Topical and Systemic Therapies for Nickel Allergy

Antonella Tammaro; Alessandra Narcisi; Severino Persechino; Cristiano Caperchi; Anthony Gaspari


Dermatitis. 2011;22(05):251-255. 

In This Article

Topical Emollients, Corticosteroids, and Immunosuppressive Therapies

Topical treatment is the first-line therapy for hand contact dermatitis and is also associated with systemic supportive therapies in chronically relapsing patients with severe allergy. Many topical molecules can be used, regardless of the type and phase of dermatitis (acute, subacute, or chronic). The main purpose is the restoration of the epidermal barrier, which is composed of corneocytes, extracellular proteins, and a lipid-rich matrix (ceramides, fatty acids, and cholesterol). Barrier damage is directly correlated to the severity of dermatitis.[5,6] The use of emollients and barrier creams (containing key stratum corneum lipids, including ceramides) seems to make it possible to reduce the use of topical corticosteroids and immunosuppressive agents such as tacrolimus and pimecrolimus. Use of these emollients and barrier creams leads to the integrity of the epidermal barrier and a consequent reduction of transepidermal water loss (TEWL) and penetration of irritant substances. Emollient creams are composed of two categories of molecules: passive and active. Passive molecules are found in lanolin, petroleum jelly, mineral oils, and silicone, whereas the active molecules are in glycerin, sorbitol, propylene glycol (with hygroscopic action), and urea and alpha-hydroxy acids. These active molecules could be used in every phase of dermatitis, including quiescent periods, to reduce the flaring up of chronic contact dermatitis.[6,7]

Topical corticosteroids are often used in the acute phase of eczema, in association with emollient agents.[5] Pelfini and colleagues grouped these agents in seven decreasing classes of potency, from superpotent to low potency.[6] Clinicians must select the appropriate corticosteroid cream in every case, based on the patient's constitution and on the characteristics and severity of the dermatitis. In the chronic phase, a preparation with superpotent or midstrength molecules might be used with occlusion for 1 to 3 weeks. In fact, the use of these agents for a more prolonged period is not advised because of possible side effects such as atrophy and telangiectasias.[6–9] A study on the effects of two moisturizers performed by Hachem and colleagues in 2002 showed an improvement of skin barrier function in the early inflammatory phase of ACD, with a reduction of TEWL. Improvement in the later phase of the dermatitis was attributed to the secondary effects of the corticosteroids on the proliferation and differentiation of keratinocytes.[8]

Tacrolimus and pimecrolimus, on the other hand, are antiinflammatory, have immunomodulators that belong to the class of topical calcineurin inhibitors (TCIs), and provide clinicians with steroid-sparing options in the long-term topical treatment of ACD. TCIs are indicated when topical corticosteroids are not indicated or when an anticipated lengthy treatment would lead to inevitable adverse effects. In 2006, Pacor and colleagues performed a randomized double-blind placebo-controlled study with two groups of patients affected by nickel sulfate–induced steroid-resistant ACD and respectively treated with tacrolimus ointment 0.1% and placebo vehicle for 14 days.[10] They observed a significant improvement in the major symptoms of eczema (erythema, oozing, scaling, and itching) in the patients of the first group, whereas no improvement was observed in the patients of the second group. Local side effects of TCIs, such as burning and itching at the application site, were transient and well tolerated. Compared with topical corticosteroids, pimecrolimus does not increase the overall incidence of skin infections (including recurrent herpes simplex infections).[10–13]


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