Treatment with local hormonal drugs (or as doctors beautifully say «topical glucocorticosteroids», and hereinafter simply «IHP») is currently considered the most effective method of treating children with atopic dermatitis, and this effectiveness has been proven by  numerous controlled studies and  many years of practice. No matter how afraid the parents are to use such drugs, it is still necessary to do this with exacerbations of atopic dermatitis, because otherwise not only the onset of remission is delayed, but the likelihood of a secondary infection, as well as other unpleasant consequences (thickening of the skin, strengthening of its pattern , violation of pigmentation), after which it becomes extremely difficult to restore the normal state of the skin. 

Despite the fact that currently quite safe drugs have been developed that can be used from an early age (you can read about them  here ), the likelihood of side effects still remains, and therefore IHL should be used with caution and observing certain rules, which will be discussed below. …

When to apply IHL

IHP should be used only with severe exacerbation, only for a short course, and only after discussion with the attending physician about the treatment regimen. Moreover, in the event of a severe exacerbation of atopic dermatitis, the use of IHL should be started as early as possible in order to avoid the addition of a secondary infection and other unpleasant consequences. But in the case of an exacerbation of mild or moderate severity, it seems advisable to start therapy with a topical calcineurin inhibitor — Elidel non-hormonal cream. And only if no improvement is observed within 5 days of its application — use IHL. Earlier this period, it makes sense to switch to IHL with a progressive  deterioration in the  baby’s skin condition , despite the use of Elidel.

There is an opinion that the use of IHP should not be limited only to the acute stage — they must also be applied during the period of remission 2 times a week as maintenance therapy for the undulating course of the disease. However, this position is not justified using controlled studies and most experts are inclined to believe that it is much safer for these purposes to use the non-hormonal Elidel cream, which is not so limited in time of use.

It should be noted that the use of IHP is inappropriate for skin recovery after an inflammatory process, since these drugs do not solve the problem of dry skin, peeling and cracks. Moreover, prolonged use of IHP can lead to side effects in the form  of skin atrophy, telangiectasia, and other unpleasant consequences that will only aggravate the situation. For the purpose of restoring the skin after stopping the inflammatory process, constant and correct use of emollients is necessary , which help not only to cope with dryness, but also to maintain a state of remission.

It should be borne in mind that the result from the use of IHP during exacerbation of atopic dermatitis is visible almost instantly, respectively, in the absence of effect for 2 weeks of continuous treatment (this period is taken from the instructions for the use of Lokoid and Afloderm — for a child it seems too large to me) should be clarified diagnosis.

You need to choose the right shape

Currently, there are several forms of IHL used in exacerbation of atopic dermatitis in children: ointment, cream, fatty ointment, emulsion, lotion. This diversity allows doctors to prescribe the most adequate therapy depending on the area of ​​skin lesion, as well as the  stage,  severity and extent of the inflammatory process, because the correct choice of the form of the drug increases not only the effectiveness of the therapy, but also its safety. Let us consider in more detail the scope of application of various dosage forms of IHL

Ointment

IHP in the form of an ointment  at the same concentration of the active substance as in the cream has a  more powerful anti-inflammatory activity, as well as a  greater occlusive effect that increases the penetration of IHP into the skin. In addition, ointments are greasy and help the skin to retain moisture. Due to these properties, IHP in the form of an ointment are most effective in the treatment of   subacute and chronic skin lesions, manifested by thickening of the skin, strengthening of its pattern, cracks. Such drugs are used, as a rule, on the  most dense areas of the skin ( feet,  palms), especially with increased dryness of the skin, as well as if it is necessary to carry out anti-inflammatory therapy in the deeper layers of the skin.

At the same time, the ointment form is not used to treat acute inflammatory processes, especially those accompanied by oozing. It is not advisable to use ointments for the treatment of lesions localized on areas of the skin with abundant hair, as well as in the face, folds, and genitals. In addition, the use of the ointment  with high humidity  in some cases  can lead to delayed perspiration and increased itching. 

