Should systemic steroids be avoided in atopic dermatitis?
Acta Eruditorum
Dr. Schwarzenberger is the former physician editor of DermWorld. She interviews the author of a recent study each month.
By Kathryn Schwarzenberger, MD, July 2, 2018
In this month's Acta Eruditorum column, Physician Editor Kathryn Schwarzenberger, MD, talks with Jonathan I. Silverberg, MD, PhD, MPH, about his recent Journal of the American Academy of Dermatology article, "A systemic review of the safety and efficacy of systemic corticosteroids in atopic dermatitis."
Dr. Schwarzenberger: In your recent JAAD article, you and your colleagues reviewed the safety and efficacy of systemic corticosteroids in atopic dermatitis. What led you to look at this?
Dr. Silverberg: I have unfortunately had many patients with atopic dermatitis who experienced terrible adverse events from use of systemic corticosteroids. Yet, in my anecdotal experience, systemic corticosteroids are still widely used for the treatment of atopic dermatitis. I sought to examine the extant literature on the safety and efficacy of systemic corticosteroids to provide an evidence-based review of their role in the management of atopic dermatitis.
Dr. Schwarzenberger: What were the most worrisome safety concerns that you identified in your study? Were you surprised by any of these?
Dr. Silverberg: Perhaps the most concerning were opportunistic infection, malignancy, thrombosis, diabetes, and hypertension. However, there were many other adverse events identified. Most of these were not surprising. However, a recent large-scale study identified in the systematic review showed that even short courses of systemic steroids increased the risk of sepsis, fractures, and venous thromboembolism. Short courses of systemic steroids are often regarded by providers as being benign and without adverse event. This study challenges some of those assumptions by demonstrating safety concerns even with short-term use of systemic corticosteroids.
Dr. Schwarzenberger: I think most dermatologists worry about rebound flares after stopping systemic corticosteroids. Did you find evidence to support this concern?
Dr. Silverberg: Yes. Rebound flares after discontinuation of systemic corticosteroids were noted in 24 articles.
Dr. Schwarzenberger: Adrenal suppression from steroids — did your study help us better understand when we need to worry about this? Are there best practices to follow?
Dr. Silverberg: A prior meta-analysis of systemic corticosteroid use for various medical disorders that was included in our systematic review showed a significantly increased risk of adrenal insufficiency with more than one month of use, as well as with medium- and high-dose corticosteroids. Only half of patients had resolution upon retesting one month later. Some studies found that even shorter courses of systemic steroids resulted in adrenal insufficiency, but it was only transient. It appears that patients being treated with less than one month of systemic steroids do not warrant routine screening for adrenal insufficiency.
Dr. Schwarzenberger: Glancing at your extensive bibliography, it looks like studies from Europe may have outnumbered those from the U.S. Did you get a sense from your study of who is actually using systemic corticosteroids to treat atopic dermatitis?
Dr. Silverberg: We did not specifically examine patterns or regional differences of systemic steroid use. However, several recent studies found that systemic steroids are commonly used to treat atopic dermatitis both in the United States and internationally.
Dr. Schwarzenberger: Do you have any other words of wisdom that you learned from this review? Will it change your practice?
Dr. Silverberg: It is important for clinicians to recognize that if systemic steroids are used, they should be limited to short courses as a bridge to steroid-sparing therapies. It is also important to recognize that even a short course of systemic steroids can be associated with considerable adverse events.
Dr. Silverberg is assistant professor of dermatology, medical social sciences, and preventive medicine at Northwestern University’s Feinberg School of Medicine. His article appeared in the Journal of the American Academy of Dermatology, 2018;78:733-40. doi: 10.1016/j.jaad.2017.09.074.