Improvement of atopic dermatitis after withdrawal from topical corticosteroids.
Fukaya, M. MD., ARCH DERMATOL VOL136,MAY 2000
Topical corticosteroids are a useful form of treatment for atopic dermatitis. However, patients are likely to be addicted after long term treatment1). This paradoxical phenomenon has so far been underestimated, and improvement following the temporary rebound flare after withdrawal of topical corticosteroids has been entirely ignored.
Report of a case
A 20-year-old man was affected with atopic dermatitis, present since early childhood. He had used topical corticosteroid intermittently but found that the amount and frequency of applications began increasing since age 18. The patient used 0.12% betamesazone ointment on his body and 0.5% predonizolone ointment on his face. Total IgE was 7179 IU/ml and his white blood cell (WBC) count showed 27.1% eosinophils.
He had developed patchy erythema and prurigo on the entire body even before withdrawing use of topical steroids.(Figure). One month after halting use, prurigo flattened and the erythema extended gradually over the whole body. After two months, exdative erythema had developed on his forehead and his features showed erythroderma. Four months after stopping the steroid treatment his rebound flare was at its worst point, especially on the face. After six months the dermatitis improved first on the face and the exdative lesions were not noticeably apparent any more. After one year the skins appearance became almost normal with the exception of some dry lesions on the elbows and wrists which were found to be consistent with features of classical atopic dermatitis. One year and a half after withdrawal, the patients eczema subsided and his total IgE was 3300 IU/ml while the white blood cell count showed only 7.8% eosinophils. Throughout the observation period, no systemic steroids were required and the patient used only white petroleum and anti-histamines as oral drugs. 10% povidone-iodine were used as a disinfectant to prevent secondary infection.
Comment
In Japan, so-called steroid withdrawal therapy was brought into the limelight in 1993 and generally become the subject of a heated debate between supporters and opponents in the dermatological field. Tamaki2) reported that 18 of 26 cases of adult type atopic dermatitis showed remission or improvement in six months to one year. Fukaya3) also showed that some patients' conditions were improved by withdrawal, but insisted that atopic dermatitis should be treated as a multifactorial disease.
The exact reasons for the rebound phenomenon are not clear. Grabbe4) showed that removal of the majority of epidermal langerhans cells by topical steroid application enhances the effector phase of murine contact hypersensitivity. It may help to explain the rebound phenomenon as contact hypersensitivity.
Vivier5) reported tachyphylaxis to the vasoconstrictive action of topically applied corticosteroids in human skin. In clinical practice, patients who develop rebound often complain about the reduced effectiveness of steroids on repeated and continuous applications before withdrawal. The rebound phenomenon could occur with regard to the mechanism of tachyphylaxis.
Spontaneous remission after flare of atopic dermatitis could be distinguished from improvement induced by topical steroid withdrawal by clinical history.It is necessary to establish a schedule of administration, which does not arouse rebound after withdrawal.
References
1. Kligman AM, Frosch PJ. Steroid Addiction. Intl.J Dermatol. 1979; 18: 23-31
2 Tamaki A, Ohashi A, Ishida T, Nakamura M: Treatment without steroid ointment for adult type atopic dermatitis, Jpn J Dermatoallergol. 1993; 1: 230-234
3 Fukaya M: Change of housing environment and withdrawal of corticosteroid as treatments of atopic dermatitis, Jpn J Allergol. 1999; 48: 520-525
4 Grabbe S, Steinbrink K, Steinert M, Luger TA, Schwarz T: Removal of the majority of epidermal langerhans cells by topical or systemic steroid application enhances the effector phase of murine contact hypersensitivity, J. Immunol. 1995; 155: 4207-4217
5. DuVivier A, Stroughton RB. Acute tolerance to effects of topical gulcocolticoids.Br J Dermatol. 1976;94:25-32