Although topical steroids have been used for the treatment of atopic eczema for over 40 years, surprisingly little work has been done to understand how best to use them for the long-term control of atopic eczema. Most RCTs have compared "me-too" products in studies lasting only a few weeks instead of addressing important questions such as optimum duration of application and whether one should use short bursts of potent steroids followed by milder preparations, or vice versa. The short-term studies have failed to evaluate speed of onset of one type of steroid when compared with another - an important consideration when trying to control the symptoms quickly in the child depicted in the case scenario. Despite widespread concern about skin thinning with topical steroids, which has arisen from occasional horror stories of people using very potent preparations continuously at sensitive sites such as the face or groin area for inappropriate periods, RCT evidence does not suggest that clinically significant skin thinning is a problem.
In relation to the child portrayed in the case scenario, a possible evidence-based treatment approach could involve the use of a potent topical steroid (for example an inexpensive preparation such as betamethasone valerate once daily) for 2-3 weeks to gain remission, followed by emollient-only "steroid holidays" to allow any skin thinning to recover. Future flares could then be treated with 3-day bursts of the same potent preparation. If this should fail to achieve sufficient overall control in terms of frequency and duration of remission, another approach would be to use the same preparation every weekend on active and previously healed sites.
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