The Role of Low-Potency Topical Steroids in Day-to

Supplement to the December 2009
&AGING
Series: Relevance of Low-Potency Topical Steroids in Dermatology
The Role of Low-Potency Topical
Steroids in Day-to-Day Practice
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The Role of Low-Potency Topical
Steroids in Day-to-Day Practice
Johnnie M. Woodson, MD
Assistant Clinical Professor of Dermatology
University of Nevada School of Medicine
Henderson, NV
T
opical corticosteroids are one of the oldest treatments for a variety of dermatologic conditions.
They are used to treat conditions such as psoriasis,
vitiligo, eczema, atopic dermatitis, phimosis, acute radiation dermatitis and lichen sclerosus. 1 Topical corticosteroids are also used to treat melasma, chronic idiopathic
urticaria and alopecia areata, but evidence of efficacy
with these conditions is limited.1
Further, their long history of safety and effectiveness
for certain conditions means they remain one of the most
useful and widely prescribed treatments in day-to-day
dermatologic practice — nearly 1.7 million prescriptions
are dispensed each year for treatment of dermatological
conditions (see Table 1).2
These benefits — safety, use across a wide spectrum of
dermatoses — make topical corticosteroids a desirable
tool for any dermatologist. This article will specifically
explore the role and use of topical low-potency steroids
(LPS) in day-to-day practice.
LPS AS DAILY TREATMENT
Some of the selected indications of topical corticosteroids
in dermatologic uses are for the treatment of seborrheic der-
matitis, psoriasis, pityriasis rosea, nummular dermatitis, atopic
dermatitis, dyshidrotic eczema, diaper dermatitis, erythroderma, lichen simplex chronicus, lichen planus, alopecia
areata, pruritus, vitiligo, acne keloidalis nuchae and granuloma
annulare. Ference and Last note that the keys to successful
treatment “[depend] on an accurate diagnosis and consideration of the steroid's delivery vehicle, potency, frequency of
application, duration of treatment and side effects.”1
To describe the effect intensity of topical corticosteroids, potency is the term used. To measure the anti-inflammatory and the antiproliferative properties, certain
assays are utilized. A very commonly used assay is the
vasoconstrictor assay and this is usually used by researchers because it correlates well with clinical efficacy.
The test is subjective, which is one of the disadvantages
of using this assay. Clinical potency of topical corticosteroids usually depends on several factors, including the
structure of the molecule, the area of the skin it is applied
to and the vehicle it is used in.
Topical corticosteroids can have a number of undesirable side effects, including atrophic changes, more fragile
skin, more easily bruised skin, increased risk for infection,
masked infection, secondary infection, contact dermatitis,
TABLE 1. DERMATOLOGY: LOW-POTENCY TOPICAL STEROID PRESCRIPTIONS OVER 1 YEAR
VEHICLE
PRESCRIPTIONS FILLED
Ointment
413,759
Cream
727,030
Liquid
545,750
Combination form
2,923
TOTAL
1,689,462
Note: Wolters Kluwer data gathered over 12 months in 2008–09.2
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LOW-DOSE STEROIDS
FIGURE 1. While higher-potency topical steroid formulations may be used short-term in particularly acute cases,
avoid them for use longer than 3 weeks and on more sensitive areas of the body, such as the face, groin and axilla.
delayed wound healing, hyperpigmentation, hypopigmentation and photosensitization.1
Because of this, dermatologists want to use the lowestpotency steroid that will effectively alleviate symptoms of
dermatoses.3 While higher-potency formulations may be
used short-term in particularly acute cases, they are to be
avoided for long-term use — longer than 2 weeks — and
on more sensitive areas of the body, such as the face, groin
and axilla.1,3,4 Milder formulations are therefore used when
day-to-day maintenance or topical use on sensitive skin,
thinner skin or children’s skin is called for.1,4
This doesn’t mean a dermatologist should use a topical
FIGURE 2. Successful treatments target the root cause to
relieve symptoms and improve quality-of-life factors such as
physiological distress and embarrassment with appearance
of skin and/or constant scratching.
