Chapter 11 Temporal Dermatology
Improvement of Atopic Dermatitis After Discontinuation of Topical Corticosteroid Treatment
By M Fukaya published in the Arch Dermatol. 2000;136:679-680.
This is the article I wrote for the Archives of Dermatology in 2000. As most of papers on steroid addiction written by Dr. Kligman and others treated general theory, I wanted to report on the actual progress of atopic dermatitis after topical corticosteroid (TCS) application was discontinued.
----- Excerpt -----
Topical corticosteroids are a useful form of treatment for atopic dermatitis. However, patients are likely to be addicted after long-term treatment. This paradoxical phenomenon has so far been underestimated, and improvement following the temporary rebound flare after discontinuation of corticosteroid therapy has been entirely ignored.
Report of a Case. A 20-year-old man was affected with atopic dermatitis since early childhood. He used topical corticosteroids intermittently but found that the amount and frequency of applications had steadily increased since he turned age 18 years. The patient used 10 to 40 g per month of 0.12% betamethazone valerate ointment on his body and 0.25% predonisolone acetate ointment on his face. Total IgE was 7179 U/mL and white blood cell count showed 27.1% eosinophils.
He had developed patchy erythema and prurigo on his entire body before discontinuing treatment with topical steroids. One month after he discontinued steroid use, prurigo flattened and the erythema extended over his entire body. After 2 months, exudative erythema developed on his forehead and his features showed erythroderma. Four months after he stopped the steroid treatment, his rebound flare was at its worst point, especially on the face. After 6 months, the dermatitis improved, first on the face; then the exudative lesions disappeared.
After 1 year, the skin’s appearance became almost normal with the exception of some dry lesions on the elbows and wrists, which were found to be consistent with features of classic atopic dermatitis. One and a half years after treatment was stopped, the patient’s eczema subsided, and his total IgE was 3300 U/mL, while the white blood cell count showed only 7.8% eosinophils. Throughout the observation period, no systemic steroids were required, and the patient used only white petrolatum or 5% zinc oxide and antihistamines as oral drugs; 10% povidone-iodine was used to prevent secondary infection.
----- End of excerpt -----
This paper describes the remission process after withdrawal – it is called description dermatology to learn how to use dermatological terms and expressions for better communication to others. Clear-cut explanation is possible with pictures. Pictures taken for the presented cases are not with me any more and I’d like to show the pictures for similar cases.
Improvement of Atopic Dermatitis After Discontinuation of Topical Corticosteroid Treatment
By M Fukaya published in the Arch Dermatol. 2000;136:679-680.
This is the article I wrote for the Archives of Dermatology in 2000. As most of papers on steroid addiction written by Dr. Kligman and others treated general theory, I wanted to report on the actual progress of atopic dermatitis after topical corticosteroid (TCS) application was discontinued.
----- Excerpt -----
Topical corticosteroids are a useful form of treatment for atopic dermatitis. However, patients are likely to be addicted after long-term treatment. This paradoxical phenomenon has so far been underestimated, and improvement following the temporary rebound flare after discontinuation of corticosteroid therapy has been entirely ignored.
Report of a Case. A 20-year-old man was affected with atopic dermatitis since early childhood. He used topical corticosteroids intermittently but found that the amount and frequency of applications had steadily increased since he turned age 18 years. The patient used 10 to 40 g per month of 0.12% betamethazone valerate ointment on his body and 0.25% predonisolone acetate ointment on his face. Total IgE was 7179 U/mL and white blood cell count showed 27.1% eosinophils.
He had developed patchy erythema and prurigo on his entire body before discontinuing treatment with topical steroids. One month after he discontinued steroid use, prurigo flattened and the erythema extended over his entire body. After 2 months, exudative erythema developed on his forehead and his features showed erythroderma. Four months after he stopped the steroid treatment, his rebound flare was at its worst point, especially on the face. After 6 months, the dermatitis improved, first on the face; then the exudative lesions disappeared.
