Tachyphylaxis to histamine-induced wheal suppression by topical 0.05% clobetasol propionate in normal versus croton oil-induced dermatitic skin

Topical corticosteroids for hives and itch (urticaria): Systematic review and Bayesian meta-analysis of randomized trials

BACKGROUND

Topical corticosteroids are widely used as a treatment for itch and wheals (urticaria), but their benefits and harms are unclear.

OBJECTIVE

To systematically synthesize the benefits and harms of topical corticosteroids for the treatment of urticaria.

METHODS

We searched MEDLINE, EMBASE, and CENTRAL from database inception to March 23, 2024, for randomized trials comparing topical corticosteroids with placebo for patients with urticaria (either chronic spontaneous or inducible urticaria or acute urticaria elicited from skin/intradermal allergy testing). Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects meta-analyses addressed urticaria severity, itch severity (numeric rating scale; range 0-10; higher is worse), and adverse events. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach informed certainty of evidence ratings. PROSPERO registration: CRD42023455182.

RESULTS

A total of 19 randomized controlled trials enrolled 379 participants with a median of mean age of 30.1 (range 21.1-44.0) years. Compared with placebo, topical corticosteroids may reduce wheal size (ratio of means 0.47, 95% CI 0.38-0.59; low certainty) and itch severity (mean difference -1.30, 95% CI -5.07 to 2.46; very low certainty). Topical corticosteroids result in little to no difference in overall adverse events (94 fewer patients per 1000, 95% credible intervals 172 fewer to 12 more; high certainty).

CONCLUSION

Compared with placebo, topical corticosteroids may result in a reduction of wheal size and little to no difference in overall adverse events. Topical corticosteroids may reduce itch severity, but the evidence is very uncertain. Future large, randomized trials addressing the use of topical corticosteroids would further support optimal urticaria management.

Steroid Phobia: Is There a Basis? A Review of Topical Steroid Safety, Addiction and Withdrawal

There is a growing concern amongst patients about topical corticosteroid (TCS) side effects, with increasing discussion of topical steroid addiction (TSA) and topical steroid withdrawal (TSW) particularly on social media platforms. However, the acceptance of TSA/TSW as a distinct condition remains controversial within the dermatological community. We conducted a literature search using PubMed, MEDLINE, Cochrane Library, Google Scholar, Embase and Web of Science to identify original articles addressing TSA/TSW. We described the definition and reported clinical features of TSA/TSW including its classification into erythemato-edematous and papulopustular subtype. To assess the validity of TSA/TSW, we summarised and objectively appraised the postulated mechanisms for this condition, including tachyphylaxis, dysregulation of glucocorticoid receptors, rebound vasodilation and impaired skin barrier leading to a cytokine cascade. Understanding the evidence including its limitations and uncertainties highlights areas for future research and helps medical practitioners better counsel and provide care to patients who may be experiencing or who have concerns about TSA/TSW.

Therapeutic effectiveness of alternative medications in oral lichen planus: A systematic review

Lichen planus is a chronic inflammatory condition affecting the skin and mucosa. The etiology is unknown but the pathogenesis appears to be an immune-mediated reaction. The mainstay drugs used in the treatment are immunomodulators. The aim of this paper is to report on the therapeutic effectiveness of the alternate medications used in the management of oral lichen planus (OLP). A systematic search of PubMed, Web of Science and Cochrane Controlled Clinical trials were done for all the papers published until December 2019. The search resulted in a total of 20 studies that were found suitable for the review. The results showed that the reduction in pain, treatment effectiveness was comparable between the steroids and alternative medications. However, the alternative medications had a therapeutic advantage in studies that had used placebo as controls and the results were statistically significant (P < 0.05). No major adverse effects were reported with the usage of alternative medications. There is definitely a therapeutic potential in the usage of alternative medications in the management of OLP. In terms of therapeutic effectiveness, they are on par with the immunomodulators. These alternative medications offer us a new therapeutic option in the management of OLP without any adverse effects.