ment before the desired response is achieved, while a severe case may not respond, or may respond very little,
even after long-term use.5
Strategies in such acute cases include varying the dose
(e.g., using stronger topical steroids on weekends and
weaker 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 potent
and gradually moving to a less-potent formulation). 5,6
Trial and error is often necessary in order to tailor the
dosage and schedule to each patient.1
When prescribing, dermatologists need to take into account the following safety considerations: body surface area, duration and
individual patient needs. Considering
A formulation that combines hydrocortisone acetate and
these factors is important in order to
pramoxine hydrochloride results in the ability to relieve
avoid potential side effects. In fact, sepruritus and inflammation associated with many dermatoses. vere side effects are rare with topical
LPS, even when they are used over
many years.4
steroid potency that is too low to treat a given patient’s
symptoms. Rather, the idea is to match lowest strength and MECHANISMS OF ACTION
smallest quantity of corticosteroid to properly address the
Topical corticosteroids have anti-inflammatory and anseverity of the dermatosis the patient has presented with.5 tiproliferative effects. The immediate anti-inflammatory
For example, mild eczema can be treated with twice- effects are that they stabilize cell membranes and prevent
a-day topical LPS, often completely clearing the outbreak the release of lysosomal contents; they reduce vascular
within 1 or 2 weeks.1,5 Moderate eczema may require a smooth muscle and sensitivity to histamine; they reduce
more potent formulation and/or longer duration of treat- mast cell sensitization induced by immunoglobulin E; and
4
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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
Urticaria
TABLE 3. ONSET OF RELIEF TIME (RELATING TO ITCH-SCRATCH CYCLE)
PRODUCT
ONSET OF ACTION
PEAK EFFECT
DURATION OF ACTION
Pramoxine hydrochloride
2 to 5 minutes
3 to 5 minutes
Several days
Hydrocortisone acetate
slow
n/a
long
Note: Adapted from University of Maryland Medical Center Complimentary and Alternative Medicine Index.14,15
they inhibit the release of histamine and other mast cell
mediators. Topical corticosteroids can also decrease the
natural cell-killing activity and decrease response to lymphocyte reaction.
In my experience, topical glucocorticosteroids also
have delayed anti-inflammatory effects, such as preventing
formation of potent inflammatory mediators, decreasing
vascular permeability, and producing the induction of
anti-inflammatory proteins. Glucocorticosteroids act on
different cell types, including polymorphonuclear leukocytes (PMNs) and lymphocytes. They decrease PMN
movement to inflammation sites, reduce PMN numbers
at inflammation sites, and decrease their ability to attach
to the inside of vascular channels called the endothelium.
Glucocorticosteroids can also decrease the production of
certain interleukins as well as tumor necrosis factor.
I’ve also found that topical glucocorticosteroids exhibit
antiproliferative effects that can affect each of the skin’s
layers. For example, in the epidermis, they can decrease
the thickness of the stratum corneum, affect the keratinocyte growth factors by suppression and decrease
melanocyte pigment production. Down in the dermis,
topical glucocorticosteroids can reduce thickening by decreasing dermal volume, thereby making the fibroblasts
less active. They can also diminish collagen and elastin
fibers of the dermis, and create fragile dermal vessels. As
a result, it’s worth noting that long-term use of steroids
can increase the risk of atrophy of the skin.
BENEFITS OF PRAMOXINE
Because of its anesthetic properties, the addition of
pramoxine may be helpful in ameliorating itch sensation.7
Pramoxine hydrochloride is widely used as a surface
anesthetic because it combines effectiveness with low systemic toxicity. 8 According to a 1954 study by Peal and
Karp, it exhibits low potential for sensitization and irritation.9 Subsequent study has confirmed the safety profile
and wide-ranging effectiveness of pramoxine.
