Prolonged Corticosteroid Exposure Associated With Adverse Effects for Patients With Atopic Dermatitis

A study published in Annals of Allergy, Asthma, & Immunology found that both adult and pediatric patients with atopic dermatitis (AD) had more negative effects with prolonged exposure to corticosteroid treatment for symptoms of AD.

Topical corticosteroids (TCS) are used most often as maintenance treatment for AD that is not able to be treated with regular skin care and moisturizers. However, TCS, while generally regarded as a safe treatment, has been associated with adverse effects like skin atrophy, telangiectasia, and striae. Prolonged use of TCS can cause dependence and reactions to withdrawal, referred to as topical steroid withdrawal syndrome (TSWS). The current study was conducted to determine the cumulative effects of TCS exposure in patients with AD.

An online survey was emailed to participants enrolled in the Allergy & Asthma Network or the International Topic Steroid Awareness Network distribution lists to fill out. The survey was also sent through social media or email to members of international AD patient organizations. The survey was conducted from November 5, 2020, to January 11, 2021. Participants were included if they were 18 years or older and either they or the child they were the caregiver of had a diagnosis of AD from a medical professional.

The survey included 26 questions that helped determine sociodemographic information, disease attributes, treatment history for AD, and experience and knowledge of TSWS in the participants. All participants self-reported areas in which they were afflicted with AD.

There were 2160 participants in the study; 1889 participants were adults with AD and 271 were caregivers of children with AD. Participants were from 70 countries, with 887 from Western or Central Europe/Australia/New Zealand, 831 from the US and Canada, 215 from Eastern Europe, 132 from the Middle East/Africa/Asia, and 53 from South America. The median age of the participants was 28.7 years and 85% were female. The children who participated were primarily male (55%) with a median age of 4.9 years. Most participants (61%) identified as White.

All participants reported use of a corticosteroid to treat AD, with 91% reporting use of a form of TCS. The average duration of OTC and prescription TCS use was 14.0 and 15.3 years, respectively, in adults and 3.7 and 3.6 years in children. A total of 75% of adults and children using OTC and prescription TCS were using the treatment 1 to 2 times per day and 50% applied TCS for 15 to 30 days per month.

The use of oral corticosteroids (OCS) was reported in 36% of all participants, with 23% reporting OCS use for AD. The average duration of use of OCS was 5.5 years in adults and 3.4 years in children.

A total of 78% of adults and 58% of caregivers of children reported feeling “very” concerned about the cumulative effects of TCS. Adults (83%) and children (64%) reported having worsening symptoms over time when using TCS, with the most reported symptom being AD spreading to other areas of the body. More than 90% of adults and children who had no response to TCS or worsening of the skin reported red, burning skin and severe itching.

Development of anxiety occurred in 51% of adults and 22% of children who used any form of corticosteroid, and development of depression and food or environmental allergies was also common.

The percentage of participants reporting developing new symptoms, symptoms akin to TSWS, worsening AD, or symptoms no longer responding to TCS increased as the duration of TCS use increased. A total of 83% of adults and 54% of children using OTC TCS, 86% adults and 66% of children using prescription TCS, and nearly all adults (95%) using topical compounded antibiotic steroid moisturizer (CASM) reported adverse events since applying treatments to their face or genitals.

Although OTC TCS, prescription TCS, and CASM were effective for a time, about half of all participants ceased use of TCS for their AD because the treatment wasn’t effective or they had new or worsening symptoms. A total of 79% of adults and 43% of children had reported symptoms of TSWS, with percentages higher for participants who applied prescription TCS to their face or genitals (90% of adults; 54% of children).

There were some limitations to this study. Patients involved with patient advocacy organizations usually have more severe disease, which could limit the generalizability of the results. The online aspect of the survey and inclusion of individuals in patient organizations may present selection bias. All responses were self-reported, which means that clinical details could not be confirmed. Responses may also have recall bias because of this. Most of the participants were also women.

The researchers concluded that a substantial cumulative corticosteroid load during lifetime AD experience was indicated in participants. Progression of the disease was related to corticosteroid exposure but will need to be confirmed through future trials.

Reference

Barta K, Fonacier LS, Hart M, et al. Corticosteroid exposure and cumulative effects in patients with eczema: results from a patient survey. Ann Allergy Asthma Immunol. Published online September 29, 2022. doi:10.1016/j.anai.2022.09.031