Like many TSW sufferers, I first came across NMT (No Moisturizing Treatment) through the blog of Tokuko Kameda.
Tokuko is a Japanese woman who was a lifelong topical steroid user and probably had one of the most severe withdrawals ever recorded. She was eventually referred to Dr Kenji Sato, who took her as an inpatient and treated her using NMT. She had an incredibly fast 3 month recovery which you can read about on her blog.
Tokuko was a godsend to the TSW community because she translated the NMT protocol into English and posted about it on her blog. Word spread quickly and eventually she was getting thousands of messages from all over the world about how NMT had helped people heal with amazing results.
When I started TSW in May 2019, I was following strict NMT for approximately 3-4 months, followed by relaxed NMT which I still do today. I will explain this more below.
This page is a full guide for anyone wishing to try treatment with NMT. I will describe the official protocol as designed by Dr Kenji Sato, and then will describe a few things I did differently that worked well for me.
Disclaimer: I AM NOT A DOCTOR. THIS IS NOT MEDICAL ADVICE. All the information has below has been taken second-hand from Dr Sato or his patients and reproduced here. Some of the protocol described below will go against the standard medical advice from your doctor. Despite the significant amount of medical research published, many countries still do not recognize TSW as a medical condition. Please do your own research, and use this information at your own risk.
NMT (No Moisturizing Treatment) as designed by Dr Sato
NMT is a treatment designed to help you come off topical steroids cold turkey, thus allowing your skin to heal itself naturally. Your job during NMT is to support this natural healing cycle of the skin, mostly through lifestyle changes.
Depending on how long you have used topical steroids, the withdrawal you experience will cause the skin to shed, break, ooze and flare, often very painfully and severely, until your skin finally resolves itself and learns to heal and regenerate. This is an extremely difficult period to go through which can last several months or possibly years and it is possible you will need significant friend/family support and time off work.
These are the key points of the NMT protocol, in order of importance (ranked by me):
- Do NOT use steroid creams under any circumstances.
- Do NOT moisturize your skin with any moisturizing creams, oils, gels or powders.
- Limit your liquid intake to 1,000ml per day, including food. This is a starting guide only, and your water limit will change as your treatment progresses (more below).
- Exercise daily for 1 hour, aiming to get your heart rate above 120bpm.
- No showering or bathing. If you must, you can shower once every 3 days for 1-2 minutes, using luke-warm water and no soap. This is to prevent infection.
- Aim to sleep before 10pm every night.
- Eat a diet high in proteins and lipids (fats).
It is essential to follow it through for the full 90 days. It is common for people to improve rapidly in the last few days, so even if you’re looking terrible at Day 80 it’s possible it will vastly improve by Day 90. Don’t give up!
Let’s explore each part of the protocol in more detail:
1. Do not use steroid creams under any circumstances
As you are going through steroid withdrawal, it’s vital that you avoid all steroid creams. Think of this as similar to a drug addict going through a drug withdrawal (technically, that’s exactly what you’re going through, too). That drug user will probably be in rehab in order to keep him/her away from the drug at all costs. If they lapse and use the drug again, even only once, they’ll go right back to square one. It’s a similar situation for you and steroid creams. For your body to learn how to operate without steroid and massive amounts of external cortisol, you need to go cold turkey.
Also be mindful that things other than steroid creams can function like steroids in the body. One you’re likely to come across is licorice. Licorice can have a steroid-like effect in your body and is found in things like candy, some teas, some desserts and various other foods and drinks. Dr Sato has said licorice should be avoided. Be careful to not ingest this unknowingly.
Another ingredient that can have steroid-like effects is Glycyrrhizin, commonly found in Chinese food and medicine products. Be careful to avoid this as well.
Other ways you might get steroids are via oral medication from your doctor. Avoid these also unless essential.
2. Do not moisturize!
This is one of the more counter-intuitive parts of the protocol, but extremely important. When going through TSW, dry skin is actually a good sign. It’s a sign that your body knows this skin is damaged and wants it to shed. Moisturizing it is the opposite of what your body wants!
The best thing you can do when your skin is dry and flaky is to leave it and let it shed. You will find that once this happens, underneath will appear stronger, healthier skin. That is the idea of a “cycle”. It will take many cycles for your skin to return to normal.
When I was going through NMT, I had days where skin was literally falling off me the entire day, it felt like I was a human snow machine. However after 2-3 days of intense shedding, I had incredibly pink healthy skin underneath. I couldn’t believe it. Since then I was always excited to see shedding, because I knew healthier skin wasn’t far away.
