Use of glucocorticosteroids in psoriasis

Role of the ACTH test and estimation of a safe dose for high potency steroids in vitiligo: A prospective randomized study

BACKGROUND

Topical corticosteroids are used as first line of therapy for vitiligo, although side effects such as adrenal insufficiency are possible.

OBJECTIVES

To establish the role of ACTH test before, during, and after treatment with high potency topical steroids; to determine if adrenal insufficiency occurs secondary to the use of high potency topical steroids in patients with vitiligo and intact cutaneous barrier; and also to determine response to treatment and side effects.

MATERIALS AND METHODS

Forty-four adults with non-segmental vitiligo affecting 20% or less of the body surface area were included and randomized to receive topical clobetasol propionate 0.05% cream (group 1) or placebo (group 2) for 12 weeks, with a maximum dose of 50 g per week. The placebo group was crossed over after week 6 and started on clobetasol until completion of the study. Serum cortisol levels with the 1 μg ACTH test were determined at baseline and on weeks 6 and 12.

RESULTS

No adrenal insufficiency was detected nor statistical significance was achieved when comparing cortisol levels between and within the groups at baseline and weeks 6 and 12. Group 1 had a better response to therapy but with more side effects.

CONCLUSIONS

Doses of 50 g or less per week of clobetasol during a period of 12 weeks are safe on adult vitiligo patients, although local side effects are possible. Repigmentation rates were incomplete with single steroid therapy, making combined therapy a better option.

Super potent topical corticosteroid use associated with adrenal suppression: clinical considerations

The potential for a variety of local and systemic side effects from the use of potent topical corticosteroids has long been recognized. However, adrenal suppression has only rarely been documented. We describe two patients with profound hypothalamic-pituitary-adrenal axis suppression resulting from the unregulated use of super potent topical corticosteroids.

White paper on hospitalization for psoriasis care

Psoriasis is a common, chronic skin disorder that is conservatively estimated to affect between 1% and 2% of the population in the United States, not including mild cases. Despite the fact that psoriasis is one of the more common skin conditions requiring medical attention, it is poorly understood by the general public. This lack of information or misinformation on the part of health care administrators and insurers can affect the medical treatment of psoriasis and concomitant reimbursement in a manner that may be inappropriate and/or inadvertently deleterious to the patient's health care. The Committee on Psoriasis of the American Academy of Dermatology has sought to address this void. The Committee on Psoriasis is comprised of several dermatologists from the major academic medical centers in the United States. The combined expertise of this group reflects decades of experience in research, diagnosis, and treatment of psoriasis, as well as other skin diseases. This group has approved the "White Paper on Hospitalization for Psoriasis Care" as a straightforward, accurate, and well-documented source of information on psoriasis and psoriasis care. The purpose of this document is to explore the relevant medical aspects of the disease, its treatment modalities and their associated risks, and the outcomes of care.

Cyclic AMP, glucocorticoid, and retinoid modulation of in vitro keratinocyte growth

The hypothesis that an imbalanced cyclic AMP and cyclic GMP ratio was central to the cutaneous expression of psoriasis prompted the design of a series of in vitro experiments. The aim of these studies was to describe the functional effects of increased intracellular cyclic AMP and of drugs therapeutic in psoriasis on epidermal keratinocyte growth. Epidermal basal cells trypsinized from neonatal mouse and adult and neonatal human skin were grown on plastic or on gelled collagen surfaces. These were used to study the effect of cyclic AMP analogues and cholera toxin (an irreversible stimulator of cyclic AMP synthesis) on keratinocyte growth. Greatly increased intracellular cyclic AMP levels, that is, 60-fold to 70-fold, stimulated neonatal mouse keratinocyte proliferation and differentiation; these same doses were cytotoxic to both neonatal and adult human cells. However, modest increases in intracellular cyclic AMP did stimulate adult human keratinocyte proliferation. The glucocorticoid triamcinolone acetonide inhibited neonatal mouse keratinocyte proliferation for approximately 1 week; the cells then became refractory to the triamcinolone acetonide effect. Triamcinolone acetonide did not apparently act through cyclic AMP-mediated events. In fact, this glucocorticoid inhibited cyclic AMP-stimulated epidermal keratinocyte proliferation. Likewise, vitamin A analogues, including the psoriasis therapy drug Ro 10-9359 inhibited neonatal mouse keratinocyte proliferation and specific differentiation events; the retinoids therapeutic in psoriasis apparently did not act via cyclic AMP-mediated events and inhibited cyclic AMP-stimulated functions. Our results indicated that cyclic AMP is a mitogenic signal for epidermal keratinocytes. This cyclic nucleotide may be important in regulating epidermal hyperproliferation. A central role for cyclic AMP in the cutaneous expression of psoriasis, however, is yet to be proven.