After 1 year, the skin’s appearance became almost normal with the exception of some dry lesions on the elbows and wrists, which were found to be consistent with features of classic atopic dermatitis. One and a half years after treatment was stopped, the patient’s eczema subsided, and his total IgE was 3300 U/mL, while the white blood cell count showed only 7.8% eosinophils. Throughout the observation period, no systemic steroids were required, and the patient used only white petrolatum or 5% zinc oxide and antihistamines as oral drugs; 10% povidone-iodine was used to prevent secondary infection.
----- End of excerpt -----
This paper describes the remission process after withdrawal – it is called description dermatology to learn how to use dermatological terms and expressions for better communication to others. Clear-cut explanation is possible with pictures. Pictures taken for the presented cases are not with me any more and I’d like to show the pictures for similar cases.
You can see initial patchy erythema is fusing into erythroderma, which turns into exudative and then remits, dries, gets pigmented and recovers into healthy skin condition. I used to keep track of eruption over time and called such a treatment style as “temporal dermatology.”
Dermatologists usually make a diagnosis seeing the current skin condition of patients, which is the observation performed on only one occasion. I thought the pattern recognition over time would further upgrade the art of dermatological diagnosis. This diagnosis style is useful for my present job in cosmetic surgery.
I used to take many pictures during a consultation till I got satisfied. Sorting through pictures is not hard work any more thanks to digital cameras and personal computers, but I was still using a film camera when I worked for the national hospital. I would use up 4 to 5 rolls of 24-expusure films per day to keep the record. Sorting through developed pictures was really tough.
Putting complaints aside, a clinical picture of atopic dermatitis or rebound flare at one moment is a nonspecific inflammation image and may not arouse the academic interest of dermatologists. I think it will be interesting to take temporal pictures and classify the cases according to the process in each case.
I actually noticed the risk of addiction and rebound during the process of sorting temporal pictures. (Otherwise, I may have missed the phenomenon.)
The following figure indicates how addiction and rebound develop.
Dermatologists usually make a diagnosis seeing the current skin condition of patients, which is the observation performed on only one occasion. I thought the pattern recognition over time would further upgrade the art of dermatological diagnosis. This diagnosis style is useful for my present job in cosmetic surgery.
I used to take many pictures during a consultation till I got satisfied. Sorting through pictures is not hard work any more thanks to digital cameras and personal computers, but I was still using a film camera when I worked for the national hospital. I would use up 4 to 5 rolls of 24-expusure films per day to keep the record. Sorting through developed pictures was really tough.
Putting complaints aside, a clinical picture of atopic dermatitis or rebound flare at one moment is a nonspecific inflammation image and may not arouse the academic interest of dermatologists. I think it will be interesting to take temporal pictures and classify the cases according to the process in each case.
I actually noticed the risk of addiction and rebound during the process of sorting temporal pictures. (Otherwise, I may have missed the phenomenon.)
The following figure indicates how addiction and rebound develop.
Addiction and rebound develop in the course of time and cannot be diagnosed with a single picture. It must be determined in the whole and successive time series. It is difficult to judge seeing only one of the above pictures if the inflammation is a rebound flare or just the aggravation of original atopic dermatitis. Diagnosis is possible only when all the above images are examined in the time series beginning with TCS application for a long time and discontinuation.
Therefore, the dermatological art of diagnosing at first glance is not available for a first-seen patient. Without the past progress depiction by means of graph or something, it is impossible to medically support TCS withdrawal.
There are various doctors providing the medical care for TCS withdrawal and many of them seem to have a memory good enough to perform “temporal dermatology.” I guess they can recall past clinical images of a patient like seeing the thumbnail vision. (I have a weak memory, which I’m not saying from modesty, and took a large number of pictures. Thanks to this I could notice the phenomenon of addiction or rebound.)
Therefore, the dermatological art of diagnosing at first glance is not available for a first-seen patient. Without the past progress depiction by means of graph or something, it is impossible to medically support TCS withdrawal.
There are various doctors providing the medical care for TCS withdrawal and many of them seem to have a memory good enough to perform “temporal dermatology.” I guess they can recall past clinical images of a patient like seeing the thumbnail vision. (I have a weak memory, which I’m not saying from modesty, and took a large number of pictures. Thanks to this I could notice the phenomenon of addiction or rebound.)