Can high steroid use for eczema (atopic dermatitis) cause cognitive and behavioral changes, such as memory loss, decreased concentration, and avoidance of challenging tasks, in a child?

Topical Steroid Use in Eczema and Cognitive/Behavioral Changes in Children

Topical steroids used for eczema treatment in children are unlikely to cause cognitive and behavioral symptoms such as memory loss, decreased concentration, and avoidance of challenging tasks unless used in excessive amounts or for prolonged periods. 1

Relationship Between Steroid Use and Cognitive/Behavioral Changes

• Topical corticosteroids are a first-line treatment for eczema and are generally considered safe when used appropriately 2
• Short courses of oral steroids (less than two weeks) are very unlikely to cause long-term side effects in children 1
• The FDA label for systemic corticosteroids (like prednisone) does list potential neuropsychiatric effects, but these are primarily associated with systemic rather than topical administration 3

Potential Neuropsychiatric Effects of Steroids

When systemic steroids are used (which is different from topical application for eczema), possible neuropsychiatric effects may include:

• Psychiatric derangements ranging from euphoria and mood swings to severe depression and psychotic manifestations 3
• Emotional instability or aggravation of existing psychotic tendencies 3
• Potential cognitive effects including impaired cognition, decreased memory retention, attention, concentration, and mental speed 3
• Irritability and insomnia in up to 29% of infants receiving systemic corticosteroid therapy 4

Topical vs. Systemic Steroids: Important Distinctions

• Topical corticosteroids applied to the skin for eczema have significantly less systemic absorption compared to oral or injectable steroids 4
• The adverse effects profile for topical corticosteroids in children is primarily related to local effects such as skin thinning, rather than systemic neuropsychiatric effects 4
• Younger patients (0-6 years) are more vulnerable to hypothalamic-pituitary-adrenal (HPA) axis suppression due to their higher body surface area-to-volume ratio compared to older children 4

Monitoring and Safety Considerations

• High-potency or ultra-high-potency topical corticosteroids should be used with caution in children and patients should be followed closely by a dermatologist 4
• Careful instruction on appropriate amount to apply and safe sites for use should be provided to caregivers 4
• Limited quantities should be supplied to prevent overuse 4
• Potential for rebound flare if high-potency corticosteroids are abruptly discontinued should be considered 4

Alternative Explanations for Cognitive/Behavioral Changes

The symptoms described could be related to other factors:

• Sleep disturbance from pruritus (itching) associated with eczema itself 4
• Psychological impact of having a chronic skin condition 4
• Other developmental or neurological conditions that may coincide with eczema 4
• Normal developmental variations in attention and task persistence in 5-year-old children 4

Recommendations for Parents

• Discuss concerns about steroid use with the child's dermatologist or pediatrician 4
• Use the lowest potency topical corticosteroid that effectively controls the eczema 2
• Apply topical steroids as directed, typically once daily is as effective as twice daily for potent preparations 2
• Consider "weekend therapy" (proactive approach) to prevent flares rather than continuous use 2
• Monitor for any behavioral changes that seem to correlate with steroid use 4
• Consider referral to a specialist if the child requires courses of steroids lasting more than two weeks 1

When to Seek Further Evaluation

• If cognitive or behavioral symptoms persist despite appropriate use of topical steroids 4
• If there is a need for systemic steroids or prolonged use of high-potency topical steroids 1
• If there are concerns about growth, development, or other systemic effects 4
• If the child's eczema is not responding adequately to appropriate topical treatment 4

In this case, a comprehensive neuropsychological evaluation may be warranted to determine if there are other causes for the cognitive and behavioral changes observed in this 5-year-old child.