The reality is that antihistamines are safe medications with very few adverse effects and can be used with confidence if necessary. The question is whether they should be used in people with atopic dermatitis.

Surely your pediatrician or doctor has prescribed them to you “for the itching” at some point, and yes, they may have provided some relief… but have you seen any improvement in the areas of dermatitis? Have you seen the redness and flaking disappear? Is the relief really that great? If it is the inflammation of the skin that causes the itching and antihistamines do not seem to improve it, do you think there is any point in taking them?

Let’s see what the scientific evidence says about this.

How do antihistamine pills work?

As their name suggests, these compounds block histamine receptors, which cause allergies, hives, and some types of itching in our bodies. Specifically, type 1 antihistamines are used for these conditions, as type 2 antihistamines are usually used for digestive conditions that have nothing to do with what we are talking about.

There are two types of type 1 antihistamines:

• Sedatives: these are drugs that are able to cross the blood-brain barrier, reach the brain, and have a mild sedative effect. They make us sleepy. Examples of this type include Polaramine® and Atarax®.
• Non-sedatives: these are the most commonly used, especially for seasonal allergies, as they do not cross the blood-brain barrier and therefore do not cause drowsiness. Other antihistamines you may be familiar with belong to this type: loratadine, desloratadine, cetirizine, ebastine, bilastine, etc.

  

Are antihistamines commonly used?

A recent publication by the JAAD revealed that 22% of patients with atopic dermatitis who visited a dermatologist in the US were prescribed an antihistamine, usually of the sedative type. Pediatricians also prescribe this type of antihistamine in 16% of cases. However, non-dermatologist specialists prescribe non-sedating antihistamines in approximately one in three patients.

I believe that these data may reflect what is happening in our country as well.

Are antihistamines effective for the itching associated with atopic dermatitis?

The reality is that numerous scientific studies, reviewed by the Cochrane Library, show that antihistamines do not actually reduce itching in atopic dermatitis. Of course, they are not useful for improving eczema.

It is known that in many cases, people with atopic dermatitis take them because they relieve other symptoms also related to atopy, such as allergic rhinitis, conjunctivitis, or food allergies.

Just because they are prescribed does not mean they are effective. In many cases, we give them with the idea that, as sedatives, they can help you fall asleep and have a better night’s sleep by “masking” the itching. However, it has been found that these medications can worsen sleep quality by shortening REM sleep. Not only that, but if their effect persists in the morning (which it often does), they can interfere with learning ability and memory.

So what are the recommendations?

You know that the star treatment for atopic dermatitis is topical corticosteroids. In some cases, we also resort to calcineurin inhibitors. And it is on these two pillars that we must focus the treatment of atopic dermatitis in children and adults to control outbreaks. Obviously, all this must be accompanied by appropriate care and moisturizing measures, which I already mentioned in another article.

I’m not the only one saying this; the American Academy of Dermatology advises against the use of antihistamines exclusively to control the itching of atopic dermatitis. They can, of course, be used in people who, in addition to their dermatitis, suffer from another condition that clearly improves with these medications (rhinitis, conjunctivitis, etc.).

I hope this article has answered your questions about antihistamines.

Do you usually use them for your dermatitis or your child’s? Do you find them useful?

If you have any further personal questions, I can help you through the online consultation.

The post Atopic dermatitis and antihistamine pills first appeared on Dra. LOREA BAGAZGOITIA.

Although we doctors prescribe them with peace of mind (because they are accepted in all atopic dermatitis treatment guidelines), the reality is that the package insert of these two creams contains “controversial” parts that can undoubtedly frighten those who use them for the first time:

“Cases of malignant disease, including cutaneous malignant disease (e.g. cutaneous T-cell lymphomas) and other types of lymphoma, and skin cancers have been described in patients using tacrolimus ointment.”

But should we be so afraid of them? I anticipate that we should not be, but I will now explain one by one the different aspects of this treatment for atopic dermatitis…

How do tacrolimus and pimecrolimus work?

Both tacrolimus and pimecrolimus slow down the action of a molecule called calcineurin, which is found inside skin cells. When this molecule does not perform its function, other cells, the T lymphocytes involved in dermatitis, are prevented from being activated, thus preventing or reducing the occurrence of flare-ups.

