Topical Treatment for the Management of Atopic Dermatitis

February 2019 | Volume 18 | Issue 2 | Supplement Individual Articles | 112 | Copyright © February 2019

Peter W. Hashim MD MHS,a Tinley Chen BA,a Adelaide A. Hebert MD,b Leon H. Kircik MDa-c

aThe Icahn School of Medicine at Mount Sinai, Department of Dermatology, New York, New York BIndiana University School of Medicine, Indianapolis, IN cUTHealth McGovern Medical School-Houston, Houston, TX DPhysicians Skin Care PLLC, Louisville, KY

tolerability of the agent. Long-term or inappropriate use of topical corticosteroids has been associated with several cutaneous and systemic side effects. Cutaneous side effects include skin atrophy, purpura, telangiectasias, striae, and acneiform or rosacea-like eruptions.7 Systemic effects, while rare, include hypothalamic-pituitary-adrenal (HPA) axis suppression, manifestations of Cushing’s syndrome, hyperglycemia, glucosuria, and growth retardation in children. In pediatric patients, their relatively large ratio of body surface area to mass results in a higher degree of absorption, augmenting the potential risk of HPA axis suppression.Caregiver concerns relating to the safety of topical corticosteroids are one of the primary barriers to treatment adherence, which can result in treatment failure in pediatric patients.10 In order to minimize the risk of systemic and cutaneous side effects, the lowest potency corticosteroid that is effective is preferred for long-term treatment, large surface areas, or thin-skinned areas (eg, face, groin, axilla). Weaker concentrations of topical corticosteroids under occlusion may have fewer systemic effects than more concentrated versions while still maintaining comparable efficacy.11 Educating patients and caregivers on the proper use of topical corticosteroids is integral to developing therapeutic plans, which should include discussions about patient preferences in vehicle preparations in order to optimize compliance and prevent treatment failure.Vehicles The selection of topical corticosteroid vehicle has an important impact on efficacy, tolerability, and patient compliance. Powders, oils, and liquids are used in different combinations to produce the major types of vehicles.Ointments are semi-solid emulsions composed of water suspended in oil. Ointments provide a high degree of skin moisturization by decreasing transepidermal water loss. Due to their occlusive properties, ointments allow for greater penetration of medication and thus confer greater potency. However, the high viscosity of the vehicle leads to a greasy sensation that patients may find unpleasant. Ointments are therefore preferred for dry, hyperkeratotic lesions and should be avoided on hair-bearing areas. Infants and children often tolerate ointments well and derive significant benefit from the occlusive nature of these formulations.Creams are emulsions of oil and water in roughly equal proportions. With lower viscosity than ointments, creams are easier to apply over large surface areas. In addition, creams are less occlusive and less potent than ointment formulations of the same medication.Lotions are mixtures of water with powder and confer decreased potency relative to ointments and creams. The low viscosity and rapid evaporation of lotions allows for easy application to large surface areas and provides for higher cosmetic appeal. Lotions are particularly well-suited for intertriginous areas.Solutions are mixtures of water with alcohol, glycols, or other non-aqueous liquids. Solutions quickly evaporate, making them most applicable for moist lesions and hair-bearing regions.Gels are semi-solid emulsions that were classically formulated in an alcohol base. These gel formulations are non-greasy and self-drying, providing for high patient satisfaction. Gels should be used with caution in areas with open erosions or fissures, where the alcohol base can be irritating. Within the last 15 years, gels have been introduced with new water-based formulations. These gels are both hydrating and well tolerated and will not irritate open skin in the way that alcohol-based gels tended to irritate.Foams are dispersions of gas bubbles in a liquid matrix. The vehicle spreads easily and absorbs rapidly into the skin. As such, foams are considered ideal vehicles for the scalp and other hair-bearing regions.Desonide Among lower potency corticosteroids, desonide is the most commonly prescribed agent in the United States.12 Desonide is a Class VI, nonfluorinated, synthetic topical corticosteroid that has been implemented since 1972 for the treatment of mild-to-moderate steroid-responsive dermatoses.13 This topical steroid is available in cream, lotion, foam, ointment, and hydrogel formulations.Several large clinical trials have demonstrated a favorable safety and efficacy profile of topical desonide in the treatment of pediatric AD.14-16 A pharmacovigilance program has provided post-marketing surveillance data on topical desonide from nearly a decade of collection.17 A total of 62 adverse event reports were obtained, 37 of which were provided by consumers and not medically substantiated. The most common adverse events were local skin irritations.Desonide 0.05% foam was approved in 2006 for the treatment of mild-to-moderate atopic dermatitis in patients 3 months of age and older.18 Prepared in a petrolatum-based emulsion aerosol foam, desonide 0.05% foam may be more tolerable than ethanol-based preparations that often sting or burn, particularly in areas where skin is already irritated. The incorporation of petrolatum delivers an occlusive layer to the skin on application, which has been shown to reduce the evaporation of moisture, increase hydration of the stratum corneum, and thereby enhance delivery.19 Moreover, the cosmetic benefit of a foam vehicle that allows for controlled and uniform applications—