Currently, moderate to severe atopic dermatitis is treated topically with a potent corticosteroid followed by a lower potency formulation, or a short course of corticosteroid followed by emollients. Berth-Jones and colleagues studied a third strategy consisting of initial treatment with fluticasone followed by maintenance emollients with twice weekly fluticasone.
They studied patients 12 to 65 years of age who had recurrent atopic dermatitis and scored higher than 4 on a standardized scale for severity of disease. Patients were excluded from the study if they had other dermatologic conditions that could interfere with assessment of the skin, and if they were receiving medications that could influence the study results. The 376 patients were initially treated with fluticasone propionate cream (0.05 percent) or ointment (0.005 percent) once or twice daily for four weeks. Patients who achieved remission (a score of 1 or lower) were randomly assigned to maintenance treatment with emollient plus fluticasone or placebo on two successive evenings per week for up to 16 weeks. Patients were assessed every two weeks during stabilization and after two, six, 10, and 16 weeks of maintenance. In addition to documentation of dermatitis, patients were assessed for evidence of skin atrophy and adverse effects of treatment.
Of the 295 patients who entered the maintenance phase, 154 used cream, and 141 used ointment. After 16 weeks, 87 patients using fluticasone twice weekly and 46 using placebo in addition to emollients still had controlled dermatitis. The median time to relapse with twice-weekly fluticasone cream or ointment was greater than 16 weeks, significantly longer than median time to relapse with emollient alone (6.1 weeks). The number needed to treat was 2.2 for cream and 6.1 for ointment. The rate of relapse was greater with fluticasone ointment than with cream (40 percent compared with 19 percent), but no differences were noted between twice-daily and once-daily applications.
The authors conclude that once the acute flare of atopic dermatitis has been controlled, fluticasone cream or ointment applied twice weekly added to maintenance emollient therapy significantly extends remission and reduces the risk of relapse.