When my skin had made a lot of progress, I decided it would be okay to get a leg/foot massage as I’d had a hard week of running. The oils worked as a moisturizer and later that night the mini flares in my skin were very noticeable. Moisture is actually an enabler of inflammation in the skin. Dry skin activates the skin’s cortisol response and encourages healing. Remember, healthy skin should be able to produce oil and moisturize itself.
3. Limit your liquid intake
One very common symptom of TSW is oozing from your skin. When the skin is open, the wounds can ooze which results in your body losing a lot of protein. Severe oozing can result in hypoalbuminemia.
Limiting water intake is an effective way to reduce or stop oozing. It is also effective at helping the body dry the top damaged layers of skin and encouraging them to shed. You will also notice it’s much harder for dry skin to flare up (a lot of moisture in TSW skin facilitates flaring.
Limiting your liquid intake is probably the hardest part of NMT but also one of the most important. You will notice a big difference in the speed your skin cycles through layers when you keep your water intake under control.
There is some confusion in the TSW community about how much you need to limit your water. Since Dr Sato kept Tokuko on 1,000ml per day, most people think they also need to keep to 1,000ml per day. However, Tokuko’s TSW was one of the most severe you’ll ever see, and she oozed non-stop. This is the result of using the strongest steroid creams on the market for nearly 50 years. Most of us have no abused steroids to that level and will likely not ooze to the level that Tokuko did.
The guideline Tokuko has given for water limits is:
- 1,000ml – 1,500ml if you weigh between 50-60kg
- 1,300ml – 1,800ml if you weigh between 80-90kg
- You can estimate your own range based on your own weight and the above guidelines.
Why such a big range? Because everyone’s TSW is different. If you are oozing very heavily, you should aim for the lower end of the range. If your skin isn’t too broken and you don’t have ooze, you can aim for the upper limits.
However a better way of gauging your water limit is from the colour of your urine. If you are clear or light yellow, you’re drinking too much water. If you’re orange to brown, you’re not drinking enough. Your urine should have a mid to dark yellow colour. This level is enough to keep you hydrated but also keep your body from holding too much moisture.
One other thing to note is, this water limit includes food. Therefore if you eat an orange, you need to look up it’s water content online (it’s 85%) and then weigh the orange. If the orange is 100g, that will count as 85ml towards your daily water limit. To find water content of foods, I use the database from Diet Grail.
This is an arduous process but it gets easier. I noticed as I got further along in NMT, I was eating mostly the same food every day and was almost able to calculate the water limit in my head. It’s an important part of the NMT protocol, so don’t skip it.
One last thing to note, if you are exercising daily (see point 6 below) then you are likely to sweat. You are allowed to drink extra water to replace your sweat. The best way to calculate this is to weigh yourself before and after your workout, so if you lose 500g then you can can drink a further 500ml of water that day (1ml of water weighs 1g).
Last point about the water limit: It is not a strict limit for everyone. To be honest, you can do anything you want with your water limit, as long as you observe the results. For example:
- If you increase your water limit by 200ml per day and nothing happens, then you can stay there.
- If you increase your water limit by 200ml per day and your skin worsens, you need to reduce it back down again.
- If you increase your water limit by 200ml per day and your skin improves (this is unlikely), increase it more! See what happens.
However, save this kind of experimenting for the later months of NMT. When you’re just starting, everything will be new. Stick to the protocol and learn. You will discover a lot about your body during that time.
4. Sleep Before 10pm
Dr Sato believes the hours between 10pm and 2am are “prime healing hours”. Your body regenerates the most during sleep, and your skin will experience the greatest healing during those hours.
5. No Showering Or Bathing
There are a few reasons for this.
The first reason is showering is a moisturizer. As the goal is to keep the skin as dry as possible, showering hinders progress in this department.
The second reason is that it can wash off crusts from the skin which will result in more oozing. When scabs form on the skin, it’s the perfect protection for new skin to regenerate underneath. Showering can soften or break these, and slow down the healing.
The third reason is showering washes away the natural flora on the skin, which is helpful for healing.
The fourth reason is shower soaps and gels are both a moisturizer and an irritant.
When your skin is particularly bad, you should refrain from showering as much as possible. It is permitted to take a very short shower every 3-4 days in cold/lukewarm water without soap for 1-2 minutes maximum (preferably shorter). This is mostly to help prevent infection.
I used to take a cold shower after every exercise session, but it was extremely short (20-30 seconds). It didn’t seem to hinder my progress noticeably.
6. Exercise daily for 1 hour
It can seem like the absolute last thing you want to do, but this is very helpful for your skin and encouraged highly by Dr Sato.
