WAIKOLOA, HAWAII – The calcineurin inhibitors are effective for long-term maintenance therapy in chronic hand dermatitis, despite their black box warning, and can help reduce the use of topical steroids, according to dermatologist Joseph F. Fowler Jr.
Pimecrolimus 1% cream is nongreasy and thus preferred by many patients over tacrolimus 0.1% ointment, he said at the seminar sponsored by the Skin Disease Education Foundation (SDEF).
Bruce Jancin/IMNG Medical Media
Dr. Joseph F. Fowler Jr.
"Please understand that I love topical steroids. We all need to use them. But I don’t want to use them continuously because of the variety of adverse effects, especially local atrophy. And if we’re worried about skin barrier function, we don’t want to thin the skin out and reduce the barrier even more with overuse of topical steroids," he said.
"So after we’ve got somebody under control with aggressive use of higher-potency topical steroids, I like to think about the calcineurin inhibitors. I also like to think about what I call the therapeutic moisturizers – those device and [over-the-counter] products that contain ceramides and natural moisturizing factors – and I’ll maybe use a low- to midpotency topical steroid two or three times a week as needed," added Dr. Fowler of the University of Louisville (Ky.).
There are several skin barrier protection products approved as prescription devices rather than medications, such as Atopiclair, Eletone, EpiCeram, Hylatopic, Neosalus, and Tetrix. Many aren’t promoted much anymore by their manufacturers, yet all have supporting evidence that they enhance the skin barrier, he said.
The two skin barrier products Dr. Fowler is most familiar with because of his involvement in clinical trials are Tetrix and Neosalus.
The investigator-blinded, nonrandomized Tetrix cream study involved patients with known allergies to three common, structurally dissimilar test antigens: nickel, neomycin, and fragrance mix. Following exposure to the test antigens, delayed-type hypersensitivity reactions on patch testing were significantly less at sites pretreated with Tetrix cream than at untreated test sites (Cutis 2008;82[suppl. 4]:21-8).
In the multicenter prospective Neosalus foam study, 31 patients with chronic allergic or irritant hand dermatitis of at least 12 months’ duration were randomized to treatment with Neosalus foam plus triamcinolone cream 0.1% or to an over-the-counter (OTC) moisturizer plus the topical steroid. During 8 weeks, patients in the Neosalus group averaged 51.4 doses of the topical steroid, compared with 72.5 doses in controls. Eczema severity scores were also significantly better in the Neosalus group (Am. J. Contact Dermat. 2000;11:165-9).
OTC moisturizers containing ceramide, a lipid that boosts stratum corneum function, include Aveeno eczema therapy moisturizing cream, CeraVe lotion and cleanser, Cetaphil Restoraderm moisturizer, and Curel Sensitive Skin Remedy, Dr. Fowler continued.
He said that he likes to choose from a short list of topical steroids for maintenance therapy. Fluticasone cream or lotion has fewer local adverse effects than many other steroids and has demonstrated long-term efficacy and safety in the setting of atopic dermatitis. Hydrocortisone butyrate lipid cream or lotion has excellent tolerability and a good moisturizing effect.
When there is concern that a patient’s dermatitis may be compounded by topical steroid allergy, clocortolone cream or desonide ointment are excellent choices; there is virtually no allergenicity to either product, according to Dr. Fowler.
"If I’m worried about topical steroid allergy, the sprays, I think, are very nice. Clobetasol spray has almost nothing in it that’s likely to be an allergen, although it’s a little oily and that can be an issue. But if you’re worried about allergy either to the steroid or to other factors in the product, that’s a good one. Also, triamcinolone ... has virtually nothing in it that’s allergenic other than occasionally the triamcinolone itself, and it’s not oily," he said.
The topical corticosteroid foams are a well-received option for maintenance therapy on hairy areas or for large surfaces.
When a higher-potency topical steroid is desired during a breakthrough episode, halcinonide cream has low allergenicity, a desirable biphasic quick and then delayed release, and good moisturizing and emollient properties, Dr. Fowler said.
He reported that he serves as a consultant to Allerderm, Coria, Galderma, Graceway, Hyland, Johnson & Johnson, Quinnova, Ranbaxy, Shire, Stiefel, Triax, and UCB.
SDEF and this news organization are owned by Elsevier.