What is the recommended treatment for a pregnant patient with severe eczema (atopic dermatitis) requiring steroid dosing?

From the Guidelines

I strongly recommend seeking an urgent dermatology consultation for your pregnant patient with severe eczema and consider prescribing a medium-potency topical steroid like triamcinolone 0.1% cream for the body and hydrocortisone 2.5% cream for the face, to be applied twice daily for 7-10 days, as the most recent and highest quality evidence suggests that topical corticosteroids are the mainstay of treatment for atopic eczema and can be used safely if certain precautions are taken 1.

Treatment Approach

While waiting for the appointment, the following treatment approach can be considered:

• Medium-potency topical steroid like triamcinolone 0.1% cream for the body and hydrocortisone 2.5% cream for the face, to be applied twice daily for 7-10 days
• For severe cases in pregnancy, oral prednisone at 20-40mg daily with a quick taper over 1-2 weeks may be necessary, though this should ideally be coordinated with both dermatology and obstetrics, as recent guidelines suggest that low-dose glucocorticoid treatment (≤10 mg daily of prednisone or nonfluorinated equivalent) can be continued during pregnancy if clinically indicated 1
• Antihistamines like diphenhydramine (25-50mg at bedtime) or cetirizine (10mg daily) can help control itching
• Moisturizing is crucial - recommend fragrance-free emollients like CeraVe or Vanicream applied multiple times daily, especially after bathing
• Wet wrap therapy can provide additional relief

Important Considerations

• The patient should avoid hot showers, harsh soaps, and known triggers
• This severe presentation warrants prompt attention as the skin barrier breakdown increases infection risk, and the chronic inflammation and sleep disruption can negatively impact both maternal and fetal wellbeing
• Recent evidence suggests that there is no significant increased risk of stillbirth, preterm delivery or congenital malformations from using prednisolone in any disease, although the usual side-effects of corticosteroid use will still occur 1

From the FDA Drug Label

Corticosteroids are generally teratogenic in laboratory animals when administered systemically at relatively low dosage levels. The more potent corticosteroids have been shown to be teratogenic after dermal application in laboratory animals There are no adequate and well-controlled studies in pregnant women on teratogenic effects from topically applied corticosteroids. Therefore, topical corticosteroids should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Drugs of this class should not be used extensively on pregnant patients, in large amounts, or for prolonged periods of time

The recommended treatment for a pregnant patient with severe eczema (atopic dermatitis) requiring steroid dosing is to use topical corticosteroids only if the potential benefit justifies the potential risk to the fetus. The treatment should be limited to the least amount compatible with an effective therapeutic regimen and not used extensively, in large amounts, or for prolonged periods of time 2.

From the Research

Treatment Options for Severe Eczema in Pregnant Patients

• Emollients are the basis of therapy for atopic dermatitis in pregnant patients 3
• Topical corticosteroids are a safe treatment option for pregnant patients with severe eczema, with mild to moderate potency preferred over potent/very potent ones 4
• Calcineurin inhibitors are also considered safe for use in pregnant patients with atopic dermatitis 3
• Ultraviolet therapy can be added to the treatment regimen if required 3
• Cyclosporin A is a possible option for systemic therapy during pregnancy, especially for severe cases of atopic dermatitis 3, 5
• For severe refractory atopic dermatitis, cyclosporine A is the first-choice long-term systemic treatment, with short-course prednisolone for flare management 5

Steroid Dosing Considerations

• Maternal use of potent/very potent topical corticosteroids, especially in large amounts, is associated with an increased risk of low birthweight 4
• The use of systemic corticosteroids, such as prednisolone, should be limited to short courses for flare management 5
• Patient and clinician education on appropriate and inappropriate atopic dermatitis treatments for use in pregnancy is vital 5

Management of Atopic Dermatitis in Pregnancy

• Atopic dermatitis management during pregnancy requires special precautions to avoid harming the fetus 6
• The presentation and histopathology of atopic dermatitis during pregnancy are identical to those of the non-pregnant individual 6
• Atopic dermatitis may worsen during pregnancy due to the T-helper 2 dominant disease environment 6