Article Text

Original research
Safety of topical corticosteroids in atopic eczema: an umbrella review
  1. Emma Axon1,
  2. Joanne R Chalmers1,
  3. Miriam Santer2,
  4. Matthew J Ridd3,
  5. Sandra Lawton4,
  6. Sinead M Langan5,
  7. Douglas J C Grindlay1,
  8. Ingrid Muller2,
  9. Amanda Roberts1,
  10. Amina Ahmed1,
  11. Hywel C Williams1,
  12. Kim S Thomas1
  1. 1Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
  2. 2Primary Care & Population Sciences, University of Southampton, Southampton, Hampshire, UK
  3. 3Population Health Sciences, University of Bristol Faculty of Health Sciences, Bristol, UK
  4. 4Dermatology Department, Rotherham NHS Foundation Trust, Rotherham, UK
  5. 5Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
  1. Correspondence to Dr Emma Axon; emma.axon{at}


Objective An umbrella review summarising all safety data from systematic reviews of topical corticosteroids (TCS) in adults and children with atopic eczema.

Methods Embase, MEDLINE, PubMed, Cochrane Database of Systematic Reviews and the Centre of Evidence Based Dermatology map of eczema systematic reviews were searched until 7 November 2018 and Epistemonikos until 2 March 2021. Reviews were included if they assessed the safety of TCS in atopic eczema and searched >1 database using a reproducible search strategy. Review quality was assessed using version 2 of 'A MeaSurement Tool to Assess systematic Reviews' (AMSTAR 2 tool).

Results 38 systematic reviews included, 34 low/critically low quality. Treatment and follow-up were usually short (2–4 weeks).

Key findings TCS versus emollient/vehicle: No meta-analyses identified for skin-thinning. Two 2-week randomised controlled trials (RCTs) found no significant increased risk with very potent TCS (0/196 TCS vs 0/33 vehicle in children and 6/109 TCS vs 2/50 vehicle, age unknown). Biochemical adrenal suppression (cortisol) was 3.8% (95% CI 2.4% to 5.8%) in a meta-analysis of 11 uncontrolled observational studies (any potency TCS, 522 children). Effects reversed when treatment ceased.

TCS versus topical calcineurin inhibitors: Meta-analysis showed higher relative risk of skin thinning with TCS (4.86, 95% CI 1.06 to 22.28, n=4128, four RCTs, including one 5-year RCT). Eight cases in 2068 participants, 7 using potent TCS. No evidence of growth suppression.

Once daily versus more frequent TCS: No meta-analyses identified. No skin-thinning in one RCT (3 weeks potent TCS, n=94) or biochemical adrenal suppression in two RCTs (up to 2 weeks very potent/moderate TCS, n=129).

TCS twice/week to prevent flares (‘weekend therapy’) versus vehicle: No meta-analyses identified. No evidence of skin thinning in five RCTs. One RCT found biochemical adrenal suppression (2/44 children, potent TCS).

Conclusions We found no evidence of harm when TCS were used intermittently ‘as required’ to treat flares or ‘weekend therapy’ to prevent flares. However, long-term safety data were limited.

PROSPERO registration number CRD42018079409.

  • eczema
  • paediatric dermatology
  • adult dermatology

Data availability statement

Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information. For any further details email or

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Data availability statement

Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information. For any further details email or

View Full Text

Supplementary materials


  • Twitter @riddmj, @IngridMuller7

  • Contributors All authors (EA, JRC, MS, MJR, SL, SML, DJCG, IM, AR, AA, HCW and KST) helped conceive of and design this overview. DJCG and EA conducted the searches. EA and JRC carried out the eligibility screening, data extraction and quality assessments. HCW and KST acted as 3rd reviewers to resolve disagreements. EA performed the statistical analysis and JRC is the study guarantor. EA and JRC collated and interpreted the data with input from all other authors. EA and JRC completed the initial drafts of the manuscript and all authors (EA, JRC, MS, MJR, SL, SML, DJCG, IM, AR, AA, HCW and KST) commented on and approved the final manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding This report presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research programme (grant ref No. RP-PG-0216-20007).

  • Disclaimer The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the department of Health and Social Care.

  • Competing interests Authors are coapplicants on an NIHR Programme Grants for Applied Research (P-PG-0216-20007) which funded this overview. The aim of the Programme Grant is to develop an intervention to support eczema self-care and the results of this overview will contribute to this intervention. MJR is funded by an NIHR Post-Doctoral Research Fellowship (PDF-2014-07-013). SML is supported by a Wellcome Senior Clinical fellowship in Science (205039/Z/16/Z). HCW was an author on four included reviews, and KST was an author on one included review.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.