17a Corticosteroids in Allergic Dermatoses Coleman

CORTICaSTEROID TREATMENT OF

ALLERGIC DERMATOSES

William P. Coleman, New Orleans, La., U.S.A.

Corticosteroids have been widely em-ployed in medical practice during thepast fifteen years. Their benefical ef-fects in certain allergic diseases, for-merly resistant to treatment, have ledto their general acceptance by aller-gists.

Mediaiiism of ActionAlthough their mode of action is un-known, it is generally acknowledgedthat they bring about attenuationin reticuloendothelial function and,thereby, suppress allergic activity. Theyfail to protect against the immediatetype of hypersensitivity reaction oranaphylaxis, at least in animals.'Corticosteroids have no antihistaminiceffect; they do, however, inhibit thedelayed hypersensitivity reaction.Corticosteroids may simply suppresssymptoms without eliminating theircause and, therefore, are most usefulin those diseases whose natural courseis to improve. Thus, acute contact der-

matitis in which the cause, whethersensitizer or irritant, has been re-moved, responds rapidly. Corticoster-oids may be necessary to control themanifestations of serum sickness untilthis disorder has run its natural course.On the other hand, these compoundsmay have to be employed indefinitelyin more chronic conditions, such asatopic dermatitis, to maintain suppres-sion of the cutaneous reaction.

Topical ApplicationIn the various allergic cutaneous dis-orders, corticosteroids may be admin-istered orally, hypodermically, topic-ally or by intralesional injection. Fortopical use they are incorporated intolotions, creams and ointments, or aero-sol preparations. Fundamentally, lo-tions should be used on active vesicularareas, creams on areas of subacrtedermatitis, and ointments on merechronic, drier, scaling lesions. Corti( o-trophin and cortisone are inactive Jn

From the Department of Allergy, Ochsner Clinic. New Orleans. La.. U.S.A. , .K A .r anPresented in a panel on Present Concepts of Steroid Therapy at the Twentieth Annual Congress of the AmerCollege of Allergists. Bal Harbour. Florida. U.S.A., March 4-6, 1964.

t!ie skin.-' Intensive pharmacologic re-search has modified the basic .structureof the important naturally occurringadrenal cortico.steroid, hydrocortisone.^These newly derived drugs show in-creased antiallergic activity, and theunsatisfactory side effects have beenfavorably altered.Hydrocortisone, prednisolone, dexam-ethasone, betamethasone, triamcino-lone, fluocinolone and fiurandrenolineare all active on the skin. Currently,controlled trials indicate that betam-ethasone, fluocinolone and triamcino-lone are more effective topically thanthe others.2

Incorporation of AntibioticsSince corticosteroids appear to in-crease the likelihood of secondary in-fection when applied to the skin, anti-biotics and antiseptics are being addedto corticosteroid preparations used fortopical application. The tendency ofatopic dermatitis to secondary impetigois well known. Lichen simplex chron-icus, tinea pedis, scabies and the bitesof fleas and insects are also prone tosecondary infection.''Antibiotics for topical use should nottend to sensitize the skin. Those nor-mally used for systemic treatmentshould be avoided. Since streptomycinand chloramphenicol are potent cu-taneous sensitizers, they should not beemployed for this purpose. One of thefactors predisposing to production ofepidermal sensitization is frequent con-tact with the sensitizer; the wide-spread use of topical neomycin is rap-idly meeting this criterion. Inagreement with these conditions, theantibiotics most commonly incorporatedwith corticosteroids into topical prepa-rations are bacitracin, gramicidin,neomycin and tyrothricin. Nystatin isincluded in some preparations tocounteract monilia infection of theSKiTi. Amphotericin B probably willsoon be substituted because it is alsoetrective against monilia and it has^ 1' nger shelf life.

^« >ical Antisepticsec mse of the increasing problem ofne development of organisms which

Pfo uce antibiotic-resistant strains.

particularly staphylococci, use of anti-septic preparations to control sepsisof the skin is becoming more common.Many of these substances may be incor-porated into the topical corticosteroidpreparations; chlorhydroxyquinoline(Quinolor®), iodochlorhydroxyquino-line (Vioform®) and chlorquinaldol(Sterosan®) are frequently employedfor this purpose.

