TCS, TCI, PDE4 inhibitors: with a number of effective topical options, which one is best for patients with atopic dermatitis? Aaron Drucker, MD, SCM, FRCPC, outlines when and where he uses topical therapies as adjunct to a robust basic skin care plan for patients with mild to moderate eczema.
Dr Drucker is a scientist at the Women's College Research Institute; a dermatologist with the Women's College Hospital; assistant professor, division of dermatology, department of medicine, at the University of Toronto; and an adjunct scientist of ICES in Canada. He also serves on the Council Executive Committee of the National Eczema Association.
Transcript
Dr Drucker: Basic skin care is incredibly important for the management of atopic dermatitis at any severity level because we know that disruption of the skin barrier is hugely important to the pathogenesis of atopic dermatitis. Disruption of the skin barrier can be the primary thing that sets it off, you have abnormality in filaggrin gene or one of these skin barrier genes.
It can also happen secondarily to inflammation. If you have a lot of inflammation in the skin, that can lead to further disruption of the skin barrier. All those things manifest in a measurement called transepidermal water loss.
What we really want to do as part of our basic skin care, no matter the severity of atopic dermatitis, is encourage regular moisturization after a bath or shower, getting moisturizer on right away. Improving that skin barrier is going to be crucial, and topical therapy is really important at just about every severity level, too.
We know that moisturizers, bland emollients, they decrease inflammation, too.
For people who have really mild atopic dermatitis, they might be able to get away with just using moisturizers. For most patients, where there's at least a moderate degree of inflammation in the skin, there's itch, there scratching, there's redness in the skin, that's a sign that probably you need more than just a moisturizer.
We use our prescription medications, like topical steroids, topical calcineurin inhibitors, which is pimecrolimus and tacrolimus, and topical phosphodiesterase-4 inhibitor, which is crisaborole. These medications all work by reducing inflammation in the skin, but they do so in different ways.
Topical steroids are the medication that we've had around for an incredibly long time. Patients are often hesitant to use them because they're concerned about side effects. We know that for the vast majority of patients, they are safe without any side effects, especially when used appropriately.
In other words, using them as they're prescribed by your physician, using them to the areas that they were prescribed.
We usually use more mild topical steroids for the face and any fold areas, like the groin, more medium-potency topical steroids for other areas of the body. Then sometimes we'll escalate to more significantly potent topical steroids for areas like the hands and feet or any areas where there's really thick atopic dermatitis.
We use the nonsteroid medications, the pimecrolimus, tacrolimus, crisaborole. They can be used anywhere on the body.
For me, most commonly, I prescribe them to be used in those more sensitive areas, like the face and folds, particularly around the eyes, where we want to avoid potential eye side effects of topical steroids, like increasing the risk of cataracts and glaucoma, which can occur with use of topical steroids around the eye.
While I'm confident that topical steroids are safe, it is good to have these alternatives, particularly for patients who aren't doing well with topical steroids or they have atopic dermatitis in areas that are more sensitive potentially to the side effects of topical steroids.
