144: How Chinese Medicine Can Help Topical Steroid Withdrawal w/ Dr. Olivia Hsu Friedman, DACM

Topical Steroid Withdrawal (TSW) is becoming more well known, but many Western medicine practitioners don't adequately recognize or treat it. My guest today will explain how Eastern medicine can help.

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My guest today is Dr. Olivia Hsu Friedman, DACM, LAc, Dipl.OM. She is the owner of Amethyst Holistic Skin Solutions and treats eczema, TSW, psoriasis, and acne patients throughout the US in person and via video conferencing using only herbal medicine.

Dr. Olivia earned a Doctorate in Acupuncture and Chinese Medicine as well as a diploma in Traditional Chinese Medicine Dermatology.

Outside of the office, Dr. Olivia serves on the Board of Directors of the American Society of Acupuncturists, the Advisory Board of LearnSkin and the faculty of the Chicago Integrative Eczema Support Group sponsored by the National Eczema Association.

Join us as we talk about the Chinese Medicine approach to Topical Steroid Withdrawal (TSW).

Has Chinese Medicine helped your TSW? Let me know in the comments!

In this episode:

  • What is topical steroid withdrawal (TSW)?
  • The big problem with using steroid creams (even the OTC ones)
  • Your first step if your skin is addicted to steroid creams
  • How can Chinese Medicine help TSW?
  • Can elimination diets (or other specific diets) heal TSW?
  • Connection between your skin + your gut tissue (from a barrier perspective)


“I think lots of times people focus on so many different food groups that they end up not eating enough to really have the nutrients to heal.” [13:33]

“A lot of people don't recognize that that skin is also what's going on in your mouth. Also, going on in your trachea, going on in your esophagus and going on in your stomach. All of that skin is exposed to the outer world too. And when this skin starts to become compromised, that skin does too.” [14:23]


Find Dr. Olivia online

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144: How Chinese Medicine Can Help Topical Steroid Withdrawal w/ Dr. Olivia Hsu Friedman, DACM {FULL TRANSCRIPT}

Jennifer: Everything recording. Okay. Hi everyone. Welcome back. Today, my guest who's joining me is someone whom I came across because of a lot of the stuff that's going on out there with topical steroid withdrawal, though she does work on other issues with the scan, but that was my primary interest in speaking with her and I actually got connected to her from one of my guests, Abby Lay. And you guys know Abby because she has been a guest on the show a couple of times and she connected me with my guest today, Dr Olivia Hsu Friedman. Dr Friedman is the owner of Amethyst Holistic Skin Solutions and treats eczema, TSW or topical steroid withdrawal, psoriasis and acne patients through her us based practice, both in person and via video conferencing and she only uses herbal medicine in her practice. Olivia earned a doctorate in acupuncture and Chinese medicine as well as a diploma in traditional Chinese medicine dermatology.

Jennifer: Outside of the office, she serves on the board of directors of the American Society of Acupuncturist, the advisory board of Learned Skin and the faculty of the Chicago Integrative Eczema Support Group sponsored by the National Eczema Association. And just so you guys know, you can find her over at her website. It's amethyst, acu.com and I'll make sure to put all of that in the show notes so you can find her. Dr. Olivia, thank you so much for joining us!

Dr. Friedman: Oh, thank you for having me. It's a pleasure to be here.

Jennifer: I will tell you, this conversation really, it excites me because, and I think I should preface this for everyone listening. I have worked and do have a number of clients that have topical steroid withdrawal and the amazing thing that opened my eyes to the potential that what you're going to talk about today offers somebody going through this. Is that one of the clients that I have, she really struggled with TSW as a result of using steroids for many, many, many years.

Jennifer: And the response from other dermatologists she would see was, “Here's another steroid cream. Try these steroids.” And it just got worse and worse. And she was able to find a TCM practitioner local to her who truly changed everything. And we want to be clear here that not all TCM practitioners focus in this area. So that's why I wanted to have you here because I think the insight that you're going to impart to people who are struggling with this or have this concern today will really be life-changing. So just to frame the conversation, from your perspective, what do you feel or what do you believe topical steroid withdrawal is from the TCM or Chinese medicine perspective?

