Relevance of Low-Potency Topical Steroids in - The Dermatologist

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Relevance of Low-Potency Topical Steroids in - The Dermatologist

Supplement to the December 2009& AGINGSeries: Relevance of Low-Potency Topical Steroids in DermatologyThe Role of Low-Potency TopicalSteroids in Day-to-Day PracticeSupplement supported by®


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The Role of Low-Potency TopicalSteroids in Day-to-Day PracticeJohnnie M. Woodson, MDAssistant Clinical Professor of DermatologyUniversity of Nevada School of MedicineHenderson, NVTopical corticosteroids are one of the oldest treatmentsfor a variety of dermatologic conditions.They are used to treat conditions such as psoriasis,vitiligo, eczema, atopic dermatitis, phimosis, acute radiationdermatitis and lichen sclerosus. 1 Topical corticosteroidsare also used to treat melasma, chronic idiopathicurticaria and alopecia areata, but evidence of efficacywith these conditions is limited. 1Further, their long history of safety and effectivenessfor certain conditions means they remain one of the mostuseful and widely prescribed treatments in day-to-daydermatologic practice — nearly 1.7 million prescriptionsare dispensed each year for treatment of dermatologicalconditions (see Table 1). 2These benefits — safety, use across a wide spectrum ofdermatoses — make topical corticosteroids a desirabletool for any dermatologist. This article will specificallyexplore the role and use of topical low-potency steroids(LPS) in day-to-day practice.LPS AS DAILY TREATMENTSome of the selected indications of topical corticosteroidsin dermatologic uses are for the treatment of seborrheic dermatitis,psoriasis, pityriasis rosea, nummular dermatitis, atopicdermatitis, dyshidrotic eczema, diaper dermatitis, erythroderma,lichen simplex chronicus, lichen planus, alopeciaareata, pruritus, vitiligo, acne keloidalis nuchae and granulomaannulare. Ference and Last note that the keys to successfultreatment “[depend] on an accurate diagnosis and considerationof the steroid's delivery vehicle, potency, frequency ofapplication, duration of treatment and side effects.” 1To describe the effect intensity of topical corticosteroids,potency is the term used. To measure the anti-inflammatoryand the antiproliferative properties, certainassays are utilized. A very commonly used assay is thevasoconstrictor assay and this is usually used by researchersbecause it correlates well with clinical efficacy.The test is subjective, which is one of the disadvantagesof using this assay. Clinical potency of topical corticosteroidsusually depends on several factors, including thestructure of the molecule, the area of the skin it is appliedto and the vehicle it is used in.Topical corticosteroids can have a number of undesirableside effects, including atrophic changes, more fragileskin, more easily bruised skin, increased risk for infection,masked infection, secondary infection, contact dermatitis,TABLE 1. DERMATOLOGY: LOW-POTENCY TOPICAL STEROID PRESCRIPTIONS OVER 1 YEARVEHICLEPRESCRIPTIONS FILLEDOintment 413,759Cream 727,030Liquid 545,750Combination form 2,923TOTAL 1,689,462Note: Wolters Kluwer data gathered over 12 months in 2008–09. 2Supplement to Skin & Aging ◆ December 2009 3


LOW-DOSE STEROIDSFIGURE 1. While higher-potency topical steroid formulationsmay be used short-term in particularly acute cases,avoid them for use longer than 3 weeks and on more sensitiveareas of the body, such as the face, groin and axilla.FIGURE 2. Successful treatments target the root cause torelieve symptoms and improve quality-of-life factors such asphysiological distress and embarrassment with appearanceof skin and/or constant scratching.delayed wound healing, hyperpigmentation, hypopigmentationand photosensitization. 1Because of this, dermatologists want to use the lowestpotencysteroid that will effectively alleviate symptoms ofdermatoses. 3 While higher-potency formulations may beused short-term in particularly acute cases, they are to beavoided for long-term use — longer than 2 weeks — andon more sensitive areas of the body, such as the face, groinand axilla. 1,3,4 Milder formulations are therefore used whenday-to-day maintenance or topical use on sensitive skin,thinner skin or children’s skin is called for. 1,4This doesn’t mean a dermatologist should use a topicalA formulation that combines hydrocortisone acetate andpramoxine hydrochloride results in the ability to relievepruritus and inflammation associated with many dermatoses.steroid potency that is too low to treat a given patient’ssymptoms. Rather, the idea is to match lowest strength andsmallest quantity of corticosteroid to properly address theseverity of the dermatosis the patient has presented with. 5For example, mild eczema can be treated with twicea-daytopical LPS, often completely clearing the outbreakwithin 1 or 2 weeks. 1,5 Moderate eczema may require amore potent formulation and/or longer duration of treatmentbefore the desired response is achieved, while a severecase may not respond, or may respond very little,even after long-term use. 5Strategies in such acute cases include varying the dose(e.g., using stronger topical steroids on weekends andweaker formulations on weekdays); stepping up the dose(i.e., starting weaker and moving to a stronger formulation);or stepping down the dose (ie, starting more potentand gradually moving to a less-potent formulation). 5,6Trial and error is often necessary in order to tailor thedosage and schedule to each patient. 1When prescribing, dermatologists need to take into accountthe following safety considerations:body surface area, duration andindividual patient needs. Consideringthese factors is important in order toavoid potential side effects. In fact, severeside effects are rare with topicalLPS, even when they are used overmany years. 4MECHANISMS OF ACTIONTopical corticosteroids have anti-inflammatory and antiproliferativeeffects. The immediate anti-inflammatoryeffects are that they stabilize cell membranes and preventthe release of lysosomal contents; they reduce vascularsmooth muscle and sensitivity to histamine; they reducemast cell sensitization induced by immunoglobulin E; and4 December 2009 ◆ Supplement to Skin & Aging


