< Back to previous page
Publication
Recommendations for pimecrolimus 1% in the treatment of mild-to-moderate atopic dermatitis from medical needs to a new treatment algoritm
Journal Contribution - Journal Article
Atopic dermatitis (AD) is a chronic inflammatory, relapsing and pruritic skin disease [1-3]. AD is estimated to affect up to 25% of children and 2-10% of adults with the prevalence of disease having doubled or tripled in industrialized countries over the past 30 years [4, 5]. The disease has a considerable impact on the quality of life (QoL) of both patients and their families [6].
Although the pathogenesis of AD is not completely understood, it is thought to result from a complex interplay between disruption of the epidermal barrier, immune dysfunction and environmental and infectious trigger factors [4, 7]. The disturbance of the skin barrier leads to increased transepidermal water loss and scaly skin, an increased disposition to skin infections, and greater penetration of irritants and allergens into the skin [4, 7, 8]. Furthermore, recent research has indicated that the diversity in the skin microbial flora (i.e., the microbiome) is significantly decreased in affected skin areas of AD patients compared with controls and that changes in microbial diversity occur during disease flares which are dependent on previous AD treatments [9].
Since AD is a chronic and relapsing disease, a multi-faceted, long-term, clinical management approach is required. The therapeutic objectives should be to reduce the signs and symptoms of disease, such as eczema and pruritus, to repair the altered epidermal barrier and to improve QoL. Furthermore, treatments should aim to address the underlying immune dysfunction, which may prevent progression to disease flares and prolong remission periods [4, 7, 10]. Timely disease control is also advisable since early onset and disease severity may be regarded as risk factors for the so called "atopic march", i.e., the subsequent development and persistence of asthma and allergic rhinitis [11]. The term "atopic march" was coined to indicate that, based on the time of onset, skin involvement seems to predispose to the development of these other atopic diseases [7, 12]. Given the chronic nature of the disease, topical treatments for AD also need to be convenient to apply, safe and well tolerated. Educational courses should be offered to patients in addition to the treatment, given that these programs can improve the long-term management of AD [13].
Several treatment options are currently available for AD patients. Standard basic therapy for all AD patients involves optimal skin care and the identification and avoidance of trigger factors [1, 3, 7]. Emollients are the current mainstay for maintenance therapy of AD. They help to restore the impaired epidermal barrier function and thereby improve eczema and pruritus [1, 3, 14, 15]. Anti-inflammatory treatments for AD include topical corticosteroids (TCSs) and topical calcineurin inhibitors (TCIs) [3]. Due to their broad anti-inflammatory actions, TCSs have been the cornerstone of topical AD therapy for the past 50 years and are recommended for treating disease flares [3, 16]. More recently, two TCIs have become available for AD treatment [3, 14]. Pimecrolimus 1% cream is indicated for the treatment of patients aged 2 years and over with mild-to-moderate AD where treatment with TCSs is either inadvisable or not possible. Tacrolimus ointment is indicated in moderate-to-severe AD in patients aged 2 years and over who are not adequately responsive to or are intolerant of conventional therapies such as TCSs; the 0.1% ointment is for adolescents over 16 years and adults, whereas the 0.03% ointment can be used for children 2 years and older. TCIs have a more specific mode of action than TCSs. They selectively inhibit activation of T cells and mast cells and suppress the production of pro-inflammatory cytokines as well as other mediators of inflammation and pruritus [17, 18]. Severe AD requiring UV therapy or treatment with immunomodulating drugs is not the focus of this paper [19].
The purpose of this review article is to evaluate clinical data on the use of pimecrolimus 1% cream in the management of mild-to-moderate AD in relation to the current medical needs of patients and in comparison with other topical AD treatments. On the basis of this review of published data and the clinical experience of the authors, a new practical algorithm for the treatment of patients with mild-to-moderate AD with pimecrolimus is proposed.
Although the pathogenesis of AD is not completely understood, it is thought to result from a complex interplay between disruption of the epidermal barrier, immune dysfunction and environmental and infectious trigger factors [4, 7]. The disturbance of the skin barrier leads to increased transepidermal water loss and scaly skin, an increased disposition to skin infections, and greater penetration of irritants and allergens into the skin [4, 7, 8]. Furthermore, recent research has indicated that the diversity in the skin microbial flora (i.e., the microbiome) is significantly decreased in affected skin areas of AD patients compared with controls and that changes in microbial diversity occur during disease flares which are dependent on previous AD treatments [9].
Since AD is a chronic and relapsing disease, a multi-faceted, long-term, clinical management approach is required. The therapeutic objectives should be to reduce the signs and symptoms of disease, such as eczema and pruritus, to repair the altered epidermal barrier and to improve QoL. Furthermore, treatments should aim to address the underlying immune dysfunction, which may prevent progression to disease flares and prolong remission periods [4, 7, 10]. Timely disease control is also advisable since early onset and disease severity may be regarded as risk factors for the so called "atopic march", i.e., the subsequent development and persistence of asthma and allergic rhinitis [11]. The term "atopic march" was coined to indicate that, based on the time of onset, skin involvement seems to predispose to the development of these other atopic diseases [7, 12]. Given the chronic nature of the disease, topical treatments for AD also need to be convenient to apply, safe and well tolerated. Educational courses should be offered to patients in addition to the treatment, given that these programs can improve the long-term management of AD [13].
Several treatment options are currently available for AD patients. Standard basic therapy for all AD patients involves optimal skin care and the identification and avoidance of trigger factors [1, 3, 7]. Emollients are the current mainstay for maintenance therapy of AD. They help to restore the impaired epidermal barrier function and thereby improve eczema and pruritus [1, 3, 14, 15]. Anti-inflammatory treatments for AD include topical corticosteroids (TCSs) and topical calcineurin inhibitors (TCIs) [3]. Due to their broad anti-inflammatory actions, TCSs have been the cornerstone of topical AD therapy for the past 50 years and are recommended for treating disease flares [3, 16]. More recently, two TCIs have become available for AD treatment [3, 14]. Pimecrolimus 1% cream is indicated for the treatment of patients aged 2 years and over with mild-to-moderate AD where treatment with TCSs is either inadvisable or not possible. Tacrolimus ointment is indicated in moderate-to-severe AD in patients aged 2 years and over who are not adequately responsive to or are intolerant of conventional therapies such as TCSs; the 0.1% ointment is for adolescents over 16 years and adults, whereas the 0.03% ointment can be used for children 2 years and older. TCIs have a more specific mode of action than TCSs. They selectively inhibit activation of T cells and mast cells and suppress the production of pro-inflammatory cytokines as well as other mediators of inflammation and pruritus [17, 18]. Severe AD requiring UV therapy or treatment with immunomodulating drugs is not the focus of this paper [19].
The purpose of this review article is to evaluate clinical data on the use of pimecrolimus 1% cream in the management of mild-to-moderate AD in relation to the current medical needs of patients and in comparison with other topical AD treatments. On the basis of this review of published data and the clinical experience of the authors, a new practical algorithm for the treatment of patients with mild-to-moderate AD with pimecrolimus is proposed.
Journal: Eur J Dermatol
ISSN: 1167-1122
Volume: 23
Pages: 758-786
Publication year:2013
Keywords:atopic dermatitis, pimecrolimus, topical calcineurin inhibitor, topical corticosteroid, treatment algorithm