Atopic Dermatitis - Guidelines for Prescribing Topical Corticosteroids

Description
  • Chronic, recurring, inflammatory disorder of the skin.
  • Often referred to as eczema, but they are not interchangable terms:
    • Eczema is a group of skin conditions, which atopic dermatitis is a part of.  Eczema is a non-specific inflmmatory skin reaction.  Atopic dermatis is a type of eczema, usually considered the most severe and long-lasting.  Other types of eczema include contact dermatitis or seborrheic dermatitis.
  • Once thought to be an allergic disorder, but there is now little support for this theory of pathogenesis.
  • Typically, first appears in early childhood (i.e. the first year of life) and subsides with advancing age.
  • Caused by a combination of skin barrier and immune system dysfunction.

  • Risk and aggravating factors:
    • Family history
    • Frequent bathing
    • Use of perfumed soaps and cosmetics
    • Dry skin
    • Low humidity
    • Overheating, perspiration
    • Contact with irritants such as solvents or detergents
    • Emotional stress

  • For more information and photos, go to:
Signs and Symptoms
  • Primary symptoms
    • Pruritis - can be intense.  The intense itch leads to a rash, especially after repeated scratching by the patient.
    • Dry skin

  • Secondary skin changes
    • Acute
      • Erythema without well-defined borders; slight swelling
      • Vesicles form and rupture releasing serous fluid (IE. weeping)
      • Crusts form as serous fluid dries
      • Excoriations caused by scratching

    • Chronic
      • Thickening of skin with accentuated skin marks (lichenification)
      • Hypo- or hyperpigmentation of the skin
      • Scaling, fissures
      • Fibrotic papules

  • Dermal lesions
    • Distribution
      • Infants: trunk, face, and extensor surfaces. (Extensor surface is an anatomy term used to describe certain areas of the body. A body part flexes when it bends and extends when it straightens. The parts of the skin that touch when a joint bends are called the flexor surfaces. The parts of the skin on the opposite side of the joint are called the extensor surfaces.)
      • Children: the flexor surface of the elbow and of the knee.
      • Adults:  scalp, face, neck, hands, upper chest, and genital areas.

    • Morphology of lesions:
      • Infants: erythema (redness) and papules (solid skin elevation not containing pus); may develop oozing, crusting vesicles.
      • Children and adults: chronic eczema may lead to skin lichenification (thickening) and scaling.

  • Classification of Severity
    • Mild: localized patches of dry skin, may or may not be reddened, infrequent itching.  No impact on sleep or daily activities.
    • Moderate: localized patches of dry red skin, redness, frequent itching - may show signs of scratching and skin thickening.  Some impact on sleep and daily activites.
    • Severe: widespread patches of dry red skin (>30% of body-surface area), persistent itching - may show signs of scratching and extensive skin thickening, cracking, bleeding and oozing.  Possible alteration of skin pigmentation.  Major impact on sleep and daily activities.
Differential Assessment

Atopic dermatitis is assessed based on signs, symptoms and history. Rule out the following conditions that may present with similar signs / symptoms:

  • Contact dermatitis - Recent contact with unknown plant? chemical? topical medicine?
  • Scabies - generalized, severe itching; burrows in finger webs and sides of fingers.
  • Tinea corporis - May cause skin flaking similar to atopic dermatitis, but otherwise looks different.  Tinea corporis leasions are well-circumscribed with a gradually expanding border with central-clearing of patch.
  • Seborrheic dermatitis - minimal itch; patches of red, greasy, scaling rash with indistinct margins on scalp, eyebrows, around ears, nose folds, on forehead, chest or upper back.
  • Impetigo - 1 to 2 mm fragile pustules (pus-filled blister) and / or honey-colored, crusted erosions] or other signs of secondary bacterial infection. Refer to guideline for Bacterial Skin Infection.
  • If only localized disease is present in adults, consider
    • Psoriasis - well-defined, red papules coalescing to plaques (patches of slightly thickened skin); typically appears as silvery scales on red plaques.
    • Lichen simplex chronicus - itchy patches of skin, thickened as a result of chronic scratching or rubbing, may be covered in small bumps.
    • Ichthyosis vulgaris - severe dry skin with characteristic fish-like scales.
  • Photosensitivity rash – ask about recent sun exposure; check medication profile for drugs assosciated with photosensitivity.
  • Cutaneous T-cell lymphoma - early stages can resemble atopic dermatitis.  However, it's not usually itchy and occurs later in life, unlike atopic dermatitis which often first appears in childhood.
  • Drug-induced skin lesion - Most commonly (90%) appears as pinkish-red macules and papules that start on trunk and spread symmetrically to face and limbs.  May also cause very pruritic hives. 
    • Rash peaks about 2 afters after stopping the offending drug and resolves in 5 to 14 days.  Antibiotics and anti-convulsants are the most common culprits.
    • Suspect if new-onset rash preceeded by starting a new medication.  Below are medications which are known to cause drug-induced skin lesions most commonly.
        • Antibiotics

          chloramphenicol, clioquinol, gentamicin,  neomycin, penicillin, streptomycin, sulfonamides

