Combination Antimicrobial, Steroid, Moisturizer for Atopic Dermatitis (AD/Eczema)

Atopic dermatitis (AD, eczema) often affects adults, especially those over 70 years of age. AD is characterized by pruritus, impaired skin barrier, and dysbiosis. Guidelines concur that moisturizers to improve barrier function and topical corticosteroids to reduce inflammation and itch are of central importance in AD therapy, but there is disagreement regarding the use of topical antimicrobials. The American Academy of Dermatology concludes that topical antimicrobials are generally not recommended, whereas the Joint Task Force states that an anti-inflammatory agent combined with an antiseptic may help patients colonized with Staphylococcus aureus. This recommendation has important implications given that approximately 70% of lesional skin is colonized with S. aureus and that colonization is correlated with disease severity. S. aureus colonization precedes AD flares, impedes skin barrier, and may drive inflammation.

Physicians from Brown University, in Providence, RI, and Northwestern University, Chicago, evaluated the degree of improvement in the severity and extent of AD lesions after using a compounded antibacterial (mupirocin), steroid (betamethasone valerate), and moisturizer (vanishing cream base) combination (CASM). This was a nonblinded retrospective review of 116 patients with AD. Multiple patients in the study had previously failed mid- or higher-potency topical steroids, systemic immunosuppressives, or phototherapy. Patients were instructed to apply the compound four times daily to the affected areas for the first 5 to 7 days, twice daily for the next 3 to 5 days, and then once daily if needed to any remaining areas for up to 1 week. They were asked to stop the medication when their symptoms cleared but could restart if they experienced a flare-up. Patients were assessed at baseline and at one follow-up visit, with an average follow-up period of 49.5 days.

Despite using a weaker steroid, almost 70% of the patients previously taking medium-potency steroids or stronger responded to CASM. Although CASM was applied more frequently than traditional therapy, the simplified treatment regimen facilitated compliance. The physicians concluded CASM may offer additional benefits for patients who have plateaued with standard therapies.

“In summary, CASM appears to be an innovative approach to treating AD, including refractory cases. With a sound scientific rationale and relatively limited safety concerns, CASM warrants further study for the treatment of AD.”

Pediatric Dermatology Vol. 34 No. 3 322–325, 2017

Case Series Study of the Efficacy of Compounded Antibacterial, Steroid, and Moisturizer in Atopic Dermatitis

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Results from this study indicate that coal tar can be maintained as a safe treatment in dermatological practice.

J Invest Dermatol. 2010 Apr;130(4):953-61.

No increased risk of cancer after coal tar treatment in patients with psoriasis or eczema.

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Two double-blind, randomized, clinical evaluations were conducted to investigate the anecdotal belief that tachyphylaxis occurs in long-term treatment of scalp seborrheic dermatitis and dandruff when using a single pyrithione zinc-based product. Evaluation of data showed a consistent benefit for all products at all time points; therefore, no evidence of decreased benefit over time was found within 48 weeks of treatment.

Int J Dermatol. 2009 Jan;48(1):79-85.

Does tachyphylaxis occur in long-term management of scalp seborrheic dermatitis with pyrithione zinc-based treatments?

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Traditionally used in an ointment vehicle for psoriasis, clobetasol propionate 0.05% is also available in spray, foam, lotion, and shampoo formulations, which may provide for improved convenience and acceptance with similar efficacy, safety, and tolerability as the traditional ointment and cream formulations. For patients who prefer a less messy vehicle, adherence and outcomes are likely to be better with the formulations other than the traditionally recommended ointment.

Am J Clin Dermatol. 2009;10(6):397-406.

Topical clobetasol propionate in the treatment of psoriasis: a review of newer formulations.

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Topical vitamin B12 offers a new therapeutic approach for eczema (atopic dermatitis) and psoriasis and may be suitable for long-term therapy as no long-term adverse effects have been reported.

British Journal of Dermatology 2004; 150: 977-983.

Topical vitamin B12–a new therapeutic approach in atopic dermatitis-evaluation of efficacy and tolerability in a randomized placebo-controlled multicenter clinical trial.

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Dermatology 2001;203:141-147

Vitamin B(12) cream containing avocado oil in the therapy of plaque psoriasis.

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Salicylic acid has been used alone as a treatment for psoriasis but is most commonly used to increase the penetration of other topical preparations, primarily corticosteroids. In this small study, the use of 6% salicylic acid gel in conjunction with tacrolimus ointment showed statistically significant improvement for the treatment of plaque psoriasis compared with the use of salicylic acid alone.”For patients with localized psoriasis, and for many of those with moderate psoriasis as well, the mainstay of treatment is still topical therapy. The quality of life is greatly affected in such patients, and they often express high levels of dissatisfaction with current treatment options. Safe, convenient, and effective topical regimens, such as combination therapy with topical tacrolimus and salicylic acid, can be of great benefit in this large population.”

Arch Dermatol. 2005 Jan;141(1):43-6.

Topical tacrolimus ointment combined with 6% salicylic acid gel for plaque psoriasis treatment.

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“Methotrexate has been used as an effective systemic chemotherapeutic drug for psoriasis by dermatologists for over 30 years. Nevertheless, pharmacokinetic data indicate that oral methotrexate can cause a decrease in red and white blood cell and platelet counts and can also cause severe liver damage, diarrhea, and stomach irritation, as dose-related drug-induced side effects. Such indications have limited its prescription by physicians. However, [Syed and Nordstrom of the Department of Dermatology, University of California-San Francisco, and researchers from three other locations note that] if its incorporation in a gel as a topical agent, in a proper dosage. imparts better results without the cited side effects, then such a formulation appears to justify a clinical evaluation. Furthermore, published data have indicated that 70% of patients prefer topical therapy for treating psoriasis.”

This article concludes: “methotrexate 0.25% in a hydrophilic gel is well tolerated and significantly more effective than placebo as a patient-applied topical medication to treat psoriasis vulgaris.”

J Cutan Med Surg 2001; 299-302

Management of psoriasis vulgaris with methotrexate 0.25% in a hydrophilic gel: a placebo-controlled, double-blind study.

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This article concludes: “Methotrexate 0.25% in a hydrophilic gel is well tolerated but is not very effective in controlling the lesions of psoriasis on the palms and soles; however, a higher concentration in a different base with better penetration could possibly provide better results.”

J Dermatol 2004 Oct;31(10):798-801

Topical 0.25% methotrexate gel in a hydrogel base for palmoplantar psoriasis.

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Tiwari, Kumar, et al. published a case report of topical methotrexate delivered by iontophoresis for the treatment of recalcitrant palmoplantar psoriasis. In a 46 y.o. male with well-defined bilateral palmar plaques of 6 years duration which were resistant to several therapies, the right palm was treated, as it had more severe lesions. Iontophoresis was performed using cotton gauze soaked in 4 to 6 ml of methotrexate disodium solution 10 mg/ml, once a week for four weeks. The researchers reported 75% improvement after four weeks of therapy. Iontophoresis allows high concentrations of drug to be delivered to a limited area and may offer a method of reducing total drug accumulation and reduced side effects.

Int J Dermatol. 2003 Feb;42(2):157-9

Topical methotrexate delivered by iontophoresis in the treatment of recalcitrant psoriasis–a case report.

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