By: Daniel Han
Atopic Dermatitis (also called eczema) affects approximately 1 in 10 Americans. Several new treatments have been approved for this condition in recent years including injections, pills, and a cream. Atopic dermatitis is a common, chronic, inflammatory skin condition characterized by intense itchy and flaky skin lesions that can badly impair the quality of one’s life. Psoriasis, also a chronic inflammatory skin condition, is characterized by red, scaly, raised plaques of skin.
Despite growth in the usage of systemic therapies to treat these skin diseases, a majority of patients today still use topical therapies, with the most commonly used treatments being topical steroids, including creams, lotions, solutions, and ointments. Even patients who do well on systemic therapies, oftentimes still struggle with mild psoriasis and eczema and end up becoming users of topical steroids. Unfortunately, there has not been a lot of innovation in topical therapy, and there is an increasing need to avoid the well-defined side effects of steroid treatments for eczema and psoriasis.
Striae, or stretch marks, are just one of the unappealing cosmetic conditions that can develop in individuals using topical steroids and cause irreversible permanent damage to the skin. They are most often observed on the inner thighs, under the breasts, and in the armpits. Another side effect derived from the overuse of topical steroids are broken capillaries and thinning of the dermis, which serves as the protective layer of the skin and is found directly beneath the epidermis. Steroid treatments can cause the dermis to become so thin that dilated blood vessels that were once covered by the thick dermis become easily visible.
This thinning of the skin can occur anywhere on the body and can reach a point where the skin becomes exceedingly fragile and easily damaged. Steroid-induced atrophy on the arms and legs, makes the skin extremely susceptible to tearing from external surroundings. And atrophy of skin on the genitals can make genital skin fragile resulting in pain and bleeding as a result of sexual contact.
A related consequence from steroid-overuse is reduced collagen in the skin. Collagen plays an essential role in cushioning the blood vessels, and by reducing the collagen in the skin, the blood vessels become exposed. Every time a person bumps their arms or legs, instead of the impact being absorbed by the cushioning of the collagen, which is no longer there, it hits the blood vessel directly, causing bleeding under the skin to occur, a condition known as purpura, which appears as purple spots under the skin.
Serious problems can also occur on the face. The use of topical steroids can result in perioral dermatitis, a red rash that typically develops around the mouth and can be mistaken for acne but does not go away quickly. Continual use of topical steroid treatments can lead to an “addiction”, and although the application of stronger steroids may help treat the condition, it can prolong the addiction even further. So, in order for the condition to clear up, steroids often must be withheld for an exceptionally long time, up to a year, during which point patients often cannot tolerate anything on their skin other than steroids. More seriously, topical steroid use around the eyes can be associated with the development of cataracts and glaucoma with extended use.
Fortunately, several new treatments have been recently approved for the treatment of eczema and psoriasis that are non-steroidal. Several of these treatments were tested in the Mount Sinai Department of Dermatology prior to their recent approvals.
Recently phosphodiesterase 4 (PDE4) inhibitors have been used to treat atopic dermatitis and
psoriasis. Phosphodiesterase inhibitors are in widespread use and include common staples like caffeine, so concern over side effects has been limited. Apremilast (Otezla®) is an oral PDE4 inhibitor approved for psoriasis; and crisaborole (Eucrisa®) is a topical PDE4 inhibitor approved for atopic dermatitis. PDE4 inhibitors have not been associated with the severe side effects of steroid treatments. PDE4 inhibitors are a class of nonsteroidal drugs that affects circulation and immunologically mediated inflammation. As noted above, a topical PDE4 inhibitor known as crisaborole has already been approved for the treatment of atopic dermatitis, and an oral PDE4 inhibitor called apremilast has been approved for psoriasis.
Side effects are primarily nausea, diarrhea, and weight loss. A more recent PDE4 inhibitor called Roflumilast has also been approved for the topical treatment of psoriasis. Roflumilast cream removes psoriasis plaques and lessens itching across the body. Additionally, there are no time restrictions associated with how long the cream may be used for treating psoriasis regardless of the area of the body affected.
Until now, PDE4 inhibition has been used safely to treat psoriasis and atopic dermatitis, and that safety profile has been corroborated in many thousands of patients. Research on these products is regularly ongoing at Mount Sinai and new products are in development. A new PDE4 inhibitor ointment is currently being investigated at Mount Sinai for treatment in both atopic dermatitis and psoriasis. For more information, or if interested to sign up for a clinical trial now, please call (212) 241-6033, or email [email protected].