          Antihistamines

          promethazine

          Beta-blockers

          metoprolol,propranolol,timolol

          Calcium Channel Blockers

          amlodipine, diltiazem, felodipine,nifedipine, verapamil

          Diuretics

          thiazide diuretics

          Sulfonylureas

          tolbutamide, chlorpropamide

          Antipsychotics

          phenothiazines, e.g., chlorpromazine, fluphenazine, perphenazine, prochlorperazine, trifluoperazine

          Miscellaneous

          aminophylline, carbamazepine, chloral hydrate, cyanocobalamin,

          fluorouracil, idoxuridine, minoxidil, nitroglycerin, nystatin, procainamide, quinine, quinidine

When to Refer

Patients with mild to moderate signs / symptoms of atopic dermatitis often do not require further investigation, however a physician assessment may be required in the following situations:

  • Moderate to severe eczema on the face - a calcineurin inhibitor to avoid skin atrophy might be more appropriate.
  • Symptoms are interfering with quality of life and sleep
  • Nummular discoid eczema - small round plaques of small papules and blisters, usually on trunk or extremeties - recommended treatment is potent topical corticosteroids.
  • Large areas of skin are involved (> 30 % of body surface area) - risk of systemic absorption of corticosteroid if large areas of skin are being treated.  Pediatric patients may be at higher risk of topical corticosteroid-induced HPA axis suppression and Cushing's syndrome than mature patients because of a larger skin surface area to body weight ratio.
  • Palms of hands and soles of feet are affected - high potency steroid is usually required to treat these areas.
  • Secondary infection - common in atopic dermatitis.  Infection may need to be treated with topical or oral antibiotics.  Signs of a secondary bacterial, fungal or viral infection include fever, excessive swelling, redness, tenderness, discharge, and folliculitis (infection of hair follicle)
  • Symptoms not relieved after 2 week course of topical corticosteroids.
  • Patient's self-diagnosis not consistent with atopic dermatitis and /or selfcare is not appropriate.
Treatment

Goals of treatment

  • Relieve dry skin and pruritus
  • Reduce inflammation
  • Reduce risk of secondary infection
  • Reduce flare-ups

Non-pharmacological general measures

  • Avoid agents that may cause irritation:
    • Environmental allergens: harsh soaps, detergents, shampoos, alcohol based products, astringents, poor home ventilation, dry grass and leaves.
    • Diet:  Food allergens are possible; common allergy triggers are: milk, egg, wheat, soy, peanut, tree nuts, fish and shellfish.  Consider allergy testing if concerned.
    • Irritants: disinfectants, solvents, cleansers, clothing fabrics and fabric softeners, wool, perfumes.
  • Advise patient that sweating and overheating can increase itching.
  • Avoid scratching if possible. Fingernails should be kept short. Mittens may be helpful for infants.
  • Advise patient of proper bathing to reduce irritation--brief duration (10-15 minutes), lukewarm water, pat dry, and apply emollients to damp skin immediately after bathing.
  • To prevent scratching, cold compresses may be helpful.

Over-the-counter Options

  • Hydration is the cornerstone of therapy for atopic dermatitis, and is sometimes all that is needed for mild flares.
    • Ensure use of quality emollients and hydrating agents, and avoid harsh soaps (see table below).
    • Soak affected areas for 10-15 minutes in warm water once daily, then patted dry.  Do not use soap.
    • Emollients should be applied immediately after bathing and drying.
    • Moisturizers should be applied regularly (at least twice daily) and immediately after bathing
    • Barrier repair creams restore ceramide to the skin--an important component of the skin barrier.

