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Systemic corticosteroids not recommended for long-term treatment of atopic dermatitis.

Systemic corticosteroids (SCSs) should be limited to short courses as a transition to steroid-sparing therapies in patients with atopic dermatitis because of the potential for adverse effects, reported Sherry Yu, MD, of Massachusetts General Hospital, Boston, and her associates.

Rebound flares are one of many adverse effects (AEs) that can occur when using SCSs, according to a systematic review of 52 reviews and 12 studies. Several of the studies from the systematic review found that rebound flares occurred after discontinuation of oral prednisone. One such study found that 15 of 38 patients (40%) with severe atopic dermatitis (AD) had to discontinue use of oral prednisone because of disease flares. Another study comparing oral vs. intramuscular methylprednisolone found that patients experienced rebound flares 1 week after discontinuing use of SCSs; in this particular study, there was no long lasting improvement in patients' AD, Dr. Yu and her associates said.

Another AE is adrenal insufficiency, defined as a cortisol level less than or equal to 500 nmol/L. In a meta-analysis of 74 articles with 3,753 participants, there was a significant increase in absolute risk of adrenal insufficiency with medium-term use (1 month to less than 1 year) and long-term use (more than 1 year) of SCSs, as well as medium and high doses of SCSs. Adrenal insufficiency can occur in as little as 4 weeks and may be subclinical. This can leave patients vulnerable to infection. Adrenal insufficiency also can manifest itself as weakness, fatigue, and shock in more severe cases.

Dr. Yu and her colleagues noted that tapering may minimize the risk of adrenal insufficiency and that a single morning dose or alternate dosing strategy may minimize this risk.

Another finding from this study was the adverse effects the SCSs have on pediatric patients. One study showed that 7 of 10 (70%) of children taking maintenance doses of beclomethasone dipropionate had growth impairment after 6 months of therapy. Significant growth disruption also was observed in children who had taken beclomethasone dipropionate only 4 weeks.

Dr. Yu and her colleagues warned that SCS should not be used to treat pediatric AD "because of growth retardation and other AEs."

Dr. Yu reported no relevant financial disclosures. The other three authors reported relationships with various companies in the industry.

SOURCE: Yu S et al. J Am Acad Dermatol. 2017 Oct 13. doi: 10.1016/j.jaad.2017.09.074.

BY IAN LACY

FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY

ilacy@mdedge.com

COMMENTARY BY DR. EICHENFIELD

THERE CONTINUES TO BE a large amount of research into atopic dermatitis (AD), and multiple topical and systemic agents are being studied for pediatric and adult AD. Some useful epidemiologic work has shown that it may have been too simplistic a perspective to think that AD in childhood always presents in early life and resolves within a few years. While about 15% of AD patients in a large English cohort study and Dutch birth cohort study (with more than 18,000 children) followed this pattern, a significant percentage had early onset with late resolution or early onset with persistence. In addition, some later-onset AD occurred, more commonly associated with asthma.The most important takeaway was that AD exists in a variety of forms--with variations in onset, persistence, severity, timing of changes or resolution, and associated comorbidities.

Understanding the effects of AD and its secondary consequences has definitely fueled a desire to more adequately control the disease and to push a "long-term disease control" model rather than episodic treatment of flares without good, proactive maintenance regimens. Systemic corticosteroids remain a troublesome treatment for AD, as discussed in the article by Dr. Sherry Yu of Massachusetts General Hospital. Systemic side effects, adrenal insufficiency, growth impairment, and rebound flares all are reasons to avoid relying on systemic corticosteroids.

Ongoing therapeutic trials for systemic agents in children and adolescents include the testing of biologic agents--such as dupilumab, interleukin-4 and interleukin-13 blockers, and JAK inhibitors--that target cytokine pathways important in AD. Studies have been published recently on the already-approved topical phosphodiesterase-4 inhibitor crisaborole, including a 1-year safety study. Work on other topical agents, such as the aryl hydrocarbon receptor mediator tapinarof, continues; this work was highlighted in the article relating the presentation of Johnny Peppers, PhD, at the congress of the European Academy of Dermatology and Venereology meeting. This agent may work through inhibiting proinflammatory mediators including interleukin-6 and interleukin-17A. The topical 1% cream is being studied for both AD and psoriasis.
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Author:Lacy, Ian
Publication:Pediatric News
Article Type:Clinical report
Date:Jun 1, 2018
Words:743
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