No serious systemic effects or cases of skin atrophy were reported in the short-term RCTs described above. Minor adverse effects such as burning, stinging, irritation, folliculitis, hypertrichosis, contact dermatitis and pigmentary disturbances occurred in less than 10% of patients. No cases of skin atrophy were seen in two longer RCTs (20 and 18 weeks duration) using histological examination and pulsed ultrasound respectively,16,22 and no serious systemic effects or cases of skin atrophy were reported with regular mild-to-moderate potency topical steroids in a longer cohort study in 14 pre-pubertal children (median treatment 6.5 years).24 No further RCTs looking at skin atrophy in people with atopic eczema were identified. Enhanced topical steroid absorption and temporary suppression of the hypothalamic-pituitary-adrenal axis have been demonstrated with wet-wrap dressings in uncontrolled studies in patients with severe widespread eczema.18,20
Four very small RCTs in healthy volunteers (12 adults) have used ultrasound to evaluate skin thickness after topical steroid application.25-28 Significant skin thinning occurred after 1 week with twice-daily 0-05% clobetasol 17-propionate and after 3 weeks with twice-daily 0-1% triamcinolone acetate and 0-1% betamethasone 17-valerate. All preparations were used for up to 6 weeks, and skin thinning reversed within 4 weeks of stopping treatment. No significant thinning was reported with twice-daily hydrocortisone prednicarbate or once-daily mometasone furoate after 6 weeks.
The majority of trials of topical steroids for atopic eczema have been of short duration even though atopic eczema is a chronic relapsing disease in which topical steroids may be required for months or years. Trials have used a wide variety of clinical scoring systems, making it difficult to compare results, and many trials have studied adults only. It is not possible to recommend a "best" topical steroid as most trials have only compared one against another but seldom against the same one and never all together. In the only trial comparing short bursts of potent steroid versus longer duration of mild topical steroids, the majority of patients were recruited from primary care and had mild eczema only. Further trials involving patients with more severe disease are needed to define the most effective method of using topical steroids in the long-term management of the disease and prevention of relapse. The majority of RCTs have not specifically addressed skin atrophy and have been of too short a duration to adequately assess risk with long-term use of topical steroids. The clinical significance of skin thinning as detected by statistically significant changes in total skin thickness when measured by ultrasound is unclear. Only one RCT has addressed the risks of skin atrophy in children,22 and further trials using a range of topical steroids of different strengths are needed to guide safe prescribing.
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