Chapter 24 Dr. Tamaki’s “Therapy”
Treatment without Steroid Ointment for Adult Type Atopic Dermatitis
By A Tamaki et al. published in the Japanese Journal of Dermatoallergology, Vol. 1, No. 1 (August 1993)
In 1991, Dr. Enomoto said that skin problems observed during the rebound period after topical steroid withdrawal is “a disorder different from the primary disease, which is more like rosacea spread over the whole body, and should be called as topical steroid withdrawal syndrome (TSWS) to distinguish from the withdrawal syndrome after systemic steroid withdrawal accompanied by adrenal suppression. Two years after this, Dr. Tamaki, who was working at Yodogawa Christian Hospital then, published the paper above. Dr. Enomoto focused on the rash peculiar to the withdrawal process, whereas Dr. Tamaki reported on successful cases of remission achieved by topical corticosteroid withdrawal.
The following is the whole text of Abstract.
----- Excerpt -----
Patients with adult type atopic dermatitis (AD) who wanted to discontinue treatment with steroid ointment were treated without this preparation. The clinical course of 26 severe cases of adult type AD was investigated. Most of these cases had developed edema, erythema, excoriations and desquamation. These symptoms were more severe and lasted longer than those of rosacea-like dermatitis. Successful cases improved in six months to one year. Six out of these 26 cases showed remission, five partial remission, seven improvement. However, four patients returned to steroid ointment treatment and three patients had to stop working. Finally, one case showed no change. These clinical courses showed no correlation with atopic history, serum IgE or the beginning of the discontinuation of the steroid ointment treatment.
----- End of excerpt -----
Those who are familiar to statistics may think, “This is a prospective cohort study or case series when it comes to study design. Out of these 26 cases, 18 saw improvement or more satisfactory results. How much is the half to one-year later improvement rate in the whole of patients with AD? Without this rate, it is impossible to calculate the relative risk to determine whether or not the treatment without steroid ointment was effective.”
Well, if topical corticosteroids are used for AD patients who have never been treated with these drugs, the recovery rate in a half to one year will be nearly 100%. But Dr. Tamaki’s study design is totally opposite. That is, it could be estimated before the study that most of the 26 patients would get worse. On the contrary, improvement or better outcomes were gained in some 70%. From the dermatological point of view, we can see this is abnormal even without the statistically processed relative risk.
Due to this abnormality, dermatologists and the Dermatological Association cast doubt saying, “It has been confirmed that topical corticosteroids are effective for AD treatment. It never happens that recovery from AD can be achieved by stopping topical corticosteroids.”
Another factor that makes the story complicated was hidden in the title. Due to the wording peculiar to Japanese, I guess quite a few people got a false idea from the Japanese title of this paper.
As one of the methods to treat hepatitis B, there is a manner called steroid withdrawal therapy. It is applied to gain a negative response of e antigens by administering and then stopping steroids to sharply increase transaminase value (rebound) to cause clinical condition similar to acute hepatitis, as it takes more time for chronic hepatitis to achieve a negative response of e antigens compared to acute hepatitis. The first report on this method was made in 1979 in Japan. Hearing “steroid ointment withdrawal therapy” (literal translation of the Japanese title of Dr. Tamaki’s paper), some doctors might have been misunderstood that this is a method to alleviate AD through withdrawal as medical intervention (that brings about rebound). Such a person might have thought that it’s not good to take the method that may afflict patients.
“Steroid withdrawal therapy”is the treatment method for hepatitis. Dr. Tamaki employed“Treatment without Steroid Ointment for Adult Type Atopic Dermatitis”as an English title of his paper.
Dr. Tamaki’s paper falls into a case report on side effects. He is not suggesting a new treatment method. What he is proposing is not a new type of therapy called “steroid ointment withdrawal” but the withdrawal from “steroid ointment therapy.”
Appraisal for the paper depends on the subject of the paper: proposal of a new treatment method or a report on side effects? If he intends to suggest a new treatment method, verification with a strict study design such as randomized controlled trial is required. In the case of a side effect report, if a given amount of case reports are gathered from many institutions or doctors, they should be introduced in the guideline or other publications to issue the warning. The Japanese Dermatological Association (JDA) guideline preparation committee has failed to perform its responsibility.
Let’s look at Dr. Tamaki’s paper more.
