Key messages
- Generally, stronger topical corticosteroids (steroid cream applied to the skin) are probably more effective than weaker preparations. Strong steroid cream applied once daily is probably as good as twice daily, and using steroid cream for two consecutive days weekly probably prevents eczema flare-ups.
- About a third of studies looked for skin thinning, but cases were very low. This made it difficult to judge differences between strategies, although there were more cases with stronger steroid cream.
- We need better-quality research on unwanted effects, over longer timeframes, but intermittent use of steroid cream probably causes fewer unwanted effects.
What is eczema and how is it treated?
Eczema is a common, long-lasting condition that results in inflamed, dry, itchy patches of skin and its severity varies; it is incurable currently, so treatment aims to control symptoms (inflammation and itching). The first choice of treatment is emollients (moisturisers) combined with treatment to reduce inflammation, often steroid cream.
What did we want to find out?
Steroid creams can be used in different ways to treat eczema, and people often feel confused about which ones to use, and how often and how best to use them. We wanted to investigate the effectiveness of different ways (strategies) of using steroid cream and whether they cause unwanted effects.
What did we do?
We summarised evidence from studies that tested different ways of using steroid cream in adults and children. We assessed treatment strategies based on changes in eczema severity assessed by doctors/researchers or participants, and unwanted effects, such as skin thinning (the skin may bruise and tear more easily). We compared and summarised their results, and rated our confidence in the evidence, based on factors such as trial methods and sizes.
What did we find?
Most studies were conducted in high-income countries, likely in hospitals, and were short term (range 1 to 6 weeks); studies that assessed prevention of eczema flares lasted longer, but under 6 months. Participant age varied; 43 studies included children only. Eczema was moderate or severe in 51 studies, mild to moderate in 16 studies, mild to severe in 3 studies, and 34 studies did not report severity. Approximately half of the studies were funded by companies that produced the steroid cream or had links to industry; 44 did not report their funding source.
We included 104 studies with 8443 people.
- Stronger versus weaker steroid cream (63 studies). We combined data from 31 studies and 2018 people. The chances of achieving cleared or marked improvement, assessed by a healthcare practitioner, were probably increased with use of stronger-potency steroid cream. For 1000 people treated, it is likely that 340 to 390 would be clear or almost clear using mild-potency steroid cream; 460 to 520 would be clear or almost clear using moderate-potency steroid cream; and 530 to 710 would be clear or almost clear using potent steroid cream.
- Twice daily versus once daily steroid cream application (25 studies). We combined data from 15 studies with 1821 people. Applying strong steroid cream once daily is probably as effective as twice daily application. Studies did not report unwanted effects well, and we are uncertain about some results. Twenty-two studies (2266 people) reported skin thinning. They identified 26 possible cases, 16 with very strong steroid cream, 6 with strong, 2 with moderate, and 2 with mild steroid cream.
- Longer versus shorter steroid cream duration (0 studies)
- Twice-weekly application (using steroid cream for two consecutive days per week) to prevent flare-ups versus no application (9 studies). We combined data from 7 studies (1149 people). Twice weekly steroid cream probably decreases the chance of eczema flare-ups. For 1000 people using flare-control creams twice weekly, we would expect approximately 248 to have one or more new flare-up compared to 576 people not using this strategy. No cases of skin thinning were identified in 7 flare-up prevention studies (1050 people).
- Other comparisons. We also looked at newer versus older steroid cream preparations, cream versus ointment, steroid cream used with wet wrap, daily versus less frequent application, different strengths of the same steroid cream, time of day applied, steroid cream alternating with topical calcineurin inhibitors (e.g. Protopic and Elidel) versus steroid cream alone, application to wet versus dry skin, and before versus after emollients. No studies compared branded versus generic steroid cream or time between application of emollient and steroid cream.
What are the limitations of the evidence?
Overall, we are moderately confident about the results on the effectiveness of steroid creams to treat eczema, but we have little confidence in results on unwanted effects, because studies were small and did not always use the most reliable methods.
How up to date is this evidence?
The evidence is up to date to January 2021.
Potent and moderate topical corticosteroids are probably more effective than mild topical corticosteroids, primarily in moderate or severe eczema; however, there is uncertain evidence to support any advantage of very potent over potent topical corticosteroids. Effectiveness is similar between once daily and twice daily (or more) frequent use of potent topical corticosteroids to treat eczema flare-ups, and topical corticosteroids weekend (proactive) therapy is probably better than no topical corticosteroids/reactive use to prevent eczema relapse (flare-ups). Adverse events were not well reported and came largely from low- or very low-certainty, short-term trials. In trials that reported abnormal skin thinning, frequency was low overall and increased with increasing potency. We found no trials on the optimum duration of treatment of a flare, branded versus generic topical corticosteroids, and time to leave between application of topical corticosteroids and emollient. There is a need for longer-term trials, in people with mild eczema.
Eczema is a common skin condition. Although topical corticosteroids have been a first-line treatment for eczema for decades, there are uncertainties over their optimal use.
