What is the best course of treatment for a patient with severe atopic dermatitis (eczema) requiring immediate dermatological attention and potential steroid dosing?

From the Guidelines

For a patient with severe atopic dermatitis requiring immediate dermatological attention, I strongly recommend initiating treatment with a short course of oral prednisone and topical high-potency steroids, while also considering referral to a dermatologist for further evaluation and potential systemic immunomodulator therapy. The most recent guidelines from 2024 1 emphasize the importance of shared decision-making between patients and clinicians when considering advanced therapies for severe atopic dermatitis.

Immediate Relief Measures

For immediate relief, the following measures can be taken:

• Prescribe a short course of oral prednisone (typically 40-60mg daily with a taper over 1-2 weeks) to reduce inflammation and itching
• Apply topical high-potency steroids like clobetasol 0.05% for the body (avoiding face) and triamcinolone 0.1% for facial involvement to reduce inflammation and itching
• Add an oral antihistamine like hydroxyzine 25-50mg at bedtime to help control itching and improve sleep
• Use wet wrap therapy to provide relief - apply topical steroids, moisturize, then wrap affected areas in damp gauze followed by dry clothing

Long-term Management

The 2024 guidelines 1 also highlight the importance of considering phototherapy and systemic therapies, including oral medications (immunosuppressants, corticosteroids, antimetabolites, Janus kinase [JAK] inhibitors) and injectable medications (biologics), for patients with severe or widespread atopic dermatitis. It is essential to rule out secondary infection and consider systemic immunomodulators if the condition persists.

Referral to a Dermatologist

Given the severity of the patient's condition, referral to a dermatologist for further evaluation and management is crucial. The dermatologist can assess the patient's condition, rule out other potential diagnoses, and develop a personalized treatment plan that may include advanced therapies such as phototherapy or systemic immunomodulators. The 2017 guidelines 1 also emphasize the importance of considering the patient's quality of life and the potential risks and benefits of different treatment options when making decisions about their care.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION: Apply a thin layer of clobetasol propionate gel, cream or ointment to the affected skin areas twice daily and rub in gently and completely. Clobetasol propionate gel, cream and ointment are super-high potency topical corticosteroids; therefore, treatment should be limited to 2 consecutive weeks, and amounts greater than 50 g per week should not be used. INDICATIONS AND USAGE: Clobetasol propionate gel, cream and ointment are super-high potency corticosteroid formulations indicated for the relief of the inflammatory and pruritic manifestations of corticosteroid responsive dermatoses.

For a patient with severe atopic dermatitis requiring immediate dermatological attention and potential steroid dosing, the best course of treatment is to apply a thin layer of clobetasol propionate gel, cream, or ointment to the affected skin areas twice daily.

• Treatment should be limited to 2 consecutive weeks.
• The total dosage should not exceed 50 g per week to avoid potential suppression of the hypothalamic-pituitary-adrenal (HPA) axis 2 2.
• Therapy should be discontinued when control has been achieved.
• If no improvement is seen within 2 weeks, reassessment of the diagnosis may be necessary.

From the Research

Treatment Options for Severe Atopic Dermatitis

• For patients with severe atopic dermatitis requiring immediate dermatological attention, treatment with systemic medications such as ciclosporin and dupilumab may be effective, as seen in a case study where rapid resolution of flares was achieved with these treatments 3.
• Topical corticosteroids are a common treatment for eczema, and potent or very potent topical corticosteroids may be more effective than mild topical corticosteroids for moderate or severe eczema 4.
• A network meta-analysis found that potent topical corticosteroids, tacrolimus 0.1%, and ruxolitinib 1.5% were among the most effective topical anti-inflammatory treatments for eczema, while mild topical corticosteroids and tapinarof 1% were among the least effective 5.

Steroid Dosing and Treatment Duration

• The optimal duration of treatment with topical corticosteroids is unclear, and there is a need for longer-term trials to determine the best treatment duration 4.
• Applying potent topical corticosteroids once a day may be as effective as twice daily application for treating eczema flare-ups, but the evidence is not conclusive 4.
• Systemic corticosteroids may be used for short-term treatment of severe eczema, but long-term use can have significant side effects, and other treatments such as ciclosporin or dupilumab may be considered for long-term management 3, 6.

Combination Therapies and Alternative Treatments

• Combination therapies, such as topical corticosteroids and antibiotics, may be effective for treating eczema, especially in cases where Staphylococcus aureus colonization is present 7.
• Other treatments, such as phototherapy, cyclosporine, mycophenolic acid precursors, azathioprine, and methotrexate, may be considered for patients with severe or refractory eczema, but the evidence for their effectiveness is limited, and they are often used off-label 6.
• Topical calcineurin inhibitors, such as tacrolimus and pimecrolimus, may be effective for treating eczema, especially for patients who are intolerant of topical corticosteroids or have failed other treatments 5.