What is the recommended treatment for a pregnant patient with severe eczema, including potential steroid dosing with prednisone (corticosteroid)?

From the Guidelines

For severe eczema in a pregnant patient, I recommend urgent dermatology referral while initiating treatment with prednisone for short-term control, typically 20-40mg daily for 5-7 days with a taper, as the benefits of treatment outweigh the risks, according to the most recent guidelines 1.

Treatment Approach

The treatment approach for severe eczema in pregnant patients should prioritize minimizing risks to the mother and fetus while effectively managing symptoms.

• Systemic corticosteroids like prednisone are considered safe for short-term use in pregnancy, with the majority of the drug not crossing the placenta 1.
• Topical steroids such as triamcinolone 0.1% or betamethasone 0.05% can be applied twice daily to affected areas to reduce inflammation and itching.
• Moisturizers like CeraVe or Vanicream should be used liberally to help manage dry skin and reduce the need for topical steroids.
• Diphenhydramine 25mg every 6 hours can help with itching, but its use should be monitored due to potential side effects.

Safety of Corticosteroids in Pregnancy

The safety of corticosteroids during pregnancy has been evaluated in several studies, with the consensus being that short-term use of prednisone at moderate doses (up to 20mg daily) is not associated with significant increased risks to the fetus 1.

• The American College of Rheumatology guideline conditionally recommends continuing low-dose glucocorticoid treatment (≤10 mg daily of prednisone) during pregnancy if clinically indicated, and strongly recommends tapering higher doses to <20 mg daily 1.
• The use of systemic corticosteroids in pregnancy should be carefully considered, weighing the benefits of treatment against potential risks, and monitoring for any adverse effects.

Monitoring and Follow-Up

The patient should follow up within 1-2 weeks after initiating treatment to assess the effectiveness of the treatment plan and make any necessary adjustments.

• Dermatology evaluation is crucial for long-term management of eczema during pregnancy, to ensure that the treatment plan is optimized and any potential complications are identified early.
• Monitoring for potential side effects of corticosteroid use, such as gestational diabetes or hypertension, is also important.

From the FDA Drug Label

The initial dosage of PredniSONE tablets may vary from 5 mg to 60 mg 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 The lowest possible dose of corticosteroids should be used to control the condition under treatment.

The recommended treatment for a pregnant patient with severe eczema, including potential steroid dosing with prednisone, is to use the lowest possible dose of corticosteroids to control the condition under treatment. The dosage requirements are variable and must be individualized based on the disease under treatment and the response of the patient. The initial dosage of prednisone may vary from 5 mg to 60 mg per day. However, no specific dosage is recommended for pregnant patients with severe eczema in the provided drug labels 2 2.

From the Research

Treatment Options for Severe Eczema in Pregnancy

• Emollients are the basis of therapy for atopic dermatitis in pregnancy 3
• Topical corticosteroids and calcineurin inhibitors are safe treatment options for pregnant patients with eczema 3
• Ultraviolet therapy can be added to the treatment plan if required 3
• Cyclosporin A is a possible option for systemic therapy during pregnancy 3, 4
• Short-course prednisolone can be used for flare management in pregnant women with atopic dermatitis 4

Systemic Anti-Inflammatory Treatment

• Cyclosporine A is the first-choice long-term systemic treatment for women with atopic dermatitis during pregnancy and breastfeeding 4
• Prednisolone is recommended for short-course use in managing flares of atopic dermatitis in pregnant women 4
• Dupilumab and azathioprine may be suitable for use during breastfeeding, but not during pregnancy 4
• Janus kinase (JAK) inhibitors, methotrexate, and mycophenolate mofetil should be avoided during preconception, pregnancy, and breastfeeding 4

Management of Severe Eczema in Pregnancy

• Early input from dermatology specialists is required to manage severe eczema in pregnant women 5
• Systemic therapy may be necessary to achieve disease control in patients with moderate to severe eczema 5
• A shared-care framework for interdisciplinary management of atopic dermatitis patients is advocated 4