TABLE 2. EXAMPLES OF COMMON CORTICOSTEROID-RESPONSIVE DERMATOSES• Allergic dermatitis• Atopic dermatitis/eczema• Contact dermatitis(allergic and irritant-specific)• Drug eruptions• Insect bites• Lichen sclerosus/planus/striatus• Neurodermatitis (lichen simplex chronicus)• Poison plant eruptions (poisons ivy, oak and sumac)• Post-chicken pox• Post-scabies• Pruritus ani• Pruritus (specific and non-specific)• Sunburn• UrticariaTABLE 3. ONSET OF RELIEF TIME (RELATING TO ITCH-SCRATCH CYCLE)PRODUCT ONSET OF ACTION PEAK EFFECT DURATION OF ACTIONPramoxine hydrochloride 2 to 5 minutes 3 to 5 minutes Several daysHydrocortisone acetate slow n/a longNote: Adapted from University of Maryland Medical Center Complimentary and Alternative Medicine Index. 14,15they inhibit the release of histamine and other mast cellmediators. Topical corticosteroids can also decrease thenatural cell-killing activity and decrease response to lymphocytereaction.In my experience, topical glucocorticosteroids alsohave delayed anti-inflammatory effects, such as preventingformation of potent inflammatory mediators, decreasingvascular permeability, and producing the induction ofanti-inflammatory proteins. Glucocorticosteroids act ondifferent cell types, including polymorphonuclear leukocytes(PMNs) and lymphocytes. They decrease PMNmovement to inflammation sites, reduce PMN numbersat inflammation sites, and decrease their ability to attachto the inside of vascular channels called the endothelium.Glucocorticosteroids can also decrease the production ofcertain interleukins as well as tumor necrosis factor.I’ve also found that topical glucocorticosteroids exhibitantiproliferative effects that can affect each of the skin’slayers. For example, in the epidermis, they can decreasethe thickness of the stratum corneum, affect the keratinocytegrowth factors by suppression and decreasemelanocyte pigment production. Down in the dermis,topical glucocorticosteroids can reduce thickening by decreasingdermal volume, thereby making the fibroblastsless active. They can also diminish collagen and elastinfibers of the dermis, and create fragile dermal vessels. Asa result, it’s worth noting that long-term use of steroidscan increase the risk of atrophy of the skin.BENEFITS OF PRAMOXINEBecause of its anesthetic properties, the addition ofpramoxine may be helpful in ameliorating itch sensation. 7Pramoxine hydrochloride is widely used as a surfaceanesthetic because it combines effectiveness with low systemictoxicity. 8 According to a 1954 study by Peal andKarp, it exhibits low potential for sensitization and irritation.9 Subsequent study has confirmed the safety profileand wide-ranging effectiveness of pramoxine.A double-blind study of 15 patients examined how theapplication of pramoxine lotion and pramoxine vehicleaffected perception of histamine-induced pruritus andthe warmth and pain thresholds that result from this pruritus.The authors found that, while cold and heat painthresholds were unaffected, warmth sensation thresholdincreased significantly — by 0.4˚ C — after histamineinduceditch. 10 Pramoxine lotion was found to significantlyreduce the cold pain threshold, while pramoxinevehicle significantly decreased warmth sensation; the remainingfactors were unaffected. 10Itch duration was shorter in 13 of the patients withpramoxine lotion and in 5 of the patients with pramoxinevehicle. 10 The reduction in duration with pramoxine lotionwas significant. 10 Pramoxine lotion also significantly reducedbaseline itch magnitude at each of the 10 time pointsand more effectively maintained reduced itch magnitudefor 2 to 6 minutes after histamine injection. 10 The authorsconcluded that “pramoxine lotion can be effective in re-Supplement to Skin & Aging ◆ December 2009 5


