Don’t use combination antifungal/corticosteroid medications in children or for treating diaper dermatitis, warned Chikoti M. Wheat, MD, of Johns Hopkins University, Baltimore, and her associates.
Lotrisone is a combination product with a high-potency topical corticosteroid, betamethasone dipropionate 0.05% cream, and a topical antifungal agent, clotrimazole 1% cream. The Food and Drug Administration does not recommend it for the population and indication mentioned above, yet it is often used so off-label, Dr. Wheat and her associates said. Mycolog-II, a combination antifungal/corticosteroid with nystatin, an antiyeast agent, and triamcinolone, a medium-potency topical steroid, was taken off the market in 2015, but patients may still have some that they are inclined to use (J Pediatr. 2017. doi: 0.1016/j.jpeds.2017.03.031).
In a study of 9,797 patients aged 0-14 years who were prescribed either Lotrisone or Mycolog-II creams from 2007 to 2014, pediatricians were most likely to prescribe the combination creams (mean, 810 patients), followed by family physicians (mean, 309 patients), and dermatologists (mean, 49 patients). No pediatric dermatologists prescribed either cream.
Why are these combination creams being used?
Sometimes a fungal infection induces an inflammatory dermatitis. In these cases the use of both an antifungal and a corticosteroid with careful monitoring can benefit the patient, the researchers said. “Research, however, has shown that when combination antifungal/corticosteroid agents are used for fungal infections, they not only result in high rates of recurrence of fungal infections but also have greater side effect profiles.”
Also, in 1984, Lotrisone was approved by the FDA for treating tinea corporis, tinea pedis, and tinea cruris in patients older than 12 years. However, lack of efficacy and severe adverse effects including hypothalamic-pituitary-adrenal axis suppression, Cushing syndrome, hyperglycemia, hirsutism, delayed growth, and skin atrophy led the FDA to recommend that Lotrisone not be prescribed for patients younger than 17 years and not be prescribed to treat diaper dermatitis.
So what should you do?
Dr. Wheat and her associates recommend a single-agent topical antifungal to treat superficial fungal infection. If there is intense itching due to infection-induced dermatitis, add a low- or medium-potency topical corticosteroid for just 7-10 days.
For diaper dermatitis with a confirmed secondary fungal infection, they recommend a topical antifungal agent in combination with a barrier cream. “If intense inflammatory changes are present, a low- to medium-potency topical corticosteroid can be used up to twice daily and tapered over 1-2 weeks with careful monitoring,” they said.
Dr. Wheat and her associates declared they had no conflicts of interest.