Table 1: Emollients, soaps and hydrating agents used for atopic dermatitis

Suitable Emollients

Mild Soaps

Hydrating (moisturizing) Agents

Barrier Repair Creams

Glaxal base

Transparent Pears soap

Complex 15

Cetaphil restoraderm

Keri lotion

Transparent Neutrogena soap

Neostrata

TriCeram

Lubriderm

Spectro Jel soapless cleanser

Uremol

EpiCeram

Moisturel

Lowila soap

Urisec

Others

Petrolatum

Cetaphil Gentle Cleanser

Lac-Hydrin

--

  • OTC corticosteroids – hydrocortisone 0.5 %, clobetasone butyrate 0.05% - see description of topical corticosteroids below
  • Itch in atopic dermatitis is not histamine-related and therefore does not respond well to non-sedating antihistamines.  Potent sedating antihistamines such as diphenhydramine or chlorpheniramine may provide some relief, possibly through central sedation.
    • Topical antihistamines should be avoided; ineffective and can sensitize the skin.


Prescription Drug Options

  • Topical corticosteroids - BMJ Clinical Evidence rating: "effectiveness has been demonstrated by clear evidence from systematic reviews, RCTs, or the best alternative source of information, and for which expectation of harms is small compared with the benefits"
  • Once or twice daily application of low or medium potency topical corticosteroid for 1 to 2 weeks to control initial flare-up.  See product section for full list of pharmacist-eligible corticosteroids for prescribing.
  • Taper mid-potency corticosteroids to a lower-potency steroid e.g. OTC hydrocortisone 0.5 % for a few days before discontinuing to prevent rebound flare-up of atopic dermatitis.  Continue using emollients and moisturizers.
  • Choice of low or medium potency steroid depends on body area affected.
    • Face, skin folds - low potency
    • Body and scalp - medium potency
  • Choice of vehicle is important. Ointments are less irritating and penetrate better to provide increased effect.  See Table 2 below for advantages and disadvantages of each vehicle.
  • Note that different formulations (e.g. cream vs. ointment) of the same strength and drug may have different potentcies.

Table 2: Properties of different topical formulations

Vehicle 

Advantages 

Disadvantages 

Cream 

Cosmetically acceptable,  good for weeping areas

Less absorption; additives can irritate 

Lotion 

Less greasy, good for large areas, hairy areas 

Alcohol base will sting/irritate open areas of eczema 

Gel 

Less greasy, good for hairy areas, oily skin 

Alcohol base will sting/irritate open areas of eczema 

Ointment 

Excellent penetration, offers emollient effect, little or no irritation, good for very dry, scaly areas 

Cosmetically less acceptable, thick, greasy 

Scalp Lotion

Superior for scalp involvement

Alcohol base will sting/irritate open areas of eczema 

  • Dose of topical can be described in fingertip units (FTU). One FTU is the amount squeezed out from a standard tube along an adult finger from very tip to the first joint. One FTU will cover twice the area of the flat of an adult hand with the fingers closed. One gram of a topical will cover approximately 2 FTUs.
  • Separate application of corticosteroid and emollients and moisturizers.  Apply the corticosteroid first, wait 5 minutes, then apply the emollients ± moisturizer.

  • Pediatrics:  Children are more susceptible to greater systemic absorption of topically applied corticosteroids, which may lead to HPA axis suppression, growth suppression, and other steroid side-effects.  Always prescribe the lowest potency steroid for the shortest duration which controls the patient’s symptoms.  More caution is warranted if treating a large area, thin skin such as on the face, or skin folds.

  • Pregnancy: If use of lubrication skin emollients does not control symptoms, topical corticosteroids are the main treatment option throughout pregnancy since systemic absorption is very low and poses no known risk to the baby.  Recommend lowest effective potency over smallest skin area for shortest duration needed to control symptoms.

  • Lactation: It is considered unlikely that application of topical corticosteroids applied by the mother would be passed to the infant via breastmilk. If a corticosteroid preparation is being applied to the breast, it should be carefully wiped off before breastfeeding.

  • Preventing recurrences
    • Continue with optimal skin care with emollients and moisturizers
    • If, despite optimal skin care, there are frequent recurrences, referral becomes necessary.  Ongoing topical corticosteroids (beyond two weeks in a row) or other options are beyond the scope of minor-ailment prescribing.
General Advice / Monitoring

Patient Education

  • Avoid known triggers and use general measures described above to reduce itching and prevent scratching.
  • Ensure patients understand atopic dermatitis is a chronic, recurring condition that can be controlled but not cured.
  • Use emollients regularly during and between flare-ups of dermatitis.
  • Adherence to topical therapy is necessary for best results. Treatment with topical corticosteroids should be continued for 48 hours after symptoms have resolved. 