Dr. Friedman: Well, I would say that essentially the way Western medicine works is to try to find a mechanism that's gone awry and we try to find a chemical that will shut it down, right? Oftentimes we're very good at finding that chemical that can do that. But the problem is we're never really looking at, “Well what caused that mechanism to go awry in the first place. And what is causing all of these other symptoms to happen too.” And so as a result, if you keep shutting something down, shutting it down, shutting it down, you're not really solving the problem. And in fact, you're probably causing a larger issue to happen. So the way we look at it in Chinese medicine is that you're basically jamming a system for a long time to the point where it explodes, right? So what happens at that point is the system, in general, has a lot of different issues now and has been compromised in a lot of different ways.

Dr. Friedman: And in order to fix that, we actually have to build that system back up again or we have to eliminate some of the issues that are causing that system continually degenerate. And we have to rebuild it. So the way the Chinese medicine actually works in this situation is it helps to do a couple of things. One is you have this fire that's going on. And you need to calm that down. So when we talk about inflammation, when we talk about erythema, when we talk about all those kinds of things, we need to get that into under control because that is just continuing to make things worse and worse. So we need to calm that down. Okay? So, that's the first thing. The second thing is we actually need to put up scaffolding for the body so that we can actually support it while it's rebuilding.

Dr. Friedman: Okay? So, that's the next thing that Chinese medicine probably does. And then the third thing is it actually helps to rebuild that system or the many systems that are now probably affected as a result of all of these other things going wrong. So those are all the things that Chinese medicine does and that's why it's a customized medicine because everybody goes through this very differently and everybody has different parts of their systems that have been affected and different parts of their body that have been affected. And we can actually use herbs that actually address each one of these things. I think what happens is Western medicine is oftentimes we find again that one mechanism and that one chemical, but we're not looking at the myriad of symptoms and finding that chemical I guess that will affect all of these things. Right?

Dr. Friedman: And so that's why lots of people are on multiple medicines. They have this medicine for this, they have this medicine for that and before you know it, you're on seven different medications to handle this one skin condition that you have. Right? So Chinese medicine looks at it more like let's look at the whole entire system and let's figure out what are all the different herbs that are actually going to help to address the picture that you're presenting. And we look at it is everybody has a different reason for having these things. There could be constitutional issues that are making you more prone to certain things. There could be lifestyle choices that are leading to this and there could be a deficiency in your body to begin with that has never been resolved. And as a result you're just more prone to these kinds of things.

Dr. Friedman: So we look at all of these things and I think people are really surprised when they come in to see me and the initial intake can be up to 60 minutes because we're talking about every little part of their life and how all of these different things could have been playing into their skin condition. We're not just looking at them and saying, “Oh you have this and this is what your lesion looks like.” We're looking at every single system that's behind the scenes that are probably playing a part in this.

Jennifer: And I think one of the complicated things is that number one, topical steroid withdrawal is not just specific to topical steroids because steroid exposure is also a concern. It comes from inhalers, different medications. I mean we can end up with this chronic longterm exposure from a number of different avenues, which is quite easy, especially with over the counter medications.

Jennifer: We assume unfortunately that over the counter means you can take as much of it as you want. It's probably not going to do any harm. And that's not always the case. But then that also this can impact people with all different types of skin issues. And you were sharing with me some really interesting information about how do we get here, where steroids tend to be the thing, that is “the go-to crutch”. Every time you walk in with a rash, whether it's psoriasis or seborrheic dermatitis or eczema, it's like, “Here's a steroid cream.”

Dr. Friedman: Yeah.

Jennifer: What are your thoughts on that?

Dr. Friedman: Well, I mean it was the wonder drug when it was invented. Because it was the very first one that dealt with inflammation and was able to settle a lot of different instances of issues. So I think it became a very easy go-to and in things that are probably not as serious, it works. And you can get it over the counter. It's very accessible and for some minor things, it is a really helpful medication. The problem is, is when things start to become more serious. And I think oftentimes, the thinking is often if a little bit is good, then a lot is better.

Jennifer: Yeah.

