From the Guidelines
For a severe atopic dermatitis exacerbation, the optimal oral prednisone regimen is 40-60 mg daily for 5-7 days, followed by a tapering schedule over the next 7-10 days, as this provides rapid relief of symptoms while minimizing the risk of side effects associated with long-term steroid use, as conditionally recommended against systemic corticosteroids for adults with atopic dermatitis, except for acute, severe exacerbations, according to the 2024 guidelines of care for the management of atopic dermatitis in adults with phototherapy and systemic therapies 1.
Key Considerations
- The use of systemic corticosteroids, such as prednisone, should be reserved exclusively for acute, severe exacerbations and as a short-term bridge therapy to other systemic, corticosteroid-sparing therapy, due to the potential for significant side effects and the availability of alternative treatments 1.
- The recommended dose and duration of oral prednisone should be individualized based on the severity of the exacerbation and the patient's response to treatment, with the goal of using the lowest effective dose and shortest duration possible while still achieving control of the flare.
- A tapering schedule is crucial to prevent rebound flares and adrenal suppression, and should be tailored to the individual patient's needs, with a typical total course lasting about 2-3 weeks.
- Concurrent use of topical treatments and moisturizers can help maintain improvement as the oral steroid is tapered, and should be continued as part of a comprehensive treatment plan for atopic dermatitis.
Important Reminders
- Systemic corticosteroids, such as prednisone, are not approved by the FDA for use in atopic dermatitis, except for acute, severe exacerbations, and their use should be carefully considered and monitored due to the potential for significant side effects 1.
- Alternative treatments, such as mycophenolate mofetil, azathioprine, and cyclosporine, may be considered for adults with refractory moderate to severe atopic dermatitis, but their use should be carefully evaluated and monitored due to the potential for significant side effects and interactions 1.
From the Research
Optimal Oral Prednisone Regimen
There is limited information available on the optimal oral prednisone regimen for a severe atopic dermatitis exacerbation. However, the following points can be considered:
- Systemic corticosteroids, such as prednisone, are rapidly effective but should only be used short-term for severe exacerbations due to their many long-term side effects 2.
- The use of systemic corticosteroids is not recommended by current guidelines and is commonly associated with disease rebound 3.
- Instead of systemic corticosteroids, other treatment options such as cyclosporin A, azathioprine, and methotrexate can be considered for chronic cases 2.
- New, targeted, systemic therapies such as dupilumab have been approved for adults with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical therapies 3.
Key Considerations
Some key considerations for managing severe atopic dermatitis include:
- Assessing the longitudinal severity of the disease to measure therapeutic response and long-term management 4.
- Evaluating the patient's response to treatment and adjusting the treatment plan as needed 5.
- Considering non-pharmacologic interventions, such as lifestyle modifications and stress management, in addition to pharmacologic treatments 4.
- Being aware of the potential side effects and limitations of different treatment options, such as the narrow therapeutic index and possible renal toxicity of cyclosporin A 2.