When should they be used?

Pimecrolimus and Tacrolimus are excellent creams for mild to moderate atopic dermatitis. We usually use them specifically for the face, neck, creases (armpits, groin) or genital area. Corticosteroid creams and calcineurin inhibitors have very similar effects. Therefore, we should not forget that corticosteroid creams are still the mainstay of treatment, as discussed in this recent article in the JAAD (Journal of the American Academy of Dermatology).

Calcineurin inhibitors “save corticosteroids”.

The most common side effects of pimecrolimus and tacrolimus are redness and burning after application. These effects do not occur with corticosteroids, which on the other hand are much cheaper. Thus, calcineurin inhibitors are now considered second-line agents, but they are very useful because they allow us to reduce the frequency with which a person with dermatitis will need corticosteroid creams.

What is the risk?

These creams were launched in the US in 2000 and in Spain in 2002. Clinical trials conducted prior to approval showed them to be safe. However, in the years following their launch, isolated cases of lymphoma and skin cancer were reported in children and adults treated with these medicines. It was therefore decided in 2006 to add this information to the package insert.

The causal relationship between topical calcineurin inhibitors and cancer has not yet been demonstrated.

The causal relationship between the creams and the appearance of these cancers has not been proven. The fact that people who used these creams developed cancer is not necessarily due to the creams; in fact, the incidence of lymphoma in people who use these creams is the same as in the normal population (article on this subject).

The frequency of lymphomas is the same among people treated with calcineurin inhibitors as in the normal population.

To date, several studies have been performed in search of this causal relationship and to date, after more than 10 years of experience, no study has concluded that these lymphomas and skin tumors occurred because of Tacrolimus or Pimecrolimus (as stated in this article published a few months ago).

In fact, opinion articles have recently been published in medical sources and scientific journals calling for a modification of the paragraph in question in the package inserts to avoid the fear it causes in patients and their parents. It is believed that because of this warning, people who could benefit from the positive effects of these drugs do not use them because of unfounded fear.

¿Se pueden utilizar en bebés?

The package inserts for both creams state that they are approved for use from 2 years of age. However, their usefulness in infants is well known to dermatologists. This is supported by the Petite study published in 2015 in Pediatrics, the premier pediatric journal, which demonstrated the safety of these medications (as well as topical corticosteroids) in more than 2000 children over 5 years.

It is safe to use calcineurin inhibitors in children under 2 years of age.

Can they be used for other skin diseases?

Strictly speaking these creams are approved exclusively for atopic dermatitis, but they can be safely used on other skin conditions, such as seborrheic dermatitis or rosacea on occasion. If you have any doubts about this, it is best to consult a dermatologist who can indicate the best option in your case.

In conclusion…

Tacrolimus (Protopic®) and pimecrolimus (Elidel®) are creams included in all atopic dermatitis treatment guidelines and we have more than 10 years of experience in their use. Although the package insert is alarming, numerous scientific studies confirm that the risk is not such and that they are an excellent choice for dermatitis of delicate areas, as well as for reducing the need for corticosteroid creams, both in children and adults.

The post Protopic®(tacrolimus) and Elidel® (pimecrolimus) for atopic dermatitis, are they safe? first appeared on Dra. LOREA BAGAZGOITIA.

As I mentioned in another post about atopic dermatitis and its treatment, one of the mainstays of treatment is corticosteroid creams, emulsions or ointments. In people with this disease, the balance of benefits and risks of this treatment is clearly on the side of benefit, although it is important to be aware that corticosteroid creams are a drug and not just another moisturizer; therefore, their use should be indicated by a pediatrician or dermatologist.

In atopic dermatitis, the benefit of topical corticosteroids outweighs their risks.

The purpose of this article is not to scare people about the risks of topical corticosteroids, but rather to provide information to help alleviate some of the (unfounded) fears surrounding this very useful and important treatment for people with atopic dermatitis.

The purpose of this post is to inform and reassure about the use of corticosteroid creams.