Sweating is a great cleanser, and exercise boosts your healthy hormones and metabolism which all encourage healing. Being sedentary generally isn’t helpful unless your skin is in a very severe condition.
The goal is to raise your heartbeat to 120bpm and break a sweat. Running is perfect, even if it’s on a treadmill. Something like yoga or pilates can also be good if it gets a sweat going.
Exercising is going to be painful and difficult at times, but many people in the NMT group have seen amazing results by adding exercise. Don’t beat yourself up if you don’t do it every day, but on good days, try and motivate yourself to do it.
7. Eat a diet high in protein and lipids
Proteins and fats are the building blocks of skin, so you need to make sure your diet is packed with both.
Why do we do this? I have not spoken personally to Dr Sato, but I do know that proteins and fats are by far the most important macronutrients. The third macrocnutrient – carbohydrates – is generally overeaten by most people and does nothing for skin. Remember, when it comes to human nutrition there are essential amino acids (proteins) and essential fatty acids (fats) but there are no essential carbohydrates.
Ideal foods to eat on NMT are fatty meats like beef, lamb, fish, organ meats, and eggs are great too.
If you are plant based, I would recommend tofu, chickpeas, beans on rice, tempeh, and oils like cold pressed coconut and olive oils. Nut and see butters can be decent sources too.
Of course, it’s recommended to avoid low-nutrition foods like junk food, processed food, sugars, soft drinks, alcohol etc. Whatever your diet it is, keep it clean and unprocessed.
Some extra tips:
Following the protocol above, you should see promising results in 90 days, if not complete recovery from your symptoms. Here are a few things I noticed during my journey that may give you more guidance:
Flares come in cycles
Flares are intense and painful, and will result in a lot of sore, broken and inflamed skin. They generally come in cycles which will differ for every person, for me it was around every 4 weeks. My skin would flare (it almost feels like really bad sunburn) and would ooze and weep. It was nearly impossible to sleep and extremely exhausting to deal with. Those nights were the worst of my life.
However, each flare was noticeably less severe than the previous one. The best advice I can give you is, hang in there. And the saying “The night is darkest right before the dawn” is especially true with NMT. Some days you think your skin is so bad it will take years to get better, then suddenly everything crusts off and you look like a brand new person in 3 days. It is very bizarre. But just know it gets better.
Also note that keeping to your water limit is extremely important during these times.
Sleep will be difficult
One thing that exacerbates the symptoms is your lack of sleep. When your skin is flaring and broken, it’s extremely difficult to sleep through the night.
While Dr Sato specifically advises not to sleep during the day and try and get your sleep only after 10pm, sleep for me was so rare that I would just sleep whenever I was able to fall asleep, which was not often.
I went many days without sleep and eventually my body shut down and I would just doze off in the middle of the day. I didn’t fight it, I had to take any sleep I could get! When it comes to sleep, just do the best you can.
Shivers and cold sweats
One “side effect” of your skin forgetting how to behave like skin without steroids is it struggles to hold in your body heat. This will result in you feeling extremely cold to the point of shivering, even if the weather is not too cold. Because your body is releasing all its heat, it will also be common for you to sweat during the night if you’re covered with a blanket.
During my worst flares, it was literally like a sauna under my blankets after just a few minutes. I would take the blanket off, lose all my heat and suddenly be shivering. So I’d put the blanket back on and it was back to a sauna. This hot/cold hot/cold dilemma went on for several weeks and as you can imagine, I barely slept at all. One thing I found helpful was I would sleep with a bed sheet instead of a duvet, which half keeps you warm but still lets some heat out so you don’t sweat buckets.
Didn’t work all that well, but it was better than no sleep at all. Again, if you go through this, the only advice I have is just knuckle down and get through it. It is difficult, but you can do it!
When your skin oozes and it dries into scabs, it has a pretty funky smell. It smells like rotting meat and it’s not pleasant. Paired with the fact you’re not allowed to shower, it’s a pretty bad combo.
What Dr Sato advises you to do with oozy scabs is to cover them with plain gauze. This will help them dry and scab over faster, and the healing process can begin.
One thing I would do is try and stand in the sun, naked if possible, and that would help dry out the skin. I also hoped it would kill some of the harmful bacteria on my skin, if there was any. Kind of like putting out old furniture in the sun.
Note that getting sun exposure is not a recommended part of NMT.
Another thing you can do is use a warm sponge or towel to just wipe down the parts of your body that are smelling particularly badly, normally this is armpits, crotch, private parts and other creases like behind elbows and knees (if they are scabbing up though, best to keep them dry).