Clinical practice guidelines for the management of atopic dermatitis 2018

Atopic dermatitis (AD) is a disease characterized by relapsing eczema with pruritus as a primary lesion. The current strategies to treat AD in Japan from the perspective of evidence-based medicine consist of three primary measures: (i) the use of topical corticosteroids and tacrolimus ointment as the main treatment for the inflammation; (ii) topical application of emollients to treat the cutaneous barrier dysfunction; and (iii) avoidance of apparent exacerbating factors, psychological counseling and advice about daily life. The guidelines present recommendations to review clinical research articles, evaluate the balance between the advantages and disadvantages of medical activities, and optimize medical activity-related patient outcomes with respect to several important points requiring decision-making in clinical practice.

Important role of kallikrein 6 for the development of keratinocyte proliferative resistance to topical glucocorticoids

One of the major adverse effects of topical glucocorticoids is cutaneous atrophy often followed by development of resistance to steroids (tachyphylaxis). Previously we showed that after two weeks, interfollicular mouse keratinocytes acquired resistance to anti-proliferative effects of glucocorticoid fluocinolone acetonide (FA). One of the top genes activated by FA during tachyphylaxis was Klk6 encoding kallikrein-related peptidase 6, known to enhance keratinocyte proliferation. KLK6 was also strongly induced by chronic glucocorticoids in human skin. Double immunostaining showed that KLK6⁺ keratinocytes, localized in suprabasal layer of mouse skin, were frequently adjacent to proliferating 5-bromo-2'-deoxyuridine-positive basal keratinocytes. We used KLK6 knockout (KO) mice to evaluate KLK6 role in skin regeneration after steroid-induced atrophy. KLK6 KOs had thinner epidermis and decreased keratinocyte proliferation. The keratinocytes in wild type and KLK6 KO epidermis were equally sensitive to acute anti-proliferative effect of FA. However, the development of proliferative resistance during chronic treatment was reduced in KO epidermis. This was not due to the changes in glucocorticoid receptor (GR) expression or function as GR protein level and induction of GR-target genes were similar in wild type and KLK6 KO skin. Overall, these results suggest a novel mechanism of epidermal regeneration after glucocorticoid-induced atrophy via KLK6 activation.

Clinical Practice Guidelines for the Management of Atopic Dermatitis 2016

Atopic dermatitis (AD) is a disease characterized by relapsing eczema with pruritus as a primary lesion. Most patients have an atopic predisposition. The definitive diagnosis of AD requires the presence of all three features: (i) pruritus; (ii) typical morphology and distribution of the eczema; and (iii) chronic and chronically relapsing course. The current strategies to treat AD in Japan from the perspective of evidence-based medicine consist of three primary measures: (i) the use of topical corticosteroids and tacrolimus ointment as the main treatment for the inflammation; (ii) topical application of emollients to treat the cutaneous barrier dysfunction; and (iii) avoidance of apparent exacerbating factors, psychological counseling and advice about daily life. The guidelines present recommendations to review clinical research articles, evaluate the balance between the advantages and disadvantages of medical activities, and optimize medical activity-related patient outcomes with respect to several important points requiring decision-making in clinical practice.

An investigator-initiated, double-blind, vehicle-controlled pilot study: assessment for tachyphylaxis to topically occluded halobetasol 0.05% ointment in the treatment of psoriasis

BACKGROUND

Topical corticosteroids are the most common first-line treatment for psoriasis. Tachyphylaxis, a decreased response to treatment with repetitive application of the drug, is a controversial phenomenon associated with topical corticosteroid treatment.

OBJECTIVE

We sought to prove or disprove tachyphylaxis to occluded halobetasol 0.05% versus vehicle.

METHODS

Patients with plaque psoriasis were recruited to this study. The study involved 3 phases (1, 2A, and 2B) with each phase being separated by a treatment vacation period. In phases 1 and 2A, 2 plaques were randomized to either halobetasol 0.05% or vehicle ointment application. In phase 2B, halobetasol 0.05% was applied to both. Target Lesion Severity Scale was used for clinical assessment.

