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Topical Management of Recalcitrant Psoriasis & Eczema

Richard M. Haber, MD, FRCPC

Division of Dermatology, University of Calgary, Calgary, AB, Canada

Introduction

Psoriasis and eczema, especially atopic eczema, are two of the most common cutaneous conditions seen by family physicians and dermatologists. Although the etiology of both conditions is unknown, immunologic abnormalities with an increase in immune mediators are thought to play major roles. These skin disorders are not curable, but can be controlled with proper topical therapy. However, psoriasis and eczema can at times be recalcitrant to conservative topical treatment. As such, it may be helpful for family physicians to be aware of more aggressive or innovative topical options for recalcitrant cases. Patients unresponsive to aggressive topical therapy may require systemic treatment or phototherapy, which carry a greater potential for adverse effects. Such cases are best managed by dermatologists with more experience in using these therapies.

Overview of Topical Corticosteroids

Due to their anti-inflammatory, immunosuppressive, and anti-proliferative properties, corticosteroids are effective for treating a variety of inflammatory dermatoses, including psoriasis and atopic eczema.

Potency

  • The potency rating of a topical corticosteroid describes the intensity of the agent’s clinical effect.1 Seven groups of topical steroid potencies have been developed, these are ranked from superpotent (Group 1) to low potency (Group 7). Table 1 lists the topical corticosteroid potencies and gives available examples in Canada.

Vehicle Considerations

  • Ointments are water-in-oil emulsions and are more hydrating to the stratum corneum. They provide an occlusive barrier, and because of an increased depot effect, drug penetration is enhanced, leading to greater potency.
    • For example, Table 1 shows the same chemical compound, triamcinolone acetonide 0.1%, can be Class 4 potency as an ointment, but only Class 5 as a cream. Therefore, an ointment can be useful in treating refractory dermatoses, especially for thick, fissured, and lichenified skin lesions.

Administration and Dosing

  • Localized recalcitrant conditions may benefit from using a corticosteroid ointment under occlusion (e.g., plastic wraps and hydrocolloid dressings), which can increase the drug permeability up to 10 times.2
  • Topical corticosteroids are usually applied once or twice daily. The duration of daily use of ultra-potent formulations should not exceed 3 weeks.3 Medium and high strength topical corticosteroids can be used up to 3 months.3 It can be difficult to adhere to these guidelines, as psoriasis and atopic eczema are chronic, requiring long-term therapy for management.

Topical Treatment Suggestions for Recalcitrant Eczema

Atopic Eczema (excluding face and body folds)

  • Potent topical corticosteroids for 2-3 weeks followed by tapering to a milder topical corticosteroid or TCI (i.e., Protopic™ ointment or Elidel® cream)
  • Pulsed potent topical corticosteroid (i.e., fluocinonide 0.05% ointment/cream used twice daily Saturday and Sunday (use with caution in young children and if treating for longer than 2-3 weeks)
  • Barrier repair creams (e.g., EpiCeram™) can be tried in conjunction with topical corticosteroids or TCIs

Chronic Hand Eczema

  • Superpotent topical corticosteroid for 2-3 weeks followed by tapering to a milder corticosteroid or TCI
  • Superpotent topical corticosteroid with saran wrap or hydrocolloid occlusion overnight

Lichen Simplex Chronicus

  • Superpotent topical corticosteroid for 2-3 weeks followed by tapering to a milder corticosteroid or TCI
  • Superpotent topical corticosteroid with saran wrap or hydrocolloid occlusion overnight
Relative Potency Class Corticosteroid % Preparation
1 Betamethasone dipropionate glycol
Clobetasol propionate
Halobetasol propionate
0.05
0.05
0.05
Cream, ointment, lotion
Cream, ointment, lotion, spray, shampoo
Cream, ointment (reintroduced and commercially available in Canada December 2010)
2 Amcinonide
Betamethasone dipropionate
Desoximetasone
Diflucortolone valerate
Fluocinonide
Halocinonide
0.1
0.05
0.25
0.1
0.05
0.1
Cream, ointment, lotion
Ointment
Cream, ointment
Cream, oily cream, ointment
Cream, ointment, gel
Cream, ointment, lotion
3 Betamethasone dipropionate
Betamethasone valerate
Mometasone furoate
Triamcinolone acetonide
0.05
0.1
0.1
0.5
Cream
Ointment
Ointment
Cream
4 Desoximetasone
Fluocinolone acetonide
Hydrocortisone valerate
Mometasone furoate
Triamcinolone acetonide
0.05
0.025
0.2
0.1
0.1
Cream, gel
Ointment
Ointment
Cream, lotion
Ointment
5 Betamethasone valerate
Fluticasone propionate
Fluocinolone acetonide
Hydrocortisone valerate
Triamcinolone acetonide
0.1
0.05
0.025
0.2
0.1
Cream, lotion
Cream
Cream
Cream
Cream, lotion
6 Desonide
Fluocinolone acetonide
0.05
0.01
Cream, ointment, lotion
Cream, lotion, oil
7 Hydrocortisone acetate 0.5-2.5 Cream, ointment, lotion
Table 1: Relative potency rankings of common topical corticosteroids in Canada

Disclaimer: I have tried to give evidence-based suggestions for treating these cutaneous diseases that can be chronic and recalcitrant to treatment. However, these are suggestions only and it must be remembered that potent topical corticosteroids can have significant side-effects as discussed. The guidelines of care for the use of topical glucocorticosteroids from the American Academy of Dermatology (reference 3) should be kept in mind, including the duration of use of superpotent and potent topical corticosteroids and maximal daily use. Extra caution needs to be given when using these agents in children. Close supervision by the prescribing physician is recommended.

References

  1. Warner MR, et al. Topical corticosteroids. In: Wolverton SE (ed). Comprehensive dermatologic drug therapy. 2nd ed. Philadelphia: Elsevier-Saunders, p595-624 (2007).
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  17. Leung DY, et al. Lancet 361(9352):151-60 (2003).
  18. McGrath JA. Australas J Dermatol 49(2):67-73 (2008).
  19. Sugarman JL, et al. J Drugs Dermatol 8(12):1106-11 (2009).
  20. English J, et al. Clin Exp Dermatol 34(7):761-9 (2009).
  21. Veien NK, et al. Br J Dermatol 140(5):882-6 (1999).
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