Are oral steroids recommended for severe atopic dermatitis?

Oral Steroids for Severe Atopic Dermatitis

Oral corticosteroids generally should be avoided in atopic dermatitis due to their unfavorable risk-benefit ratio, with short courses only considered in cases of acute severe exacerbations as a bridge therapy to other systemic treatments. 1

Assessment Before Considering Systemic Therapy

Before considering any systemic therapy for atopic dermatitis (AD), a systematic approach should be taken:

1. Confirm diagnosis and rule out alternative conditions
2. Optimize topical therapy first:
   • Liberal use of emollients/moisturizers, especially after bathing 2, 3
   • Appropriate potency topical corticosteroids (TCS) for active lesions 3
   • Consider topical calcineurin inhibitors (TCIs) for sensitive areas 1, 4
   • Consider crisaborole for mild to moderate eczema 2
3. Address trigger factors and complications:
   • Identify and eliminate triggering substances 2
   • Treat any secondary infections 1, 2
4. Consider phototherapy for moderate to severe cases before systemic agents 1

Problems with Oral Corticosteroids in AD

Oral corticosteroids have significant drawbacks in AD management:

• Rebound phenomenon: After discontinuation or dose reduction, patients often experience marked worsening with more severe lesions, intense pruritus, exudates, and even systemic symptoms like fever 5
• Unfavorable risk-benefit profile for long-term use 2
• May exacerbate the acute phase of AD by accentuating the Th2 immune pattern 5

Appropriate Systemic Options for Severe AD

When topical treatments and phototherapy fail, guidelines recommend considering:

1. Immunomodulators such as cyclosporine, azathioprine, and methotrexate as preferred options 1
2. Newer biologics like dupilumab for severe chronic AD 6
3. Oral corticosteroids only as a short-term bridge therapy to other systemic treatments during acute severe exacerbations 1

When Oral Steroids Might Be Considered

The International Eczema Council and American Academy of Dermatology guidelines indicate that oral steroids should only be considered in very limited circumstances:

• Acute severe exacerbations requiring immediate control 1
• As a bridge therapy while transitioning to other systemic treatments 1
• Short courses only to minimize adverse effects 1

Important Caveats and Pitfalls

• Never use oral steroids as long-term therapy for AD due to side effects and rebound phenomenon
• Avoid repeated short courses as this can lead to steroid dependence
• Always have a plan to transition to more appropriate long-term therapy
• Monitor closely for rebound flares when tapering oral steroids
• 10% of AD patients may receive oral steroids despite recommendations against their routine use 1

Decision Algorithm for Severe AD Management

1. First ensure topical therapy has been optimized:

   • Proper use of emollients
   • Appropriate potency TCS
   • TCIs for sensitive areas
   • Treatment of secondary infections

2. If inadequate response, consider phototherapy

3. If still inadequate:

   • Consider systemic immunomodulators (cyclosporine, azathioprine, methotrexate)
   • Consider newer biologics like dupilumab

4. Only consider oral steroids if:

   • Acute severe exacerbation requiring immediate control
   • Need for bridge therapy while initiating other systemic treatments
   • Plan for short duration with tapering schedule
   • Monitoring for rebound phenomenon

The evidence clearly shows that while oral steroids may provide temporary relief, their use in AD should be highly restricted due to the significant risk of rebound flares and adverse effects.