Steroid-Sparing Properties of Emollients in Dermatology
Steroid-Sparing Properties of Emollients in Dermatology
Topical corticosteroids (TCS) and topical calcineurin inhibitors (TCIs) are very effective treatments in inflammatory dermatoses, but carry risks with long-term use. TCS are associated with cutaneous atrophy and tachyphylaxis and TCIs can be irritating and contain a black box warning of an increased risk of cancers including lymphoma and non-melanomatous skin cancers. Nevertheless, they are appropriate treatments for inflammatory conditions such as psoriasis and atopic dermatitis (AD) and should be used more often with disease flares and less as maintenance therapy. Given the associated risks of long-term continuous use with these pharmacologic agents, alternatives are needed with similar anti-inflammatory and barrier repair properties that can be used indefinitely without risk. Some over-the-counter (OTC) ingredients such as colloidal oatmeal and petrolatum, as well as anti-inflammatory prescription moisturizers (medical device creams), have demonstrated efficacy with little complications in skin barrier repair and symptom relief in steroid-responsive conditions. With regimented application, these non-drug options are safe and effective and can limit the longterm continuous use of TCS or TCIs.
Topical corticosteroids (TCS) are the cornerstone of treatment for inflammatory dermatoses, particularly for the swift resolution of acute flares, as TCS can calm inflamed and irritated skin due to rapid absorption and action. A wide range of potencies and vehicles enables tailoring of therapy to be site-specific and considerate of patient preference. Long-term continuous therapy with TCS can lead to localized side effects such as cutaneous atrophy, telangiectasias, acne and rosacea exacerbation, and tachyphylaxis, as well as systemic absorption if used on large surface areas causing hypothalamic-pituitary-adrenal (HPA) axis suppression, growth retardation in children, and cataract and glaucoma formation in adults. Thus, intermittent therapy should be supplemented with alternative treatments that can help limit localized side effects and provide epidermal barrier dysfunction improvement.
Topical calcineurin inhibitors (TCIs; tacrolimus ointment/Protopic®; pimecrolimus cream/Elidel®) represent secondline therapies for the short-term and non-continuous chronic treatment of moderate-to-severe atopic dermatitis (AD) in non-immunocompromised adults and children who have failed to respond adequately to or are not suitable for other topical prescription AD treatments. TCIs inhibit calcineurin in T-cells, reducing the production of interleukin (IL)-2 and related proinflammatory cytokines. Clinical studies have demonstrated longterm efficacy, minimal systemic absorption, and few transient side effects, such as localized irritation, with the use of these agents. TCIs do not induce skin atrophy or inhibit collagen synthesis, enabling their use on the face, neck and intertriginous areas. In 2006 the United States Food and Drug Administration (USFDA) placed a black box warning on TCIs based on safety concerns over the possible risk of systemic absorption and on data from transplantation research reporting systemic immune suppression with oral calcineurin inhibitors (tacrolimus and cyclosporine) is associated with an increased cancer risk. To date, this risk remains theoretical and is based mainly on the drug's mechanism of action, data from animal studies and a few single case reports of lymphoma and skin cancer in patients treated with TCIs.
Recently, medical device creams ( Table 1 ), which are nonsteroidal agents with emollient, anti-inflammatory and antipruritic properties, have entered the marketplace for the treatment of inflammatory dermatoses to help treat epidermal barrier dysfunction as well as limit potential long-term use of TCS and TCIs. Atopiclair® is a hydrolipidic cream containing Butyrospermum parkii (shea tree), glycyrrhetinic acid (licorice), Vitis vinifera (grapevine) extract, bisabolol (German chamomile), hyaluronic acid and tocopheryl acetate (vitamin E), and is thought to have moisturizing, anti-inflammatory and antioxidant properties. It also contains telmesteine, which inhibits elastase, collagenase and matrix metalloproteinases, helping to prevent epidermal breakdown. MimyX™ contains lipid components that mimic the normal skin barrier (triglycerides, phospholipids, and squalene) along with the anti-inflammatory cannabinoid N-palmitoylethanolamine (N-PEA), an endogenous fatty acid amide thought to target the peroxisome proliferator-activated receptor-alpha (PPAR-α). Other added ingredients such as purified water, olive oil, glycerin, pentylene glycol, vegetable oil, and hydrogenated lecithin have humectant and emollient effects. EpiCeram® is a microencapsulation system emulsion of ceramide, conjugated linoleic acid, cholesterol and palmitic acid formulated with Euphorbia cerifera (candelilla) wax, corn syrup solids, squalene, glycerin, petrolatum, and dimethicone. Eletone® has a high lipid content dispersed in an outer aqueous phase (Hydrolipid Technology™) in petrolatum, purified water, and mineral oil. Hylatopic Plus® is an emollient cream and foam containing Theobroma grandiflorum seed butter (a skin conditioning butter made from the fruit of a the Cupuaçu tree that is native to Brazil), hyaluronic acid, glycerin, dimethicone, petrolatum, and tocopheryl acetate (vitamin E). All of the medical device creams are indicated for the treatment of various dermatoses such as AD, allergic contact dermatitis, and radiation dermatitis, which are associated with symptoms of itching, burning, and pain.
