We searched the following databases up to September 2013: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2013, Issue 9), MEDLINE (from 1946), Embase (from 1974), LILACS (from 1982), and the GREAT database. We searched five trials databases and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs).
SELECTION CRITERIA: Pairs of authors independently assessed eligibility for inclusion, extracted data, and evaluated the risk of bias. We performed meta-analyses if feasible.
MAIN RESULTS: We included 36 RCTs (2706 participants), of which 31 examined topical
steroids; seven,
calcineurin inhibitors; and three,
lithium salts. The comparative interventions included placebo,
azoles,
calcipotriol, a non-steroidal anti-inflammatory compound, and
zinc, as well as different anti-inflammatory treatments compared against each other. Our outcomes of interest were total clearance of symptoms,
erythema, scaling or
pruritus scores, and adverse effects. The risk of bias in studies was most frequently classified as unclear, due to unclear reporting of methods.Steroid treatment resulted in total clearance more often than placebo in short-term trials (four weeks or less) (relative risk (RR) 3.76, 95% confidence interval (CI) 1.22 to 11.56, three RCTs, 313 participants) and in one long-term trial (lasting 12 weeks).
Steroids were also more effective in reducing
erythema, scaling, and
pruritus. Adverse effects were similar in both groups.There may be no difference between
steroids and
calcineurin inhibitors in total clearance in the short-term (RR 1.08, 95% 0.88 to 1.32, two RCTs, 60 participants, low-quality evidence).
Steroids and
calcineurin inhibitors were found comparable in all other assessed efficacy outcomes as well (five RCTs, 237 participants). Adverse events were less common in the
steroid group compared with the
calcineurin group in the short-term (RR 0.22, 95% CI 0.05 to 0.89, two RCTs, 60 participants).There were comparable rates of total clearance in the
steroid and
azole groups (RR 1.11, 95% CI 0.94 to 1.32, eight RCTs, 464 participants, moderate-quality evidence) as well as of adverse effects in the short-term, but less
erythema or scaling with
steroids.We found mild (class I and II) and strong (class III and IV)
steroids comparable in the assessed outcomes, including adverse events. The only exception was total clearance in long-term use, which occurred more often with a mild
steroid (RR 0.79, 95% CI 0.63 to 0.98, one RCT, 117 participants, low-quality evidence).In one study,
calcineurin inhibitor was more effective than placebo in reducing
erythema and scaling, but there were similar rates in total clearance or adverse events for short-term treatment. In another study,
calcineurin inhibitor was comparable with
azole when
erythema, scaling, or adverse effects were measured for longer-term treatment.Lithium was more effective than placebo with regard to total clearance (RR 8.59, 95% CI 2.08 to 35.52, one RCT, 129 participants) with a comparable safety profile. Compared with
azole,
lithium resulted in total clearance more often (RR 1.79, 95% CI 1.10 to 2.90 in short-term treatment, one RCT, 288 participants, low-quality evidence).
AUTHORS' CONCLUSIONS: