Potent Topical Steroids Research Articles

Efficacy of topical pimecrolimus in the treatment of chronic vulvar pruritus: A prospective case series – a non‐controlled, open‐label study

Background: Chronic vulvar pruritus has been a most distressing physical and sociologic disorder for many patients, as well as for their physicians. Potent topical steroids are the conventional therapy for this distressing condition. Side effects or steroid resistance can be encountered. A second‐line therapy is required. Objectives: A single‐centre, non‐controlled, open‐label study was designed to assess the efficacy of topical pimecrolimus in the treatment of chronic vulvar pruritus. Methods: Fifteen married adult women with symptoms of vulvar pruritus ⩾4 months were included in the study. The patients did not have any relief with topical steroids. There were no objective physical findings. Topical pimecrolimus 1% cream (Elidel cream®, Novartis) was applied twice daily to the vulvar region. Patients were followed up 4 weeks later. After the trial was stopped, the patients remained in regular review for 3 months. Results: Thirteen patients tolerated pimecrolimus. They showed a clinical response within 2–4 weeks. Ten patients showed a complete response, three showed a partial response. After the trial had stopped, the patients with complete response were followed‐up by telephone for another 3 months, and were found to be in remission. Conclusions: We found that topical pimecrolimus provides relief for chronic vulvar pruritus. Pimecrolimus can be chosen as the second‐line therapy in patients with vulvar pruritus.

Successful Treatment of Inflammatory Linear Verrucous Epidermal Nevus with Tacrolimus and Fluocinonide

Inflammatory linear verrucous epidermal nevus (ILVEN) is a relatively rare disorder that is characterized by an early age at onset; severely pruritic linear papules and plaques; histologic features resembling spongiotic dermatitis, psoriasis, or lichenified dermatitis; and poor response to treatment. To report the successful treatment of ILVEN with potent topical steroid and tacrolimus ointments. An 11-year-old girl presented with a 1-year history of markedly pruritic, progressive linear eruption that extended from the right foot to the right buttock. She had failed treatment with pimecrolimus, calcipotriol, mometasone furoate, triamcinolone, tazarotene, and alpha-hydroxy acid. Histologic examination revealed the findings of spongiotic dermatitis. The lesions resolved with fluocinonide ointment and tacrolimus 0.1% ointment. The combination of two therapeutic agents with different mechanisms of action likely resulted in the successful treatment of this usually resistant condition.

LIQUEN SIMPLE CRÓNICO VULVAR UNILATERAL

SUMMARY A case of chronic simple liquen (Vidals Liquen) compromising the left vulvar area is presented. A lack of response to several topical previous treatments motivated vulvar biopsy that confirmed the diagnosis. The relationship with anxiety and/or depression is stressed. The treatment with antihistaminics and potent topical steroids yielded good results.

The Association Between HLA DR, DQ Antigens, and Vulval Lichen Sclerosus in the UK: HLA DRB1*12 and its Associated DRB1*12/DQB1*0301/04/09/010 Haplotype Confers Susceptibility to Vulval Lichen Sclerosus, and HLA DRB1*0301/04 and its Associated DRB1*0301/04/DQB1*0201/02/03 Haplotype Protects from Vulval Lichen Sclerosus

Lichen sclerosus (LS) is considered to have an immunogenetic background. Several small studies, using serological typing, have reported that HLA-DR11, DR12, and DQ7 were increased in LS, with DR17 less frequent. This study aimed to validate and detect new HLA-DR and DQ associations with LS in females and its characteristic clinical parameters. The cases, 187 female LS patients, and 354 healthy controls were all UK North Europeans. PCR-sequence specific primers method was applied to genotype the HLA-DR, DQ polymorphisms that correspond to 17 serologically defined DR and seven DQ antigens. Statistical analysis was performed with two-tailed Fisher's exact test with Bonferroni adjustment (p value after Bonferrroni adjustment, Pc). We found increased frequency of DRB1*12 (DR12) (11.2%vs 2.5%, pc < 0.01) and the haplotype DRB1*12/DQB1*0301/04/09/010 (11.2%vs 2.5%, p < 0.001, pc < 0.05), and a lower frequency of DRB1*0301/04 (DR17) (11.8%vs 25.8%, pc < 0.01) and the haplotype DRB1*03/DQB1*02DRB1*0301/DQB1*0201/02/03 (11.2%vs 24.6%, pc < 0.0001) in patients compared with controls. HLA DR and DQ antigens were not associated with time of onset of disease, site of involvement, structural changes of genitals, and response to treatment with potent topical steroids. In conclusion, HLA-DR and DQ antigens or their haplotypes appear to be involved in both susceptibility to and protection from LS.

Clobetasol propionate foam in the treatment of psoriasis

Psoriasis is a common, chronic, distressing skin disorder that frequently affects the scalp, skin, nails and joints. Despite treatment, many patients suffer from unremitting disease and decreased quality of life. Scalp-type psoriasis is particularly difficult to treat. Although topical corticosteroids are the mainstay of therapy for moderate-to-severe disease, patients frequently object to the messiness and unfavourable cosmetic appearance of topical treatments. In this context, foam vehicles, which have the advantage of minimal residue and increased ease of application, have emerged as novel alternatives to traditional creams, ointments and solutions. Clobetasol propionate foam 0.05% (OLUX™, Connetics Corporation), a high potency topical steroid, has been shown to alleviate symptoms of several dermatological conditions, including scalp and body psoriasis, improve disease severity and increase quality of life. Dose should be limited to 50 g/week, given the risk of adrenal suppression. Because patient preference is an important determinant of medication efficacy in clinical practice, clobetasol foam is a useful new formulation in the treatment of psoriasis and other skin conditions.

Successful Hair Transplant of Eyebrow Alopecia Areata

Alopecia areata of the eyebrows can be difficult to treat. Intralesional triamcinolone or potent topical steroids are considered the mainstay of medical therapy. This case illustrates the results of an experimental hair transplant to the eyebrows following years of modest response to intralesional triamcinolone. The aim of this study was to ascertain the benefits of a hair transplant for chronic eyebrow alopecia areata not responding to appropriate medical therapy. A hair transplant was performed with tumescent anesthesia and a total of 85 mini and micrografts placed in the right eyebrow. Followup after the hair transplant occurs every 8 weeks. The patient was free of eyebrow alopecia areata for 8 months following the initial hair transplant. Although the disease relapsed, hair growth is now manageable with intralesional cortisone injection performed six times per year. For the first time in years, this patient was given 8 months of reprieve from his eyebrow alopecia areata and is currently well-maintained on monthly intralesional cortisone which originally was of only modest benefit. The patient is pleased with the outcome.

Successful Hair Transplant of Eyebrow Alopecia Areata

Background: Alopecia areata of the eyebrows can be difficult to treat. Intralesional triamcinolone or potent topical steroids are considered the mainstay of medical therapy. This case illustrates the results of an experimental hair transplant to the eyebrows following years of modest response to intralesional triamcinolone. Objective: The aim of this study was to ascertain the benefits of a hair transplant for chronic eyebrow alopecia areata not responding to appropriate medical therapy. Methods: A hair transplant was performed with tumescent anesthesia and a total of 85 mini and micrografts placed in the right eyebrow. Followup after the hair transplant occurs every 8 weeks. Results: The patient was free of eyebrow alopecia areata for 8 months following the initial hair transplant. Although the disease relapsed, hair growth is now manageable with intralesional cortisone injection performed six times per year. Conclusions: For the first time in years, this patient was given 8 months of reprieve from his eyebrow alopecia areata and is currently well-maintained on monthly intralesional cortisone which originally was of only modest benefit. The patient is pleased with the outcome.

Sulfamethoxypyridazine-responsive pemphigoid nodularis: A report of two cases

Pemphigoid nodularis is a chronic and uncommon variant of bullous pemphigoid. The condition is characterized by the presence of prurigo nodularis-like lesions, possible history of blistering, and immunohistochemical findings of bullous pemphigoid. These patients are often unresponsive to conventional therapy with potent topical and systemic steroids and different immunosuppressive agents used alone or in combination. We describe two cases of pemphigoid nodularis treated successfully with sulfamethoxypyridazine without any adverse effects.

Topical pimecrolimus in the treatment of genital lichen planus: a prospective case series

A potent topical steroid is the conventional therapy for genital lichen planus (GLP). Side-effects or steroid resistance can be encountered and second-line therapy such as topical tacrolimus may be required. In our experience tacrolimus may be poorly tolerated in genital skin because of a burning sensation. In addition, there is impairment of Langerhans cell function, raising concerns about its long-term use. These adverse effects may not be as marked with pimecrolimus. To our knowledge, pimecrolimus has not been used in the treatment of GLP. To assess the efficacy and tolerability of topical pimecrolimus in the treatment of GLP. Eleven women with GLP were recruited: 10 had erosive vulval disease and one had classical lichen planus of perianal skin. Ten patients had poor disease control, and despite using topical steroids appropriately, two of these also had steroid-related side-effects in adjacent unaffected skin. The eleventh patient had adequate disease control but marked steroid atrophy. Topical pimecrolimus 1% cream (Elidel cream; Novartis, Camberley, U.K.) was applied twice daily to affected areas. Patients were followed up between 4 and 6 weeks later. They remain under regular review and at the time of writing mean follow-up is 5.2 months (range 2-10). Nine patients (82%) tolerated pimecrolimus, including three patients previously intolerant of tacrolimus. These nine patients showed a clinical response at 4-6 weeks: two showed a complete response with no residual disease activity visible and seven had a partial response. With longer follow-up, six (55%) of the women had a complete response and three (27%) were considered to have a partial response. Eight patients noted symptomatic improvement and one felt that her symptoms were the same as with steroid use. Two patients (18%) with erosive lichen planus were unable to tolerate pimecrolimus due to local irritation. We have found that topical pimecrolimus 1% cream is an effective treatment for GLP. Local irritation can limit its use, but it may be better tolerated than topical tacrolimus: three of our complete responders had previously been intolerant of tacrolimus. Topical pimecrolimus may be a valuable second-line treatment for patients with steroid-related side-effects or steroid-resistant GLP.

