What to tell parents about side effects
Discuss the benefits and potential harms of topical corticosteroids with parents (and youngsters who are old enough to understand), emphasizing that when used correctly, the benefits outweigh the risks.
Potential side effects include skin atrophy, striae, telangiectasia, hypopigmentation, rosacea, glaucoma, and cataracts, with studies suggesting that local adverse effects are related to the potency.13 Because there are few prospective controlled trials of sufficient duration, however, the incidence of local reactions to topical corticosteroids in patients with AD is uncertain.
The potential for topical corticosteroids to suppress the hypothalamic-pituitary-adrenal (HPA) axis has been investigated in a small number of studies, with inconclusive results. Effects on the HPA axis appear to be associated with percutaneous absorption in patients who either have a more severe case of AD or are <2 years old.14 A recent systematic review confirmed that the degree of systemic absorption is based on the severity and extent of the disease as well as the formulation and potency of the topical agent.14,15
When to consider TCIs
Pimecrolimus and tacrolimus, the 2 TCIs on the market, are second-line agents for AD. Both have US Food and Drug Administration (FDA) approval for short-term treatment of moderate to severe AD in immunocompetent patients who have failed to respond to topical corticosteroids and children >2 years.26,27 Both TCIs provide targeted anti-inflammatory activity without the local and systemic side effects of topical corticosteroids.
Pimecrolimus cream 1% is approved for treatment in children >2 years.27 Tacrolimus ointment 0.03% is approved for children ages 2 to 15 years with moderate to severe AD, and tacrolimus ointment 0.1% is approved for children older than 16 years with moderate to severe AD.26 Data from clinical trials have shown that pimecrolimus reduces the number and severity of flares, extends the time between flares, and decreases pruritus and other cutaneous signs associated with AD.3 Common side effects, which are usually mild and resolve within days, include pruritus, burning, and stinging at the application site.
In 2006 the FDA added a black-box warning stating that their long-term safety has not been established—a response to widespread off-label use of TCIs in children <2 years and concerns about a theoretical cancer risk based on their mechanism of action—and concluded in 2010 that the labeling adequately warns providers of the potential safety risks.28 Recent reviews have concluded that systemic exposure to topical TCIs is minimal and that there is no evidence linking TCIs to an increased risk of lymphoproliferative disease.16,17,29
Combining corticosteroids and TCIs
In clinical practice, both topical corticosteroids and TCIs are often used for long-term management of moderate to severe AD. TCIs are valuable alternatives to continuous use of corticosteroids for patients with persistent AD and recurrent flares. They’re also beneficial for patients with outbreaks in sensitive areas, such as the face and genitals.
Adjunctive therapies—what’s best for pruritus?
Pruritus is a major feature of AD, and a source of considerable distress. Here are some treatment options that often come up, and what we know about their usefulness.
Antihistamines. There is no evidence to support the use of nonsedating antihistamines in the treatment of AD. Sedating systemic antihistamines such as hydroxyzine and diphenhydramine don’t have a direct effect on the pruritus either, but they can be used to help patients with acute flare-ups improve their sleep.9,14
CASE 2 Antihistamines would not be recommended for Angela at this time; instead, you wait to see whether the topical corticosteroid you have just prescribed is effective. If the patient is still having trouble sleeping after she completes the corticosteroid trial, you can recommend the use of a sedating antihistamine at night as a sleeping aid.
Wet wraps. Wet wrap treatments using occlusive dressings were first recommended as a safe and effective treatment more than 20 years ago.18 Their application may be indicated for children with severe or refractory AD, provided there are no signs or symptoms of infection.
No large prospective studies have evaluated the safety and efficacy of wet wrap treatment or compared it with more conventional modalities. In a recent review, temporary systemic bioactivity of the corticosteroid was the only reported adverse effect.18
There are numerous wet wrap techniques. One effective short-term intervention is to use cream or ointment and a double layer of cotton bandages, with a moist first layer and a dry second layer. Wet wrap dressings with once-daily diluted topical corticosteroids can be used for up to 14 days.18
Coal tar. Although coal tar and coal tar derivatives have been used for many years in the treatment of AD, a lack of data on the clinical efficacy of their application, along with the cosmetic disadvantage, makes compliance with this treatment challenging.