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Am Fam Physician. 2002;66(4):676-677

Atopic eczema (also known as atopic dermatitis) is a chronic, relapsing skin condition that affects about 15 percent of British schoolchildren. Although topical corticosteroids can control symptoms, the results are frequently unsatisfactory, and skin thinning can occur with prolonged use of these agents. Thomas and colleagues compared the outcomes of three-day treatment with a potent corticosteroid with seven days of conventional therapy using a mild steroid preparation.

They studied children up to 15 years of age who had mild or moderate atopic eczema and had consulted an English medical school clinic or one of 13 affiliated general practices. Children with severe eczema, eczema limited to the face or diaper area, or contraindications to the study medications were excluded from the study. The 174 children in the study were randomly assigned to treatment with 1 percent hydrocortisone ointment twice daily for seven days or 0.1 percent betamethasone valerate twice daily for three days. Children in the three-day group received an identical placebo for the remaining four days to maintain blinding.

The primary outcome was itching and scratching, as reported daily by each child on a five-point scale. Relapse was set at scores of two or more for three consecutive days. Other outcomes measured were the median duration of the first relapse, disease severity, number of undisturbed nights, and quality of life. Skin thickness was measured using ultrasonography. Compliance was assessed by weighing the tubes of medication at each follow-up visit. Rescue medication was available if the eczema was judged to be uncontrolled. The cost of treatment was assessed, based on cost of medications and professional services provided.

Both groups of patients showed improvements in disease severity and quality of life. More than one half of the children in each group had a greater than 20 percent improvement in disease severity. The median number of scratch-free days was 118 for patients in the mild-therapy group and 117.5 for patients in the potent-therapy group. The number and duration of relapses were similar between the two groups. Both groups showed improvement in all secondary outcomes, with no significant differences between treatment groups.

About one third (36 percent) of patients in the mild-treatment group did not complete treatment, compared with 25 percent of those in the potent-therapy group. The number and type of adverse effects were similar in each group. Difficulties were encountered in measuring skin thickness, but the authors conclude from the data available that skin thickness was within the normal range up to 18 weeks after the study in about 50 percent of the participants who were measured. Total cost was slightly higher in the mild-treatment group, but the difference was not significant.

The authors conclude that both treatment strategies were equally effective in controlling mild to moderate atopic eczema in children.

editor's note: Feedback from patients and families in this study showed one half preferring the short course of therapy with potent agents and one half preferring the longer course with a less potent agent. Regardless of patient choice, the crucial factor was adherence to the treatment strategy. Even in the study situation, the dropout rate was high, attributed primarily to noncompliance with protocols. Despite an apparently simple twice-daily application regimen, patients had difficulty strictly following treatment plans. In practice, we need to take extra time to find out which approach fits best with the belief systems and practical realities of the patient and family. Patients choosing the less potent option must understand about the longer treatment regimen. Conversely, those selecting the short course of therapy must be prepared to discontinue it after three days. In chronic conditions such as eczema, many patients are uncomfortable with discontinuing therapy, and physicians can fall into the trap of renewing potent agents that are not intended for long-term use.—a.d.w.

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