From the Guidelines
For patients allergic to corticosteroids, topical calcineurin inhibitors such as tacrolimus or pimecrolimus are recommended as first-line alternatives, as they have significantly improved the clinical management of patients with atopic dermatitis (AD) 1. When considering alternative topical treatments, it's essential to weigh the risks and benefits of each option. Topical calcineurin inhibitors have been shown to be effective in managing AD, with benefits including reduced inflammation and improved skin barrier function.
- Key points to consider when using topical calcineurin inhibitors include:
- Patient education on proper use and potential risks, such as infection and immunosuppression 1
- Contraindications, including use in patients younger than 2 years of age, those with compromised immune systems, or pregnant/breastfeeding women 1
- Potential for adverse effects, such as skin burning or stinging, which typically resolve with continued use Other alternatives, such as phosphodiesterase-4 inhibitors (e.g., crisaborole), tar preparations, and topical antihistamines (e.g., doxepin cream), may also be effective for specific conditions, but topical calcineurin inhibitors remain the preferred choice for patients with a known allergy to corticosteroids, due to their established efficacy and safety profile 1.
- Additional considerations for alternative treatments include:
- Moisturizers containing ceramides or colloidal oatmeal for symptomatic relief of dry, itchy skin
- Tar preparations for psoriasis and eczematous conditions
- Topical antihistamines for relief of itching and pruritus It's crucial to individualize treatment based on patient-specific factors, such as disease severity, affected area, and medical history, to ensure the best possible outcome in terms of morbidity, mortality, and quality of life.
From the FDA Drug Label
In a one-year safety study in pediatric patients age 2-17 years old involving sequential use of ELIDEL Cream and a topical corticosteroid, 43% of ELIDEL patients and 68% of vehicle patients used corticosteroids during the study.
Alternative topical treatments to corticosteroids for a patient with a known allergy to corticosteroids may include:
- Pimecrolimus (TOP) cream, as it has been studied for the treatment of mild to moderate atopic dermatitis in patients who may not be able to use topical corticosteroids due to allergy or other reasons 2, 2, 2. Note that the provided drug labels do not explicitly state that pimecrolimus is an alternative to corticosteroids for patients with a known allergy to corticosteroids, but rather provide information on its use in patients with atopic dermatitis.
From the Research
Alternative Topical Treatments to Corticosteroids
For patients with a known allergy to corticosteroids, several alternative topical treatments are available. These include:
- Topical calcineurin inhibitors, such as pimecrolimus and tacrolimus, which have been shown to be safe and effective in the treatment of atopic dermatitis 3, 4, 5, 6
- Phosphodiesterase 4 (PDE4) inhibitors, such as crisaborole, which have been demonstrated to be effective in achieving lesion clearance and reducing relapse in atopic dermatitis 7, 6
Benefits of Alternative Treatments
The alternative topical treatments have several benefits, including:
- A more selective mechanism of action, which reduces the risk of adverse effects 3
- No association with skin atrophy or significant systemic absorption 5
- Efficacy in treating other inflammatory skin diseases, such as flexural psoriasis, seborrhoeic, contact and hand eczema 5
- Low systemic absorption and no increased risk of systemic adverse events or malignancy 6
Preferred Sites for Alternative Treatments
The alternative topical treatments are preferred for use on areas of the skin that are more susceptible to topical corticosteroid side effects, such as:
- The face, neck, flexures, and genital areas 5