Assess Benefit

  • Expect improvement of symptoms within 7 days of corticosteroid therapy; if no improvement, discontinue the product and consult physician.
  • Inflammation should decrease by approximately 50% in 7 to 10 days.
  • Sleep or daily activities should no longer be impacted.
  • Itch should be tolerable.
  • If symptoms have resolved, discontinue the topical corticosteroid (step-down to low potency product first if using moderate potency) and continue with regular emollient use.
  • If maintenance therapy with corticosteroids is needed beyond 14 days, refer patient or contact physician to discuss twice-weekly use of corticosteroids for flare-up prevention.

Assess for Adverse Effects

  • Topical corticosteroids used appropriately seldom cause serious adverse effects.
  • The likelihood of adverse effects is directly related to the potency of the product and the amount of product used. Patients using large amounts should be referred to their physician for evaluation and consideration of other treatment options.
  • If stinging and burning on application is very bothersome, recommend / prescribe a different product.
  • Discontinue product and refer to physician if local side effects such as easy bruising, telangiectasia (red spots caused by dilated superficial blood vessels), striae (stretch marks) or skin atrophy (thinning, wrinkling, depression) are reported (See dermnetnz.org/treatments/topical-steroids).
Products

Detailed information on contraindications, cautions, adverse effects and interactions is available in individual drug monographs in the CPS, (e-CPS), Lexi-Comp, AHFS, www.drugs.com or other reliable drug monograph references. For comprehensive drug comparisons, see RxFiles charts (www.rxfiles.ca).  This information should be routinely consulted before prescribing.

Table 3: Topical corticosteroids

Potency

 

Drug

Strength/formulation*

Low (OTC)

Hydrocortisone

0.5 % cream, ointment

Low

Desonide

0.05 % cream, ointment, lotion, foam

Low

Hydrocortisone*

1 % cream, ointment lotion

2 % cream, lotion

2.5 % cream, lotion

Mild

Betamethasone valerate

0.05 % cream, ointment

0.1 % cream, lotion, scalp lotion

Mild

Hydrocortisone-17 valerate

0.2 % cream

Moderate (OTC)

Clobetasone-17 butyrate

0.05 % cream

Moderate

Desoximetasone

0.05 % cream

Moderate

Diflocortolone valerate

0.01 % cream

Moderate

Hydrocortisone-17 valerate

0.2 % ointment

Moderate

Mometasone furoate

0.1 % cream, lotion

Moderate

Triamcinolone acetonide

0.1 % cream, ointment

Moderate

Beclomethasone Dipropionate

0.025% cream


*Hydrocortisone 1% is Schedule 1 (Rx) if patient is under two years old or if dispensed in amounts greater than 30 g.

**See Saskatchewan Drug Plan formulary for product brand names and DINs - http://formulary.drugplan.health.gov.sk.ca/

Prescribing and Billing Details
  • pseudoDIN: 00951094
    • May bill 4 claims per 365 days per patient

