What is the role of oral corticosteroid (steroid) treatment for severe atopic dermatitis (eczema)?

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Last updated: May 14, 2025 • View editorial policy

From the Guidelines

Oral steroids should be avoided for the treatment of extreme eczema due to their potential side effects and the availability of more effective and safer alternatives, as recommended by the most recent guidelines 1. When considering treatment options for extreme eczema, it is essential to prioritize morbidity, mortality, and quality of life as the primary outcomes.

  • The use of oral steroids, such as prednisone or prednisolone, may provide temporary relief for severe eczema flares, but their long-term use is associated with significant side effects, including mood changes, increased appetite, fluid retention, elevated blood pressure, blood sugar issues, and bone density loss 2.
  • Recent guidelines from the American Academy of Dermatology recommend against the use of systemic corticosteroids for the treatment of atopic dermatitis, except in cases of acute severe exacerbations and as a bridge therapy to other systemic treatments 1.
  • Instead, the guidelines suggest the use of alternative treatments, such as dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib, which have been shown to be effective and safer for the treatment of moderate-to-severe atopic dermatitis 1.
  • It is crucial to note that the decision to initiate any treatment should be made using shared decision-making between patients and clinicians, taking into account the severity of the disease, its impact on the patient, and the efficacy, safety, and accessibility of the available interventions 1.
  • In cases where oral steroids are deemed necessary, a short course of prednisone starting at 40-60mg daily for adults (0.5-1mg/kg for children) and tapering over 2-3 weeks may be considered, but it is essential to carefully monitor the patient for potential side effects and adjust the treatment plan accordingly 2.

From the FDA Drug Label

The initial suppressive dose level should be continued until satisfactory clinical response is obtained, usually four to ten days in the case of many allergic and collagen diseases. More severe disease states usually will require daily divided high dose therapy for initial control of the disease process The answer to the question of oral steroid treatment for extreme eczema is that prednisone (PO) may be used for initial control of the disease process, with the initial suppressive dose continued for 4 to 10 days.

  • Key points:
    • Daily divided high dose therapy may be required for more severe disease states.
    • Alternate day therapy may be considered after initial control is established.
    • The benefit-risk ratio should be carefully weighed for each patient 3

From the Research

Oral Steroid Treatment for Extreme Eczema

  • There is no direct evidence in the provided studies regarding oral steroid treatment for extreme eczema.
  • However, the studies suggest that systemic treatments, including corticosteroids, are reserved for severe cases of atopic dermatitis (AD) 4, 5, 6.
  • Phototherapy is considered a valid second-line intervention for AD, and it can be used as monotherapy or in combination with systemic drugs, such as corticosteroids 4, 5.
  • The studies focus on the safety and efficacy of phototherapy for AD, including narrowband ultraviolet B (NB-UVB) and ultraviolet A1 (UVA1) 7, 8.
  • While oral steroids are not directly mentioned, the studies imply that systemic corticosteroids may be used in conjunction with phototherapy for severe cases of AD 4, 5, 6.

Alternative Treatments

  • Phototherapy, including NB-UVB and UVA1, has shown beneficial effects in reducing physician-assessed signs and patient-reported symptoms of AD 7, 8.
  • Other systemic therapies, such as cyclosporine, mycophenolic acid precursors, azathioprine, and methotrexate, may be considered for long-term treatment of AD, although their use is often "off label" in the United States 6.
  • Topical corticosteroids and calcineurin inhibitors are commonly used for mild to moderate AD, but their long-term use can have adverse effects 6.

Safety and Efficacy

  • The safety and efficacy of phototherapy for AD have been established, although the evidence is not always of high certainty 7.
  • Adverse events associated with phototherapy, such as phototoxic reaction and UV burn, are relatively rare 7.
  • The decision to use systemic therapies, including corticosteroids, should be based on efficacy and safety readouts from well-designed, long-term trials 6.

References

Research

Management of atopic dermatitis: safety and efficacy of phototherapy.

Clinical, cosmetic and investigational dermatology, 2015

Research

Safety and Efficacy of Phototherapy in the Management of Eczema.

Advances in experimental medicine and biology, 2017

Research

Long-Term Treatment of Atopic Dermatitis.

Dermatologic clinics, 2017

Research

Phototherapy for atopic eczema.

The Cochrane database of systematic reviews, 2021

Research

Phototherapy for atopic eczema with narrow-band UVB.

Journal of the American Academy of Dermatology, 1999

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.