To improve the treatment of atopic dermatitis by limiting oral steroid use, documenting failure of topical therapy and counseling for oral corticosteroid side effects,

Review Summary statement 47 in Atopic dermatitis: A practice parameter update 2012: Systemic Immunomodulating Agents

Summary Statement 47: Immunomodulating agents, such as cyclosporine, mycophenolate mofetil, azathioprine, IFN-g, and corticosteroids, have been shown to provide benefit for patients with severe refractory AD, although the clinician should consider their potential serious adverse effects. (A) 
The use of systemic corticosteroids, such as oral prednisone, might be required in the treatment of severe chronic AD, although there is a paucity of controlled studies, despite widespread use of this therapy. In a double-blind, placebo-controlled, crossover trial of 26 children with severe AD, those receiving 4 weeks’ treatment with combined oral plus nasal beclomethasone dipropionate improved significantly more than those receiving placebo.1 No adverse effects were observed, but 24-hour urinary cortisol excretion was slightly reduced. 
In another pediatric study, 20 children with chronic severe AD were treated with systemic flunisolide in a multicenter, randomized, double-blind, placebo-controlled, crossover study.2 Patients’ clinical severity scores improved significantly after 2 weeks of flunisolide treatment compared with placebo. After treatment with flunisolide, no worsening of symptoms or relapse occurred. No side effects were observed during the study. 
In a different approach to systemic corticosteroid therapy in pediatric patients, intravenous bolus therapy with 20 mg/kg/d methylprednisolone for 3 days resulted in improvement in 5 of 7 patients without significant side effects.3 Nevertheless, the PRACTALL consensus report states that in cases of acute flare-up, while patients might benefit from a short course of systemic therapy with corticosteroids, long-term use and use in children should be avoided.4 
A recent comparison study of oral prednisolone versus cyclosporine in adults found a high rebound exacerbation rate in patients treated with prednisolone in spite of the use of moderatepotency topical steroids and emollients.5 Clinical improvement with systemic corticosteroids is often associated with rebound flaring of AD after discontinuation. If a short course of oral corticosteroid therapy is given for a patient with severe AD, it is important to taper the dosage as it is discontinued. Intensified skin care with topical anti-inflammatory therapy should also be instituted during the corticosteroid taper to suppress rebound flaring of AD. 

References:

  1. Heddle RJ, Soothill JF, Bulpitt CJ, Atherton DJ. Combined oral and nasal beclo- methasone diproprionate in children with atopic eczema: a randomised controlled trial. BMJ 1984;289:651-4, (Ib).
  2. La Rosa M, Musarra I, Ranno C, Maiello N, Negri L, Del Giudice MM. A randomized, double-blind, placebo-controlled crossover trial of systemic flunisolide in the treatment of children with severe atopic dermatitis. Curr Ther Res Clin Exp 1995;56:720-6. (Ib)
  3. Galli E, Chini L, Moschese V, Paone F, Menichelli A, Fraioli G, et al. Methyl- prednisolone bolus: a novel therapy for severe atopic dermatitis. Acta Paediatr 1994;83:315-7, (III).
  4. Akdis CA, Akdis M, Bieber T, Bindslev-Jensen C, Boguniewicz M, Eigenmann P, et al. Diagnosis and treatment of atopic dermatitis in children and adults: European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Report. J Allergy Clin Immunol 2006;118:152-69, (IV).
  5. Schmitt J, Schakel K, Folster-Holst R, Bauer A, Oertel R, Augustin M, et al. Prednisolone vs. ciclosporin for severe adult eczema. An investigator-initiated double- blind placebo-controlled multicentre trial. Br J Dermatol 2010;162:661-8, (Ib).

Download and review the European Guidelines for treatment of atopic dermatitis  European Guidelines Part 2 


Guidelines for treatment of atopic eczema (atopic dermatitis) Part II. Ring J, Alomar A, Bieber T, Deleuran M, Fink-Wagner A, Gelmetti C, Gieler U, Lipozencic J, Luger T, Oranje AP, Schäfer T, Schwennesen T, Seidenari S, Simon D, Ständer S, Stingl G, Szalai S, Szepietowski JC, Taïeb A, Werfel T, Wollenberg A, Darsow U; European Dermatology Forum; European Academy of Dermatology and Venereology; European Task Force on Atopic Dermatitis; European Federation of Allergy; European Society of Pediatric Dermatology; Global Allergy and Asthma European Network.  J Eur Acad Dermatol Venereol. 2012 Sep;26(9):1176-93. doi: 10.1111/j.1468-3083.2012.04636.x. Epub 2012 Jul 19.

Oral glucocorticosteroids 
Oral glucocorticosteroids are used in many European countries for treatment of Atopic Eczema (AE). Well known side effects limit their use especially for long-term treatment. Funding of expensive clinical trials in the near future is unlikely. 

Controlled clinical trial data demonstrating efficacy   There is one controlled trial available that demonstrates equal efficacy of therapy with systemic glucocorticosteroids as ciclosporin.1 Broad experience from clinical use by many experts indicates efficacy. 

Evaluation summary   Short-term treatment with oral glucocorticosteroids is effective (-, D). 

Recommendations 
Systemic steroids have a largely unfavourable risk ⁄ benefit ratio for treatment of AE. (-, D). 

Short-term (up to 1 week) treatment may be an option to treat an acute flare in exceptional cases of atopic eczema. Restrictive use, largely limited to adult patients with severe atopic eczema, is recommended (-, D). 

The recommended daily dose should be adjusted to body weight. 
Long term use in AE patients is not recommended. The indication for oral steroids in children should be handled even more cautiously than in adults (-, D). 

References:
1. Schmitt J, Schakel K, Folster-Holst R, Bauer A, Oertel R, Augustin M, et al. Prednisolone vs. ciclosporin for severe adult eczema. An investigator-initiated double- blind placebo-controlled multicentre trial. Br J Dermatol 2010;162:661-8.