1. How do topical corticosteroids work in atopic dermatitis?

Topical corticosteroids are used primarily for their anti-inflammatory effects. The drug penetrates the inflammatory cells found in dermatitis skin and reduces certain mechanisms that cause inflammation locally. They are usually used when basic hygiene and hydration measures are not sufficient. More than one hundred randomized clinical trials (the highest quality scientific studies) have been published in the scientific literature demonstrating their efficacy for atopic dermatitis.

Topical corticosteroids act by reducing inflammation and are classified according to their potency.

There are 7 groups into which they are divided according to their potency in reducing inflammation. The dermatologist (this could be done through a consultation with an online dermatologist) will indicate the most appropriate depending on where it should be used and for how long.

2. WHAT ARE THE SKIN RISKS?

In general, the risk of topical corticosteroids is very low, especially when used according to a dermatologist’s guidelines. I will describe below the problems that can occur as a result of their use, but I would like to make it clear that they are all generally due to inappropriate and abusive use over very long periods of time. Even when atopic dermatitis lasts for years and repeated cycles of one or more topical corticosteroids are performed, it is rare to achieve any of the effects you will read about below.

• CUTANEOUS ATROPHY: The use of strong corticosteroids (which we rarely prescribe, especially in children) can cause skin atrophy. This is a significant thinning of the skin, which resembles cigarette paper, and can cause stretch marks, which can make the veins under the skin more visible.

This is extremely rare in the treatment of atopic dermatitis because super-potent corticosteroids are not usually used, and if they are used, it is on an ad hoc basis. One study showed that continuous use of fluticasone (one of the most commonly used corticosteroids in children) on the same skin for 10 weeks did not cause atrophy.

• ROSACEA-LIKE ERUPTION: Continuous use on the face can cause the appearance of pimples and pinker skin in the area of use, which is almost indistinguishable from rosacea, which I will talk about in another post. This is usually seen in adults who have been using a corticosteroid on the face for years without medical control and is therefore extremely rare in children.

• OTHER SKIN CHANGES: Other less common skin changes may include lightening of the skin color (e.g., in Asia and Africa, they have been used to depigment the skin) or the appearance of more hair.

It is common in children with atopic dermatitis to see areas of lighter skin, which tends to be more noticeable in the summer. This color change is called dartros or pityriasis alba and is due to the atopic dermatitis itself and not to topical corticosteroids, as is often thought.

• CORTICOID ALLERGY: It is very rare, but it is possible to be allergic to a certain type of corticosteroid cream; this is suspected when a person does not improve at all or even gets worse after using a certain corticosteroid. As I said, it is rare, but if it is suspected, specific tests should be done to confirm it.

3. What are the risks to the REST OF THE BODY?

You may have heard many times that corticosteroids (or as they say, “cortisone”) are bad because they can raise blood pressure, make us swell or cause diabetes (elevated blood sugar). These are well-known side effects of corticosteroids, but they usually occur with long, systemic (i.e., oral or intravenous) treatments.

It is very rare for topical corticosteroids to cause systemic effects after appropriate use.

When applying a cream, emulsion, or ointment, depending on the area of the body, some of the medication may enter the bloodstream, but this amount is negligible in most cases. However, this should be taken into account in areas such as the folds of the skin, the genitals, or the eyelids, where the skin is so thin that the proportion of the drug that enters the blood is greater (compared to, for example, areas such as the palms of the hands or the forehead). In any case, it never reaches half of the amount applied.

Therefore, it is rare for blood levels to cause the typical manifestations of systemic corticosteroids. In any case, we have to keep in mind that this could happen if the treatment is abused; therefore, it is important to follow the advice of a dermatologist (whether online or in person) who will adjust the dose and type of corticosteroid according to the area or extent where it is to be applied.

4. ARE THERE ALTERNATIVES to its use?

There are alternative treatments to topical corticosteroids, but in my opinion they should not replace corticosteroids, but may be useful to supplement treatment in some cases.

Topical pimecrolimus and tacrolimus are alternative treatments to topical corticosteroids.

These treatments are topical calcineurin inhibitors (tacrolimus and pimecrolimus). These are also medications that have been shown to be safe in the long term, but I will discuss them in more detail in another post.

The post 4 questions about corticosteroid creams for atopic dermatitis first appeared on Dra. LOREA BAGAZGOITIA.