----- Excerpt -----
Adult AD patients are increasing recently. Though there remains much to be clarified for the causes, abuse of steroid ointments is considered one of the reasons. From our experience, contact dermatitis that seemed to be cleared soon sometimes persisted while applying steroid ointment and exhibited typical flare of AD later. In addition, steroid ointment became ineffective for some patients after a while. Mainstream opinion for such a case in JDA is to apply a more potent steroid ointment or short-term systemic corticosteroid to control the symptoms. Is it really true? With this method, patients have to continue to use steroids forever. It’s time to review the current way of treatment.
----- End of excerpt -----
I have met Dr. Tamaki. He is a good-natured person and never argues against dermatologists sticking to steroids without paying attention to the risks of addiction and rebound as I would. His way of writing the paper reflects such a mild character. He tried to point out the problem of topical steroid therapy commonly employed as of 1993 in an indirect way. This made him avoid clearly remarking that this paper is the side effect report, and therefore some with knowledge can understand what he intends to say and others without cannot.
----- Excerpt -----
While some patients recovered well by just stopping steroid ointment application, others did not and couldn’t help resuming it to suppress the symptoms due to their vocation or other reasons. In almost all the cases of rosacea-like dermatitis, patients recovered just by discontinuing steroid ointment, which is the big difference from AD cases. As there were no correlations with atopic history, serum IgE, beginning of the discontinuation and duration of steroid ointment treatment (not indicated here). It is still difficult to specify in what case good results can be gained by discontinuing steroid ointment. This may be because AD is a multifactorial skin disorder. Additionally the inflammation, having once resided, will recur if patients fail to stick to their regimens to preserve health. Though this paper covers 26 patients who had to be hospitalized due to severe exacerbations, I have seen 2 to 3 times more patients who successfully withdrew from steroid ointment by coming to the hospital regularly. Right now, we can’t say any adult type AD will reside just by stopping steroid ointment. But it is also true that most individuals who do not want to use steroid ointment run to physicians, pediatricians or even Chinese herbal medicine or folk medicine to seek help. I hope the presented method can be one option for treating intractable adult AD.
----- End of excerpt -----
What he said is correct, but the word “this presented method” in the last sentence might have made more readers think “treatment without steroid (ointment)” was the treatment method. Dr. Tamaki might have wanted to discuss topical steroid withdrawal as one way of medical intervention to facilitate patients’ recovery without using such negative words as side effects. (As far as I know, he is such a kind of person.) But his vague expression might have eventually spread misunderstanding.
I myself avoid using “steroid ointment withdrawal therapy” to evade misunderstanding. Steroid addiction is the most optimum word and used worldwide.
Dr. Tamaki tried to analyze the results according to the incentives of the 26 patients: 1. Patient’s own decision; 2. Agreement between patient and doctor; and 3. Doctor’s active encouragement. In case 1, all a doctor has to do is to accept a patient’s desire. In cases 2 and 3, it is predicted there was some sort of intervention from a doctor in some way. I estimate that Dr. Tamaki might have recommended patients try steroid ointment withdrawal therapy without saying, “How about discontinuing topical corticosteroids as you might be addicted to steroids,” out of fear that patients may have steroid phobia.
If so, it was a very Japanese way of solving the problem.
If other dermatologists had understood his intention, the conflict over steroid addiction might have soft-landed. I think he wanted to establish a cooperative relationship between patients and dermatologists by using the word “steroid ointment withdrawal therapy” without referring to steroid addiction even though it is a real problem that a patient has it as a result of prolonged use of topical corticosteroids. But most dermatologists could not read his intention from this paper. I myself had a very strange feeling when I first read this paper. I can understand his intention now that I have met him some times and know his personality.
However, the chance of a soft landing Dr. Tamaki prepared in his own fashion was erased by Dr. Kawashima, who emphatically criticized Dr. Tamaki at medical conferences such as the Central Japan Branch Academic Conference in 1998. I think Dr. Kawashima tried to attain soft landing in another form by making the steroid ointment withdrawal therapy a culprit that gave an excuse for the atopic business. His strategy seems to have succeeded. Talking about topical steroid withdrawal is a taboo for dermatologists now.
Has this problem been really muffled? I myself began to raise the question after several years of rest.
The facts in natural science, if concealed, will some day cause contradiction in a visible way.
