Use of Systemic Corticosteroids for Atopic Dermatitis

International Eczema Council Consensus Statement

A.M. Drucker; K. Eyerich; M.S. de Bruin-Weller; J.P. Thyssen; P.I. Spuls; A.D. Irvine; G. Girolomoni; S. Dhar; C. Flohr; D.F. Murrell; A.S. Paller; E. Guttman-Yassky

Disclosures

The British Journal of Dermatology. 2018;178(3):768-775. 

In This Article

Abstract and Introduction

Abstract

Background Guidelines discourage the use of systemic corticosteroids for atopic dermatitis (AD), but their use remains widespread.

Objectives To reach consensus among an international group of AD experts on the use of systemic corticosteroids for AD.

Methods A survey consisting of statements accompanied by visual analogue scales ranging from 'strongly disagree' to 'neutral' to 'strongly agree' was distributed to the International Eczema Council (IEC). Consensus was reached in agreement on a statement if < 30% of respondents marked to the left of 'neutral' towards 'strongly disagree'.

Results Sixty of 77 (78%) IEC members participated. Consensus was reached on 12 statements, including that systemic corticosteroids should generally be avoided but can be used rarely for severe AD under certain circumstances, including a lack of other treatment options, as a bridge to other systemic therapies or phototherapy, during acute flares in need of immediate relief, in anticipation of a major life event or in the most severe cases. If used, treatment should be limited to the short term. Most respondents agreed that systemic corticosteroids should never be used in children, but consensus was not reached on that statement. The conclusions of our expert group are limited by a dearth of high–quality published evidence. If more stringent consensus criteria were applied (e.g. requiring < 20% of respondents marking towards 'strongly disagree'), consensus would have been reached on fewer statements.

Conclusions Based on expert opinion from the IEC, routine use of systemic corticosteroids for AD is generally discouraged and should be reserved for special circumstances.

Introduction

In clinical practice guidelines and position statements concerning the management of atopic dermatitis (AD), the use of systemic corticosteroids (CS), including prednisone, hydrocortisone and celestone, is generally discouraged, with use limited to special circumstances (Table 1).[1–8] While systemic CS can lead to rapid clearing of AD, their side–effect profile and the risk of severe rebound flares after discontinuation limit their use.[9]

Evidence of the benefits and risks of systemic CS in AD is scarce.[10] One randomized controlled trial (RCT) comparing ciclosporin with prednisolone ended early owing to rebound flares occurring in both groups, with 52% of subjects in the prednisolone arm experiencing such a flare.[11] Systemic CS use in children with AD has been studied in two RCTs, but with very small sample sizes.[12,13] Based on their use in other conditions, the long–term intermittent use of systemic CS is well known to cause a multitude of side–effects,[14–16] and even use for 30 days or less has been associated with increased rates of sepsis, venous thromboembolism and fracture.[17] A recent systematic review of studies in children taking systemic CS for > 2 weeks found significant increases in infections, growth delay and obesity.[18]

Despite reasons for caution, systemic CS are still commonly used for patients with moderate–to–severe AD. In a recent clinical trial for adults with moderate–to–severe AD, which took place in North America and Europe, 36% of participants reported use of systemic CS in the year prior to the trial.[19] Baseline data from a German registry of moderate–to–severe AD revealed that 13% of participants had been on systemic CS in the 3 months prior to enrollment,[20] and in another German study, 10% of patients with AD had used systemic CS over 2 years.[21] In a survey of 61 U.K. consultant dermatologists, 42% listed systemic CS as their first–line systemic agent for adult moderate–to–severe AD.[22] In surveys of European and North American paediatric dermatologists, oral CS were the first–line systemic agents for severe paediatric AD for 31% and 5% of respondents, respectively.[23,24]

To address the concern of inappropriate use and overuse of systemic CS for AD in clinical practice and to provide guidance for clinicians as to what circumstances may constitute appropriate use, a consensus process was initiated among the councillors and associates of the International Eczema Council (IEC).

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