LOW-DOSE STEROIDSlieving histamine-induced pruritus” — a finding that canbe applied to a wide variety of dermatoses (see Table 2). 10Another recent randomized, double-blind, controlledcomparative trial found a 61% decrease in itch intensity inthe group of patients treated with a pramoxine 1% lotion,whereas the control group had only a 12% reduction initch intensity. 11 The authors found it to be a “safe, convenientand effective topical lotion.” 11Pramosone ® (hydrocortisone acetate 1% or 2.5%,pramoxine hydrochloride 1%) lotion offers the antiinflammatoryeffects of hydrocortisone acetate with theadded benefits of a topical anesthetic. 12 It reduces skinredness, swelling, itching and irritation while decreasingrelated pain when applied to the affected area by blockingthe transmission of nerve impulses. 13Hydrocortisone acetate is an LPS that acts effectivelyas an anti-inflammatory agent for mildly inflamed dermatosesor for maintenance of moderately inflamed dermatoses.7 Pramoxine hydrochloride is a topicalanesthetic with very low potential for irritation and sensitization,making it particularly well-suited to dermatologicalapplications.The combination of these two active ingredients resultsin the ability to relieve pruritus and inflammation associatedwith many dermatoses. In addition, I’ve foundPramosone offers a preparation with efficacy superior tothat of hydrocortisone acetate alone, while maintainingan equivalent safety profile. The combination of the ingredientspresents an ideal combination of rapid onset andextended duration of relief (see Table 3). 14,15 It’s worthnoting that Pramosone contains emollients to workagainst the dry skin that is often associated with use ofsimilar topical agents. As a result, it has been used to provideeffective itch relief for more than 30 years.CONCLUSIONSuccessful treatment not only targets the root cause andrelieves symptoms, it also improves quality of life for thepatient and, perhaps, the patient’s caregiver. Quality-oflifefactors include relieving physiological distress andembarrassment with appearance of skin and/or constantscratching; minimizing time spent at the doctor’s office,at the pharmacy and recuperating; ensuring that the patientcan participate in daily activities; and preventing exacerbationof further skin conditions.LPS are a part of a treatment plan that meets these criteria.Their well-tested history has demonstrated their efficacyand effectiveness. The topical mode of deliverymeans they are easy to use. And, finally, the low potencyminimizes the potential for sensitivity, irritation andother side effects. It is clear that low-potency topicalsteroids have solidified a place in dermatologic practice,and that they will continue to remain an important partof treating patients on a day-to-day basis. ■References1. Ference JD, Last AR. Choosing topical corticosteroids. Am FamPhysician. 2009;79(2):135–140.2. Low Potent Steroid TRx — 12 months [data on file]. Ferndale, MI:Ferndale Laboratories, Inc.; 2009.3. Lam J, Friedlander SF. Atopic dermatitis: A review of recent advancesin the field. Pediatr Health. 2008;2(6):733–747.4. American Academy of Dermatology. Treating eczema with steroids.2009. Accessed October 27, 2009, athttp://www.skincarephysicians.com/eczemanet/steroids.html.5. New Zealand Dermatological Society. Treatment of atopic dermatitis.2009. Accessed October 27, 2009, athttp://www.dermnetnz.org/dermatitis/treatment.html.6. PCP Dermatological Society. Guidelines for the management ofatopic eczema. 2006. Accessed October 27, 2009, at http://www.gptraining.net/training/tutorials/clinical/dermatology/eczema.htm.7. Littz J. Treatment of itching without corticosteroids. In: Bernhard J,editor. Itch mechanisms and management of pruritus. New York: Mc-Graw Hill; 1994, p. 383–397.8. Fisher AA. The safety of pramoxine hydrochloride when used as atopical (surface) anesthetic. CUTIS. 1998;62(3):122–123.9. Peal L, Karp M. A new surface anesthetic agent: Tronothane. Anesthesiology.1954:15(6);637–643.10. Yosipovitch G, Maibach HI. Effect of topical pramoxine on experimentallyinduced pruritus in humans. J Am Acad Dermatol. 1997;37(2Pt 1):278–280.11. Young TA, Patel TS, Camacho F, et al. A pramoxine-based anti-itch lotionis more effective than a control lotion for the treatment of uremic pruritusin adult hemodialysis patients. J Dermatolog Treat. 2009;20(2):76–81.12. Pramosone Cream, Lotion and Ointment — Product Insert [dataon file]. Ferndale, MI: Ferndale Laboratories, Inc.; 2009.13. Dawn A, Yosipovitch G. Treating itch in psoriasis. Dermatol Nurs.2006;18(3):227–233.14. University of Maryland Medical Center. Complimentary and AlternativeMedicine Index: Pramoxine. 2009. Accessed October 27,2009 at http://www.umm.edu/altmed/drugs/pramoxine-104850.htm.15. University of Maryland Medical Center. Complimentary and AlternativeMedicine Index: Hydrocortisone. 2009. Accessed October27, 2009 at http://www.umm.edu/altmed/drugs/hydrocortisone-063400.htm.6 December 2009 ◆ Supplement to Skin & Aging

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