note that Dr. Aron doesn’t make any claims regarding RSS as it’s simply not an issue on the Aron Regime. His treatment is specifically for atopic eczema and he regards the curing of RSS as a simple by-product to his treatment.

Why the Debate?

Atopic eczema affects countless individuals all over the world. An improper diagnosis can mean years of extended suffering and since children have the highest incidence of eczema, the choice of treatment can prolong suffering in children by months and years.

TSW has also had instances of children dying while going through the process. TSW advocates argue that the resulting deaths were not directly correlated to TSW but in every case, the child had deteriorating health conditions that ultimately led to loss of life. There are news reported cases of close calls, deaths and other stories that don’t get reported. The latest story was a child who passed away just this summer. His Mother promptly left a Facebook TSW group and asked anyone with information correlating TSW and death to please message her. The fact that there are even arguments about it should have patients questioning TSW – and advocates questioning their decision to recommend TSW to others who are suffering an already debilitating skin condition.

Alternatively, the side effects of topical steroids are often promoted by TSW advocates, in defense of using TSW as alternative therapy. They believe there is a greater risk of side effects from TS than TSW. However, this uncommon view is not shared by most doctors and there is much evidence that TS have no side effects when prescribed and used correctly.

“It’s very important to continue medical treatment that’s been prescribed and speak to the doctor who’s prescribed that before you make a decision,”
“Alternative therapy doesn’t have much place in the treatment of dermatological conditions like eczema. Following proven, known safe methods of treatment is the way to go.”
~The chair of the Australian Medical Association’s Council of General Practice, Dr Brian Morton

What Are the Risks?

Topical steroids always carry “potential” side effects and antibiotic resistance is a community concern however, it is worth noting that Dr. Aron has treated thousands of patients suffering from both eczema and RSS and there has never been a single report of systemic/local side effects from the use of TS. Likewise, there has never been an incidence of antibiotic resistance developing from the Aron Regime.

Topical steroid withdrawal advocates typically oppose doctor prescribed medications while enduring TSW and this often leads to increasing health risks. Suffering is increased and this means the body’s metabolic processes will slow down. Infection is not typically dealt with. Enlarged lymph nodes (a sign of infection) are common throughout TSW while they tend to disappear completely on the Aron Regime.

There are also psychological implications to going through TSW, including many cases of severe depression and social isolation/alienation.

HPA Axis Suppression is another concern. The body regulates the amount of naturally produced steroids through the Hypothalamus-Pituitary-Adrenal (HPA) Axis. TS get absorbed into the skin, and can also be absorbed into the blood stream. If too much gets absorbed, it will “fool” the HPA Axis into thinking the body is producing too many steroids. The production of steroids will be reduced accordingly. This explains why the advice to stop steroids “cold turkey” can cause issues for many patients who immediately cease using steroids. Oddly, this advice is still given on many internet forums.

HPA Axis Suppression is commonly diagnosed for patients going through TSW while none of Dr. Aron’s patients see this. It should come as no surprise that HPA Axis Suppression and TSW share many of the same symptoms.

“The most feared complication of abrupt withdrawal of prolonged or high-dose corticosteroid therapy is suppression of the HPA axis, which leads to secondary adrenal insufficiency. The symptomology of chronic adrenal insufficiency is characterized by anorexia, nausea, vomiting, abdominal pain, weakness, tiredness, asthenia, prostration, myalgia, arthralgia, weight loss, postural hypotension, somnolence and depression.”

From the Book ‘Phobias: The Psychology of Irrational Fear’, by Randi E. McCabe Ph.D

ACTH stimulation, A.M. plasma cortisol, and urinary free-cortisol tests can all detect HPA Axis Suppression and ensure that it is not a concern.

What Does the Research Say?

A Random Controlled Trial (RCT) is the gold standard in medical research.

There is not a single RCT that supports Topical Steroid Addiction. There is strong evidence that the discontinuation of topical steroids will ultimately cure the skin of red skin syndrome but the “wait time” will do nothing to help with the skin condition of eczema during this period. It is unlikely that a RCT will be seen in the future as this would require that a sample group be allowed to suffer for a period of months to several years.

Is Topical Steroid Addiction an actual clinical condition? The National Eczema Association created a task force to look into this after an increasing amount of patient concerns. After several months of investigation into Topical Steroid Addiction and the resulting RSS, they published their finding here and in conclusion, it is stated, “TCS withdrawal is likely a distinct clinical adverse effect of TCS misuse. Patients and providers should be aware of its clinical presentation and risk factors.”

This doesn’t necessarily mean that a patient is misusing TS – as “misuse” can happen when TS are not properly prescribed. Once again, it seems that the system of conventionally prescribed TS are failing many patients.

