Dermatology Education Initiative - Inflammatory Skin Disorder Express Report™

Based on Data Presented at the Hawaii Winter Clinical Dermatology Conference, January 12–16, 2007, Kohala Coast, Hawaii.

Publication date: 2007-04-01

New Super-potent Topical Corticosteroid for the Management of Inflammatory Skin Disease

This report was reviewed for medical and scientific accuracy by Mark A. Gendreau, MD, Associate Vice Chairman, Senior Staff Physician, Lahey Clinic, Burlington, Massachusetts.

Expert Commentary

Elaine C. Siegfried, MD, Director, Kids Dermatology; Associate Clinical Professor, Department of Dermatology, Saint Louis University School of Medicine; St. Louis, Missouri

For most dermatologists, treating patients with chronic inflammatory skin disease is a daily challenge. Atopic dermatitis is the most common chronic skin disorder seen in infants and children. Atopic dermatitis is characterized by a distinctive distribution of diffuse erythema and scaling associated with significant pruritis, ^1,2 often drastically affecting quality of life. Onset is often before 6 months of age, ³ with approximately 85% of patients exhibiting clinical manifestations before 5 years of age. ^4,5,6 The incidence of atopic dermatitis is increasing, especially in industrialized countries, affecting an estimated 17% of children in the US. ⁷ The negative impact of atopic dermatitis is significant, including profound sleep disturbance that not only injures the affected child, but also interferes with normal parent-child and family interactions. For the majority of patients, atopic dermatitis improves with time, but at least 10% of patients have moderate-to-severe and unremitting lifelong disease, ² creating a financial burden for both the family and society. Psoriasis is a chronic, immune-mediated disease characterized by recurring and remitting inflammatory disease, ranging from mild to severe and affecting the skin, the scalp, and sometimes the mucous membranes or joints. Onset can occur at any age, most often in young adults. Psoriasis may be under-recognized in infants and young children, especially in those without a strong family history of the disease, who are often misdiagnosed as having eczema. Common sites of involvement in this age group are the face, the scalp, and the diaper area. At any age, the social and emotional impact of psoriasis can be overwhelming. ⁸

As no cures for atopic dermatitis or psoriasis currently exist, treatment options focus on relieving symptoms, reducing inflammation, controlling the disease long term, and restoring quality of life while minimizing adverse effects associated with treatment.

Topical corticosteroids have been the mainstay of treatment for both atopic dermatitis and psoriasis for decades. A plethora of topical corticosteroids are FDA-approved and commercially available in a range of potencies and choice of vehicle. Despite the extensive use of these products, data regarding optimal topical corticosteroid concentrations, duration and frequency of therapy, and quantity of application are limited. ⁹ The cutaneous adverse effects of topical corticosteroids (eg, hypopigmentation, telangiectasias, and striae) are well-described, ^1,2 but generally become apparent after chronic use. Subclinical cutaneous atrophy can occur after short-term use. While early skin atrophy is barely perceptible to the discerning eye, it is associated with enhanced systemic absorption and many more insidious and difficult-to-monitor extracutaneous corticosteroid side effects. Suppression of the hypothalamic-pituitary-adrenal (HPA) axis has been the most well-accepted surrogate marker for these systemic adverse effects. Application of some topical corticosteroids for as little as 2 to 4 weeks has frequently been associated with HPA-axis suppression. ^1,2,10 Infants and children are at greatest risk for percutaneous absorption and toxicity because of their higher ratio of body surface area (BSA) to body weight. ¹¹ Due to the chronic nature of atopic dermatitis and psoriasis, data demonstrating safety and efficacy in treating these diseases is crucial, especially in the pediatric population.

This monograph reviews data on a new, super-potent topical corticosteroid presented at the 2007 Hawaii Wint