Reviewing Frequent Concerns regarding the use of Topical Corticosteroids in Paediatric Eczema

The big idea:

To help patients better understand the usage of topical corticosteroids and address misconceptions on corticosteroid treatment of eczema, this study reviewed the possible adverse side effects of topical corticosteroids on patients by reviewing published evidence combined with clinical experience from a panel of physicians working in paediatric dermatology.

Introduction to how topical corticosteroids (TCS) treat eczema:

• Glucocorticosteroids have anti-inflammatory, immunosuppressive, anti-proliferative and vasoconstrictive effects.

  • On the cellular level, glucocorticoids act as ligands that regulate gene expression and transcription of various mRNA, resulting in both the beneficial and potentially deleterious effects of steroids.

• Topical corticosteroids treat atopic eczema by reducing skin inflammation (redness and swelling), suppressing an overactive immune response, slowing down the rapid growth of skin cells, and narrowing small blood vessels.

  • These combined effects help control eczema flare-ups and relieve symptoms such as itching, redness, and thickened patches of skin.

What the study found:

1. Efficacy and potency:

   1. Formulation of TCS affects its ability to penetrate through the skin.

   2. Cream formulation was more potent than ointment formulation, resulting in the highest vasoconstrictor activity.

2. Frequency of application:

   1. Putting TCS thrice daily adds very little to a once-daily application, especially after several days of use.

   2. Patients are advised to follow the doctor's direction.

3. Amount of TCS to be applied:

   1. Sufficient, but not a very thick application of TCS has to be used for adequate use of the drug. 

   2. It is recommended that the steroid is applied liberally and then carefully rubbed or massaged into inflamed skin.

4. Atrophy (skin thinning):

   1. Results under misuse of TCS (e.g. ‘off label use’ to areas of hyperpigmentation or hypopigmentation for prolonged periods of time, particularly in higher absorption sites such as the axillae (underarms), flexures (anatomical bends in the body) and groin).

   2. However, atrophy is not a problem if TCS is used correctly.

5. Striae/rubra distensae (linear scars produced by stretching of skin):

   1. TCS do not induce striae when used to treat atopic eczema in children unless used inappropriately or in overdose, and only then at certain sites (i.e. the axillae and groin)

6. Infected excoriated skin: 

   1. TCS should be the first-line treatment for excoriated or infected eczematous skin. Concurrent infection should be treated if clinically significant.

   2. There is no evidence that putting TCS on excoriated or infected eczema is deleterious.

7. Hypopigmentation:

   1. TCS do cause short-term vasoconstriction, which may be mistaken as hypopigmentation, but the hypopigmentation seen in patients with eczema is typically secondary to the eczema and resolves with appropriate treatment of the eczema, particularly after exposure to UV light.

What this means for eczema:

• Topical corticosteroids remain the most common and effective treatment to atopic eczema.

• It is important for patients to utilise the drug accordingly based on their doctor’s advice as misuse can result in adverse side-effects such as skin thinning.

Link to study:

https://pubmed.ncbi.nlm.nih.gov/25752907/