Methods of IncreasingPenetrationPenetration of topical corticosteroidsmay be greatly enhanced by use of oc-clusive dressings and by intralesionalinjections. Occlusive dressings madeof plastic materials are left in place upto 12 hours. Of particular value forthe hands and feet, they may be ap-plied at night and discarded during theday. This technic is especially usefulin lichenified dermatitis. Tye andFishers suggested pretreatment of theskin with moist heat in areas not amen-able to use of occlusive dressings.They believed that this enhanced thecutaneous absorption of topically ap-plied corticosteroids by inducing hydra-tion of the horny layer. The methodwas thought to be especially helpful incoping with the lesions of severe, re-calcitrant acne. Intralesional corticos-teroid treatment has been successfulin a wide variety of dermatologic dis-orders, among which is nodular dermalallergid, a form of allergic vasculitismanifested by urticaria, purpura andnodules in the skin. Triamcinolone sus-pension, in full strength or diluted 2:1or 3:1, is injected at intervals of twoto three weeks.

Systemic CorticosteroidsCorticosteroids may be administeredorally or hypodermically to patientswith allergic dermatoses. Their use inthese conditions is governed by thesame principles as in all branches ofmedicine. They are employed to savelife, to tide the patient over the acutephase of an illness which is usually ofshort duration, and to suppres.s theeffects of a chronic disease in order tokeep the patient comfortable. Theymay be life-saving in exfoliative der-matitis or in the Stevens-Johnson syn-

1 7 a Corticosteroids in Allergic Dermatoses Coleman

drome. Acute drug eruptions, severeurticaria and angioneurotic edema, orsevere erythema multiforme are ex-amples of disorders which may requirecorticosteroids to tide the patient overthe acute phase. It is preferable togive a fairly large dosage at first (atleast 30 mg. of prednisone or equiva-lent daily) and gradually reduce thisrather than the reverse in these in-stances.

Atopic DermatitisAtopic dermatitis is an example of achronic incapacitating disease whichmay require systemic administrationof corticosteroids to suppress symp-toms. Frequently, only small doses arerequired. Obviously, patients takingcorticosteroids for long periods of timeshould be kept under close observation,with particular attention to hyperten-sion, ulcer, central nervous systemeffects and growth stunting in children.

Urticaria and AngioneuroticEdemaTopical corticosteroids are of no valuein the treatment of urticaria and angio-neurotic edema. In acute urticarialreactions or in serum sickness reac-tions, oral or injectable corticosteroidsare useful to tide the patient over theacute phase. On the other hand, corti-costeroids are probably contraindicatedin chronic urticaria because of thetendency of patients to become depend-ent upon these compounds.

Contact DermatitisOral or injectable corticosteroids arealso effective in acute contact derma-titis until this self-limited disorder hasrun its natural course. Topical prepa-rations are not particularly effective.Corticosteroid creams are effective insubacute contact dermatitis and theointments, in conjunction with occlu-sive dressings, in chronic contact der-matitis.

Erythema NodosumThis condition may be secondary to awide variety of disorders includingrheumatic fever, septic pharyngitis,scarlet fever, endocarditis, pericarditis.

tuberculosis, leprosy, sarcoidosis, coc-cidioidomycosis, meningococcemi; i,lymphogranuloma venereum, histoplas-mosis, American leishmaniasis, andingestion of certain drugs, especiallyiodides, bromides or sulfonamides.^Obviously, in some of these conditionscorticosteroids would be indicated,whereas in others they would not. Theyare definitely indicated in leprosy butare contraindicated in tuberculosis.They are unnecessary in coccidioido-mycosis, since erythema nodosum inthis disease is a favorable sign.

Erythema MultiformeThis dermatosis is associated withsystemic infections, including those ofviral origin, drug toxicity, particularlyantipyrine, pregnancy, food allergy,deep roentgentherapy and cancer. TheStevens-Johnson syndrome (ectoder-mosis erosiva pluriorificialis) is a seri-ous, frequently fatal variant of eryth-ema multiforme. Whereas oral orinjectable corticosteroids may be use-ful in severe erythema multiforme,they may be lifesaving in the Stevens-Johnson syndrome.

