What is the role of oral steroids, such as prednisolone, in treating severe eczema?

Oral Steroids in Severe Eczema: Limited Role with Significant Caveats

Oral steroids like prednisolone have a limited but definite role in severe atopic eczema, but should never be considered for maintenance treatment and are not recommended to induce stable remission—they should only be used to "tide over" occasional patients during acute crises after all other treatment avenues have been explored. 1, 2

The Evidence Against Routine Use

The most compelling evidence comes from a 2010 randomized controlled trial directly comparing prednisolone to ciclosporin in severe adult eczema. This trial was terminated early by an independent safety board due to unexpectedly high numbers of treatment failures with prednisolone (15/38 withdrawals due to significant exacerbations). 3 Only 1 of 21 patients (5%) achieved stable remission with prednisolone compared to 6 of 17 (35%) with ciclosporin (P = 0.031). 3 The investigators concluded that despite frequent use in daily practice, prednisolone is not recommended to induce stable remission of eczema. 3

When Oral Steroids Might Be Considered

The British Medical Journal guidelines specify that systemic corticosteroids should only be used in these narrow circumstances: 1, 2

• Acute severe flares requiring rapid control when topical therapy has failed
• Short-term "tiding over" during crisis periods, not for ongoing management 1, 2
• Only after exhausting all other options, including optimized topical corticosteroids, emollients, infection management, and consideration of second-line treatments 1, 2

The FDA label for prednisolone lists atopic dermatitis as an approved indication, but this reflects regulatory approval rather than optimal clinical practice. 4

Why Oral Steroids Fail in Eczema

The fundamental problem is that eczema typically rebounds after oral steroid withdrawal, often with worse severity than baseline. 3 The 2010 trial demonstrated this dramatically—patients experienced significant exacerbations requiring withdrawal from the study. 3 This rebound phenomenon makes oral steroids particularly problematic for a chronic relapsing condition like eczema.

Proper Treatment Hierarchy

First-line treatment remains topical corticosteroids combined with liberal emollient use. 2 Use the least potent topical preparation that controls symptoms, applied no more than twice daily. 2 Potent and moderate topical corticosteroids are more effective than mild preparations for moderate-to-severe eczema. 5

For severe cases requiring systemic therapy, consider these alternatives before oral steroids: 1, 2

• Ciclosporin: Significantly more efficacious than prednisolone for inducing stable remission 3
• Phototherapy: Narrow band ultraviolet B (312 nm) for treatment-resistant cases 1, 2
• Other immunosuppressants: Azathioprine, though evidence is still experimental 1

Critical Safety Concerns

When oral steroids are used, be aware that: 1

• Pituitary-adrenal suppression is a significant risk, particularly with prolonged use
• Corticosteroid-related mortality has been documented in other inflammatory conditions—up to 77% of deaths in pemphigus vulgaris were steroid-related 1
• The decision should never be taken lightly and requires careful patient counseling 1, 2

Practical Algorithm for Severe Eczema

1. Optimize topical therapy first: Use potent topical corticosteroids (not mild) for moderate-to-severe disease, applied once daily (as effective as twice daily for potent preparations). 5

2. Address secondary infections aggressively: Use flucloxacillin for bacterial superinfection (most commonly Staphylococcus aureus), and continue topical steroids during antibiotic treatment. 2

3. Implement proactive maintenance: After achieving control, use twice-weekly topical corticosteroids on previously affected areas to prevent relapse—this reduces flare likelihood from 58% to 25%. 5

4. If topical therapy fails after 4 weeks: Refer to dermatology for consideration of ciclosporin or phototherapy, not oral steroids. 2, 3

5. Reserve oral steroids only for: Acute crisis situations requiring rapid temporary control while arranging definitive systemic therapy. 1, 2

Common Pitfall to Avoid

Do not use oral steroids to "get control" before starting topical therapy or as a bridge to maintenance treatment. 3 This approach leads to rebound flares and does not establish durable remission. The evidence shows this strategy fails in the majority of patients. 3