Complications
Skin conditions, such as atopic dermatitis, have important psychological ramifications for both the patient and the family. Psychological interventions have been shown to improve disease tolerance in adults with atopic dermatitis, particularly in cases of severe disease (most notably itching).[179][180]
Adverse effects of topical corticosteroids include skin atrophy, hypopigmentation, striae, purpura, focal hypertrichosis, acneiform eruptions, and telangiectasias.[85] Skin atrophy is generally the most concerning for physicians and patients. Risk factors for atrophy include higher-potency topical corticosteroid use, occlusion, use on thinner and intertriginous skin, older patient age, and long-term continuous use. Allergic contact dermatitis to topical corticosteroids or other ingredients in their formulations can be determined via patch testing.[85]
Systemic adverse effects associated with topical corticosteroid use are rare, but include hypothalamic-pituitary-adrenal axis suppression, reduction of linear growth rate, Cushing syndrome, and reduction of bone density.[96] These events usually occur in patients using large quantities of potent corticosteroids; using the lowest-potency formulation that effectively treats a patient's dermatitis will help to minimize adverse effects. An association with cataracts or glaucoma is unclear, but minimizing periocular corticosteroid use is advised.[85]
The most consistent risk factor associated with TSW/TSA is prolonged, inappropriate use of potent topical corticosteroids on the face or in intertriginous areas (which would be inadvisable in any case).[85] While these are still poorly understood groups of reactions, the evidence to date is that they typically occur in four stages: a few days (usually) after discontinuation, there is an acute eruption of burning red, exudative skin, which may extend to untreated areas; skin becomes dry and itchy with shedding (desquamation); skin starts to recover but is more sensitive, and intermittent flares may occur; skin recovers to the state prior to topical corticosteroid cessation. The recovery process may be prolonged. Continued use of topical corticosteroids should be reevaluated and alternative treatment options explored if a suspected TSW has occurred.[178]
There is a theoretical risk of malignancy in patients using topical calcineurin inhibitors. The Food and Drug Administration recognizes that a causal relationship has not been confirmed, while advising that the long-term safety of these drugs has not been established, and recommending limiting their use to affected areas and avoiding long-term use when possible.
A prospective evaluation of the long-term safety of topical calcineurin inhibitors in approximately 8000 pediatric patients with atopic dermatitis (44,629 person-years) reported six confirmed incident cancers.[101] The cancer incidence was as expected, given matched background data (standardized incidence ratio 1.01, 95% CI 0.37 to 2.20); no lymphomas were reported. The study concluded that pediatric patients using a calcineurin inhibitor for atopic dermatitis are not at increased risk of developing malignancies.[101] Conversely, a subsequent systematic review to evaluate the risk of lymphoma associated with topical calcineurin inhibitor treatment concluded that the use of either topical tacrolimus or pimecrolimus significantly increased the risk of lymphoma.[102] Subgroup analyses showed that both topical tacrolimus and pimecrolimus significantly increased risk of non-Hodgkin lymphoma, but found no increased risk of Hodgkin lymphoma.[102]
Patients are at increased risk for bacterial cutaneous infections. Consider infection any time that a patient has a flare of their atopic dermatitis. The skin often shows increased erythema with pustules or crusting. Colonization of the skin surface, even in the absence of overt evidence of skin infection, can prompt worsening of the disease status. Depending on the level of severity of the skin findings, treatment may include dilute bleach baths, or topical or systemic antibiotics. Consider use of a topical antibiotic first if the infection is limited.[113]
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Adverse effects include hepatotoxicity and myelotoxicity, as well as concerns that long-term use may increase the risk of certain malignancies. Myelotoxicity has been shown to be related to activity of thiopurine methyltransferase (TPMT), an enzyme necessary for the metabolism of azathioprine.
Assess TPMT activity before initiating therapy, and reduce the dose in patients with reduced TPMT activity. Consider TPMT testing in patients with abnormal complete blood counts that persist despite dose reduction of azathioprine.
This is a severe skin infection caused by herpes simplex virus in a patient with atopic dermatitis. Characteristic lesions are grouped vesicles or pustules, and may later progress to "punched out" ulcerations. Patients often have extensive skin involvement, although areas of active dermatitis seem to be most severely affected.[1]
Patients are treated with antivirals.
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