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Steroid Cream Safer Than Oral Drug for Skin Disease

Study also finds it works as well for affliction of elderly

WEDNESDAY, Jan. 30, 2002 (HealthDayNews) -- Topical steroids work as well or better than oral ones for a serious skin disorder that attacks the elderly, and they have fewer of the potentially deadly side effects, a new study says.

The condition -- called bullous pemphigoid -- is an itchy, blistering autoimmune disease. The treatment of choice for the malady has been oral corticosteroids, such as prednisone, that quiet the immune system. However, these are potent and highly toxic drugs, and patients can sometimes suffer fatal complications from therapy.

The new study by French scientists suggests that coating patients with a steroid skin cream is as effective as conventional therapy for mild to moderate blisters. In addition, the topical remedy appears even better for severe patients, cutting mortality rates and slashing the number of complications associated with oral steroids. The findings appear in tomorrow's issue of the New England Journal of Medicine.

Dr. Robert Stern, a Harvard University dermatologist and author of an editorial accompanying the journal article, says the new work is important for several reasons.

"This is a disease that is not rare, and the disease doesn't kill people. But because the people that develop the disease are generally frail, the side effects of therapy are substantial," Stern says. On the other hand, the blisters can lead to rampant infections with their own set of woes.

"Topical therapy, which is clearly safer [than oral steroids], can do a better job of controlling the disease, particularly among those who are more affected," Stern says.

Doctors in France diagnose some 500 new cases a year of bullous pemphigoid, in which immune cells attack the tissue anchoring the outer layer of skin to the "basement membrane" beneath. The United States has five times the population of France, so it likely has five times the caseload of the skin disease, Stern says. The average age of patients with the disorder is 65, and nearly two-thirds are over 80, experts say.

The latest study, led by Dr. Pascal Joly, a dermatologist at the University of Rouen, followed 188 men and women with extensive bullous pemphigoid, as well as 153 people with more moderate blisters. About half were given daily doses of prednisone, while the rest were coated nearly head to toe with clobetasol propionate, a potent corticosteroid cream.

The initial dose of the lotion started high, at 40 grams per day, but was gradually tapered as the blisters cleared. The prednisone dose was also scaled back over time.

After one year, 76 percent of the patients in the group with serious blistering who had received the cream treatment were still alive, compared with 58 percent in the oral steroid group -- a 32 percent difference. More who got the lotion had control of their condition after three weeks than those taking prednisone -- 99 percent versus 91 percent. Researchers say their rate of serious complications was also lower, 29 percent versus 54 percent.

In patients with less aggressive disease, the two treatments were equally successful and produced roughly the same rates of survival. However, patients who received the lotion had fewer cases of pneumonia, severe infections, blood clots and diabetes that required insulin.

The cream also appeared to shield patients from psychiatric complications, which occasionally accompany use of oral steroids. None of those in the lotion arm became psychotic or delirious, compared with 10 in the other group, the researchers say.

Stern notes that even the 24 percent mortality rate in the topical treatment group was high. At such a large dose, steroids in the cream must affect the entire body, he says. To reduce the risk of serious side effects, doctors could tweak the dose of lotion they prescribe, depending on the severity of a patient's blisters.

Dr. Lawrence Chan, a Northwestern University skin specialist, says he currently uses a mix of oral steroids, steroid lotions and immune-suppressing drugs to treat bullous pemphigoid. However, he'd consider trying cream alone for some patients in light of the new results.

"Using less strong medication is always advisable," Chan says.

What To Do

To learn more about bullous pemphigoid, try DermNet or the American Osteopathic College of Medicine.

For more on the side effects of corticosteroids, try the National Jewish Medical and Research Center.

SOURCES: Interviews with Lawrence Chan, M.D., director, section of immunodermatology, and assistant professor, dermatology, Northwestern University Medical School, Chicago; Robert Stern, M.D., chief, dermatology, Beth Israel Medical Center, and professor, dermatology, Harvard Medical School, Boston; Jan. 31, 2002, New England Journal of Medicine
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