COVER FOCUS Seasonal Allergies and Atopic Dermatitis: A Missing Link? Evidence increasingly suggests that dermatologists need to watch for allergens in AD—from the interaction between environmental allergens and eczema to corticosteroid allergy. BY LEON H. KIRCIK, MD AND JAMES Q. DEL ROSSO, DO ommon seasonal allergy symptoms—itchy eyes, creating buzz not only about corticosteroids in general runny noses, and scratchy throats—lead many but also their cross-reactivity among themselves.3 Table patients to visit an allergist, but a growing num- 1 shows five core structural classes: A, B, C, D1, and D2. ber are seeking help at dermatologists’ offices as Cross-reactivity issues spark the need to screen patients Cwell. Allergen exposure through the skin may initiate sys- temic allergies especially, in patients who are predisposed TAKE HOME TIPS to atopic dermatitis (AD), allergic rhinitis, and asthma.1,2 While many dermatologists may be aware of this research, Allergen exposure through the skin may initiate systemic the implications for patient care may be less obvious. allergies especially, in patients who are predisposed to atopic Airborne allergens from pollen, trees, grass, plants, and dermatitis (AD), allergic rhinitis, and asthma. Airborne ragweed can cause these typical allergic reactions, and the allergens from pollen, trees, grass, plants, and ragweed can heightened systemic response to allergens may instigate a cause typical allergic reactions, and the heightened systemic flare of AD. Furthermore, contact allergy or other cutaneous response to allergens may instigate a flare of AD; contact reactions can also result when allergens comes into contact allergy or other cutaneous reactions can also result when with the skin. Reactions typically include pruritus, erythema- allergens comes into contact with the skin. When topical tous eruptions, and urticaria. When topical corticosteroids corticosteroids are used the issue of allergy may be com- are used to treat eczema or skin reactions associated with pounded. Although uncommon, some patients do develop seasonal allergies, the issue of allergy may be compounded. allergic contact dermatitis to topical corticosteroids used Although uncommon, some patients do develop allergic during treatment. Group C corticosteroids are associated contact dermatitis to topical corticosteroids used during with a lower risk of sensitization, relative to other classes, and treatment. In such cases, they may improve initially, how- may be preferred for long-term management of patients ever the eczematous eruption persists due to contact allergy with AD. In addition to prescription therapy, good skin care, to the active corticosteroid ingredient. incluidng barrier repair, is important. Finally, the role of vehi- cles and delivery systems in patient adherence as well as CORTICOSTEROID CLASSES repair of the disrupted epidermal barrier in chronic inflam- In 2005, the American Contact Dermatitis Society des- matory skin diseases is of utmost important. ignated corticosteroids their “allergen of the year,” thus 34 PRACTICAL DERMATOLOGY JUNE 2012 COVER FOCUS for class-specific sensitization through specified patch TIPS FOR PATIENTS tests, and studies have shown the possibility that some adverse drug reactions may be caused by cross-reactivity You may suggest the following to patients especially sensi- among different classes of corticosteroidsHeadline and sulfon- tive or allergic to seasonal pollens and grasses. amides.4-6 For example, Class A components can cross- react with Class D2, requiring caution for physicians to • Wear a mask and gloves when working outside, doing avoid prescribing a product in either class in a known household tasks, or grooming pets. sensitized patient.7-12 • Frequently launder clothing that has been worn for extend- Group C corticosteroids are associated with a lower risk ed periods during gardening or mowing the lawn. of sensitization, relative to other classes, and may be pre- • Wash hair, face, arms, and legs after performing outside ferred for long-term management of patients with atopic Deck tasks. dermatitis. Group C corticosteroids were rarely allergenic • Bathe pets frequently, as they bring pollen inside on their in sensitization studies.14-16 Within this group, clocortolone fur and trigger pollen allergies. BYLINE pivalate cream 0.1% (Cloderm Cream, Promius Pharma) offers a reasonable balance of safety and efficacy, and is and atopic dermatitis, their efficacy often is hindered by well suited to manage inflammatory dermatoses.13 Clinical patient non-adherence issues and the emergence of side studies have shown that clocortolone pivalate cream 0.1% effects.20-22 Much effort has gone into devising more effec- is a safe andext text effective text text