What is the regimen of prednisolone (corticosteroid) in an acute exacerbation of atopic dermatitis (eczema)?

From the Guidelines

For an acute flare of eczema, a short course of oral prednisolone is typically recommended, starting with 0.5-1 mg/kg/day (usually 30-40 mg daily for adults) for 5-7 days, followed by a taper over 1-2 weeks to prevent rebound flaring. This approach is based on the principle of using the least potent preparation required to keep the eczema under control, as outlined in the management of atopic eczema guidelines 1. The use of oral prednisolone in this context is supported by the need to quickly control severe inflammation while topical treatments are optimized.

When prescribing prednisolone, it's best taken as a single morning dose with food to minimize gastrointestinal side effects and adrenal suppression. During and after the prednisolone course, patients should continue using emollients liberally and topical anti-inflammatory treatments (such as moderate to potent topical corticosteroids or calcineurin inhibitors) to maintain control of the eczema. The guidelines for the management of atopic dermatitis suggest that proactive application of topical corticosteroids or topical calcineurin inhibitors can be an effective strategy for preventing disease flares 1.

Key points to consider in the management of acute eczema flares include:

• Starting with a short course of oral prednisolone to control severe inflammation
• Tapering the dose over 1-2 weeks to prevent rebound flaring
• Using emollients liberally and topical anti-inflammatory treatments to maintain control of the eczema
• Addressing potential triggers like allergens or irritants and ensuring proper skin care routines are followed
• Considering proactive application of topical corticosteroids or topical calcineurin inhibitors to prevent disease flares, as supported by recent guidelines 1.

Systemic corticosteroids work by suppressing multiple inflammatory pathways involved in eczema, including reducing T-cell activation and inflammatory cytokine production, which explains their rapid effectiveness in controlling acute flares 1. However, they should not be used repeatedly for long-term management due to potential side effects including adrenal suppression, weight gain, mood changes, and increased infection risk.

From the FDA Drug Label

The initial dose of prednisolone sodium phosphate oral solution, (15 mg prednisolone base) may vary from 1. 67 mL to 20 mL (5 to 60 mg prednisolone base) per day depending on the specific disease entity being treated. IT SHOULD BE EMPHASIZED THAT DOSAGE REQUIREMENTS ARE VARIABLE AND MUST BE INDIVIDUALIZED ON THE BASIS OF THE DISEASE UNDER TREATMENT AND THE RESPONSE OF THE PATIENT In the treatment of acute exacerbations... daily doses of 200 mg of prednisolone for a week The regimen of prednisolone in acute flare of eczema is not explicitly stated in the provided drug label. However, based on the information provided for other conditions, the dose may vary from 5 to 60 mg per day, and in some cases, such as acute exacerbations of multiple sclerosis, 200 mg per day for a week has been used 2.

• The dosage requirements are variable and must be individualized based on the disease and patient response.
• The label does not provide a specific dosage for eczema, so a conservative approach would be to consult with a healthcare professional to determine the best course of treatment.

From the Research

Regime of Prednisolone in Acute Flare of Eczema

• The use of systemic corticosteroids, such as prednisolone, for atopic dermatitis (eczema) is generally discouraged, but can be used rarely for severe cases under certain circumstances 3.
• According to the International Eczema Council consensus statement, systemic corticosteroids should be avoided but can be used for severe eczema as a bridge to other systemic therapies or phototherapy, during acute flares, or in anticipation of a major life event 3.
• The evidence-based management of eczema suggests that systemic corticosteroids can be used for severe disease, but their use should be limited to the short term 4.
• There is no specific guidance on the regime of prednisolone in acute flare of eczema, but topical corticosteroids are recommended as a first-line treatment for eczema, with potent and moderate topical corticosteroids being more effective than mild topical corticosteroids 5, 6.
• The long-term safety of topical corticosteroids has been studied, and intermittent use of topical corticosteroids probably results in little to no difference in risk of growth abnormalities, non-skin infections, impaired vaccine response, and lymphoma/non-lymphoma malignancies 7.

Treatment Options

• Topical anti-inflammatory treatments, such as potent and very potent topical steroids, tacrolimus 0.1%, and ruxolitinib 1.5%, are ranked among the most effective treatments for improving patient-reported symptoms and clinician-reported signs of eczema 6.
• Topical corticosteroids can be used once daily rather than twice daily, and topical calcineurin inhibitors are useful for sensitive sites 4.
• Systemic corticosteroids, such as prednisolone, can be used for severe eczema, but their use should be limited to the short term and under certain circumstances 3, 4.

Safety and Efficacy

• The safety and efficacy of topical corticosteroids have been studied, and potent and moderate topical corticosteroids are probably more effective than mild topical corticosteroids, primarily in moderate or severe eczema 5.
• The long-term safety of topical corticosteroids has been studied, and intermittent use of topical corticosteroids probably results in little to no difference in risk of growth abnormalities, non-skin infections, impaired vaccine response, and lymphoma/non-lymphoma malignancies 7.
• Local adverse events, such as skin thinning, are not well reported and come largely from low- or very low-certainty, short-term trials 5, 6.