What is the recommended treatment approach for pediatric patients with severe dermatitis or psoriasis using oral steroids, such as prednisolone?

Oral Steroids for Pediatric Dermatitis and Psoriasis

Oral steroids are not recommended as first-line treatment for pediatric dermatitis or psoriasis due to their significant adverse effect profile and potential for rebound flares upon discontinuation. Instead, a stepwise approach using topical therapies, phototherapy, and safer systemic agents should be employed for severe cases.

Treatment Approach for Pediatric Dermatitis

First-Line Therapies

• Topical corticosteroids remain the mainstay of treatment for pediatric dermatitis, with potency selection based on disease severity, body location, and patient age 1
• Careful monitoring is essential, especially in children 0-6 years and infants who are vulnerable to HPA axis suppression due to their high body surface area-to-volume ratio 2
• Limited quantities of high-potency steroids should be prescribed with clear application instructions to prevent overuse and adverse effects 2

For Facial and Sensitive Areas

• Topical calcineurin inhibitors (TCIs) like tacrolimus 0.1% are recommended for facial and genital psoriasis in children 2
• TCIs have shown excellent improvement in facial and inverse psoriasis within 30 days in pediatric patients 2

For Moderate-to-Severe Cases

• Combination therapy using topical vitamin D analogs (calcipotriene/calcipotriol) with topical corticosteroids is effective for plaque psoriasis 2
• Rotational therapy alternating between different topical agents can serve as a steroid-sparing approach to reduce adverse effects 2

For Severe, Recalcitrant Cases

• Narrowband UVB phototherapy is recommended for moderate to severe pediatric plaque and guttate psoriasis 2
• For systemic therapy, methotrexate is the most common systemic medication used for moderate to severe pediatric psoriasis 2
• Biologic agents (etanercept, ustekinumab, adalimumab) are approved for pediatric psoriasis when other treatments fail 3

Role of Oral Steroids in Pediatric Dermatitis/Psoriasis

Limited Indications

• Oral prednisolone may be considered as a short-term intervention for severe atopic dermatitis while planning for steroid-sparing agents 4
• When used, prednisolone dosing in pediatric patients ranges from 0.14 to 2 mg/kg/day in three or four divided doses 5
• Short courses ("burst therapy") should be limited to 2 weeks with a tapering schedule to prevent rebound flares 4

Significant Concerns

• A case report noted that a 3-year-old boy with generalized pustular psoriasis became dependent on acitretin and oral high-dose corticosteroids until the addition of NB-UVB allowed discontinuation of systemic steroids 2
• Rebound flares are a significant risk when high-potency corticosteroids are abruptly discontinued 2

Monitoring and Safety Considerations

• For children receiving topical corticosteroids, regular monitoring by a dermatologist is essential to ensure proper use and prevent adverse effects 2
• When systemic therapy is required, the goal should be to control or clear the disease, maintain stability for several months, then taper to the lowest effective dose 2
• Long-term maintenance should use the lowest effective dose with the least toxic therapy 2

Special Considerations for Different Age Groups

• Infants and young children (0-6 years) are particularly vulnerable to HPA axis suppression due to their high body surface area-to-volume ratio 2
• High-potency or ultra-high-potency topical corticosteroids should be used with extreme caution in this age group 2
• For adolescents approaching childbearing potential, certain medications like tazarotene and acitretin should be avoided or used with strong caution due to teratogenicity risks 2