The Aron Regime does not offer a RCT as evidence either. While Dr. Aron has successfully used this treatment over 40 years, it has just recently become “mainstream” and it is very likely that a RCT will be conducted in the next decade as hundreds of doctors have now adopted this treatment program in the last few years. Professor Peter Lio of Northwestern University ( Chicago Integrative Eczema Center ) has been following the AR precepts and has expressed interest in performing a trial at some point . Dr Carol Hlela ( Head of Pediatric Dermatology ) at Red Cross Children’s Hospital in Cape Town will be doing a trial with Dr. Aron in 2016, with the prospect of presenting a paper at the South Africa Dermatology Congress in August 2016. An academic analysis of the AR is in the pipeline. Finally, on this front, there is a significant chance that an Aron Regime clinic will be opened in London ( UK ) in February 2016 and this will enable Dr. Aron to start training doctors in the finer points of management of Atopic Eczema as well as the straightforward aspect of compounding in an appropriate way.

In continuing to look at the research, is there danger is this newer approach?

There is a published medical study in the Journal of Pediatric Dermatology with a RCT that supports extended, daily use of TS as a safe and effective treatment, as prescribed in the early stages of the Aron Regime. In this particular study, 70 out of 92 children were given TS daily for a period of 10 months and enough that they were virtually kept free of eczema. Both their treated and untreated skin were evaluated with dermoscopy, a technique which utilizes a mini-microscope to search for even the most subtle signs of TCS side effects with a result of no skin thinning in any child.

We conclude that routine, appropriate, long-term use of TCS (Topical Corticosteroids) in children with dermatitis does not cause skin atrophy. These data do not support the widely held belief that routine use of TCS will “thin the skin. Parents, pharmacists, and health practitioners should be confident about the safety of using this treatment.”

Length of Treatment

Topical steroid withdrawal takes months to years to cure red skin syndrome while the Aron Regime typically cures this condition in days to weeks. TSW does not help to improve the underlying skin condition so eczema may still be a problem of the same magnitude after TSW is completed. The Aron Regime substantially improves the condition and results are typically seen in the first few days.

After RSS is cured, the treatment of TS may again be resumed in both TSW and with the Aron Regime to manage ongoing eczema. For many, TS may be eliminated and patients may choose to treat naturally – if the severity of eczema allows for this.

I never advocate that all TS users should abandon them. I am not anti-steroid fundamentalist. What I am persisting here is only that some of them are really suffering from TSA. Both dermatologists and patients could use TS more safely without anxiety after studying TSA well.
~Dr. Mototsugu Fukaya (TSW advocate)

Quality of Life

TSW decreases quality of life substantially, usually for many months and years. It is a long-suffering, painful process and some individuals are several years in and still waiting to be healed. The Aron Regime improves quality of life almost instantly. The skin shows significant signs of improvement within hours and the patient is often living a normal quality of life again in the first few weeks.

illustration showing how to get from point a to point b and get rid of RSS

The Bottom Line

Getting to “Point B” is the goal. Both the Aron Regime and TSW will get a patient to this point. Once there, there is no more steroid withdrawal/addiction or RSS. Using topical steroids, at Point B, is completely optional for both the Aron Regime and TSW.  Regardless of the path in getting there, eczema will go into remission for some and others will need to address eczematic challenges going forward.  There is no cure for eczema so neither approach will cure the underlying eczema, however, the Aron Regime will positively affect the underlying eczema while curing RSS. TSW will eventually cure RSS but it has no effect on eczema – so patients must typically make an “educated guess” where the RSS ends and the eczema begins. There is no current approach that can promise perfect skin at the end and there are varying degrees of eczema that will always require less or more maintenance.

There is no evidence that the body will heal “better” by discontinuing the use of prescribed medications. Many illnesses require doctor intervention and for severe cases of atopic eczema, this certainly appears to be true. TSW is not a complementary therapy. It is an alternative therapy, meaning that there is no scientific evidence that it works and you are being asked to forego professional medical advice on the chance that it appears to have worked for someone else. TSW is nearly always “self-diagnosed” and rarely supported by medical doctors.

TSW does appear to be a real condition for a very small percentage of the population and evidence suggests that it only exists in adults who have used extreme amounts of TS for several decades. The idea that children need to be put through TSW is a concept founded entirely upon credulity. This is the opinion of the vast majority of all doctors and the National Eczema Association.

The strongest argument for using TS to manage atopic eczema lies in understanding that they can provide the fastest and greatest possible healing (along with relief) and that any possible side-effect can be monitored and detected early on – allowing you and your doctor to change direction if necessary. By making yourself aware of the risks, you can eliminate every one and achieve a far better quality of life and healing – without fear of getting RSS or experiencing any ongoing side effects of TS.

As the Aron Regime continues to influence and affect how the condition of atopic eczema is treated, the etiology of RSS will be better understood, the condition of RSS marginalized and likely eliminated altogether. It is a fallacy to believe that healing “naturally” is not without many side effects and risks. There are risks to any choice of therapy. It is advised that patients consider “Risk vs Benefit”, while working with a trained medical doctor, in treating the skin condition of both RSS and atopic eczema.

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