Treatment-Resistant Atopic Dermatitis: Issues with Tachyphylaxis or Adherence?

eczema

The complex, chronic, and varying nature of atopic dermatitis (AD) and its treatment can be particularly challenging to manage. Topical corticosteroids are first-line treatments for AD, but many patients report that they are ineffective or that they lose effectiveness over time.  

Tachyphylaxis describes a diminished response to successive doses of a medication. An experimental setting showed tachyphylaxis to topical corticosteroids occurred in just days and patients have reported topical corticosteroids become less effective over time. However, a diminished response to topical corticosteroids has not been conclusively demonstrated in a clinical setting.1,2  

The very rapid response that some patients with apparent tachyphylaxis achieve when treated with mild to moderate potency topical corticosteroids in the hospital setting suggests that apparent tachyphylaxis to topical corticosteroids in patients with AD may actually be due to poor adherence to treatment. Adherence to topical treatment is poor in the short run and terrible in the long run.3 Since individuals with AD use their topical medications less frequently over time, they may attribute their ongoing disease as “resistant” to topical corticosteroids when it is actually inadequately controlled due to inadequate use of the treatment.
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A very small study tested the notion that treatment-resistant AD is due at least in part to poor adherence. Twelve participants with AD that was clinically resistant to topical corticosteroids were treated with an easy to use topical corticosteroid spray under conditions designed to promote good adherence. The desoximetasone spray improved AD disease outcomes in all 12 participants.4  

Poor adherence appears to underlie much of what is perceived as poor efficacy or tachyphylaxis.5 Sometimes, just changing the vehicle to make treatment easier can promote better adherence and rapid improvement.6 While the established dogma regarding tachyphylaxis is “the more they use the medication, the less it works,” it seems far more likely that the less patients use their medication, the less it works.

The implications for AD management may be profound. AD treatment algorithms often recommend complicated treatments involving a variety of topical products and lifestyle modifications. It may be that getting patients to use their triamcinolone better could be the key to success. 
 

Dr Cline is with the Center for Dermatology Research in the department of dermatology at Wake Forest School of Medicine in Winston-Salem, NC. 

Dr Strowd is with the Center for Dermatology Research in the department of dermatology at Wake Forest School of Medicine in Winston-Salem, NC.

Dr Feldman is with the Center for Dermatology Research and the Department of Dermatology, Pathology, and Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, NC. 

References

1. Miller JJ, Roling D, Margolis D, Guzzo C. Failure to demonstrate therapeutic tachyphylaxis to topically applied steroids in patients with psoriasis. J Am Acad Dermatol. 1999;41(4):546-549.

2. Czarnowicki T, Linkner RV, Suarez-Farinas M, Ingber A, Lebwohl M. An investigator-initiated, double-blind, vehicle-controlled pilot study: assessment for tachyphylaxis to topically occluded halobetasol 0.05% ointment in the treatment of psoriasis. J Am Acad Dermatol. 2014;71(5):954-959.e1. doi:10.1016/j.jaad.2014.05.040

3. Alinia H, Moradi Tuchayi S, Smith JA, et al. Long-term adherence to topical psoriasis treatment can be abysmal: a 1-year randomized intervention study using objective electronic adherence monitoring. Br J Dermatol. 2017;176(3):759-764. doi:10.1111/bjd.15085

4. Hogue L, Cardwell LA, Roach C, et al. Psoriasis and atopic dermatitis “resistant” to topical treatment responds rapidly to topical desoximetasone spray [published online December 17, 2018]. J Cutan Med Surg. doi:10.1177/1203475418818082

5. Mooney E, Rademaker M, Dailey R, et al. Adverse effects of topical corticosteroids in paediatric eczema: Australasian consensus statement. Australas J Dermatol. 2015;56(4):241-251.

6. Lewis DJ, Feldman SR. Rapid, successful treatment of atopic dermatitis recalcitrant to topical corticosteroids. Pediatr Dermatol. 2018;35(2):278-279.