Routine use of corticosteroids for atopic dermatitis discouraged by IEC

The International Eczema Council (IEC) is recommending that the routine use of systemic corticosteroids for atopic dermatitis be discouraged and instead, it should be reserved for special circumstances.

In September, the council issued guidelines for the use of systemic corticosteroids for atopic dermatitis. The guidelines were published in the British Journal of Dermatology.

A goal of the survey was to assess how and when physicians prescribe corticosteroids for atopic dermatitis, said lead author Aaron Drucker, M.D., an early career scientist at Women’s College Research Institute in Toronto.

“There are many papers that show these drugs are being used a lot, particularly in patients who have moderate or severe atopic dermatitis. Hopefully, our guidelines can provide some guidance as to when systemic corticosteroids are appropriate. We want to see if our recommendations limit usage,” Dr. Drucker said.

The guidelines are based on a survey of 60 council members. A consensus was reached on 12 statements.

THE FINDINGS

• Systemic corticosteroids should generally be avoided, but can be used rarely for severe atopic dermatitis 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 short-term.
• Most respondents agreed that systemic corticosteroids should never be used in children, but consensus was not reached on that statement.
• Treatment in adults 18 and over with systemic corticosteroids for severe atopic dermatitis should be limited to short-term use:  94 percent consensus
• For children under the age of 12, corticosteroids should mostly be avoided due to concerns over side effects and rebound flares on discontinuation:  86 percent consensus. And, 84 percent agreed that this should apply to children and teens between 12 and 17.
• Systemic corticosteroids may be used for severe atopic dermatitis in adults when there are no other viable treatment options:  81 percent consensus.
• Systemic corticosteroids may be used rarely for severe disease in adults:  80 percent consensus.

ADULT PATIENTS

Three other consensus statements for adult patients are that systemic corticosteroids may be used for severe atopic dermatitis in an acute flare in need of immediate relief; these agents should generally be avoided in the treatment of disease; and that they may be used for severe disease in anticipation of an important life event like a wedding.

There was also consensus for adults that systemic corticosteroids may be used for severe atopic dermatitis as a bridge to other systemic agents or phototherapy, and that these agents may be used for the most severe disease such as erythrodermic atopic dermatitis.

“None of the consensus statements were all that surprising, and I do not think that most of them are controversial,” Dr. Drucker says. “One statement was that systemic corticosteroids could be used if a patient has an important upcoming life event. That helps put the decision in the hands of the patient, as long as you go over the risks and benefits of these drugs with them.”

PEDIATRICS

The survey almost reached consensus on the statement that systemic corticosteroids should never be used in young children. Although the survey did not evaluate usage based on geography, “we know systemic corticosteroids are used differently in different places,” Dr. Drucker said.

One of the limitations of the survey is that it does not delineate the protocol for using systemic corticosteroids.

“Potential next steps are coming up with ways to evaluate how these agents are being used, when they are being used and ways that we can try to ensure that when they are being used in patients with atopic dermatitis that they are being used appropriately,” Dr. Drucker said.

DISCLOSURES

Dr. Drucker has been a consultant for Sanofi and has received research funding from Regeneron and Sanofi.

REFERENCES

Drucker AM, Eyerich K, de Bruin-Weller MS, et al. “Use of systemic corticosteroids for atopic dermatitis: International Eczema Council consensus statement,” British Journal of Dermatology, Sept. 2, 2017. DOI: 10.1111/bjd.15928