Treatment without Steroid Ointment for Adult Type Atopic Dermatitis
By A Tamaki et al. published in the Japanese Journal of Dermatoallergology, Vol. 1, No. 1 (August 1993)
In 1991, Dr. Enomoto said that skin problems observed during the rebound period after topical steroid withdrawal is “a disorder different from the primary disease, which is more like rosacea spread over the whole body, and should be called as topical steroid withdrawal syndrome (TSWS) to distinguish from the withdrawal syndrome after systemic steroid withdrawal accompanied by adrenal suppression. Two years after this, Dr. Tamaki, who was working at Yodogawa Christian Hospital then, published the paper above. Dr. Enomoto focused on the rash peculiar to the withdrawal process, whereas Dr. Tamaki reported on successful cases of remission achieved by topical corticosteroid withdrawal.
The following is the whole text of Abstract.
----- Excerpt -----
Patients with adult type atopic dermatitis (AD) who wanted to discontinue treatment with steroid ointment were treated without this preparation. The clinical course of 26 severe cases of adult type AD was investigated. Most of these cases had developed edema, erythema, excoriations and desquamation. These symptoms were more severe and lasted longer than those of rosacea-like dermatitis. Successful cases improved in six months to one year. Six out of these 26 cases showed remission, five partial remission, seven improvement. However, four patients returned to steroid ointment treatment and three patients had to stop working. Finally, one case showed no change. These clinical courses showed no correlation with atopic history, serum IgE or the beginning of the discontinuation of the steroid ointment treatment.
----- End of excerpt -----
Those who are familiar to statistics may think, “This is a prospective cohort study or case series when it comes to study design. Out of these 26 cases, 18 saw improvement or more satisfactory results. How much is the half to one-year later improvement rate in the whole of patients with AD? Without this rate, it is impossible to calculate the relative risk to determine whether or not the treatment without steroid ointment was effective.”
Well, if topical corticosteroids are used for AD patients who have never been treated with these drugs, the recovery rate in a half to one year will be nearly 100%. But Dr. Tamaki’s study design is totally opposite. That is, it could be estimated before the study that most of the 26 patients would get worse. On the contrary, improvement or better outcomes were gained in some 70%. From the dermatological point of view, we can see this is abnormal even without the statistically processed relative risk.
Due to this abnormality, dermatologists and the Dermatological Association cast doubt saying, “It has been confirmed that topical corticosteroids are effective for AD treatment. It never happens that recovery from AD can be achieved by stopping topical corticosteroids.”
Another factor that makes the story complicated was hidden in the title. Due to the wording peculiar to Japanese, I guess quite a few people got a false idea from the Japanese title of this paper.
As one of the methods to treat hepatitis B, there is a manner called steroid withdrawal therapy. It is applied to gain a negative response of e antigens by administering and then stopping steroids to sharply increase transaminase value (rebound) to cause clinical condition similar to acute hepatitis, as it takes more time for chronic hepatitis to achieve a negative response of e antigens compared to acute hepatitis. The first report on this method was made in 1979 in Japan. Hearing “steroid ointment withdrawal therapy” (literal translation of the Japanese title of Dr. Tamaki’s paper), some doctors might have been misunderstood that this is a method to alleviate AD through withdrawal as medical intervention (that brings about rebound). Such a person might have thought that it’s not good to take the method that may afflict patients.
“Steroid withdrawal therapy”is the treatment method for hepatitis. Dr. Tamaki employed“Treatment without Steroid Ointment for Adult Type Atopic Dermatitis”as an English title of his paper.
Dr. Tamaki’s paper falls into a case report on side effects. He is not suggesting a new treatment method. What he is proposing is not a new type of therapy called “steroid ointment withdrawal” but the withdrawal from “steroid ointment therapy.”
Appraisal for the paper depends on the subject of the paper: proposal of a new treatment method or a report on side effects? If he intends to suggest a new treatment method, verification with a strict study design such as randomized controlled trial is required. In the case of a side effect report, if a given amount of case reports are gathered from many institutions or doctors, they should be introduced in the guideline or other publications to issue the warning. The Japanese Dermatological Association (JDA) guideline preparation committee has failed to perform its responsibility.
Let’s look at Dr. Tamaki’s paper more.
