In severe atopic dermatitis, when is systemic corticosteroid therapy appropriate and what is the recommended dose, duration, and tapering regimen?

Systemic Corticosteroids in Severe Atopic Dermatitis

Systemic corticosteroids should generally be avoided in severe atopic dermatitis due to high risk of rebound flares and substantial adverse effects, but may be used only as a short-term bridge (maximum 1-2 weeks) to steroid-sparing therapies at 0.5-1 mg/kg/day with mandatory tapering. 1

Primary Recommendation: Avoid Systemic Steroids

The 2024 American Academy of Dermatology guidelines conditionally recommend against systemic corticosteroids for atopic dermatitis based on low-certainty evidence and substantial risk of serious adverse events. 1 The only randomized trial comparing prednisolone to cyclosporine was discontinued prematurely specifically due to severe rebound flares in the prednisolone arm. 1

Why Systemic Steroids Are Problematic

• Rebound flares occur commonly upon discontinuation or dose reduction, often exceeding the severity of the original presentation. 1, 2
• Short-term adverse effects include hypertension, glucose intolerance, gastritis, weight gain, and emotional lability. 2, 3
• Long-term risks include decreased bone density, adrenal suppression, growth suppression in children, opportunistic infections, and cataracts. 2, 3
• Despite being very effective short-term and easy to prescribe, the risk-benefit ratio does not favor their use. 1

When Systemic Steroids May Be Considered

Clinicians might consider short courses of systemic corticosteroids only in these limited circumstances: 1

• When no other treatment options are immediately available
• As a bridge to other long-term steroid-sparing therapies (dupilumab, cyclosporine, methotrexate, azathioprine)
• In acute severe exacerbations while initiating steroid-sparing agents 1, 2

Dosing Protocol (When Absolutely Required)

Adult Dosing

• Dose: 0.5-1.0 mg/kg/day (typically 40-60 mg/day for average adult) 4, 2, 5
• Duration: Maximum 1-2 weeks 4, 2
• Formulation: Oral prednisone or prednisolone 2

Pediatric Dosing

• Dose: 0.5-1.0 mg/kg/day (same weight-based range as adults) 4
• Special caution: Children have increased risk of HPA axis suppression and growth impairment 1, 2
• Systemic steroids are not recommended for children unless required to manage comorbid conditions 2

Mandatory Tapering Regimen

• A taper is required regardless of treatment duration to decrease risk of adrenal suppression and rebound flares. 4, 2, 5
• Rapid taper over 5-7 days while simultaneously initiating a steroid-sparing systemic agent. 4
• For moderate-to-severe reactions, gradual reduction over 2-4 weeks may be appropriate. 5
• If the rash returns during taper, return to the previous effective dose and slow the taper rate rather than restarting at high doses. 5

Preferred First-Line Systemic Therapies

The 2024 AAD guidelines make strong recommendations for these agents instead of systemic steroids: 1

Biologics (Strongest Evidence)

• Dupilumab - First-line biologic with superior safety profile, no routine laboratory monitoring required 1, 4
• Tralokinumab - Strong recommendation 1

JAK Inhibitors (Strongest Evidence)

• Abrocitinib, baricitinib, upadacitinib - All have strong recommendations 1
• Require monitoring of hemogram, liver enzymes, and lipid levels 1

Traditional Immunosuppressants (Conditional Recommendations)

Cyclosporine (most evidence-based traditional agent): 1

• Dose: 3-5 mg/kg/day divided twice daily 1, 4
• More effective than methotrexate and azathioprine in network meta-analysis 1
• Limit treatment to no more than 12 months due to cumulative renal toxicity 1
• Monitoring: CBC, comprehensive metabolic panel, magnesium, uric acid, lipids, blood pressure 4
• Most prominently associated with renal impairment and hypertension 1

Methotrexate (second-line): 1, 4

• Adult dose: 7.5-25 mg/week 4
• Pediatric dose: 0.2-0.7 mg/kg/week 4
• Requires folate supplementation 1, 4
• Monitor CBC and comprehensive metabolic panel 4
• Most prominently associated with liver damage 1

Azathioprine (second-line): 1, 4

• Adult dose: 1-3 mg/kg/day 4
• Pediatric dose: 1-4 mg/kg/day 4
• Requires TPMT enzyme testing before initiation 4
• Most prominently associated with cytopenias 1

Mycophenolate (alternative): 1, 4

• Adult dose: 1.0-1.5 g orally twice daily 4
• Pediatric dose: 30-50 mg/kg/day 4
• Less randomized trial evidence than other agents 1

Stepwise Treatment Algorithm

1. Optimize topical therapy first: High-potency topical corticosteroids once or twice daily for 1-4 weeks with liberal emollient use 4, 2

2. Consider phototherapy: Narrow-band UVB should be trialed before systemic agents when available 4, 2

3. Initiate steroid-sparing systemic therapy: Prefer dupilumab (if accessible) or cyclosporine as first-line systemic agents 4, 2

4. Reserve prednisone for crisis only: In acute severe flares while awaiting steroid-sparing therapy effect, limit prednisone to ≤1-2 weeks maximum 4, 2

Critical Pitfalls to Avoid

• Do not prescribe prednisone for maintenance therapy - Chronic use creates dependence and severe rebound flares 4, 2
• Avoid prolonged tapers - Tapering longer than 2 weeks perpetuates the adverse cycle of chronic steroid exposure 4
• Do not delay steroid-sparing agents - Initiate dupilumab or cyclosporine promptly rather than repeating short courses of prednisone 4, 2
• Do not use continuous or chronic intermittent systemic steroids - This approach is explicitly not recommended 2
• Systemic steroids are substantially less expensive than biologics and JAK inhibitors, but because of lower certainty evidence, potential for serious adverse events, and need for stringent monitoring, they are not considered first-line treatments 1

Monitoring Requirements (If Systemic Steroids Used)

• Blood pressure monitoring 2
• Ophthalmologic examination for longer courses 2
• HPA axis suppression testing for extended durations 2
• Growth velocity measurement in pediatric patients 2