Dermatology Education Initiative-Inflammatory Skin Disorders Express Report

Based on Data Presented at the 31^st Hawaii Dermatology Seminar March 3–9, 2007, Maui, Hawaii

Publication date: 2007-05-29

New Treatment Options for the Management of Inflammatory Skin Disease

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

This Inflammatory Skin Disorders Express Report™ reviews data on fluocinonide cream 0.1‰, a new superpotent topical corticosteroid, presented at the 31^st Hawaii Dermatology Seminar. These data suggest fluocinonide cream 0.1‰, is less atrophogenic and less likely to cause HPA-axis suppression than other superpotent topical corticosteroids. Such an agent would be a welcome addition to the dermatologist’s armamentarium in treating chronic inflammatory skin disease such as atopic dermatitis and psoriasis.

Expert Commentary

Mark G. Lebwohl, MD, Professor and Chairman, Department of Dermatology, Mount Sinai School of Medicine, New York, New York

Since their introduction several decades ago, topical corticosteroids have been the cornerstone of treatment for chronic inflammatory dermatoses, such as atopic dermatitis and psoriasis. These agents, which range in potency from superpotent to least potent (Class 1 to Class 7, respectively), have broad anti-inflammatory properties. Topical corticosteroids are available in a variety of vehicles, including creams, ointments, lotions, gels, and foam. The vehicle used can substantially affect the corticosteroid’s clinical action, potency, and patient acceptability. ¹

When treating atopic dermatitis, the lowest potency topical corticosteroid likely to be effective may be considered initially, particularly in infants and in patients with mild exacerbation of disease. Mid-potency topical corticosteroids may be used in children and adults for relatively brief treatment periods. Potent and superpotent topical corticosteroids are typically reserved for short-term treatment of severe or lichenified areas in adults, switching to lower potency agents or less frequent application for maintenance therapy after resolution or significant improvement. Corticosteroid-free topical agents can be used for maintenance therapy.

When treating psoriasis, patient age, severity of disease, and type and extent of surface area involvement must be considered in the selection of a topical corticosteroid. Direct application of an agent of appropriate potency to a psoriatic lesion often results in rapid improvement. Low-potency topical corticosteroids are typically used for the face, groin, and axillary areas; on areas with thin skin; and in infants. ² On the face and intertriginous skin, topical calcineurin inhibitors are also effective without corticosteroid side effects. For other areas and adults, mid-potency agents are appropriate initial therapy, but higher potency corticosteroids are often used on thick chronic plaques resistant to lower potency agents. Topical corticosteroids are best used to treat psoriasis affecting less than 10‰ to 20‰ of total body surface area (BSA). ³ Phototherapy or systemic therapies are reserved for widespread or severe psoriasis.

Although topical corticosteroids are extremely effective in treating chronic dermatoses, long-term safety remains an issue of concern. Adverse effects such as skin atrophy, telangiectasias, hypopigmentation, and potential suppression of the hypothalamic-pituitary-adrenal (HPA) axis have been associated with higher potency topical corticosteroids and prolonged treatment. ^4-6 HPA-axis suppression is of particular concern in children because of their higher ratio of total BSA to body weight. ⁷ Moreover, topical corticosteroids are readily absorbed when the skin barrier is impaired, as can occur with atopic dermatitis and psoriasis. The potential for these adverse events varies with respect to dose, duration and frequency of administration, BSA requiring treatment, and functional status of the skin barrier. ⁷

Fluocinonide Cream 0.1‰ Least Atrophogenic of Superpotent Topical Corticosteroids Evaluated

To assess the degree o