  • May prescribe sufficient quantity for 7 days of treatment, with one refill to be dispensed if improvement, but not full resolution, noted after the 7 day follow-up.  Maximum of 14 days total treatment duration.
  • Only products with an official indication from Health Canada for atopic dermatitis are considered for these guidelines.  Only the active ingredients in the "products" section are approved for pharmacist prescribing.
Treatment Flowchart
Pharmacist Assessment Documents
References / Useful Resources
  1. Flohr C, Williams HC. Epidermiology. In: Bieber T, Leung DY, eds. Atopic dermatitis. 2nd ed. New York, NY: Informa Healthcare; 2009:11-35.
  2. Ruzicka T. Atopic eczema between rationality and irrationality. Arch Dermatol. 1998;134:1462-1469. doi:10.1001/archderm.134.11.1462.
  3. National Institute for Health and Care Excellence. Atopic eczema in under children: Management of atopic eczema in children from birth up to the age of 12 years – NICE guidelines [CG57]. National Institute for Health and Care Excellence. http://www.nice.org.uk/guidance/cg57/chapter/Key-priorities-for-implementation. Published December 2007. Accessed August 2015.
  4. Sibbald D. Dermatological Conditions: Atopic, Contact, and Stasis Dermatitis  In: Compendium of Therapeutics for Minor Ailments. Ottawa, ON: Canadian Pharmacists Association. http://www.e-therapeutics.ca. Subscription required. Updated 2014. Accessed February 2015.
  5. Miller, PF. Bacterial Skin Infections: Impetigo, Furuncles and Carbuncles. In: Compendium of Therapeutics for Minor Ailments. Ottawa, ON: Canadian Pharmacists Association. http://www.e-therapeutics.ca/search#. Subscription required. Updated 2013. Accessed March 2015.
  6. CPMA Dermatitis and Dry Skin and the Skin Therapy Letter 2011 Vol 1. Available from: http://www.torontodermatologycentre.com/UserFiles/File/SkinTherapyLetter-Feb.2011,MoisturizersinDrySkin&Eczema-Family%20Physician%20Edition.pdf.
  7. Corticosteroids: Topical. In: CPS Drug Monographs. Ottawa, ON: Canadian Pharmacists Association. Available from: http://www.e-therapeutics.ca/search#. Subscription required. Updated 2015.
  8. Green C, Colquitt JL, Kirby J, Davidson P. Topical corticosteroids for atopic eczema: clinical and cost effectiveness of once-daily vs. more frequent use. Br J Dermatol. 2005;152(1):130-141. doi:10.1111/j.1365-2133.2005.06410.x.
  9. Bolognia JL, Jorizzo JL, Schaffer JV. Glucocorticosteroids. In: Callen JP, Cerroni L, Heymann WE, et al., eds. Dermatology. 3rd ed. Philadephia, PA: Elsevier Inc;2012:2075-2088.
  10. Weinstein M. Atopic Dermatitis. In: Compendium of Therapeutic Choices. Ottawa, ON: Canadian Pharmacists Association. http://www.e-therapeutics.ca/search#. Subscription required. Updated 2015. Accessed February 2015.
  11. Bath-Hextall FJ, Birnie AJ, Ravenscroft JC, Williams HC. Interventions to reduce Staphylococcus aureus in the management of atopic eczema: an updated Cochrane review. Br J Dermatol. 2010;163(1):12-26. doi:10.1111/j.1365-2133.2010.09743.x.
  12. Katsambas AD, Dessinioti C, Lotti TM, D’Erme AM, eds. European Handbook of Dermatological Treatments. 3rd ed. New York, NY: Springer; 2015. https://books.google.ca/books?id=fHi6CAAAQBAJ&pg=PA1431&lpg=PA1431&dq=safety+of+calcineurin+inhibitor+in+pregnancy&source=bl&ots=9SVjMG3D3h&sig=CCoOdzrKlCuVshH8xGksBrYo5f4&hl=en&sa=X&ved=0CCsQ6AEwAWoVChMImbPX5qW4xwIVCFmSCh3FPAnz#v=onepage&q=safety%20of%20calcineurin%20inhibitor%20in%20pregnancy&f=false.
  13. Atopic Dermatitis. In: DynaMed. https://dynamed.ebscohost.com/ . Subscription required. Accessed February 2015.
  14. Howe W, Weston W. Treatment of atopic dermatitis (eczema) In: UpToDate. www.uptodate.com . Subscription required. Accessed February 2015.
  15. Green P. Skin Disorders: Bacterial Skin Infections In: Compendium of Therapeutic Choices. Canadian Pharmacists Association. http://www.e-therapeutics.ca. Accessed March 2015.
  16. Eichenfield LF, Tom WL, Berger TG et al. Guidelines of care for the management of atopic  dermatitis : Section 2: Management and Treatment of Atopic Dermatitis with Topical Therapies. J Am Acad Dermatol. 2014;71(1):116-132. doi: http://dx.doi.org/10.1016/j.jaad.2014.03.023.
  17. Sidbury R, Tom W, Bergman J et al. Guidelines of care for the management of atopic dermatitis  : Section 4. Prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol. 2014; 71(6): 1218-1233. doi: http://dx.doi.org/10.1016/j.jaad.2014.08.038.
  18. Allergy – Eczema In: C-Health. chealth.canoe.ca. Accessed February 2015.
  19. Atopic Dermatitis (Eczema) In: Mayo Clinic. www.mayoclinic.org. Accessed February 2015.
  20. Regier L. Topical Corticosteroids: Comparison Chart. In: RxFiles. www.rxfiles.ca. Subscription required. Accessed February 2015.

Prepared by medSask, Your Medication Information Service 
Reviewed by Dr. L. Sandomirsky, Family Physician and Loren Regier, Pharmacist, RxFiles Academic Detailing Program
 Sponsored by the Saskatchewan College of Pharmacists
Posted May 2010; Updated August 2016.