Cream

Creams are created as «oil in water». In comparison with ointments, they have a lower  ability to retain water,  do not penetrate deep into the skin,  being retained in the upper layer of the epidermis. Such properties of IHP in the form of a cream make it possible to use them in acute and subacute inflammatory processes (including in the presence of oozing), as well as in the localization of the inflammatory process on delicate sensitive areas of the skin (face, chest, neck, genital area), in the area of ​​folds and in areas with abundant hair. 

Due to the fact that the cream is easily absorbed and does not leave a greasy sheen, from an aesthetic point of view, it is more preferable than an ointment. However, it is worth remembering that creams can excessively dry the skin, and therefore, in addition to them, it is advisable to actively use emollients  or, if possible, replace the cream with more «fatty» forms (ointment, oily ointment).

Greasy ointment

Such a dosage form today exists only in Advantan. It was created for the treatment of chronic dermatoses, especially those accompanied by increased dryness of the skin, since, unlike other forms, there is no water in the oily ointment — only fat (oil). The restrictions on the use of this form are the same as for the usual ointment.

Emulsion and lotion

The basis of IHL in the form of emulsions and lotions is, as a rule, alcohol or water without fat (oil) or with a minimum amount of it, and therefore they have a pronounced drying effect, respectively, their use on dry skin areas is highly undesirable. The most common use of these forms is on the scalp, as the oil-free base facilitates easy distribution of the product on the surface of the skin without hair sticking. Alcohol and water have a cooling effect when evaporated, which can relieve itching.

However, it should be remembered that these forms often contain alcohol and propylene glycol, which can cause hypersensitivity or inflammation when used in patients with an acute course of atopic dermatitis, accompanied by erosions or cracks. 

Take a skin reaction test

If we take the instructions for any IHL, then among the side effects we will find, among other things, local reactions in the form of irritation, itching, burning, erythema, etc. Such reactions are not so common, however, before applying the drug to the inflamed areas, you should make sure that the patient does not have an individual intolerance, otherwise the existing problem can be aggravated.

To determine the tolerability of the drug, it seems appropriate to make a skin reaction test. To do this, apply a small amount of the drug to the flexor (inner) part of the elbow and assess the condition of the skin at the site of application  after 30 minutes, 4-6 hours, 12 and 24 hours. In the indicated area, the skin is the most delicate, and therefore if no negative reaction is found in the area of ​​application of the drug within 24 hours, it can be used.

If there is a reaction, then it should be remembered that patients with an allergy to IHP often have cross-reactions with several drugs of this group, and the choice should be approached with extreme caution. At the same time, intolerance to absolutely all drugs, as a rule, does not occur, and therefore it is still possible to choose a remedy suitable for a particular patient.

Applying IHP to the skin

Apply IHP in a thin layer only on damaged areas. Applying IHP in a denser layer does not increase the effectiveness of therapy, but the risk of side effects may increase in this case.

Do not mix

Unfortunately, sometimes even specialists (especially pediatricians) recommend mixing IHL before direct application to the skin, for example, with a baby cream (at best, with an emollient), arguing that such mixing will reduce the likelihood of side effects. However, this hypothesis is not supported by  data from randomized controlled trials. On the contrary, such a tactic when using modern IHP (Advantan, Lokoid, Afloderm, Elokom) is inappropriate, since “dilution” of IHP decreases their anti-inflammatory activity, and, consequently, the effectiveness of treatment. As a result, the duration of the use of IHP increases, which is precisely what contributes to the development of side effects. 

The method of mixing IHP with emollients (and not with baby cream! (How it differs from emollients can be read  here )) makes sense to use only when highly active fluorinated IHP are used, which have practically not been used in pediatrics for almost 20 years.

The use of emollients in addition to hormone therapy is certainly necessary, since the  penetration of anti-inflammatory drugs into the skin  depends in part on  the saturation of the stratum corneum with water. However, IHP should be applied approximately one hour after applying the emollient.

