Treatment of Eczema with Oral Cortisone

Filed under: 4 - Atopic Dermatitis

The oral use of cortisone has a place in the treatment of eczema in infants and children, but I do not think such an important place as it has in asthma. I have treated about sixty eczematous children with it, and have come to some fairly definite conclusions about it. In the first place, it is not a cure, and not infre­quently when it is discontinued, the eczema returns and is worse and harder to get rid of than it was be­fore. This is particularly true if it is used in patients where there is a bacterial element to the eczema, as there is in atopic erythroderma and infectious eczematoid dermatitis. I have come to the conclusion that it is best not to use it for atopic erythro­derma, unless just for a few days to tide over some very difficult situation.

The reason for this is that in atopic erythroderma it is necessary to use too large doses and to continue it over too long a period of time. When it is discontinued, the whole trouble is likely to recur worse than it was before and may be harder to get rid of, so that the duration of the eczema may be actually increased rather than lessened by the use of cortisone. I expect that the reason probably is that bacterial growth is encouraged rather than inhibited. I do not ad­vise its use for a baby who has blue feet with or without erythroderma, or for nummular eczema.

I have found these things out by bitter experience. It ought not to be used if the eczema can be reasonably well controlled in other ways. It is, however, of very considerable value in certain situa­tions. I have had several babies with oozy, crusted faces, which were kept inflamed by rubbing to such an extent that the usual methods of treatment were of no value. The oozing and itching were promptly controlled with cortisone, and did not recur to any great extent when it was discon­tinued.

Pig.   37.-Before  cortisone treatment.     (From New   England  J.  Med.,   1953.)
Fig.   38.-After one  week  of  cortisone  treat­ment.   (From New England J. Med., 1953.)

Another type of patient for whom cortisone is often satisfactory is the child of 3 to 5 years with a diffuse deep-seated papular eruption all over. Cortisone will usually re­lieve this quite promptly and give you and the patient a breathing spell, and a chance perhaps to find the cause of the eczema, which is often some specific food in this type of eruption.

Another indication is in the older child whose eczema is just so terrible that nothing can be done with it. He has been to a number of different doctors, has been dieted, innumerable salves have been used, and still he is no better. He is awake most of the night, and so is his mother, so that a very bad situation has developed in

the family. They all are worn out, and irritable, and immediate relief of the situation is necessary. Still an­other situation where cortisone is of value is in severe atopic dermatitis due to pollen, as in pollen eczema it is not necessary to continue the corti­sone very long.

I have made it a rule never to give more than 75 mg. of cortisone a day to an infant or young child with eczema; if they need more than this I do not want to treat them with cortisone. I usually start with this amount, and in a few days when the eczema is controlled, as it usually is, drop the dose to 67.5 mg. a day for a few days, then to 50 mg., and finally to 37.5 mg. There are few patients with eczema who get any benefit from a dose smaller than this. To the babies under 2 years I have given 5 grains of potassium chloride daily; for older children I have simply pro­hibited the use of added salt to the food after it has been brought to the table. I have usually had the mother call me by telephone three days after the cortisone was started, have seen the child a week after it was started, and from then on every two to four weeks according to circumstances. I do not try to get rid of the eczema entirely, lout simply to keep it under reasonably good control, as this can usually be done with moderate doses. It seems to me that the use of large doses is not justified in such a disease as eczema, because the trouble that may arise from large doses may be worse than the original disease.

There is a rumor around that corti­sone stops the growth of children. As I write (April, 1955), nothing to my knowledge has as yet been published about this. I have kept growth rec­ords in the last three years of forty-three allergic children who have been treated with cortisone for periods varying from three months to three years. There were 417 months of cortisone treatment.

Fig. 39.-Cushing’s syndrome, produced by only 50 mg. of cortisone a day. This is very unusual. (Prom New England J. Med., 1953.)

During this time these children gained 80.75 inches in height. Forty-three normal chil­dren of the same age, height, sex, and percentile height group would have gained in the same time 86.25 inches. This is a difference of only about 7 per cent. These figures have been examined by two expert statisticians and they reached the conclusion that from them it could not be concluded that the use of cortisone retarded growth, nor could it be concluded that it did not retard growth. It is clear, however, that if growth is retarded it is not retarded enough to amount to anything, which after all is what we want to know, and no child who needs cortisone should have it withheld for fear that it will dwarf him – it will not.

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