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Matthew J. Zirwas, M.D., presented a comprehensive primer on the drug types at the October Maui Derm NP + PA Fall 2019 meeting in Asheville, N.C. Read his insights in this article.
Whether patients visit the dermatology clinic for a simple itch, rash, eczema flare or any other dermatoses, chances are providers will treat it with a topical steroid, systemic steroid, topical immunomodulator, topical phosphodiesterase type 4 (PDE 4) inhibitor or antihistamine.
Those are among the most common drugs that dermatologists prescribe or recommend, says Matthew J. Zirwas, M.D., who presented a comprehensive primer on the drug types at the October Maui Derm NP + PA Fall 2019 meeting in Asheville, N.C.
Yet, patients and even providers might not use them optimally, notes to Dr. Zirwas, who practices in Bexley, Ohio.
Topical steroids are a go-to drug for any kind of dermatitis or steroid-responsive dermatoses. The most important message to patients about topical steroids is that as long as patients use the medications correctly, they need not worry about skin thinning or other side effects, according to Dr. Zirwas.
“The vast majority of patients have topical steroid phobia, which is a fear of side effects from topical steroids. The fear is out of proportion to the actual risk of side effects from topical steroids,” he says. “One of the biggest reasons for treatment failure in dermatology is patients being afraid to use the topical medication because they have a phobia about the side effects.”
Dermatology providers need to counsel patients that topical steroids are extremely safe when used as directed. But cutaneous side effects can happen if patients or providers use topical steroids for too long, at too high a potency or on an area of the body for which they’re not prescribed. Skin problems that can occur include skin atrophy, irreversible striae, telangiectasias, purpura, hyper- or hypo-pigmentation, acne-like perioral or periorbital dermatitis, cataracts and increased intraocular pressure when applied periorbitally.
Dr. Zirwas typically recommends patients use topical steroids five days on and two days off. In his experience, patients are more likely to comply with a regimen broken down by days than by weeks, such as two weeks on and one week off.
“I’ll adjust how many days a week I have them use the steroid based on the location that they’re using it and the potency of the steroid,” he says.
Drug potency is an important consideration. Topical steroids are classified as the strongest class 1 to the weakest class 7.
“I will use a super potent steroid when I’m treating most areas on the trunk or extremities. I may use a medium-potency steroid if I’m treating large areas. And I will use a low-potency steroid when I’m treated the eyelids or flexural skin,” Dr. Zirwas says. “The other thing I would say is we’re taught in dermatology that ointments are stronger than creams. That’s true if they’re used by the patient in the same way. But my experience is that patients don’t put ointments on nearly as much. And when they do put them on, ointments don’t stay on and end up getting rubbed off. So, it’s fairly rare that I use any ointment.”
Short-term systemic steroids are generally safe and can be combined with topical therapy to significantly improve the quality of life in dermatitis patients with very little additional risk, according to Dr. Zirwas.
Short-term systemic steroids do not cause osteoporosis or avascular necrosis of the femoral head. Short-term use of the drugs, however, can cause a bump up in glucose among patients with diabetes and there is an increased risk of sepsis in the 90 days after getting short term systemic steroids.
“When I use a systemic steroid, I normally start at 40 mg a day and only do that for a couple of days, usually two days. Then I cut them down to 20 mg a day and have patients on that for two days. Then I will keep them on very low-dose steroids – an average dose of about 5 mg a day or 10 mg every other day – for several weeks to prevent a quick rebound,” Dr. Zirwas says. “People usually use the higher doses for longer and then get people off of the steroids pretty quickly. I’ve found that I get fewer side effect complaints from patients and get very good results by using the higher doses for just a short period of time.”
Dr. Zirwas says the most common side effect that he sees from short-term systemic steroids is when patients are taking the higher doses: they can become irritable and mean.
“We often don’t warn people about that and should,” he says. “I don’t see that happen at the lower doses and that’s part of the reason I only use the higher doses for a few days and keep patients at the lower doses for longer.”
TOPICAL CALCINEURIN INHIBITORS
Topical calcineurin inhibitors are extremely safe, except in rare situations. And the very effect that means they’re working might prevent people from continuing to use them.
“The main pearl about topical calcineurin inhibitors is that we have very good evidence that there really is not any cancer risk associated with them. I tell patients that these drugs are going to come with a warning that they may cause cancer, but all of the evidence has really shown there is no risk of cancer,” he says.
Both pimecrolimus and tacrolimus cause burning. Dermatology providers should tell patients that means the drugs are working and the burning usually goes away in about a week, according to Dr. Zirwas.
ABOUT PDE-4 INHIBITORS
The FDA approved topical crisaborole to treat atopic dermatitis patients older than two years. There’s no limit on therapy duration. With no risk of skin atrophy, crisaborole is safe to use on face, eyelids, skin folds and external genital regions.
Crisaborole also often stings on application, according to Dr. Zirwas.
Some best practices include using crisaborole as a long-term maintenance drug, treating patients first with a topical steroid to gain control of the skin problem then switching to topical crisaborole for maintenance.
“There’s not a whole lot that I think people don’t know about using PDE-4 inhibitors. They’re extremely safe. The best safety profile of anything we have topically is of this group,” Dr. Zirwas says.
It’s well known that antihistamines help with the histamine-driven itch most prominent in urticaria but not with other types of itch.
“When we’re recommending non-sedating antihistamines, I almost always recommend two to four times the normal dose because they have much more effectiveness at higher doses,” he says.
Non-sedating anti-histamines effectiveness increases with increasing dose but side effects do not. So, Dr. Zirwas recommends starting at a high dose and titrating back if it’s working. Doses for the most popular antihistamines are loratadine 30 mg twice daily; fexofenadine 360 mg twice daily; and cetirizine 20 mg twice daily.
“Cetirizine works best, but about one patient in six gets sedated with it,” Dr. Zirwas says.
The bottom line with all these medications is dermatology providers should emphasize to patients that the drugs are safe when used appropriately, he says.
Dr. Zirwas has ties to Abbvie, Aerolase, Aclaris, Aructis, Asana, AsepticMD, AvillionDS, Biopharma, Fit Bit, Foamix, Genentech/Novartis, Incyte, Janssen, L’Oreal, Leo, Lilly, Menlo, Ortho Derm, Pfizer, Regeneron/Sanofi and UCB