Dr. Friedman: And so we have various levels of steroids that increase in their strength. And so I think that mentality is applied to a lot of these skin diseases as well as like lung conditions and other things that they use steroids for. But the problem again is that we're looking at one mechanism and we're solving it with one chemical instead of looking at the entire system and saying, “What are all these things that are leading to these specific symptoms?”

Jennifer: Yeah. Yeah.

Dr. Friedman: So I think that's where we're not completely treating the whole body and we're looking at things too… We're looking at too small of a perspective when we're trying to treat disease.

Jennifer: Yeah. You get lost within the forest amongst the trees. And you know what? To be fair, I think the same goes for some of the, we'll just say, lifestyle changes that people like to make with skin issues. And I want to mention this now before we dive into what are some of the ways that you look at topical steroid withdrawal? Because I want to offer this and as well as what you do to people listening to this who are seeking out help because topical steroid withdrawal is frankly… I've always said living with skin rashes as hell. Topical steroid withdrawal is like some really deeper level of hell to go through.

Jennifer: It's very hard. It can drive you to dark places that you never imagined you could go. And without appropriate support, I don't know how you make it through that tunnel unless you've just got some really deep desire to keep on going because a lot of people struggle tremendously. And so some of the steps that they will take is they'll read online, “Oh well, I'm going to clean up my diet. I'm going to eat a super clean, I'm going to only eat these fruits and vegetables because these things have whatever in them and I'm going to get rid of this.” And the diet gets whittled down and they think that that's going to fix it. Or they're… What are your thoughts on that initial step when you're at the point where your skin is addicted to steroids?

Dr. Friedman: I think people have to have a better understanding of where are you in the progression of your disease. And at certain points it does make sense to look at your diet and to change your diet and to improve it. And let's not get me wrong. I mean, it's always a good idea to eat healthy.

Jennifer: Yes. Yes.

Dr. Friedman: Right? I mean, we can agree that's always a good thing. However, if you're further along in your condition, those simple changes are not going to make a big enough difference because your system has now been compromised and beyond being compromised, it probably is not functioning properly and it's probably broken down to some degree. Right? And it needs to be fixed. So what you could have done with nutrients at the earlier stages is now no longer the answer. I think the way to look at it is if you break your arm, you're not going to bring out a bandaid and fix it that way. Okay? You actually probably have to go to an orthopedic surgeon and have it reset and be put in a cast and you probably will have to take some serious drugs too because the pain is going to be horrendous. So it's looking at that way. Like I think lots of times when people think of diet as being their solution, it's that bandaid to the broken arm.

Jennifer: And topical steroid withdrawal is just, it's a beast. And when you've gotten to the point where your body is so mixed up about whether it should be producing cortisol and what needs to happen and your hair is falling out and you just can't sleep and everything is thrown off, I think at least from my experience working with clients is that no matter what you do with your diet. I think cleaning it up is important. I completely agree with you. But I also agree that focusing and fixating on that as being the one way forward and being like, “Oh my gosh. It's got to be a food sensitivity. Or I must have a food allergy. It must be the food.”

Dr. Friedman: Well I think it's also… Sorry to interrupt you, but I think it's also a sense of control. Because if you have something like TSW, your whole life and body is out of control. And it's trying to find something that you can gain control with again. And diet is something that you can control. Right? And it is something you can think about and puzzle out, “Well, if I eat this, this set it out,” or whatever. The problem is that I think lots of times people focus on so many different food groups that they end up not eating enough to really have the nutrients to heal. So I really, really talk to my patients a lot about diet. And I think that if you have a definite food that's setting you off every single time, well, you know what? It's probably an allergy then it's probably the food group itself specifically.

Dr. Friedman: Right? And the other part of it is that when your skin has been so compromised, you then become sensitive to everything. Right? I mean, things that were once benign are now an issue. And I think a lot of people forget that skin, while they always look on the outside, right? That is your protective barrier to the outside world. But a lot of people don't recognize that that skin is also what's going on in your mouth. Also, going on in your trachea, going on in your esophagus and going on in your stomach. All of that skin is exposed to the outer world too. And when this skin starts to become compromised, that skin does too. And as a result, you become so much more sensitive to everything. So one week you can probably find that when you eat this food, it's triggering you, and the next week you'll eat the same food and it's not. And it's really because the skin can't tell the difference between what's a threat and what's not a threat anymore. And so it just over activates on everything.