Some items that helped me during NMT
NMT is a very testing time so if there’s any way you can make it easier on yourself, you should do it. Here are a few things I used:
P.S. If you have trouble finding these (many are hard to find where I live in New Zealand) I get all my stuff from iHerb. Their range is great and they ship worldwide. I have included links below. Also if you buy anything there, you can use the code ZBS600 at checkout for a 5% discount 🙂
Collagen powder – Collagen contains the perfect combination of amino acids to rebuild skin cells. I noticed a significant difference in my healing time after I started taking 2-3 scoops per day. Even though that’s above the recommended dosage, remember your body is shedding far more skin than a normal person and therefore needs to rebuild far more skin too. When shopping for collagen powders and pills you’ll find different types of Collagen (types 1 to 5). It is Collagen Types 1 and 3 that our body uses to rebuild skin. However, taking the other Types won’t hurt either.
Collagen pills – Collagen pills were helpful when my water limit was very strict. My preferred way to take collagen was mixed with matcha or in a smoothie, but when my water limit was tight I couldn’t just drink whenever I wanted. To get enough collagen I would take pills instead. It’s the same thing, just a different avenue. I really like these collagen pills from Neocell because they also contain Vitamin C (see next point).
Vitamin C – Vitamin C is important because it is essential for synthesizing collagen – the protein our skin is made of. It’s best to get your Vitamin C from fruits and whole foods, but with the water limit getting enough fruits can be troublesome. Supplementing is a good way around this. Aim for a high dose. I like to use liposomal Vitamin C like this one as it provides superior absorption (the next best thing to an IV).
Dry brush – Every morning if my skin wasn’t in a badly broken stage, I would dry brush. It always felt extremely calming and removed a lot of dead skin, which is what scratching is supposed to do. However dry brushing is far more gentle than scratching and probably more effective too. Some people claim it’s also good for kickstarting the lymph system underneath the skin but I didn’t really look into that. To dry brush, simply run the brush softly in long strokes against the skin. Now that my skin has thickened up, I use it every day and love it! Best to do it outside. It’s always very satisfying to see all the dead skin flakes blowing away in the wind!
This is the dry brush I use. It is cheap and has lasted well, and easy to travel with too.
B-Fan – This was recommended to me by a fellow NMT guy named Ben. Took quite a long time to arrive after I ordered it, so I didn’t really get to use it during my bad flares, but it would have been an absolute godsend during those cold-sweat nights. The B-fan is designed to blow cool air under your covers, and is designed to assist “hot sleepers” who usually sweat in the night. TSW makes us all hot sleepers so this gadget is perfect. Anything that helps you get a bit of extra sleep is definitely worth it!
Dry Sauna – I was a huge fan of the dry sauna during my flares, especially in winter. I always found sweating very helpful for the skin, and my healing accelerated after daily saunas. Another great thing about saunas was, it allowed me to raise my water limit because I sweated so much. Often I used to lose a litre of sweat, sometimes more! That added an extra 1,000ml to my daily limit and made it much more bearable.
(note that a dry sauna differs from a steam sauna – the steam in a steam sauna will moisturize your skin externally, but a dry sauna will only expose your skin to your own sweat – this is far more preferable).
Turmeric – Turmeric is something I always take whenever I’m unwell because it helps with both preventing infections and reducing inflammation. For me it’s difficult to add into my meals every day so I simply take a daily supplement. I like this one because it includes black pepper, which enhances its absorption.
My diet during NMT:
My diet during NMT was not complicated. It consisted of about ten foods. I ate:
- Grass fed beef
- Grass fed lamb
- All kinds of fruits and berries
- Chicken and beef liver
- Nut butters
- Natural unsweetened yogurt (usually mixed with flavoured collagen powder).
I also went through about five tubs of Ultima Replenisher. This is an electrolyte drink (a bit like Gatorade). Since we cannot drink a lot of water, I used this as a hydrating supplement to make sure I was always hydrated. I buy mine from iHerb and raspberry is the best flavour! 🙂
My final piece of advice (and probably the thing that helped me the most!) is I would highly recommend joining the NMT Support Group and the NMT Education Group on Facebook. There is a wealth of information there, with many other TSW sufferers to lean on for support. Even Tokuko and Dr Sato are members and often answer quetions. If you have questions about NMT, it is very likely it has already been answered in there (use the search bar).
I know how tough this journey is, so if you ever have questions or need more information, don’t hesitate one second to reach out to me. Just leave a comment on one of my blog posts or message me on my Instagram. You can also find me in the Facebook groups that I mentioned above.
Sending love and healing you way!
Note: If you buy anything I’ve recommended from iHerb, use my referral code ZBS600 at checkout, you’ll get a 5% discount 🙂