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.2021 Jul 7;11(7):e046476.
doi: 10.1136/bmjopen-2020-046476.

Safety of topical corticosteroids in atopic eczema: an umbrella review

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Safety of topical corticosteroids in atopic eczema: an umbrella review

Emma Axon et al. BMJ Open..

Abstract

Objective: An umbrella review summarising all safety data from systematic reviews of topical corticosteroids (TCS) in adults and children with atopic eczema.

Methods: Embase, MEDLINE, PubMed, Cochrane Database of Systematic Reviews and the Centre of Evidence Based Dermatology map of eczema systematic reviews were searched until 7 November 2018 and Epistemonikos until 2 March 2021. Reviews were included if they assessed the safety of TCS in atopic eczema and searched>1 database using a reproducible search strategy. Review quality was assessed using version 2 of 'A MeaSurement Tool to Assess systematic Reviews' (AMSTAR 2 tool).

Results: 38 systematic reviews included, 34 low/critically low quality. Treatment and follow-up were usually short (2-4 weeks).

Key findings: TCS versus emollient/vehicle: No meta-analyses identified for skin-thinning. Two 2-week randomised controlled trials (RCTs) found no significant increased risk with very potent TCS (0/196 TCS vs 0/33 vehicle in children and 6/109 TCS vs 2/50 vehicle, age unknown). Biochemical adrenal suppression (cortisol) was 3.8% (95% CI 2.4% to 5.8%) in a meta-analysis of 11 uncontrolled observational studies (any potency TCS, 522 children). Effects reversed when treatment ceased.TCS versus topical calcineurin inhibitors: Meta-analysis showed higher relative risk of skin thinning with TCS (4.86, 95% CI 1.06 to 22.28, n=4128, four RCTs, including one 5-year RCT). Eight cases in 2068 participants, 7 using potent TCS. No evidence of growth suppression.Once daily versus more frequent TCS: No meta-analyses identified. No skin-thinning in one RCT (3 weeks potent TCS, n=94) or biochemical adrenal suppression in two RCTs (up to 2 weeks very potent/moderate TCS, n=129).TCS twice/week to prevent flares ('weekend therapy') versus vehicle: No meta-analyses identified. No evidence of skin thinning in five RCTs. One RCT found biochemical adrenal suppression (2/44 children, potent TCS).

Conclusions: We found no evidence of harm when TCS were used intermittently 'as required' to treat flares or 'weekend therapy' to prevent flares. However, long-term safety data were limited.

Prospero registration number: CRD42018079409.

Keywords: adult dermatology; eczema; paediatric dermatology.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.

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Conflict of interest statement

Competing interests: Authors are coapplicants on an NIHR Programme Grants for Applied Research (P-PG-0216-20007) which funded this overview. The aim of the Programme Grant is to develop an intervention to support eczema self-care and the results of this overview will contribute to this intervention. MJR is funded by an NIHR Post-Doctoral Research Fellowship (PDF-2014-07-013). SML is supported by a Wellcome Senior Clinical fellowship in Science (205039/Z/16/Z). HCW was an author on four included reviews, and KST was an author on one included review.

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Figure 1
PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
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