Abstract and Introduction
Abstract
Topical corticosteroids (TCS) and topical calcineurin inhibitors (TCIs) are very effective treatments in inflammatory dermatoses, but carry risks with long-term use. TCS are associated with cutaneous atrophy and tachyphylaxis and TCIs can be irritating and contain a black box warning of an increased risk of cancers including lymphoma and non-melanomatous skin cancers. Nevertheless, they are appropriate treatments for inflammatory conditions such as psoriasis and atopic dermatitis (AD) and should be used more often with disease flares and less as maintenance therapy. Given the associated risks of long-term continuous use with these pharmacologic agents, alternatives are needed with similar anti-inflammatory and barrier repair properties that can be used indefinitely without risk. Some over-the-counter (OTC) ingredients such as colloidal oatmeal and petrolatum, as well as anti-inflammatory prescription moisturizers (medical device creams), have demonstrated efficacy with little complications in skin barrier repair and symptom relief in steroid-responsive conditions. With regimented application, these non-drug options are safe and effective and can limit the longterm continuous use of TCS or TCIs.
Introduction
Topical corticosteroids (TCS) are the cornerstone of treatment for inflammatory dermatoses, particularly for the swift resolution of acute flares, as TCS can calm inflamed and irritated skin due to rapid absorption and action. A wide range of potencies and vehicles enables tailoring of therapy to be site-specific and considerate of patient preference. Long-term continuous therapy with TCS can lead to localized side effects such as cutaneous atrophy, telangiectasias, acne and rosacea exacerbation, and tachyphylaxis, as well as systemic absorption if used on large surface areas causing hypothalamic-pituitary-adrenal (HPA) axis suppression, growth retardation in children, and cataract and glaucoma formation in adults. Thus, intermittent therapy should be supplemented with alternative treatments that can help limit localized side effects and provide epidermal barrier dysfunction improvement.
Topical calcineurin inhibitors (TCIs; tacrolimus ointment/Protopic®; pimecrolimus cream/Elidel®) represent secondline therapies for the short-term and non-continuous chronic treatment of moderate-to-severe atopic dermatitis (AD) in non-immunocompromised adults and children who have failed to respond adequately to or are not suitable for other topical prescription AD treatments. TCIs inhibit calcineurin in T-cells, reducing the production of interleukin (IL)-2 and related proinflammatory cytokines. Clinical studies have demonstrated longterm efficacy, minimal systemic absorption, and few transient side effects, such as localized irritation, with the use of these agents. TCIs do not induce skin atrophy or inhibit collagen synthesis, enabling their use on the face, neck and intertriginous areas. In 2006 the United States Food and Drug Administration (USFDA) placed a black box warning on TCIs based on safety concerns over the possible risk of systemic absorption and on data from transplantation research reporting systemic immune suppression with oral calcineurin inhibitors (tacrolimus and cyclosporine) is associated with an increased cancer risk. To date, this risk remains theoretical and is based mainly on the drug's mechanism of action, data from animal studies and a few single case reports of lymphoma and skin cancer in patients treated with TCIs.
Recently, medical device creams ( Table 1 ), which are nonsteroidal agents with emollient, anti-inflammatory and antipruritic properties, have entered the marketplace for the treatment of inflammatory dermatoses to help treat epidermal barrier dysfunction as well as limit potential long-term use of TCS and TCIs. Atopiclair® is a hydrolipidic cream containing Butyrospermum parkii (shea tree), glycyrrhetinic acid (licorice), Vitis vinifera (grapevine) extract, bisabolol (German chamomile), hyaluronic acid and tocopheryl acetate (vitamin E), and is thought to have moisturizing, anti-inflammatory and antioxidant properties. It also contains telmesteine, which inhibits elastase, collagenase and matrix metalloproteinases, helping to prevent epidermal breakdown. MimyX™ contains lipid components that mimic the normal skin barrier (triglycerides, phospholipids, and squalene) along with the anti-inflammatory cannabinoid N-palmitoylethanolamine (N-PEA), an endogenous fatty acid amide thought to target the peroxisome proliferator-activated receptor-alpha (PPAR-α). Other added ingredients such as purified water, olive oil, glycerin, pentylene glycol, vegetable oil, and hydrogenated lecithin have humectant and emollient effects. EpiCeram® is a microencapsulation system emulsion of ceramide, conjugated linoleic acid, cholesterol and palmitic acid formulated with Euphorbia cerifera (candelilla) wax, corn syrup solids, squalene, glycerin, petrolatum, and dimethicone. Eletone® has a high lipid content dispersed in an outer aqueous phase (Hydrolipid Technology™) in petrolatum, purified water, and mineral oil. Hylatopic Plus® is an emollient cream and foam containing Theobroma grandiflorum seed butter (a skin conditioning butter made from the fruit of a the Cupuaçu tree that is native to Brazil), hyaluronic acid, glycerin, dimethicone, petrolatum, and tocopheryl acetate (vitamin E). All of the medical device creams are indicated for the treatment of various dermatoses such as AD, allergic contact dermatitis, and radiation dermatitis, which are associated with symptoms of itching, burning, and pain.