Efficacy

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Versus placebo

The effectiveness of topical corticosteroids versus placebo has been demonstrated in one systematic review (search date 1999,13 RCTs)1 and two further RCTs2,3 comparing topical steroids with placebo (vehicle) applied for up to 6 weeks in patients with atopic eczema (Table 17.1). Twelve studies found significant improvement with topical steroid compared with placebo.3-13 Reference 11 includes 2 RCTs - see Table 17.1. The three remaining studies were unable to demonstrate a significant difference between steroid and placebo.2,14,15 No long-term studies were identified.

Versus each other

One systematic review (40 RCTs) was identified comparing a variety of topical steroids with each other.1 The review found significant improvements in 13-100% of people after 1-6 weeks of treatment.

Prevention of relapse

One RCT in adults has examined the effectiveness of topical steroids in preventing a relapse of atopic eczema.16 The study included 54 adults with atopic eczema that had completely healed with a 4-week course of a potent topical steroid (0-005% fluticasone propionate). The study showed that subsequent application of fluticasone propionate 0-005% ointment on two consecutive days a week for 16 weeks was significantly more effective in maintaining an improvement compared with placebo. In a further open uncontrolled study, 90 patients (aged 17-63 years) were treated once daily with mometasone furoate 0-1% cream for 3 weeks. The 78% of patients who had cleared or almost cleared after this time were treated prophylactically with the same preparation twice weekly for 6 months, after which time 90% remained relapse-free.17

Application under wet wraps

One RCT (40 children aged 1-15 years) has examined the use of wet-wrap bandaging (wet cotton tubular dressings) applied over diluted topical steroids to improve penetration of topical steroid and control of symptoms.18 In this study children were treated once daily with either one-tenth strength mometasone furoate 0-005% ointment or one-tenth strength fluticasone

Do topical steroids help?

Table 17.1 Topical steroids versus placebo in atopic eczema: results of RCTs2-15

Intervention and duration

Number of participants (age in years)

Outcome

Triamcinolone acetonide 0-05% twice daily for 2 100 weeks2

Prednicarbate 0-25°% ointment twice daily for 4 51 (18-60)

weeks3

Betamethasone dipropionate 0-05°% ointment twice 36 (2-63) daily for 3 weeks4

Hydrocortisone valerate 0-2% cream three times 20 (2-75) daily for 2 weeks5

Halcinonide 0-1% cream twice daily for 3 weeks6 58 (0-8-86)

Halcinonide 0-1°% ointment three times daily for 2 233 (2-67) weeks7

Hydrocortisone valerate 0-2% ointment twice daily 64 (>12) for 2 weeks8

Betamethasone dipropionate cream 0^05% twice 30 (19-57) daily for 4 days9

Desonide cream once daily for 1 week10

Fluticasone propionate 0^005% twice daily for 4 203 (12-82)

weeks11

Fluticasone propionate 0.005% twice daily for 4 169 (12-84)

weeks11

Hydrocortisone buteprate 0-1% cream once daily for 194 (17-76) 2 weeks12

Clobetasol propionate 0^05% cream twice daily for 81 (>12) 4 weeks13

Triamcinolone acetonide 0-5% once daily14 40 (2 with atopic dermatitis )

Hydrocortisone acetate 1% twice daily for 1 week 69 (>16) then emollient only for 1 week versus 2 weeks of emollient only15

Clear or marked Improvement: 38% active treatment, 22% controls

Excellent, good or fair: 79% active treatment, 37% controls. Significantly reduced pruritus on active treatment

Good or excellent: 94% active treatment, 13% controls

Excellent or better: 75% active treatment, 20% controls

57% of people achieved a better response with active treatment than control ('better response' not defined)

Good or excellent: 85% active treatment, 44% controls

Disease severity score: 70% reduction with active treatment, 15% with control

Itch-free on days 3-4: 36% active treatment, 22% controls

Improvement or resolution: 67% active treatment,16% controls

Cleared, excellent or good: 80% active treatment, 38% controls

Cleared, excellent or good: 80% active treatment, 34% controls

Excellent or good: 69% active treatment, 26% controls

Good, excellent or clear: 82% active, 29% controls

One cleared in actively treated area, the other showed no improvement in either area

Global assessment of parameters showed marked improvement in both groups. Trend towards greater improvement in the steroid group but not statistically significant propionate 0-005% ointment unoccluded for 2 weeks, and then randomised to receive the same treatment with or without wet-wrap bandaging for a further 2 weeks. Patients treated with wet wraps finished the study with significantly less extensive and less severe disease, and a significant improvement in subjective scores. However, improvement in patients not receiving wet wraps plateaued after week 2 and no statistically significant improvement in disease extent, severity or subjective scores was seen at week 4.

Three further uncontrolled studies have shown improvement in eczema severity with wet wraps over one-tenth strength betamethasone valerate 0-01% cream or various dilutions of fluticasone propionate 0-05% cream, applied for 2-14 days continuously or twice weekly for 3 months.19-21

Frequency of application

One systematic review (three RCTs, n = 569) has addressed this issue.1 The review found no clear evidence to support twice daily over once daily administration of topical corticosteroid, suggesting once daily treatment as a first step in all patients with atopic eczema.

Pulsed or continuous treatment: One RCT

(207 children with mild-to-moderate atopic dermatitis, aged 1-15 years) has compared 3-day bursts of a potent topical steroid (betamethasone valerate 0-1% ointment) followed by a 4-day rest period versus continuous use of a mild preparation (hydrocortisone 1% ointment) for 7 days. Participants used the preparations as required over an 18-week trial period. No significant difference in patient symptoms or clinical disease severity was demonstrated between the two treatment groups.22 Another RCT study of 40 children (published in abstract form) concluded that pulsed clobetasone butyrate 0-05% is more effective than continuous treatment.23

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