Systemic propranolol is currently a widespread treatment when managing infantile hemangiomas (IH), but what about topical propranolol?. Little has been reported regarding this indication. In a very interesting paper just published by Dr. Guangqi Xu et al in the Journal of the American Academy of Dermatology the authors evaluate the efficacy and safety of topical propranolol in the treatment of superficial IHs.

The authors communicate their retrospective experience in 25 patients suffering from a total of 28 superficial IHs. 1% propranolol ointment was applied three times a day, rubbed on the lesion, during a mean duration of 21 weeks. The median age of the patients was 4 months. A good response to therapy was documented in 16 IHs (57%), a partial response in 9 IHs (33%) and no response in 3 IHs (10%). Interestingly, therapy seemed to be more efficacious in younger patients. Based on this last finding the authors suggest that treatment was more effective in the proliferation phase than in the maturation phase. No significant side effects were detected.

Of course, the authors underline that this is a small retrospective study and therefore, prospective, controlled, randomized studies are needed to define the exact role topical propranolol should play in the management of superficial IHs.

Dr. Xu an co-workers confirm previous reports: according to their results 1% propranolol ointment is effective and safe in superficial IHs and the authors support its use as adjuvant treatment during the usual wait-and-see period.

Topical propranolol for treatment of superficial infantile hemangiomas.

Xu G, Lv R, Zhao Z, Huo R.

J Am Acad Dermatol. 2012 Apr 17.  

PMID:

22516113

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

More studies are needed…

Atopic dermatitis can be a chronic disabling disorder with a significant impact on patients quality of life. Currently, we do have efficacious systemic therapies, especially for the short term, such as corticosteroids, ciclosporine and photo-therapy. Most of these therapies are conditioned on the long term, mainly due to security reasons. Therefore, we still need to develop new treatments which combine efficacy, safety and the possibility of maintenance therapy. In this scenario, the recently published study by Dr. Schram and co-workers deserves to be read in detail as it is the first randomized controlled trial comparing methotrexate and azathioprine in severe atopic eczema. Two potentially efficacious agents to treat atopic dermatitis but with little reported evidence to support this indication.

The authors designed a single-blind, parallel-group randomized controlled study enrolling 42 adult patients suffering from severe atopic eczema to be treated with methotrexate 10-22,5 mg/wk or azathioprine 1,5-2,5 mg/Kg/day during 12 weeks, and 12 weeks of follow-up. At the end of the treating period (week 12), patients receiving methotrexate had a mean relative reduction in the severity scoring of atopic dermatitis index of 42% (SD,18%) compared with 39% (SD, 25%) in the azathioprine group (P=0,52). At weeks 12 and 24 the impact both therapies had on patients quality of life and symptoms was similar.There were no statistically significant differences in the number and severity of adverse events between both groups.

The authors conclude that methotrexate and azathioprine can be considered as adequate alternatives for the treatment of severe atopic eczema in adults as they were both safe in the short term and they had both clinically relevant positive impact on the disease. Future studies with bigger numbers of patients and longer time of treatment and follow-up will help us to define the role these drugs can have in our every day management of patients suffering from atopic eczema.

ORIGINAL ARTICLE:

A randomized trial of methotrexate versus azathioprine for severe atopic eczema. Schram ME, Roekevisch E, Leeflang MM, Bos JD, Schmitt J, Spuls PI. J Allergy Clin Immunol. 2011 Aug;128(2):353-9. PMID: 21514637

COMMENTARY:

A randomized trial of methotrexate vs. azathioprine for severe atopic eczema: a critical appraisal. Patel AN, Langan SM, Batchelor JM. Br J Dermatol. 2012 Apr;166(4):701-3. PMID: 22452432

Ingenol mebutate gel has just been approved by the US Food and Drug Administration (FDA) to treat actinic keratosis (AK) on the face, scalp, trunk and extremities. Ingenol mebutate is a field-directed topical therapy currently available in two concentrations: a 0.015% (150 mcg/g) concentration, designed to treat the face and scalp once daily in three consecutive days, and a 0.05% (500 mcg/g) concentration for treatment of the trunk and extremities applied once daily for two consecutive days. Significant efficacy versus placebo has been documented in several reported clinical trials. In terms of safety the most frequent adverse reactions are local skin irritative reactions, pruritus and pain.  

AK are a very prevalent disorder in sun-exposed Caucasian populations. They are frequently multiple and they are considered as the earliest stage in the development of an important percentage of squamous cell carcinomas. Of course the very short duration of this self-administered therapy makes it a very interesting alternative to existing topical therapies, improving adherence to therapy.

In case you are interested in reading in detail reported clinical trials you may consult this paper:

Ingenol Mebutate Gel for Actinic Keratosis.

Mark Lebwohl, M.D., Neil Swanson, M.D., Lawrence L. Anderson, M.D., Anita Melgaard, M.Sc.Stat., Zhenyi Xu, M.D., and Brian Berman, M.D., Ph.D.

N Engl J Med 2012; 366:1010-1019.  PMID: 22417254