treatment text text in text AD, text contact text textdermati text - tive strategies for addressing the dry skin conditions asso- tis, eczema,text and text psoriasis, text text andtext thistext producttext text demonstratestext text text ciated with various dermatologic disorders by providing no cross-allergenicitytext text text textwith text the textA, B, text or Dtext corticosteroid text text text additional moisture content to products.22 Studies show classes.17-19text text text text text text text text text text text patients prefer less greasy treatments options over oint- textT text text text text text text text text text text ment corticosteroid formulations.23,24 While there remains ADHERENCE STRATEGIES a role for ointments in patient care, they are best for acute Selecting an appropriate topical corticosteroid is just treatment for short term use. An emollient-type cream or a first step. While topical corticosteroids are the most aqueous-based gel is more likely to encourage long-term common treatment modality for patients with psoriasis adherence due to ease of use and spreadability, lack of TABLE 1: CLASSES OF CORTICOSTEROIDS1 Class A — Hydrocortisone Type Hydrocortisone, hydrocortisone acetate, cortisone acetate, tixocortol pivalate, prednisolone, methylprednisolone, cloprednol, fludro- cortisone, and prednisone Class B — Acetonides (and related substances) Triamcinolone acetonide, triamcinolone alcohol, mometasone, amcinonide, budesonide, desonide, fluocinonide, fluocinolone aceton- ide, flunisolide, procinonide, and halcinonide Class C — Betamethasone Type Betamethasone, betamethasone sodium phosphate, dexamethasone, dexamethasone sodium phosphate, desoximetasone, clocorto- lone pivalate, rimexolon, and flucortolone Class D — Esters Class D1 — Less Labile Clobetasol propionate, hydrocortisone-17-valerate, aclometasone dipropionate, betamethasone valerate, betamethasone dipropio- nate, prednicarbate, clobetasone-17-butyrate, clobetasol-17-propionate, fluocortolone caproate, fluocortolone pivalate, and flupred- nidene acetate Class D2 — Labile Prodrug Esters Hydrocortisone-17-butyrate, 17-aceponate, 17-buteprate, and prednicarbate 1. Rietschel RL, Fowler JF, Fisher AA. Fisher’s Contact Dermatitis. Lewiston, New York: BC Decker; 2008; 257. JUNE 2012 PRACTICAL DERMATOLOGY 35 COVER FOCUS Leon H. Kircik, MD, FAAD is Director of Derm Good overall skincare, including use Research, PLLC and Physicians Skin Care, PLLC. of moisturizing barrier repair creams, He is Clinical Associate Professor of Dermatology at Mount Sinai Medical Center and Indiana may be helpful for these patients, University School of Medicine. especially if they are attentive to James Q. Del Rosso, DO, FAOCD is Dermatology Residency barrier management in advance of Program Director at Valley Hospital Medical Center in Las Vegas, Nevada; Clinical Professor (Dermatology) at Touro allergy season. University College of Osteopathic Medicine in Henderson, Nevada; and in private practice at Las Vegas Skin & Cancer messiness and residue caused by the vehicle, and lack of Clinics, Las Vegas and Henderson, Nevada. skin irritation. Another key factor in patient adherence is the amount of 1. Spergel JM. From atopic dermatitis to asthma: the atopic march. Ann Allergy Asthma Immunol. 2010; 105(2):99-106. 2. Morgenstern V, Zutavern A, Cyrys J, et al. Atopic diseases, allergic sensitization, and exposure to traffic-related air drug prescribed and the method of dispensing it. Especially pollution in children. Am J Respir Crit Care Med. 2008; 177(12):1331-7. for management of recurrent or chronic dermatoses, pre- 3. American Contact Dermatitis Society. History of allergen of the year. http://www.contactderm.org/i4a/pages/index. cfm?pageid=3467 scribers should be sure to order a sufficient quantity of 4. Rerkpattanapipat T, Chiriac AM, Demoly P. Drug provocation tests in hypersensitivity drug reactions. Curr Opin Allergy medication to meet the patient’s need between office visits. Clin Immunol. 2011; 11(4):299-304. 5. Patel JS, Scheiner ED. Acute parotitis induced by trimethoprim/sulfamethoxazole. Ear Nose Throat J. 2011; 90(2):E22. More recently, metered pumps have come on the market, 6. Baxter JD, Funder JW, Apriletti JW, et al. Towards selectively modulating mineralocorticoid receptor function: lessons helping patients to more accurately “dose” their topical from other systems. Mol Cell Endocrinol. 2004; 217(1-2):151-65. 7. Jacob SE, Steele T. Corticosteroid classes: a quick reference. J Am Acad Dermatol. 2006; 54:723-7. medications and not overuse them. Metered-pumps are 8. De Groot AC, Weyland JW, Nater JP. Unwanted effects of cosmetics and drugs used in dermatology. Third Ed. associated with high rates of patient satisfaction. Amsterdam: Elsevier; 1994. 9.