Jennifer: Yeah. That's a great point actually. That is a great point that you bring up. And that makes me also wonder too. So one of my clients, and I was sharing this with you before we started, we realized at a certain point that what was probably going on here was TSW. And she found someone locally through TCM Dermatology, I think it's dot org. And that was so game-changing for her. Not overnight. I don't want to oversell here, guys. You're listening to this, you're going, “Oh, I need to find someone tomorrow. I'll feel better.” That's not how it works. It's a road. It's a long road.

Jennifer: But it was the first time with the help of the TCM, the dermatology doctor, that she really was starting to see relief. Her hair wasn't falling out as much. She was able to control body temperature more. Her skin wasn't as bad as she even in her voice sounded just so much stronger.

Dr. Friedman: Yeah.

Jennifer: So what is it about what you do that can support someone who is going through topical steroid withdrawal?

Dr. Friedman: Well, I think it's a combination of things. As I mentioned before, we're offering not just something that's quelling the symptoms that are going on. We're actually helping to rebuild the body system so that it actually is working properly again. And another thing that I want to add is that because we do spend probably a lot more time with our patients, there is that personal connection that allows us time to actually talk about things from an emotional and psychological issue as well.

Dr. Friedman: And that's an area where I really spend a lot of time with my patients, is really listening to them and hearing how they're going through this experience and helping them work with the emotional, psychological component of it. Because I mean, that is oftentimes, it's not an area that you talk about a lot in the Western world. I mean, and it's a huge part of any illness. One of the things that I found really interesting is that in the Western world we think of if you have something like a TSW, your skin then becomes this very, very red or very lots of times it doesn't look great. At the end of the day, it will affect how you feel about yourself. It'll affect how you think about yourself. And in the Western way, we think of it as this is your reaction to what you've got.

Dr. Friedman: But in the Eastern way, we think, “No. You actually have this condition and as part of these symptoms.” There's an emotional symptom that comes with that too. And you will start to feel this way as a result. And as your skin improves, those emotions will also recalibrate too. So we think of it more as a symptom and part of the pattern of your condition versus your reaction to having this skin condition. So I spend a lot of time talking to people about the emotional, psychological component of their condition through TSW. I mean, like you mentioned a number of times. I mean this is something where I have met up with a lot of people who are suicidal. I have met up with a lot of people who are in and out of the hospital. I've met a lot of people who have lost their jobs as a result of having this condition. Yeah. Yeah.

Jennifer: Isolated. You lose your relationships a lot of times as well.

Dr. Friedman: You're isolated from a lot of people because a lot of people also don't understand what's going on with them and they try to offer well-meaning advice and it's really very misguided. So it's a very, very lonely road. And so these are a lot of the things I talk about with my patients and I try to help them find their way back as well. So I think that's another part of healing is really dealing with that part as well. And I think it's something that speaks to the whole body versus this idea of you are like a car who has this part that's broken and needs to be fixed. And then in 20 minutes, you're all better. That's not the way the body works. It's so much more complicated than that.

Jennifer: No. It's not. And you use herbs as part of the process. I'm just curious. Is it the same type of herbs that you would use for other issues or does topical steroid withdrawal tend to have maybe a set of herbs that are more specific to it? I'm just curious how that works.

Dr. Friedman: There are a lot of different herbs that can be used in skin diseases. There are some that overlap depending on what the condition actually is. And then there's some that are very specific to different things. I would also add that because it's a very customized medicine, we're looking at people as individuals and we're saying, “What's going on with you that's different than somebody else? How are you constitutionally different than somebody else and therefore need different kinds of herbs to support that? How do you live and how does that support what's going on with your condition as well?”

Dr. Friedman: So there are some herbs that are common. And it's funny because I have treated a bunch of people who are on the same Facebook group and they'll start comparing the herbs that are in their formula and they'll say, “Oh well, Olivia gave me this, this and this. What about you?” And they'll see that there's some similar herbs, but what they don't understand is the ratio could be very different and how long they're actually going to be on that particular herb as well can be very different. And what they might start out with might be very different than what they're going to be on next week. So, they think they have the secret sauce and they'll say, “Oh, well. This must be the secret for TSW.” And it's like, “Well, it's a secret for you for this moment. But next week it may not be.”