RESULTS

Twenty patients were enrolled. No difference in time to clearance (P=.88) or time to recurrence (P=.92) of the treated plaques was found between phases 1 and 2A. Percentage of improvement was higher in phase 2A compared with phase 1 (89.4%, P<.05 vs 71%, P<.05), as a result of reduction of vehicle effect. In phase 2B, a greater improvement was found for previously corticosteroid-treated plaques.

LIMITATIONS

Limitations are small sample size and 1 corticosteroid tested.

CONCLUSION

No evidence of tachyphylaxis to the topical corticosteroid halobetasol 0.05% ointment treatment in patients with plaque psoriasis was found.

Topical therapies for pruritus

Itch, or pruritus, is the predominant symptom associated with acute and chronic cutaneous disease, and in some cases may be debilitating. To date, there is no single universally effective anti-itch treatment. Because the pathophysiology of itch in most cutaneous or systemic disorders remains unclear, antipruritic therapy is often directed against a variety of targets, including the epidermal barrier, immune system, or the nervous system. Topical therapy is the mainstay of dermatologic management of acute or localized itch or in patients with contraindications to systemic therapies. This review will summarize current topical therapies to treat pruritus and discuss potential future therapies.

The efficacy of topical hyaluronic acid in the management of oral lichen planus

BACKGROUND

The aim of this study was to evaluate the efficacy of a topical hyaluronic acid (HA) gel preparation (0.2%) in the management of oral lichen planus (OLP).

METHODS

A total of 124 patients with erosive OLP participated in a randomized, placebo-controlled, double-blind trial to evaluate the efficacy of a topical HA preparation. Outcome measures included soreness relief following immediate application, oral function and size of erosive/ulcerative area. Patients were medicated for 28 days and completed a log diary recording oral function and soreness scores.

RESULTS

Application of topical HA produced a significant reduction (P < 0.05) in soreness scores when compared with placebo for up to 4 h post-application. There was no difference between treatment groups (P > 0.05) with respect to oral function. Patients treated with 0.2% HA showed a significant reduction (P < 0.05) in the size of the erosive/ulcerated area after 28 days of treatment when compared with baseline. There was no significant difference in changes in ulcerative areas between treatment groups.

CONCLUSIONS

Topical HA (0.2%) does appear to be of some benefit in the management of erosive lichen planus providing efficacy for up to 4 h after administration. Very frequent applications should be considered to obtain a more significant clinical benefit. Topical HA gel may be a useful addition to the treatment option for OLP.

Calcineurin inhibitors for the treatment of atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is a chronic disease characterized by periods of remission and relapse. Therapeutic objectives for AD should be to quickly reduce disease symptoms by targeting pathophysiological pathways, and to provide long-term management by reducing recurrences.

OBJECTIVE

Calcineurin inhibitors currently appear to be one of the most promising alternative systemic and topical compounds to treat AD. This review focuses on new developments of topical calcineurin inhibitors, therapeutic regimens including long-term management, and prophylaxis of AD.

METHODS

The published clinical studies that present data on treatment of AD with calcineurin inhibitors were assessed.

RESULTS/CONCLUSION

Topical calcineurin inhibitors such as tacrolimus and pimecrolimus provide an effective treatment for AD. They are useful for long-term management and prophylaxis of AD. Safety concerns with regard to increased risk for lymphomas or skin cancer could not be confirmed but will remain under careful observation.

Clobetasol propionate foam, 0.05%

Clobetasol propionate foam (clobetasol foam), a new formulation of the superpotent corticosteroid, has anti-inflammatory, antipruritic and vasoconstrictive properties. It was reported that the absorption rate of clobetasol was greater from the foam than from the solution in cadaver skin. In patients with moderate to severe scalp psoriasis, topical application of clobetasol 0.05% foam twice daily for 2 weeks induced significant improvement of all signs and symptoms of the disease compared with placebo. Compared with clobetasol 0.05% solution, clobetasol foam demonstrated greater improvement of scaling after 2 weeks of treatment and after 2 weeks of follow-up. The investigator's global assessment rated 74% of patients in the clobetasol foam group to be clear or almost clear (90 to 100%) of scalp psoriasis compared with 10% of the placebo foam group. Adverse events at the application site of clobetasol 0.05% foam were limited to one case each of dry skin, eczema, and skin hypertrophy. Clobetasol foam 7 g/day for 2 weeks induced reversible suppression of the hypothalamic-pituitary-adrenal axis in 3 out of 13 patients (methodology of assessment not provided).