A double-blind study of 15 patients examined how the
application of pramoxine lotion and pramoxine vehicle
affected perception of histamine-induced pruritus and
the warmth and pain thresholds that result from this pruritus. The authors found that, while cold and heat pain
thresholds were unaffected, warmth sensation threshold
increased significantly — by 0.4˚ C — after histamineinduced itch. 10 Pramoxine lotion was found to significantly reduce the cold pain threshold, while pramoxine
vehicle significantly decreased warmth sensation; the remaining factors were unaffected.10
Itch duration was shorter in 13 of the patients with
pramoxine lotion and in 5 of the patients with pramoxine
vehicle.10 The reduction in duration with pramoxine lotion
was significant.10 Pramoxine lotion also significantly reduced baseline itch magnitude at each of the 10 time points
and more effectively maintained reduced itch magnitude
for 2 to 6 minutes after histamine injection.10 The authors
concluded that “pramoxine lotion can be effective in reS u p plem en t to S kin & A gin g
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LOW-DOSE STEROIDS
lieving histamine-induced pruritus” — a finding that can
be applied to a wide variety of dermatoses (see Table 2).10
Another recent randomized, double-blind, controlled
comparative trial found a 61% decrease in itch intensity in
the group of patients treated with a pramoxine 1% lotion,
whereas the control group had only a 12% reduction in
itch intensity.11 The authors found it to be a “safe, convenient and effective topical lotion.”11
Pramosone ® (hydrocortisone acetate 1% or 2.5%,
pramoxine hydrochloride 1%) lotion offers the antiinflammatory effects of hydrocortisone acetate with the
added benefits of a topical anesthetic. 12 It reduces skin
redness, swelling, itching and irritation while decreasing
related pain when applied to the affected area by blocking
the transmission of nerve impulses.13
Hydrocortisone acetate is an LPS that acts effectively
as an anti-inflammatory agent for mildly inflamed dermatoses or for maintenance of moderately inflamed dermatoses. 7 Pramoxine hydrochloride is a topical
anesthetic with very low potential for irritation and sensitization, making it particularly well-suited to dermatological applications.
The combination of these two active ingredients results
in the ability to relieve pruritus and inflammation associated with many dermatoses. In addition, I’ve found
Pramosone offers a preparation with efficacy superior to
that of hydrocortisone acetate alone, while maintaining
an equivalent safety profile. The combination of the ingredients presents an ideal combination of rapid onset and
extended duration of relief (see Table 3).14,15 It’s worth
noting that Pramosone contains emollients to work
against the dry skin that is often associated with use of
similar topical agents. As a result, it has been used to provide effective itch relief for more than 30 years.
CONCLUSION
Successful treatment not only targets the root cause and
relieves symptoms, it also improves quality of life for the
patient and, perhaps, the patient’s caregiver. Quality-oflife factors include relieving physiological distress and
embarrassment with appearance of skin and/or constant
scratching; minimizing time spent at the doctor’s office,
at the pharmacy and recuperating; ensuring that the patient can participate in daily activities; and preventing exacerbation of further skin conditions.
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LPS are a part of a treatment plan that meets these criteria. Their well-tested history has demonstrated their efficacy and effectiveness. The topical mode of delivery
means they are easy to use. And, finally, the low potency
minimizes the potential for sensitivity, irritation and
other side effects. It is clear that low-potency topical
steroids have solidified a place in dermatologic practice,
and that they will continue to remain an important part
of treating patients on a day-to-day basis. ■
References
1. Ference JD, Last AR. Choosing topical corticosteroids. Am Fam
Physician. 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 advances in the field. Pediatr Health. 2008;2(6):733–747.
4. American Academy of Dermatology. Treating eczema with steroids.
2009. Accessed October 27, 2009, at
http://www.skincarephysicians.com/eczemanet/steroids.html.
5. New Zealand Dermatological Society. Treatment of atopic dermatitis. 2009. Accessed October 27, 2009, at
http://www.dermnetnz.org/dermatitis/treatment.html.
6. PCP Dermatological Society. Guidelines for the management of
atopic 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: McGraw Hill; 1994, p. 383–397.
8. Fisher AA. The safety of pramoxine hydrochloride when used as a
topical (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 experimentally induced pruritus in humans. J Am Acad Dermatol. 1997;37(2
Pt 1):278–280.
11.Young TA, Patel TS, Camacho F, et al. A pramoxine-based anti-itch lotion is more effective than a control lotion for the treatment of uremic pruritus in adult hemodialysis patients. J Dermatolog Treat. 2009;20(2):76–81.
12. Pramosone Cream, Lotion and Ointment — Product Insert [data
on 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 Alternative Medicine 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 Alternative Medicine Index: Hydrocortisone. 2009. Accessed October
27, 2009 at http://www.umm.edu/altmed/drugs/hydrocortisone063400.htm.