An Appropriate Response to the Black-Box Warning: Corrective, Barrier Repair Therapy in Atopic Dermatitis.
Due to years of sophisticated research on T cell function, many dermatologists have viewed atopic dermatitis (AD) largely as an inflammatory disorder of TH1/TH2 imbalance. Hence, therapy has largely consisted of topical immunomodulators and/or steroids. The imposition of "black box" warnings about the potential toxicity associated with prolonged use of the immunosuppressive drugs, tacrolimus 0.1% or 0.3% ointment (Protopic((R)), Astellas Pharma U.S., Inc., Deerfield, IL) and pimecrolimus 1% cream (Elidel((R)), Novartis, Basel, Switzerland), as well as legitimate concerns about the adverse side effects of potent topical steroids, has stimulated a search for alternate forms of therapy. Recent genetic studies point to the primary role of a defective barrier to water loss and microbial invasion in the provocation of AD, creating a rationale for 'barrier repair' therapy. This approach utilizes topical applications of specific combination of the three (3) epidermal lipids that comprise the epidermal permeability barrier in a ratio (ceramide-dominant) that corrects the biochemical abnormality in AD.1,2 We review here both recent concerns about the topical immunomodulators, as well as the rationale for barrier repair therapy.
Dermatology Service, Veterans Affairs Medical Center, and Department of Dermatology, University of California, San Francisco, CA.
Peter M
PM
Elias