Inhibition by glucocorticoids of the mast cell-dependent weal and flare response in human skin in vivo

1. This study examines the relative contributions made by inhibition of mast cell degranulation, reduction of mast cell recruitment and maturation, and lowering the responsiveness of the vasculature to histamine, in the inhibition by glucocorticoids of the weal and flare in human skin. 2. One forearm of healthy human volunteers was treated for 24 h (n=6) or daily for 21 days (n=10) with 0.05% clobetasol propionate. The other arm served as control. Weal and flare responses were elicited by intradermal injection of 20 microl of 0.3 mM codeine. The areas of the responses were measured using scanning laser Doppler imaging. Microdialysis was used to assess histamine release. Mast cell numbers and tissue histamine content were assessed in 4-mm punch biopsies. Histamine (20 microl of 1 microM i.d.) was used to assess the status of the vasculature. 3. No significant effects were seen at 24 h. At 21 days, clobetasol reduced the areas of the codeine-induced weal and flare responses by 59 and 58% respectively (both P=0.006). Mast cell numbers were reduced by 47%, (P=0.014) and total tissue histamine content by 52% (P=0.006). Codeine-induced histamine release was reduced by 44% (P=0.022). The weal, but not the flare, induced by histamine was significantly inhibited (P=0.019). Echography revealed a 15% thinning of the skin by clobetasol. 4. These results demonstrate that reduction of the weal and flare responses to codeine following clobetasol treatment, results primarily from reduced mast cell numbers and tissue histamine content rather than inhibition by corticosteroids of mast cell degranulation.

Topical therapy for psoriasis with the use of augmented betamethasone and calcipotriene on alternate weeks

BACKGROUND

Topical corticosteroids, commonly used for psoriasis, show diminished response on continuous use.

OBJECTIVE

We tested efficacy of topical corticosteroid and calcipotriene used on alternate weeks versus daily corticosteroid in patients with psoriasis.

METHODS

In a randomized, observer-blind design, the experimental group of 25 patients with stable plaque psoriasis received augmented betamethasone dipropionate 0.05% cream once daily in the first and third weeks and calcipotriene 0.005% ointment twice daily in the second and fourth weeks. The control group of 27 patients received augmented betamethasone once daily for 4 weeks.

RESULTS

The experimental regimen was more effective than the control regimen as evidenced by (1) more patients with at least a 90% reduction in Psoriasis Area and Severity Index (PASI) score (difference 49.5%, 95% confidence interval [CI], 26.1%-72.9%, P <. 001), (2) lower PASI after 2 weeks (P < or =.04), and (3) greater percentage reduction in PASI after 2 and 4 weeks (difference 23.1% [CI, 11.1%-35.1%] and 46.4% [28.9%-63.8%], respectively; P <.001). The study had power of 93.7%. No patient had skin irritation.

CONCLUSION

Use of augmented betamethasone and calcipotriene on alternate weeks is more effective than daily corticosteroid and represents a novel strategy for treating psoriasis.

The management of oral lichen planus

OBJECTIVE

To review the current literature regarding the medical treatment of oral lichen planus (OLP).

DATA SOURCES

PubMed on-line Medline data searches were carried out for the years 1966-1998 to identify reports on therapy of OLP.

METHODS OF STUDY SELECTION

Single case reports or open trials were included if they covered new therapeutic approaches or suggested significant modifications of known treatment modalities. Review papers were limited to those dealing with the topic.

DATA EXTRACTION AND SYNTHESIS

Every paper was critically examined. Because of the great heterogeneity of the response criteria, many data could not be directly compared. Stronger weight was given to therapies that have proven to be effective under placebo-controlled research protocols. Attention was also drawn to potential and effective adverse effects of every drug used.

