dition, unlike other structural classes of TCS, the clocortolone
pivalate molecule is associated with a very low rate of inherent
allergenicity, a factor that is clinically relevant as TCS allergy is
easily misdiagnosed. 8,9,13
Formulation Characteristics and Vehicle Components
As mid-potency TCS are commonly used to treat eczematous
dermatoses that are associated with marked increase in transepidermal
water loss (TEWL) and decreased stratum corneum
(SC) hydration, the emollient cream vehicle was designed to
include very few excipients. Some excipients were selected
specifically to help improve the SC permeability barrier that
is impaired in many eczematous and inflammatory dermatoses.
11,12-18 The inclusion of “barrier friendly excipients,†such as
white petrolatum, mineral oil, and stearyl alcohol, provides
adjunctive clinical benefit and may reduce the potential for irritant
contact reactions and secondary xerotic skin changes.13-18
The further rationale of incorporating vehicle components that
can assist in reducing SC permeability barrier impairment is to
counteract potential adverse sequelae that TCS application can
have on the SC, which result primarily from a decrease in SC
lipid synthesis at sites of application.19
The excipients included in both the original brand and authorized
generic clocortolone pivalate 0.1% cream and their
primary vehicle functions that are likely to be clinically relevant
are listed in Table 1. The 3 major excipients included in the clocortolone
pivalate 0.1% cream that have emollient properties
and can enhance the functional integrity of the SC permeability
barrier are white petrolatum (occlusive emollient), mineral oil
(light non-vegetable oil occlusive emollient), and stearyl alcohol
(long-chain fatty alcohol emollient).10 All 3 of these agents
are well established as vehicle excipients that have been used
for decades in many skin-care products with a very favorable
track record of skin tolerability and safety. Mineral oil has been
applied to skin for cosmetic purposes since the late 1800s.20
Stearyl alcohol is a commonly used fatty alcohol, which provides
lubricant and emollient characteristics to skin and serves
as both a non-toxic emulsifier and a slight thickening agent that
assists in providing a “creamy†quality to the formulation.21
Ultimately, these 3 excipients function collectively to assist
clocortolone pivalate by promoting skin hydration at the sites
of active skin disease whilst the clocortolone pivalate is functioning
to reduce cutaneous inflammation caused by the skin
disease itself. As a TCS is not to be conceptualized as a “moisturizer,â€
patients are still encouraged to use a gentle cleanser
and moisturizer or “barrier repair†formulation diffusely, especially
those patients with AD, asteatotic eczema, and xerotic
skin, where replenishment of SC lipids and increased hydration
provide adjunctive benefit.4,15-17,20-23 However, inclusion in a TCS
formulation of excipients that enhance the SC permeability barrier
helps to sustain its proper function in areas of eczematous
dermatitis where the TCS is being applied. 19
Another important characteristic of a TCS formulation is the
avoidance of ingredients that can be allergenic or induce irritancy.
Clocortolone pivalate 0.1% cream does not contain
any fragrances or lanolin, both of which can be problematic
in eczematous dermatitis, such as AD.10,13,23 An additional advantage
of clocortolone pivalate 0.1% cream is the absence
of penetration enhancers, such as propylene glycol (in high
concentrations) or ethanol, which can induce allergenicity,
irritancy, and/or SC barrier impairment.11,13,15 A final comment
about cutaneous allergenicity is worthy of mention. The clocortolone
pivalate molecule falls into TCS Category C within
the classification system used to differentiate the potential
for different TCSs to induce ACD.8 This category exhibits the
lowest potential risk for ACD induced by a topically applied
corticosteroid compound (<0.2%).24,25
Importantly, all of the favorable characteristics demonstrated
by the original brand of clocortolone pivalate 0.1% cream apply
also to the authorized generic clocortolone pivalate 0.1%
cream because the formulations are identical and produced by
the same manufacturer.
Effects of Clocortolone 0.1% Cream on the Statum Corneum Permeability Barrier
A total of 18 healthy adult female subjects were enrolled in the
treatment phase of a study that evaluated the effects of clocortolone
pivalate 0.1% cream, hydrocortisone butyrate 0.1%
lipocream (HB-LC), and hydrocortisone butyrate 0.1% lotion
(HB-L) on both TEWL and skin hydration.26 Each subject was
instructed to stop the use of all topical products with effects
on skin moisturization (ie, soaps, creams, lotions, sunscreens,
insect repellants, etc.) on their upper extremities during a
3-day pre-conditioning period prior to testing. On day 1, four
5cm x 5cm sites (2 sites on each volar forearm) were identified
and underwent “dry shaving†as a method to induce SC
permeability barrier dysfunction. Both increased TEWL and
decreased skin hydration have been shown to occur using this
methodology. On day 2, baseline measurements for TEWL and
corneometry were obtained using recognized instrumentation
from each of the 4 dry-shaved volar forearm sites and 1 nonshaved,
non-treated off-site located to the side of one volar
forearm prior to treatment. Measurements were repeated 1
hour (± 10 minutes), 2 hours (± 15 minutes), and 4 hours (± 15
minutes) after each subject underwent application to a given
test site of a defined amount of clocortolone pivalate 0.1%
cream, HB-L, and HB-LC, with the fourth dry shaved skin site
left untreated to serve as “damaged control skin.†As noted
above, a site of normal undamaged skin was also identified
to serve as a “normal skin control.†Before each set of measurements
was taken, subjects were required to acclimate in
the environmentally-controlled room for 30 to 45 minutes.
The results of this study are depicted in Figure 1 and Figure
2, demonstrating, based on this assay, that clocortolone piva-