Clinical Question

Which strategies for using topical corticosteroids in the treatment of eczema increase effectiveness and avoid adverse effects?

Evidence-Based Answer

High- and medium-potency topical corticosteroids increase treatment success compared with low-potency topical corticosteroids, but there is no difference in effectiveness between high- and medium-potency topical corticosteroids. (Strength of Recommendation [SOR]: C, limited-quality disease-oriented evidence.) Application of topical corticosteroids once daily is probably as effective as twice daily. Weekend therapy (i.e., application on two consecutive days per week) likely prevents eczema relapses without an increased risk of adverse effects.¹ (SOR: B, inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Eczema, also known as atopic dermatitis, is a chronic inflammatory skin condition that is common worldwide and has a significant impact on quality of life. It affects up to 20% of children and 5% of adults.¹ Topical corticosteroids are the most commonly prescribed treatment, and prescribing patterns vary widely in the United States.² The authors of this review sought to identify the most effective strategies for topical corticosteroid use to treat eczema in adults and children, including different potencies, frequencies, and techniques of application. They also identified potential adverse effects.

The Cochrane review included 104 randomized controlled trials and 8,443 participants in several separate meta-analyses.¹ Most were conducted in high-income countries over a short period, ranging from one to six weeks. Primary outcomes were clinician-assessed improvement in signs of eczema using scaled instruments and clinician-reported local adverse effects (mainly thinning of the skin). Secondary outcomes were patient-reported symptoms and systemic adverse effects (i.e., abnormal cortisol levels).

Although several validated instruments for grading eczema severity are available, 62 trials reported the primary outcome using investigator global assessment scores on a 4-, 5-, or 6-point scale of eczema severity, with lower numbers indicating milder disease.¹ To compare the effectiveness of different topical corticosteroid strategies, the authors pooled data from studies that used investigator global assessment scales and created a dichotomous outcome of treatment success (i.e., cleared or markedly improved by investigator global assessment) vs. not successful (i.e., all other categories). Examples of topical corticosteroids used in the studies included hydrocortisone 0.5% to 2.5% cream/ointment (low potency), desonide (Desowen) 0.05% to 0.1% cream/ointment (medium potency), triamcinolone 0.1% cream/ointment (high potency), and clobetasol 0.05% cream/ointment (very high potency).

Medium-potency topical corticosteroids were more effective than low-potency corticosteroids (four trials; n = 420; number needed to treat [NNT] = 6; 95% CI, 4 to 12). No adverse effects were reported in either group. High-potency topical corticosteroids were more effective than low-potency corticosteroids (nine trials; n = 392; NNT = 3; 95% CI, 2.4 to 5.7). A comparison of high-potency and medium-potency topical corticosteroids showed no significant difference in treatment success (15 trials; n = 1,053; odds ratio [OR] = 1.33; 95% CI, 0.93 to 1.89). A comparison of very high-potency and high-potency topical corticosteroids showed no significant difference (three trials; n = 216; OR = 0.53; 95% CI, 0.13 to 2.09). When reported, low-certainty evidence demonstrated that the rates of local and systemic adverse effects were low across all comparison groups. For the secondary outcome of patient-reported symptoms, there were few data for meta-analysis; few studies reported this outcome, but data generally favored high- and medium-potency topical corticosteroids over low-potency topical corticosteroids.

In trials that compared the frequency of topical corticosteroid use, there was no significant difference between a twice-daily and once-daily application for clinician-reported investigator global assessment (15 trials; n = 1,821; OR = 0.97; 95% CI, 0.68 to 1.38) and patient-reported symptoms (two trials; n = 300; OR = 1.91; 95% CI, 0.62 to 5.83). The authors compared weekend therapy (i.e., treatment over two consecutive days each week) with no topical corticosteroid use or a reactive application when a flare-up was present for the prevention of eczema relapses following a two- to four-week stabilization phase. Clinician-reported data showed a lower risk of relapse with weekend therapy (seven trials; n = 1,149; NNT = 3; 95% CI, 2.6 to 4.0). Patient-reported data showed better response to weekend therapy (one trial; n = 343; NNT = 2.5; 95% CI, 1.6 to 4.4). No adverse effects were reported in the trials analyzing weekend therapy.

Although the trials included in the meta-analysis encompassed all eczema severity levels, most trials were limited to participants with moderate or severe eczema, defined using one of several standard diagnostic criteria; this may limit applicability to patients with mild eczema. Few trials used a validated instrument recommended for assessing eczema severity, such as the Eczema Area and Severity Index (EASI) or the Objective SCORing Atopic Dermatitis (SCORAD) tool. The lack of standardization of investigator global assessment to assess eczema severity may limit the quality of data.³ The evidence for safety and adverse effect reporting was methodologically inconsistent and of relatively short duration. The American Academy of Dermatology (AAD) recommends a twice-daily application of topical corticosteroids for the treatment of eczema but states that once-daily application may be sufficient.⁴ The National Institute for Health and Care Excellence (NICE), which specifically addresses eczema in children, recommends once- or twice-daily application.⁵ AAD and NICE recommend weekend therapy to prevent relapse in those with frequent disease flare-ups.^4,5 This Cochrane review supports current practice guidelines and provides additional guidance for selection of topical corticosteroid potency.

Editor's Note: The NNTs and related CIs reported in this Cochrane for Clinicians were calculated by the authors based on raw data provided in the original Cochrane review.

The practice recommendations in this activity are available at https://www.cochrane.org/CD013356.

The opinions and assertions expressed herein are those of the authors and do not reflect the official policy or position of the U.S. Air Force, U.S. Department of Defense, or the U.S. government.