Safety of topical corticosteroids in atopic eczema: an umbrella review

Abstract

ObjectiveAn umbrella review summarising all safety data from systematic reviews of topical corticosteroids (TCS) in adults and children with atopic eczema.MethodsEmbase, MEDLINE, PubMed, Cochrane Database of Systematic Reviews and the Centre of Evidence Based Dermatology map of eczema systematic reviews were searched until 7 November 2018 and Epistemonikos until 2 March 2021. Reviews were included if they assessed the safety of TCS in atopic eczema and searched >1 database using a reproducible search strategy. Review quality was assessed using version 2 of 'A MeaSurement Tool to Assess systematic Reviews' (AMSTAR 2 tool).Results38 systematic reviews included, 34 low/critically low quality. Treatment and follow-up were usually short (2–4 weeks).Key findingsTCS versus emollient/vehicle: No meta-analyses identified for skin-thinning. Two 2-week randomised controlled trials (RCTs) found no significant increased risk with very potent TCS (0/196 TCS vs 0/33 vehicle in children and 6/109 TCS vs 2/50 vehicle, age unknown). Biochemical adrenal suppression (cortisol) was 3.8% (95% CI 2.4% to 5.8%) in a meta-analysis of 11 uncontrolled observational studies (any potency TCS, 522 children). Effects reversed when treatment ceased.TCS versus topical calcineurin inhibitors: Meta-analysis showed higher relative risk of skin thinning with TCS (4.86, 95% CI 1.06 to 22.28, n=4128, four RCTs, including one 5-year RCT). Eight cases in 2068 participants, 7 using potent TCS. No evidence of growth suppression.Once daily versus more frequent TCS: No meta-analyses identified. No skin-thinning in one RCT (3 weeks potent TCS, n=94) or biochemical adrenal suppression in two RCTs (up to 2 weeks very potent/moderate TCS, n=129).TCS twice/week to prevent flares (‘weekend therapy’) versus vehicle: No meta-analyses identified. No evidence of skin thinning in five RCTs. One RCT found biochemical adrenal suppression (2/44 children, potent TCS).ConclusionsWe found no evidence of harm when TCS were used intermittently ‘as required’ to treat flares or ‘weekend therapy’ to prevent flares. However, long-term safety data were limited.PROSPERO registration numberCRD42018079409.

Dupilumab Treatment in Children Aged 6–11 Years With Atopic Dermatitis: A Multicentre, Real-Life Study

“…Indeed, in paediatric patients, AD management mostly relies on emollients and topical corticosteroids (TCs). TCs should be used with caution in children because their body surface area to weight ratio is higher than in adults; as a result, they have a high degree of drug absorption [ 4 ]. For this reason, the potential for both cutaneous and systemic side effects, including possible hypothalamic-pituitary-adrenal axis suppression, should be considered [ 5 ].…”

Safety of tacrolimus 0.03% and 0.1% ointments in young children with atopic dermatitis: a 36‐month follow‐up study

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Effectiveness and safety of lotion, cream, gel, and ointment emollients for childhood eczema: a pragmatic, randomised, phase 4, superiority trial

“…24 Reducing topical corticosteroid use might be desirable in terms of simplifying treatment burden and minimising the risk of adverse effects, but should not distract from the appropriate use of topical corticosteroids to treat inflamed skin. 25 The findings from a nested qualitative study emphasised how the acceptability of the same product varies between users. 26 These findings are consistent with previous qualitative research, which identifies trade-offs between effectiveness and acceptability when choosing an emollient.…”