What is the recommended steroid dosing for widespread atopic (atopic dermatitis) dermatitis?

From the Guidelines

For widespread atopic dermatitis, I strongly recommend against the use of systemic corticosteroids, such as prednisone, except in cases of acute, severe exacerbations and as a short-term bridge therapy to other systemic, corticosteroid-sparing therapy, due to the potential for significant morbidity and mortality associated with their long-term use 1. When considering treatment options for widespread atopic dermatitis, it is essential to prioritize the use of topical corticosteroids and other non-systemic therapies to minimize the risk of adverse effects and optimize quality of life.

• The guidelines of care for the management of atopic dermatitis in adults with phototherapy and systemic therapies, published in the Journal of the American Academy of Dermatology in 2024, provide evidence-based recommendations for the management of atopic dermatitis in adults using phototherapy modalities and systemic therapies available for use in the United States 1.
• The use of systemic corticosteroids, such as prednisone, is conditionally recommended against due to the low strength of evidence and the potential for significant adverse effects, including rebound flares upon discontinuation 1.
• In cases where systemic therapy is necessary, alternative options such as mycophenolate mofetil, azathioprine, and cyclosporine may be considered, although their use should be carefully monitored due to the potential for toxicity and other adverse effects 1.
• The decision to initiate systemic therapy should be made using shared decision-making between patients and clinicians, taking into account the severity of atopic dermatitis, its impact on the patient, and the efficacy, safety, and accessibility of the available interventions 1.

From the Research

Steroid Dosing for Widespread Atopic Dermatitis

• The use of topical corticosteroids is the first-line treatment for atopic dermatitis flare-ups 2.
• Topical corticosteroids are classified by strength and the risk of adverse effects, and the risk of adverse effects increases with prolonged use, a large area of application, higher potency, occlusion, and application to areas of thinner skin such as the face and genitals 3.
• For widespread atopic dermatitis, the choice of topical corticosteroid depends on the severity of the disease, the size of the affected area, and the patient's age and medical history 3.
• Clobetasol propionate is the most potent of all topical steroids and is successfully applied in the treatment of various skin diseases such as atopic dermatitis, but its potency is accompanied by local and systemic side effects 4.
• The quantity of corticosteroid prescribed depends on the duration of treatment, the frequency of application, the skin location, and the total surface area treated, and correct patient application is critical to successful use 3.
• Patients may be taught application using the fingertip unit method, where one fingertip unit is the amount of medication dispensed from the tip of the index finger to the crease of the distal interphalangeal joint and covers approximately 2% body surface area on an adult 3.
• Topical corticosteroids are applied once or twice per day for up to three weeks for super-high-potency corticosteroids or up to 12 weeks for high- or medium-potency corticosteroids, and there is no specified time limit for low-potency topical corticosteroid use 3.
• Systemic immunomodulatory medications, such as cyclosporine and methotrexate, may be used for severe atopic dermatitis, but their safety and efficacy must be carefully evaluated, and the incidence of serious bacterial and opportunistic infections must be considered 5.