To establish the effectiveness and safety of different ways of using topical corticosteroids for treating eczema.
We searched databases to January 2021 (Cochrane Skin Specialised Register; CENTRAL; MEDLINE; Embase; GREAT) and five clinical trials registers. We checked bibliographies from included trials to identify further trials.
Randomised controlled trials in adults and children with eczema that compared at least two strategies of topical corticosteroid use. We excluded placebo comparisons, other than for trials that evaluated proactive versus reactive treatment.
We used standard Cochrane methods, with GRADE certainty of evidence for key findings. Primary outcomes were changes in clinician-reported signs and relevant local adverse events. Secondary outcomes were patient-reported symptoms and relevant systemic adverse events. For local adverse events, we prioritised abnormal skin thinning as a key area of concern for healthcare professionals and patients.
We included 104 trials (8443 participants). Most trials were conducted in high-income countries (81/104), most likely in outpatient or other hospital settings. We judged only one trial to be low risk of bias across all domains. Fifty-five trials had high risk of bias in at least one domain, mostly due to lack of blinding or missing outcome data.
Stronger-potency versus weaker-potency topical corticosteroids
Sixty-three trials compared different potencies of topical corticosteroids: 12 moderate versus mild, 22 potent versus mild, 25 potent versus moderate, and 6 very potent versus potent. Trials were usually in children with moderate or severe eczema, where specified, lasting one to five weeks. The most reported outcome was Investigator Global Assessment (IGA) of clinician-reported signs of eczema.
We pooled four trials that compared moderate- versus mild-potency topical corticosteroids (420 participants). Moderate-potency topical corticosteroids probably result in more participants achieving treatment success, defined as cleared or marked improvement on IGA (52% versus 34%; odds ratio (OR) 2.07, 95% confidence interval (CI) 1.41 to 3.04; moderate-certainty evidence). We pooled nine trials that compared potent versus mild-potency topical corticosteroids (392 participants). Potent topical corticosteroids probably result in a large increase in number achieving treatment success (70% versus 39%; OR 3.71, 95% CI 2.04 to 6.72; moderate-certainty evidence). We pooled 15 trials that compared potent versus moderate-potency topical corticosteroids (1053 participants). There was insufficient evidence of a benefit of potent topical corticosteroids compared to moderate topical corticosteroids (OR 1.33, 95% CI 0.93 to 1.89; moderate-certainty evidence). We pooled three trials that compared very potent versus potent topical corticosteroids (216 participants). The evidence is uncertain with a wide confidence interval (OR 0.53, 95% CI 0.13 to 2.09; low-certainty evidence).
Twice daily or more versus once daily application
We pooled 15 of 25 trials in this comparison (1821 participants, all reported IGA). The trials usually assessed adults and children with moderate or severe eczema, where specified, using potent topical corticosteroids, lasting two to six weeks.
Applying potent topical corticosteroids only once a day probably does not decrease the number achieving treatment success compared to twice daily application (OR 0.97, 95% CI 0.68 to 1.38; 15 trials, 1821 participants; moderate-certainty evidence).
Local adverse events
Within the trials that tested 'treating eczema flare-up' strategies, we identified only 26 cases of abnormal skin thinning from 2266 participants (1% across 22 trials). Most cases were from the use of higher-potency topical corticosteroids (16 with very potent, 6 with potent, 2 with moderate and 2 with mild). We assessed this evidence as low certainty, except for very potent versus potent topical corticosteroids, which was very low-certainty evidence.
Longer versus shorter-term duration of application for induction of remission
No trials were identified.
Twice weekly application (weekend, or ‘proactive therapy') to prevent relapse (flare-ups) versus no topical corticosteroids/reactive application
Nine trials assessed this comparison, generally lasting 16 to 20 weeks. We pooled seven trials that compared weekend (proactive) topical corticosteroids therapy versus no topical corticosteroids (1179 participants, children and adults with a range of eczema severities, though mainly moderate or severe).
Weekend (proactive) therapy probably results in a large decrease in likelihood of a relapse from 58% to 25% (risk ratio (RR) 0.43, 95% CI 0.32 to 0.57; 7 trials, 1149 participants; moderate-certainty evidence).
Local adverse events
We did not identify any cases of abnormal skin thinning in seven trials that assessed skin thinning (1050 participants) at the end of treatment. We assessed this evidence as low certainty.
Other comparisons
Other comparisons included newer versus older preparations of topical corticosteroids (15 trials), cream versus ointment (7 trials), topical corticosteroids with wet wrap versus no wet wrap (6 trials), number of days per week applied (4 trials), different concentrations of the same topical corticosteroids (2 trials), time of day applied (2 trials), topical corticosteroids alternating with topical calcineurin inhibitors versus topical corticosteroids alone (1 trial), application to wet versus dry skin (1 trial) and application before versus after emollient (1 trial). No trials compared branded versus generic topical corticosteroids and time between application of emollient and topical corticosteroids.