Erythema Annulare CentrifugumThis condition is a rare, recurrent dis-ease characterized by polycyclic, eryth-ematous, somewhat bizarre, ringed le-sions that tend to grow eccentrically,break up, disappear and be replacedby similar lesions. The cause is un-known. It may be related to derma-titis herpetiformis. At times it isassociated with internal malignantdisease. Shelley and Hurley,' who re-ported this condition in associationwith generalized pigmentation and hy-pertrophy of the breasts, demonst;ratedspecific circulating autoantibodies tothe patient's own cystic breast tissueand a positive L. E. phenomenon. Theybelieved that this represented an auto-immune disease. Oral or injectiiblecorticosteroids are frequently helpfulin controlling this disorder.Recent evidence suggests that at'picdermatitis may also be an autoimnr. medisorder.8 Although a preparation fortopical use may be all that is requ redto control this condition, one may 1 ave

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Dermatologia Internationalis July-September 1965

.0 resort to oral or injectable corticos-leroids if the disease is intractable.

Superficial Fungous DiseasesIn addition to griseofiuvin, cortieoster-oids and other antibiotics may be indi-cated in the treatment of kerion ortinea pedis. Although the basic lesionis fungal, there appears to be an al-lergic inflammatory component to thesedisorders and secondary infection iscommon.

Drug ReactionsNumerous types of dermal reactions,most of which are self-limited, occuras allergic reactions to various drugs.Whereas penicillin is the most com-mon offender, almost any drug is cap-able of causing an eruption. Cortico-steroids are useful in controlling thesymptoms for the duration of the re-action, which may be prolonged.

SummaryThe method of action of corticosteroidsis unknown. Corticosteroids are mostuseful in diseases whose natural courseis to improve and, therefore, are espe-cially applicable to the allergic derma-toses. They may be administeredtopically, systemically or by intrale-sional injection. Antibiotics and anti-septics are incorporated into corti-costeroid preparations to minimize thelikelihood of secondary infection. Cor-ticosteroid administration in variousallergic cutaneous disorders is dis-cussed.

SommaireLe mode d'action des corticosteroidesest inconnu. Les corticosteroides sontoes plus utiles dans les affections dontI evolution normale est vers une ame-lioration et done, particulierement

applicables aux dermatoses allergiques.On peut les appliquer localement, sys-tematiquement ou par injection intra-lesionale. Des antibiotiques et desantiseptiques sont incorpores dans lespreparations de corticosteroides, afinde reduire au minimum la probabilited'une infection secondaire. L'admini-st ration de corticosteroides pour diversdesordres cutanes allergiques estdiscutee.

SumarioSe desconoce el mecanismo de accionde los eorticoesteroides. Estos medica-mentos son extremadamente utiles enlas enfermedades cuyo curso natural eshacia la curacion y por ese motivo sonespecialmente utiles en las dermatosisalergicas. Pueden utilizarse en aplica-ciones topicas, por via oral o por viaintralesional. Con objeto de disminuirla infeccion secundaria se puedenanadir antibioticos o antisepticos. Sediserta sobre la importancia de laadministracion de eorticoesteroides enalgunas enfermedades alergicas de lapiel.

References1. Feinbcrg. S. M.: Danrenberg, T. B., and Malkiel,

b. : ACTH and cortisone in allergic manifentations;therapeutic results and studies* on immunologicaland tissue reactivity, J. Allergy 2i:\9b. 1951.

2. CorticosteroidB in dermatoloKy, Brit. M. J. a:434,1963.

3. Grater, W. C : Corticosteroid choice in allergy, AnnAllergy 2;:464, 1963.

4. Derbes, V. J . : Insect bitea and stings, in cyclo-pedia of Medicine, Surgery and Specialtiej, Phila-delphia, Pa., U.S.A., F. A. Davis & Co., 1963, Vol.

5. Tye, M. J., and Fisher, B. K.: Acne treated withcompress and a corticosteroid cream, A.M A ArchDermat. «9:141, 1964.

6. Andrews, G. C , and Domonkos, A. N. • Di.neasesof the Skin, Bth ed., Philadelphia, Pa U S AW. B. Saunders Co., 1963, p. 112.

7. She:;ey, W. B., and Hurley, H. J . : An unusual auto.,immune syndrome, A.M.A. Arch. Dermat. «/:889,

8. Wise, L. J., Jr . : Shames, J. M.; Derbes, V. J., andHunter, F. M.: Fluorescent antibody studies inchronic dermatitis, A.M.A. Arch. Dermat. 81,:31,