Jennifer: Yeah.

Dr. Friedman: Try to give that to somebody else, you might not get the same results because there are very different situations.

Jennifer: Yeah. And the other thing that I think it's worth mentioning is that not all acupuncturists, no matter whether like my sister is five elements, she, she learned five elements, acupuncture and you're TCM. But not everybody specializes in skin. You're a part of this very specific subset of acupuncturists that have specialized in skin conditions. So what does that mean? Why should someone look for that if they're really struggling? I'm not saying that they shouldn't go to somebody that they trust in their own community, but your specialty is different.

Dr. Friedman: Yeah. I would say it's very similar to the way we actually have practitioners in the Western world. If you have a skin disease, chances are you're not going to a general practitioner or a pediatrician or whatever. You're probably going to somebody who's a dermatologist. And it's the same thing in Eastern medicine. Somebody who's gotten a specific degree in a particular area is obviously going to know a lot more about that. If you spend two years studying dermatology, you're going to know more than somebody who was trying to learn a general sense of how the body works and things like that.

Dr. Friedman: And I think that it's really important for people to understand that there are specialties in Eastern medicine as well. Just because you're an acupuncturist doesn't mean that you're an herbalist. Just because you're an herbalist doesn't mean that you're a dermatologist. So you really have to look at people's training and really look at is your problem something that they specialize in. And if it is, you will want to see how much training they've had.

Dr. Friedman: Somebody who has studied with Mazin Al-Khafaji in Eastern medicine for dermatology is more likely to be able to solve your problems for dermatology than somebody who did not. Dr Al-Khafaji is considered the master. In Chinese medicine, we study with masters and we follow them probably throughout our careers to gain more and more information about those particular areas. In Western medicine, you can go to any number of universities and probably study dermatology. So, that's a little bit different. But yeah. You want to see somebody who has that certification in dermatology. And then even in dermatology, lots of times we have people specialize in different types of dermatological conditions. I happen to specialize in TSW because I started seeing some patients and then helped them and then they just started sending more and more people.

Dr. Friedman: So I feel like I'm in a better place to help and serve people who have TSW. But I'll be honest, there's a lot of people who have never seen anybody who has TSW and are not familiar with it, but they might be awesome at acne or psoriasis or whatever. And I think different regions of the United States oftentimes lend themselves to different conditions as well. I mean, I know somebody who's in Hawaii and they're in a very damp types of climate all the time. So they come up with fungal diseases and all those kinds of things and they're great at that. And then I have people who practice in Denver and it's super dry and they have every single skin disease that has anything to do with dryness. So, I think where you're located and the types of patients who come to you can then make you a specialist. I mean, just like Dr. Leo is a specialist in eczema.

Jennifer: Yeah. Yeah. And here's another good question. With the support of someone like yourself who specializes in TCM dermatology, but you also have a lot of experience with topical steroid withdrawal. So if someone comes into your practice, and I know, and we all know everybody's listening, we all know that everybody's journey is unique, but normally if really your condition, your case is pretty severe, how long have you found in your practice that it takes someone to start feeling more like themselves? I don't want to say 100% better because I'm not even a hundred percent sure what that is for everybody. And sometimes everybody's like, “I feel better,” is not exactly where they thought they'd be, but it's way better than where they were. Because, I think setting expectations is important. What do you tell your patients about what they should expect from a timeframe perspective?

Dr. Friedman: I would say like you've already alluded to, it does depend on the person and this is why. Because it really depends on how many systems have been compromised and how much damage has been done. So you have to go and start the process and see how well you respond. But I usually find that patients see changes all along the way if we're on the right track. For example, they can be more subtle at the beginning where I've treated someone with TSW who could not sleep through the night and without sleep it's really hard to heal in general. In the first few weeks that we started working, she realized that she was getting more and more sleep and that she's actually sleeping through the night by the time we got to one month. And she's like, “This is really amazing. I have not slept for years.”

