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Changing a long-standing habit

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By Warren R. Heymann, MD
April 16, 2016

Topical corticosteroid has no influence has no influence on inflammation or efficacy after ingenol mebutate treatment of grade I to III actinic keratosis (AK): A randomized clinical trial.

This is a randomized controlled clinical trial of patients with multiple AK and field cancerization of the face or scalp that was treated in 2 areas with ingenol mebutate (IM, Picato 0.015%) daily for 3 days. After treatment, 1 area was randomized to receive topical clobetasol propionate (0.05%) twice daily for 4 days. Assessments included local skin reaction (LSR). Clobetasol propionate application had no influence on LSR (P= .939), pain (P= .500), pruritus (P= .312), or AK cure rate (P= .991). Overall, IM cleared 86% of all AK lesions, exerting a therapeutic effect on all AK severity. The authors concluded that the application of clobetasol propionate does not alleviate IM-induced LSR after 3 days of IM treatment.

I started my dermatology residency 36 years ago and have been using field therapy throughout my entire clinical career, mostly with 5-FU. My standard practice would be to have the patient apply a mild topical steroid (such as desonide) following after the course of 5-FU was completed. I don’t know why I did this — like so much of what I learned, it was probably because that was what one of my attending physicians told me to do. Patients got better, so I never gave it a second thought. I did the same post-therapy for imiquimod and IM. I would love to see this same study done with the other modalities. I think IM is an excellent product despite the recent warnings of zoster and ocular toxicity (I have no conflict of interest). This article will change my approach on how I advise patients to care for their skin after utilizing IM. I will probably just recommend a moisturizer.

Erlendsson AM, et al; J Am Acad Dermatol 2016; 74(4): 709-15. 

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