In the event that a secondary bacterial or fungal infection has joined the existing inflammation, an antibacterial or antifungal agent should be added to hormone therapy. However, they also cannot be mixed with IHP — it is necessary to clarify with a specialist the scheme for applying such drugs.

Which areas cannot be applied with IHL

Modern IHP approved for use in children are relatively safe even when applied to large areas of the skin. However, you should not use them under an occlusive dressing (a dressing that ensures hermetic isolation of the skin area it covers and prevents this area from contact with the environment, including air), which is often used to better penetrate the drug into the skin. This limitation is due to the fact that babies’ skin is thinner and more delicate than that of an adult, and therefore IHL  penetrates into it in the required amount  and without additional dressings. It is also worth remembering that a diaper or a diaper that fits snugly to the body can create an effect similar to that of an occlusive dressing, which means that you should not apply IHP under them.

As for folds (which can create a compress effect), areas with increased hair cover, as well as areas with particularly sensitive delicate skin (including the face, genitals), IHP should not be applied to them in the form of ointment and oily ointment.

IHP is also not advisable to use in the presence of atrophic skin changes. And the most important prohibition: IHL should never be applied to the eyelids and skin around the eyes, as this  can lead to glaucoma or cataracts!

Application frequency

The frequency of application of a particular IHP depends on its pharmacokinetics and is indicated in the instructions attached to it. As for the drugs approved for use in children, as a rule, it is 1-2 times a day. However, it should be noted that at present there is no clear evidence that the use of IHP in children 2 times a day significantly accelerates the relief of the inflammatory process and reduces the duration of treatment, at the same time, more frequent application clearly increases the risk of side effects. However, the use of IHP less often than 1 time per day is also unjustified, since it can significantly delay the onset of remission.

Thus, children should  receive the minimum dose of the drug sufficient to achieve the effect. In this regard, it  seems reasonable to prescribe daily single applications of IHP as the first stage of therapy. 

Duration of IHL use

Modern IHP can be used for a long period, up to complete remission, but no more than 3-4 weeks of daily use (depending on the drug). Of course, in this case, it is also necessary to observe the dosage of the drug established by the instructions for use.

It should be remembered that the use of IHL in children has some peculiarities. In particular, in childhood, suppression of adrenal cortex function may develop more rapidly. In addition, since babies have a greater ratio of skin surface area to body weight than adults, long-term hormonal therapy can lead to impaired growth and development. Accordingly, during long-term treatment of IHP in children, it is necessary to monitor body weight, growth and plasma cortisol levels.

Also, long-term use of IHL in babies on the face, neck and genitals is not recommended, since the skin there is especially delicate and thin.

If, after the expiration of the maximum allowed time for the use of IHP, stable remission is not achieved, it should still be replaced with Elidel, which can be treated for a longer period until remission is achieved.

Do not cancel abruptly

It is important to remember that abrupt cessation of the use of IHL after prolonged therapy can lead to the development of a withdrawal syndrome (otherwise, rebound syndrome). The essence of this syndrome is the deterioration of the patient’s condition, manifested, as a rule, in the intensified development of symptoms and conditions,  the elimination of which was directed by the drug (and sometimes the  emergence of qualitatively new symptoms or conditions that were absent in the patient before), with a sharp cessation or decrease taking the drug. In the case of IHL, this syndrome usually manifests itself  in the form of dermatitis with intense redness of the skin and a burning sensation.

In order to prevent the development of withdrawal syndrome, hormone therapy should be stopped gradually. The following scheme seems reasonable: for 7 days in a row, IHP is applied once a day, then 3 times every 1 day, then 3 times every 2 days, and only after that the drug is completely canceled. Thus, the entire treatment regimen takes 22 days.

Do not violate the instructions for use

Before using any IHL, you should consult a specialist, carefully study the instructions, make sure that the drug is suitable, there are no contraindications (including age), etc.

In the course of treatment, in no case should the frequency and duration of use, as well as the dosage, be exceeded, as recommended in the instructions for a particular IHP.

Compliance with these rules will help to achieve an early onset of remission, as well as reduce the likelihood of side effects.

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