Safety of topical corticosteroids in atopic eczema: an umbrella review
Safety of topical corticosteroids in atopic eczema: an umbrella review
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.
adult dermatology, eczema, paediatric dermatology
1-12
Axon, Emma
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Chalmers, Joanne R
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Santer, Miriam
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Ridd, Matthew J.
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Lawton, Sandra
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Langan, Sinead M
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Grindlay, Douglas J C
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Muller, Ingrid
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Roberts, Amanda
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Ahmed, Amina
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Williams, Hywel C.
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Thomas, Kim S.
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7 July 2021
Axon, Emma
762e9bad-78e1-4309-9533-933b7cc29013
Chalmers, Joanne R
f41b7630-e3d1-488b-a633-be6ee711f84d
Santer, Miriam
3ce7e832-31eb-4d27-9876-3a1cd7f381dc
Ridd, Matthew J.
de8b7ad0-5afa-4231-99f6-d6778744ddd4
Lawton, Sandra
610566de-d907-4721-ac53-6ef72f9e708d
Langan, Sinead M
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Grindlay, Douglas J C
b5b1d50d-7cda-4349-87c0-f226c5c7f18f
Muller, Ingrid
2569bf42-51bd-40da-bbfd-dd4dbbd62cad
Roberts, Amanda
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Ahmed, Amina
b193d9a0-c848-4901-9103-d09bd9d651d5
Williams, Hywel C.
3914e691-2348-4704-a044-e8d2af92444e
Thomas, Kim S.
f21619f9-467f-45dd-b9d4-be4014f11f3b
Axon, Emma, Chalmers, Joanne R, Santer, Miriam, Ridd, Matthew J., Lawton, Sandra, Langan, Sinead M, Grindlay, Douglas J C, Muller, Ingrid, Roberts, Amanda, Ahmed, Amina, Williams, Hywel C. and Thomas, Kim S.
(2021)
Safety of topical corticosteroids in atopic eczema: an umbrella review.
BMJ Open, 11 (7), , [e046476].
(doi:10.1136/bmjopen-2020-046476).
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.
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Accepted/In Press date: 20 April 2021
Published date: 7 July 2021
Additional Information:
Funding Information:
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.
Funding Information:
Funding This report presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research programme (grant ref No. RP-PG-0216-20007).
Publisher Copyright:
© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.
Keywords:
adult dermatology, eczema, paediatric dermatology
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Local EPrints ID: 450270
URI: http://eprints.soton.ac.uk/id/eprint/450270
ISSN: 2044-6055
PURE UUID: 25dfe9e4-96bf-4030-afb4-831ae2201d9c
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Date deposited: 19 Jul 2021 17:00
Last modified: 06 Jun 2024 01:47
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Contributors
Author:
Emma Axon
Author:
Joanne R Chalmers
Author:
Matthew J. Ridd
Author:
Sandra Lawton
Author:
Sinead M Langan
Author:
Douglas J C Grindlay
Author:
Amanda Roberts
Author:
Amina Ahmed
Author:
Hywel C. Williams
Author:
Kim S. Thomas
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