Dr. Friedman: And then as continue to work together, she had full sleeves of red erythema and within the next couple months that completely went away. So you're going to see changes all along the way as long as we're on the right course for you. But they just might be not directly your skin. They could be things like your sleep, they could be suddenly you don't find yourself being so irritated all the time or suddenly you may not be as itchy. I have had patients say to me, “It's funny. I can't remember the last time I itched and I used to itch all the time.” So it's things like this where it's not like overnight where you just go, “Oh, I'm not itching it all anymore.” But I'll usually ask questions and people will say, “Huh, I never really thought about that I don't think I introduced your day. I don't think I itched the day before that. That's interesting.”

Jennifer: Yeah.

Dr. Friedman: So I usually tell people to give themselves three months. And the reason I say that is because in the very beginning I usually do a little bit of a trial with the herbal formulas to make sure people can handle them, that they can handle the taste, that they don't have to make a huge investment to see what it's like. We also gauge how they're responding to it and whether or not that dosage is right for them. Once we get past that trial, they start to take longer doses of it and then we meet like every couple of weeks. During that time period I usually have to change the herbs a little bit to make sure we're addressing it for their particular constitution, their particular situation.

Dr. Friedman: And I have to play with it a little bit. And so we have to see how people respond. But usually within the next couple of weeks like they'll start to see things happen. And by the three month period you usually can tell how quickly you've responded and guess how much longer you want to do this. And most people are very incentivized when they see progress to keep going. I've also had people… I mean, it's not always a linear progression where you're awful one day and then you're great at three months. It's usually a little bit of back and forth. I would say you typically will still have a little bit of flaring, but the goal is to get you to a point where the intensity of the flares go down and the frequency of the flares is much more limited.

Dr. Friedman: And so, you get to this point where when you first start with me you're up and down, up and down, up and down, like on your own. But when you start to take the herbs and maybe it's more a curve like this. Right? And then maybe as you continue to take the herbs, you're more like this.

Jennifer: Right.

Dr. Friedman: And over time the goal is to not have them at all. So usually if you can see that progress, then you realize that this is working for me and you keep going. I mean I've had people who they start to question me and they're like, “Oh, I'm not sure if this is really working for me. I think I'm not going to take this anymore.” And so they go off for a few weeks and then all of a sudden all these symptoms come back and I get a call from them or like, “Well okay. So I didn't think it was working, but I haven't been taking herbs and now I'm like way worse. So obviously it was doing something.”

Jennifer: Yeah. And I think it's about opening up your mind and creating space for that type of hope that something is working. Because you get a lot of times you become so negative that it's hard to believe that anything can even help you. And that's one reason why I wanted to talk to more people like yourself who are either working with or living with TSW because I think we need to have more stories put out there.

Jennifer: And not just to help people recognize this issue but also to find ways forward and to know that there is hope. There is potential. And I really have loved supporting my client that has gone through this who's working with a TCM dermatology acupuncturist and has really seen a lot of improvements and I've just been so impressed and I'm glad that I could have you here and I wanted to make sure everybody knew. So you do have a newsletter that they can sign out for and you do offer consults no matter where people live anywhere in the US. Is that pretty specific to the US or you do work from outside? [inaudible 00:31:10].

Dr. Friedman: I've actually taken on a bunch of international patients recently too.

Jennifer: Okay. Perfect. But they can find you at amethystacu.com and that way I'll put that in the show notes so that everybody can find your link easily and go check you out and connect with you there. But I just wanted to thank you so much for joining this. This has been a fantastic and super interesting conversation and it really makes me hopeful in sharing this that other people will find their answers and stop banging their head against the wall trying to do it with things that, like you said, there's a point when a bandaid can help, but then after a certain point, we got to let the bandaids go and really work with something that has the capacity to move the marker forward when the system is so debilitated at that point. And I'm glad that people can have you as a resource for that. So thank you so much for joining us.

Dr. Friedman: You're welcome. Thank you so much for having me, Jen. I really appreciated being able to talk with you today.

“I think lots of times people focus on so many different food groups that they end up not eating enough to really have the nutrients to heal.”

Jennifer Fugo, MS, CNS

Jennifer Fugo, MS, CNS is an integrative Clinical Nutritionist and the founder of Skinterrupt. She works with women who are fed up with chronic gut and skin rash issues discover the root causes and create a plan to get them back to a fuller, richer life.

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