----- Excerpt -----
Adult AD patients are increasing recently. Though there remains much to be clarified for the causes, abuse of steroid ointments is considered one of the reasons. From our experience, contact dermatitis that seemed to be cleared soon sometimes persisted while applying steroid ointment and exhibited typical flare of AD later. In addition, steroid ointment became ineffective for some patients after a while. Mainstream opinion for such a case in JDA is to apply a more potent steroid ointment or short-term systemic corticosteroid to control the symptoms. Is it really true? With this method, patients have to continue to use steroids forever. It’s time to review the current way of treatment.
----- End of excerpt -----
I have met Dr. Tamaki. He is a good-natured person and never argues against dermatologists sticking to steroids without paying attention to the risks of addiction and rebound as I would. His way of writing the paper reflects such a mild character. He tried to point out the problem of topical steroid therapy commonly employed as of 1993 in an indirect way. This made him avoid clearly remarking that this paper is the side effect report, and therefore some with knowledge can understand what he intends to say and others without cannot.
----- Excerpt -----
While some patients recovered well by just stopping steroid ointment application, others did not and couldn’t help resuming it to suppress the symptoms due to their vocation or other reasons. In almost all the cases of rosacea-like dermatitis, patients recovered just by discontinuing steroid ointment, which is the big difference from AD cases. As there were no correlations with atopic history, serum IgE, beginning of the discontinuation and duration of steroid ointment treatment (not indicated here). It is still difficult to specify in what case good results can be gained by discontinuing steroid ointment. This may be because AD is a multifactorial skin disorder. Additionally the inflammation, having once resided, will recur if patients fail to stick to their regimens to preserve health. Though this paper covers 26 patients who had to be hospitalized due to severe exacerbations, I have seen 2 to 3 times more patients who successfully withdrew from steroid ointment by coming to the hospital regularly. Right now, we can’t say any adult type AD will reside just by stopping steroid ointment. But it is also true that most individuals who do not want to use steroid ointment run to physicians, pediatricians or even Chinese herbal medicine or folk medicine to seek help. I hope the presented method can be one option for treating intractable adult AD.
----- End of excerpt -----
What he said is correct, but the word “this presented method” in the last sentence might have made more readers think “treatment without steroid (ointment)” was the treatment method. Dr. Tamaki might have wanted to discuss topical steroid withdrawal as one way of medical intervention to facilitate patients’ recovery without using such negative words as side effects. (As far as I know, he is such a kind of person.) But his vague expression might have eventually spread misunderstanding.
I myself avoid using “steroid ointment withdrawal therapy” to evade misunderstanding. Steroid addiction is the most optimum word and used worldwide.
Dr. Tamaki tried to analyze the results according to the incentives of the 26 patients: 1. Patient’s own decision; 2. Agreement between patient and doctor; and 3. Doctor’s active encouragement. In case 1, all a doctor has to do is to accept a patient’s desire. In cases 2 and 3, it is predicted there was some sort of intervention from a doctor in some way. I estimate that Dr. Tamaki might have recommended patients try steroid ointment withdrawal therapy without saying, “How about discontinuing topical corticosteroids as you might be addicted to steroids,” out of fear that patients may have steroid phobia.
If so, it was a very Japanese way of solving the problem.
If other dermatologists had understood his intention, the conflict over steroid addiction might have soft-landed. I think he wanted to establish a cooperative relationship between patients and dermatologists by using the word “steroid ointment withdrawal therapy” without referring to steroid addiction even though it is a real problem that a patient has it as a result of prolonged use of topical corticosteroids. But most dermatologists could not read his intention from this paper. I myself had a very strange feeling when I first read this paper. I can understand his intention now that I have met him some times and know his personality.
However, the chance of a soft landing Dr. Tamaki prepared in his own fashion was erased by Dr. Kawashima, who emphatically criticized Dr. Tamaki at medical conferences such as the Central Japan Branch Academic Conference in 1998. I think Dr. Kawashima tried to attain soft landing in another form by making the steroid ointment withdrawal therapy a culprit that gave an excuse for the atopic business. His strategy seems to have succeeded. Talking about topical steroid withdrawal is a taboo for dermatologists now.
Has this problem been really muffled? I myself began to raise the question after several years of rest.
The facts in natural science, if concealed, will some day cause contradiction in a visible way.