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An Alternative Conclusion
- David P Levy, Ashton Under Lyne Lancashire OL6 9RW (3 April 2002)
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Another alternative conclusion
- Adam Jacobs (4 April 2002)
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David P Levy, Consultant Paediatrician Tameside General Hospital,Fountain Street, Ashton Under Lyne Lancashire OL6 9RW
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Randomised controlled trial of short bursts of a potent topical corticosteroid versus prolonged use of a mild preparation for children with mild or moderate atopic eczema Conclusion of the study should be reversed Editor-Thomas et al concluded that a short burst of a potent steroid (0.1% betamethasone valerate) is as effective and as safe as prolonged use of a weak preparation (1% hydrocortisone) for mild or moderate disease. Their study lasted only 18 weeks and they only considered skin thinning as a potential side-effect. Atopic eczema is a life-long condition that requires regular use of topical preparations often for months to years. Children will often have concomitant asthma and hay fever and be using various doses of inhaled and nasal steroids. These steroids are additive and can suppress the pituitary-adrenal axis as well as affecting growth idiosyncratically. The stronger topical steroids will undoubtedly clear the eczema up quicker but the eczema will inevitably return. Do we then carry on using the potent preparations only to find that patients are using them more frequently than is required? The mainstay of treatment is patient education, the frequent use of emollients and the treatment of superadded infection with antibiotics. Indeed, I was delighted to see that there was no significant difference between the two preparations in the study. It is always good medical practice to use the lowest possible dose of a medicine that provides the desired result, thus lowering the risk-benefit ratio. I would therefore like to propose an alternative conclusion to the study, namely: “A weak topical steroid is as effective as using a short burst of a potent preparation” or “ Short bursts of a potent steroid conveys no added benefit than the regular use of a mild preparation in mild to moderate atopic eczema in children”. I would also recommend that if a potent preparation is considered necessary for childhood eczema, then the child should be referred to either a paediatrician with an interest in dermatology or to a consultant dermatologist. These patients require very careful follow up. David Levy No competing interests. 1 Randomised controlled trial of short bursts of a potent topical corticosteroid versus prolonged use of a mild preparation for children with mild or moderate atopic eczema BMJ 2002;324:768-771 |
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Adam Jacobs, Director Dianthus Medical Limited, SW19 3TZ
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The following conclusion is also consistent with the data reported by Thomas et al [1]: 'The emollient in which the steroids were applied was an effective treatment for atopic eczema. This efficacy was independent of any steroids included in the emollient.' The systemtatic review that Thomas et al quote [2] reported that 'We could not find one RCT comparing betamethasone 17-valerate and placebo, which is worrying as this is used as the standard comparator for most new topical corticosteroids developed subsequently.' As Thomas et al's study did not include a placebo control, how can we know whether either steroid had any effect at all? References: 1. Thomas KS, Armstrong S, Avery A et al. Randomised controlled trial of short bursts of a potent topical corticosteroid versus prolonged use of a mild preparation for children with mild or moderate atopic eczema. BMJ 2002;324:768-71 2. Hoare C, Li Wan Po A, Williams HC. Systematic review of treatments for atopic eczema. Health Technol Assess 2000;4:25-28 |
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