Beyond Our Pages

Beyond Our Pages

Successful treatment of Zoon’s vulvitis with high potency topical steroid

Zoon's vulvitis is a rare, chronic condition of the vulva that presents with burning, pruritus, and dysuria with characteristic lesions and histopathology. Several treatment options have been reported with limited success. A 63-year-old woman with Zoon's vulvitis diagnosed on histopathology was treated with clobetasol propionate 0.05%. Complete resolution of her symptoms and lesions occurred in less than 1 week. No recurrence of her symptoms has occurred after 9 months. Zoon's vulvitis may be successfully and expeditiously treated with high potency topical steroids.

HIGHLY POTENT AND MODERATELY POTENT TOPICAL STEROIDS ARE EFFECTIVE IN TREATING PHIMOSIS: A PROSPECTIVE RANDOMIZED STUDY

We report a prospective randomized study comparing the effects of highly potent and moderately potent topical steroids in treating pediatric phimosis. A total of 70 boys 1 to 12 years old with phimosis were randomly assigned to receive topical application of either betamethasone valerate 0.06% (a highly potent steroid) or clobetasone butyrate 0.05% (a moderately potent steroid). Parents of the boys were instructed to retract the foreskin gently without causing pain, and to apply the topical steroids over the stenotic opening of the prepuce twice daily for 4 weeks, then for another 4 weeks if no improvement was achieved. Retractibility of the prepuce was graded from 0 to 5. Response to treatment was arbitrarily defined as improvement in the retractibility score of more than 2 points. Mean treatment and followup periods were 4.3 and 19.1 weeks, respectively. The response rates in boys treated with betamethasone valerate and clobetasone butyrate were 81.3% and 77.4%, respectively (p = 0.63). Mean retractibility score decreased from 3.9 +/- 1.0 to 1.7 +/- 1.1, and 4.2 +/- 1.0 to 1.9 +/- 1.0 in the betamethasone and clobetasone groups, respectively. Both steroids were effective in all age groups. Pretreatment retractibility score did not affect treatment outcomes. No adverse effect was encountered. Highly potent and moderately potent topical steroids are of comparable effectiveness in treating phimosis. A less potent steroid may be considered first to decrease the risk of the potential adverse effects.

Necrolytic Acral Erythema

A 46‐year‐old hepatitis C‐positive African American woman presented with a several month history of worsening, well‐marginated, erythematous, dusky plaques on the dorsum of her feet and ankles. After an initial skin biopsy showed spongiotic dermatitis, she was treated with emollients, high potency topical steroids, and keratolytics, all of which were of no benefit. A punch biopsy from the dorsum of her foot showed acanthosis, individual keratinocyte necrosis, confluent upper epidermal necrosis, and a superficial and deep perivascular lymphocytic infiltrate. Given the patient's positive hepatitis C status and clinicopathological correlation, a diagnosis of necrolytic acral erythema was rendered. Empiric therapy with oral zinc sulfate was initiated despite a normal plasma zinc level, and the skin lesions resolved with post‐inflammatory hyperpigmentation. Necrolytic acral erythema, considered one of the necrolytic erythemas, is a cutaneous manifestation of hepatitis C virus infection. A total of nine cases have been reported in the literature, seven from Egypt and two from the United States. All reported patients have been hepatitis C positive. This case represents the third reported patient from the US with necrolytic acral erythema.

Amyopathic dermatomyositis presenting during pregnancy

Amyopathic dermatomyositis presenting during pregnancy

Dermoscopic assessment of long-term topical therapies with potent steroids in chronic psoriasis

We investigated the value of the dermoscope for monitoring the long term safety of high potency topical steroids in patients with chronic psoriasis. We observed for the first time that the overuse of topical steroids resulted in the appearance of clinically unapparent but dermoscopically apparent "red lines" (linear telangiectasias) in the treated plaques and/or skin adjacent to the treated plaques (P < .03). We concluded that dermoscopy may help reveal the early signs of impending steroid-induced atrophy ("red lines") before they become clinically evident with the naked eye and before the atrophy becomes permanent.

