Guidelines on the Management of Atopic Dermatitis ... - Dermatology

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28. Atopic eczema in children: management in children from birth up to the age of 12 years Clinical
Guideline NICE December 2007
Topical pharmacological treatment of atopic dermatitis
Topical corticosteroids (TCS) [1++; A]
Topical corticosteroids continue to be the mainstay of atopic dermatitis treatment. 1,2 For
more than four decades TCSs have provided effective flare control through their antiinflammatory,
antiproliferative, immunosuppressive, and vasoconstrictive actions. 3 They
suppress the release of inflammatory cytokines, and they act on a variety of immune cells,
including T lymphocytes, monocytes, macrophages, dendritic cells and their
precursors. 4 Various strengths and formulations of TCS are available. The extent to which
they induce cutaneous vasoconstriction and inhibit inflammation corresponds with their
potency. There are no adequate trials to suggest superiority of one corticosteroid within a
potency group over another.
The extensive use of topical corticosteroids in clinical practice is supported by an everexpanding
body of clinical trial data, which helps to provide physicians with sensible
recommendations for the quantity, frequency, and duration of topical corticosteroid
therapy. 5,6 <strong>Guidelines</strong> for prescribing TCS are well described. 7,8 Preparations of very weak or
moderate strength are used on the face and genital area, whereas those of moderate or
potent strength are used on other areas of the body. 9 Patients should be educated about the
different steroid potencies in order to minimise untoward side-effects. 10
Better absorption of topical corticosteroids is observed in areas of inflammation and
desquamation compared to normal skin, and absorption occurs more readily through the
outer dermis in infants than through the skin of adults. 11
The vehicle through which the active steroid is delivered plays an important role in
absorption and can enhance its efficacy. Generally ointments are more effective than
creams, as the emollient action and occlusive effect result in better penetration. Ointments
also require fewer preservatives so the potential for irritant and allergic reactions is lower.
Wet wraps and application under occlusion enhance absorption of topical steroids.