WASHINGTON The most significant justification for proactive topical steroid therapy administered between atopic dermatitis flares is that "normal-looking" skin is not really normal, said Dr. Andreas Wollenberg.
"It doesn't follow our dermatological tradition to treat skin that doesn't look diseased," Dr. Wollenberg said during a debate session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. But even when symptoms temporarily subside, "there is a barrier defect in the normal-looking skin. There is an infiltration of inflammatory cells in the normal looking skin. And there is an alteration of the dendritic cells in the normal looking skin."
Administering therapy proactively, as opposed to only upon flaring, increases a patient's sense of control over the disease. "From the patient's point of view, it's the patient who rules the disease, and not the disease who rules the patient," he said. "Our patients love proactive therapy."
Proactive treatment also can decrease the number of flares, as well as flare duration and severity, compared with as-needed therapy, said Dr. Wollenberg, of the Department of Dermatology and Allergy, Ludwig-Maximilians-Universität, Munich. He recently completed a study showing that tacrolimus 0.1% ointment given twice weekly "significantly reduced the number of [disease exacerbations or DE] requiring substantial therapeutic intervention … the percentage of DE treatment days … and increased the time to first DE," (Allergy 2008;63:742-50).
In a rebuttal, Dr. Mark Boguniewicz of the National Jewish Medical and Research Center in Denver, cautioned that "before we accept a new paradigm like this we need to consider a few things. A critical appraisal of the current data would be useful."
"Should we ignore practice guidelines, practice parameters, consensus statements, package inserts, and the [Food and Drug Administration] boxed warnings, and can we afford to?" he asked. "And what do the adherence studies tell us?
"Does it make sense to apply topic medications to normal-appearing skin in a disease where most of our patients outgrow the problem early on?"
He also pointed out that the effects of long-term corticosteroids on unaffected skin are not known.
Both presenters disclosed financial and consulting relationships to multiple pharmaceutical companies.