Pinch skin grafting for idiopathic inflammatory medial meatal fibrotizing otitis

Objectives: Idiopathic inflammatory medial meatal fibrotizing otitis is an uncommon disorder of the external auditory canal characterized by desquamation of the medial canal skin, chronic inflammation, and eventual canal stenosis. Medical treatment consists of regular debridement, topical and systemic steroids, and antimicrobials for acute infections. Surgical treatment of canal stenosis by removal of the fibrotic plug followed by split thickness skin grafting has been reported. However, skin grafting of the canal prior to development of complete stenosis has not been reported. Methods: Case report of a 72-year-old male hearing aid user who was referred for a 7-month history of recurrent external otitis and subsequent stenosis of the external auditory canals. On physical exam, he had erythema, granulation tissue, and synechia in the medial external auditory canals bilaterally. Treatment consisted of regular debridements, external canal wicks, high potency topical steroids, oral steroids, ear powder, and systemic and topical antibiotics. After 20 months of medical treatment, the external canals remained patent but failed to epithelialize. Pinch skin grafts from the posterior auricular area were applied to the medial canal tissue in the office under local anethesia. Results: After 6 weeks, the skin grafts have become adherent to the medial canal tissue and are beginning to epithelialize the canal. There has been no further stenosis. Conclusion: Pinch skin grafting in medial meatal fibrotizing otitis is a promising technique for restoring the epithelium in this chronic condition. The long-term viability of the epithelium and the affect on disease progression deserves further investigation.

Intermittent Topical Corticosteroid/Tacrolimus Sequential Therapy Improves Lichenification and Chronic Papules More Efficiently than Intermittent Topical Corticosteroid/Emollient Sequential Therapy in Patients with Atopic Dermatitis

Atopic dermatitis (AD) is a common, chronic, relapsing, severely pruritic, eczematous skin disease. Topical steroids are the mainstay of treatment. However, the adverse effects of steroids on hormonal function are the major obstacle for their use as long-term topical therapy. Intermittent dosing with potent topical steroids and/or combination therapy with steroid and tacrolimus have been frequently used in the daily management of AD to overcome the problems accompanying the long term use of steroids. We compared the clinical effects of topical steroid/tacrolimus and steroid/emollient combination treatments in 17 patients with AD. An intermittent topical betamethasone butyrate propionate/tacrolimus sequential therapy improved lichenification and chronic papules of patients with AD more efficiently than an intermittent topical betamethasone butyrate propionate/emollient sequential therapy after four weeks of treatment. Only one out of 17 patients complained of a mild, but temporary, burning sensation after tacrolimus application. The intermittent topical steroid/tacrolimus sequential therapy may be a useful adjunctive treatment for AD.

Intermediate cell histiocytosis: a case report of a rare disorder

Histiocytoses are a heterogeneous group of disorders including: X, non-X, as well as the rare intermediate cell histiocytosis. This classification is based on clinicopathological as well as ultrastructural aspects. Intermediate cells belong to the dendritic cell group involved in antigen presentation to lymphocytes. These cells characteristically express S-100 and CD1a and lack Birbeck granules. We report a case of an 80 year old male with intermediate cell histiocytosis. This patient presented with multiple pruritic firm papules and nodules on the bilateral anterior lower extremities. An extensive systemic work-up revealed only a single lytic lesion in the skull. He received high potency topical steroids with good resolution of his pruritus, but with no effect on the cutaneous nodules. He has remained without systemic involvement after one year and the lytic lesion remained unchanged.

Herbal creams used for atopic eczema in Birmingham, UK illegally contain potent corticosteroids

Aims: To determine whether “herbal creams” reported as being effective for the treatment of childhood atopic eczema contained corticosteroids. Methods: Patients attending the paediatric dermatology clinic at Birmingham Children’s Hospital,...

The efficacy of topical tazarotene monotherapy and combination therapies in psoriasis

Tazarotene (Tazorac®, Allergan, Inc.) is the first topical retinoid approved for the treatment of plaque psoriasis. It has a similar onset of action compared to potent topical steroids and has the advantage of a longer remission. The common side effects associated with the drug include skin irritation (including pruritus), erythema and a burning sensation. To overcome some of these shortcomings, it has been used in combination with steroids, calcipotriene and phototherapy. Combination therapy not only results in a decrease in adverse side effects, but also enhanced efficacy. Clinical study data have shown that combination therapy is just as important as tazarotene monotherapy, if not more.