CONCLUSIONS

Among the various medications advocated for the treatment of OLP, several lack conclusive findings from adequately controlled trials. Mainly high-potency topical corticosteroids in an adhesive medium appear at present the safest and most efficacious. Adjuvant agents as antimycotics may be useful in topical steroid treatment. Systemic corticosteroids may be occasionally indicated for severe recalcitrant erosive OLP or for diffuse mucocutaneous involvement. Topical cyclosporine should be considered in steroid-unresponsive cases considering that its efficacy in OLP could be related to a systemic effect and its high cost. Classical PUVA therapy seems to have too many side effects; topical application of psoralen is promising but still experimental. Topically and systemically delivered retinoids combined with topical corticosteroids could improve the efficacy of these agents whereas complete remission is difficult to achieve with retinoids alone and they frequently cause adverse effects. Finally, there are only few data concerning the long-term effect of the medical treatments upon the course of OLP and we do not know if therapy influences the malignant evolution of OLP.

Long-term, intermittent treatment of chronic hand eczema with mometasone furoate

Chronic hand eczema can be incapacitating, and there is little knowledge of the efficacy and safety of long-term treatment with topical corticosteroids. We compared the efficacy and safety of two different schedules for the treatment of chronic hand eczema with a potent topical corticosteroid, mometasone furoate. In a prospective, open, randomized trial, 120 patients with chronic hand eczema were treated daily with mometasone furoate fatty cream until the dermatitis cleared or for a maximum of 9 weeks. Those who cleared were randomized to treatment for up to 36 weeks with mometasone furoate on Sunday, Tuesday and Thursday (group A), mometasone furoate on Saturday and Sunday (group B) or no further corticosteroid treatment (group C). In the event of relapse, patients were permitted daily treatment with mometasone furoate for 3 weeks on two separate occasions. For 50 of 106 randomized patients, daily treatment for 3 weeks controlled their dermatitis; 29 needed 6 weeks and 27 needed 9 weeks of treatment. During the maintenance phase, 29 of 35 (83%) in group A, 25 of 37 (68%) in group B and nine of 34 (26%) in group C had no recurrences (P = 0.001, chi2-test). Side-effects were minimal. It is concluded that long-term, intermittent treatment of chronic hand eczema with mometasone furoate fatty cream is effective and safe.

Ocular inflammation models by topical application: croton-oil induced uveitis

PURPOSE

The aim of the present investigation was to develop a new ocular inflammation model in the rabbit by comparison of the inflammation response induced by the topical application of several irritating agents (carrageenan, Freund's adjuvant, alkali and croton oil).

METHODS

The following parameters were determined after the application of each irritant to the eyes of female, white, New Zealand rabbits: Corneal edema and the Tyndall effect (slit-lamp biomicroscopy), corneal thickness (biometer-pachometer) and aqueous humor levels of the prostaglandin E2 (R.I.A), total protein (Weichselbaum technique), albumin, albumin/globulin (Doumas technique) and leukocytes (coulter counter).

RESULTS

Croton oil 1-4% (40 microl) produced edema and a Tyndall which showed a proportional increase with croton oil concentration. Ultrasonic pachometer measurement of the variation in corneal thickness (3-168 h) showed a dose-dependent response (p<0.01) from the 8th to the 168th hour. Uveitis and considerable increases in the levels of the prostaglandin E2 (4.50+/-0.40 pg/0.1 ml vs. 260.03+/-2.03 pg/0.1 ml), total protein (0.25+/-0.05 g/l vs. 2.10+/-0.08 g/l), albumin, albumin/globulin and leukocytes were observed in the aqueous humor 24 h after topical application of croton oil 3% (40 microl). All the values obtained were statistically significant (p<0.01).

CONCLUSIONS

The topical application of 3% croton oil (40 microl) was most appropriate for the evaluation of the inflammatory process in the anterior chamber and for the determination of the effects of intraocular penetration. The inflammatory mechanism in this model is thought to involve the activation of the arachidonic acid pathway accompanied by the breakdown of the blood-aqueous barrier permitting high molecular weight proteins to enter the aqueous humor. Typology: anterior uveitis with corneal edema.