Oral Prednisone for Severe Eczema
Oral prednisone should NOT be used for severe eczema except in rare circumstances as a short-term bridge therapy, and only after all other treatment options have been exhausted. 1
Why Oral Corticosteroids Are Not Recommended
Systemic corticosteroids have a limited but definite role in "tiding over" occasional patients with severe atopic eczema, but the decision should never be taken lightly. 1 The key concerns are:
- Oral corticosteroids should NOT be considered for maintenance treatment until all other avenues have been explored 1
- It is particularly important to try to avoid oral corticosteroids during crises 1
- Prednisolone is significantly LESS efficacious than ciclosporin for severe adult eczema - in a randomized controlled trial, only 1 of 21 patients (5%) achieved stable remission with prednisolone compared to 6 of 17 (35%) with ciclosporin (P = 0.031) 2
- The trial comparing prednisolone to ciclosporin was terminated early due to unexpectedly high numbers of withdrawals from significant eczema exacerbations (15 of 38 patients) in the prednisolone group 2
What Should Be Used Instead
First-Line Treatment
- Potent or very potent topical corticosteroids (such as clobetasol propionate 0.05%) applied twice daily for up to 2 weeks 3
- Liberal and frequent emollient use throughout the day, especially after bathing 3
- Avoid irritants, hot showers, and excessive soap use 3
Second-Line Options Before Considering Systemic Therapy
- Tacrolimus 0.1% ointment - ranked among the most effective topical anti-inflammatory treatments alongside potent topical steroids 4
- JAK inhibitors (ruxolitinib 1.5%, delgocitinib 0.5% or 0.25%) - ranked as most effective for investigator global assessment 4
- Weekend (proactive) therapy with topical corticosteroids - decreases likelihood of relapse from 58% to 25% (RR 0.43,95% CI 0.32 to 0.57) 5
Systemic Therapy When Absolutely Necessary
- Ciclosporin (2.7-4.0 mg/kg daily) is the preferred systemic agent for severe eczema that has failed all topical treatments 2
- Prednisolone is NOT recommended to induce stable remission of eczema despite its frequent use in daily practice 2
Critical Pitfalls to Avoid
- Do not use oral corticosteroids as first-line therapy - ensure all topical treatments have been optimized first, including checking for treatment adherence 1
- Do not use oral corticosteroids for maintenance therapy - they are only appropriate as a short-term bridge in exceptional circumstances 1
- Do not prescribe prednisolone expecting stable remission - the evidence shows it is ineffective for this purpose and patients frequently experience significant exacerbations 2
- Consider secondary bacterial infection (particularly Staphylococcus aureus) if topical treatments fail - add flucloxacillin or erythromycin if penicillin-allergic 3