A Call to Retire Systemic Corticosteroids for Pediatric Atopic Dermatitis

Hadley was just 4 months old when she developed atopic dermatitis (AD). It worsened with time and by age 2 years, the rash was widespread, itchy, and painful. Her doctor prescribed an oral steroid treatment to get it under control in addition to the topical steroids she was already using. The oral steroids quickly beat back the eczema, but soon after she finished the course, it returned with a vengeance—a pattern that would repeat over and over again. She cycled through 15 different oral steroid treatments over 3 years, each time experiencing temporary relief followed by raging rebounds. Her mother, Ashley, recalls that she developed sleep problems and mood swings related to the treatment.

Hadley’s story is surprisingly common among the children and families who connect with our organization, Global Parents for Eczema Research. Even parents of very young children like Hadley describe repeated treatments with systemic corticosteroids for AD. In a cross-sectional survey of Canadian parents, one in five reported that their children had received systemic steroid treatment for their AD.¹

Why does this practice, the use of systemic steroids, so common? It is partly because we currently have so few effective, affordable treatment options for moderate to severe AD,² particularly in children. Moderate to severe AD adversely and overwhelmingly affects the patient and, usually, the entire family as well, due to sleep disruption, stress, and the time demands of managing the disease. When a child is in the throes of a flare, parents are often desperate for treatments to relieve their child’s discomfort, especially the unrelenting itch. Likewise, physicians want to help but until recently, they have had very few tools to work with.

Systemic corticosteroid treatment, administered through oral medication or injection, is one of those tools. It provides fast, real relief from AD symptoms. Patients are often incredibly grateful for the reprieve, even if it is fleeting. The itch, redness, pain, and sleep loss subside, and the patient feels “well” at long last. In addition to being fast-acting, the treatment is inexpensive compared with other options. When an adult patient or child presents to the doctor’s office in a state of misery, both parties are eager to reach for something that can alleviate the symptoms. For these reasons, systemic corticosteroid treatment has become an attractive option for doctors and parents alike. In one recent survey, 58% of adult patients with AD and caregivers of children with the condition reported treatment with systemic corticosteroids either currently or in the past.³

But this common strategy comes at a cost. A 2018 systematic review published in Journal of the Academy of Dermatology⁴ and a 2017 article in PloS One⁵ catalogued a litany of side effects associated with systemic corticosteroids, including growth suppression in children, osteoporosis, osteonecrosis, adrenal insufficiency, Cushing syndrome, hypertension, glucose intolerance, diabetes, gastroesophageal reflux, peptic ulcer disease, behavioral changes, opportunistic infections, cataracts, glaucoma, hyperlipidemia, malignancy, thrombosis, sleep disturbance, and rebound flaring. Given this toxicity profile, systemic corticosteroids are not recommended to be used for more than a brief period.^6-8 Further, a majority of AD experts who responded to a survey by the International Eczema Council recommended against the use of systemic corticosteroid treatment for children younger than 12 years.⁸

There certainly are instances when prescribing an systemic steroid may be the best option for the patient–eg, for acute, severe exacerbations and as a short-term bridge therapy to other systemic, steroid-sparing treatment, as recommended by AD experts in consensus guidelines of care for AD.⁹

But with the known side-effect profile, we argue that the use of systemic steroids for the routine management of AD in children should be retired altogether. Patients and parents can play a role in changing this practice if they have a better understanding of the risks of long-term and repeat use, but so can physicians and payers, particularly as newer, safer options for controlling more severe AD in children become available.

Indeed, it is time to reevaluate the use of these medications in light of the evolving therapy landscape for AD. That is a hopeful development for children with moderate to severe AD and their caregivers who should not have to trade off the risks of untreated AD for another set of perhaps even more concerning risks associated with treatment itself.

References

1. Bridgman AC, Eshtiaghi P, Cresswell-Melville A, Ramien M, Drucker AM. The burden of moderate to severe atopic dermatitis in Canadian children: a cross-sectional survey.
J Cutan Med Surg. 2018;22(4):443-444. doi:10.1177/1203475418761859

2. Alexander T, Maxim E, Cardwell LA, Chawla A, Feldman SR. Prescriptions for atopic dermatitis: oral corticosteroids remain commonplace. J Dermatolog Treat. 2018;29(3):238-240. doi:10.1080/09546634.2017.1365112

3. McCleary KK. Understanding the Lived Experience of Eczema: The “Voice of the Patient” Report on the Eczema Patient-Focused Drug Development Meeting. More Than Skin Deep collaboration; March 2020. Accessed May 27, 2021. http://www.morethanskindeep-eczema.org/uploads/1/2/5/3/125377765/mtsd_report_-_digital_file_1.pdf

4. Yu SH, Drucker AM, Lebwohl M, Silverberg JI. A systematic review of the safety and efficacy of systemic corticosteroids in atopic dermatitis. J Am Acad Dermatol. 2018;78(4):733-740.e11. doi:10.1016/j.jaad.2017.09.074

5. Aljebab F, Choonara I, Conroy S. Systematic review of the toxicity of long-course oral corticosteroids in children. PLoS One. 2017;12(1):e0170259. doi:10.1371/journal.pone.0170259

6. Sidbury R, Davis DMR, Cohen DE, et al. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014;71(2):327-349. doi:10.1016/j.jaad.2014.03.030

7. Wollenberg A, Barbarot S, Bieber T, et al; European Dermatology Forum, European Academy of Dermatology and Venereology, European Academy of Allergy and Clinical Immunology, European Task Force on Atopic Dermatitis, European Federation of Allergy and Airways Diseases Patients’ Associations, European Society for Dermatology and Psychiatry, European Society of Pediatric Dermatology, Global Allergy and Asthma European Network, European Union of Medical Specialists. Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part I. J Eur Acad Dermatol Venereol. 2018;32(5):657-682.
doi: 10.1111/jdv.14891.

8. Wollenberg A, Barbarot S, Bieber T, et al; European Dermatology Forum, European Academy of Dermatology and Venereology, European Academy of Allergy and Clinical Immunology, European Task Force on Atopic Dermatitis, European Federation of Allergy and Airways Diseases Patients’ Associations, European Society for Dermatology and Psychiatry, European Society of Pediatric Dermatology, Global Allergy and Asthma European Network, European Union of Medical Specialists. Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part II. J Eur Acad Dermatol Venereol. 2018;32(6):850-878.
doi: 10.1111/jdv.14888.

9. Drucker AM, Eyerich K, de Bruin-Weller MS, et al. Use of systemic corticosteroids for atopic dermatitis: International Eczema Council consensus statement. Br J Dermatol. 2018;178(3):768-775. doi:10.1111/bjd.15928