Another audience member asked if patients should apply the topical steroid on top of intact blisters and the wounds created by broken blisters. This should be done, Dr. Jonkman advised. "The medication won't work on top of an intact blister because it's too far away from the dermis. But because it's systemic therapy it will come from the blood into the skin," he explained.

A third audience member asked if Dr. Jonkman had ever used whole-body clobetasol in patients with pemphigus foliaceous. He replied that he hasn't because the opportunity hasn't arisen, although he said he suspects it would be effective in milder cases.

Background Studies

Dr. Jonkman credited French dermatologists with the idea of using topical corticosteroids to treat patients with bullous pemphigoid. In a landmark multicenter trial nearly a decade ago, researchers randomized 341 bullous pemphigoid patients to 40 g/day of topical clobetasol propionate cream or to oral prednisone for 1 year. Patients with moderate disease received 0.5 mg/kg per day of prednisone, while those with severe disease got 1 mg/kg.

The topical regimen proved superior to oral prednisone in the 188 patients with extensive disease. Disease was controlled at 3 weeks in 99% of patients on clobetasol, significantly higher than the 91% rate with prednisone. Moreover, the 1-year survival rate was 76% in the topical therapy arm, compared with 58% with oral therapy. Severe complications were half as common in the clobetasol arm.

In patients with moderate bullous pemphigoid, the two forms of therapy were similar in terms of disease control at 3 weeks, overall survival, and severe complications (N. Engl. J. Med. 2002;346:321-7).

Dr. Jonkman noted that more recently the French group tweaked their topical regimen, adopting a milder approach similar to his own. In a 312-patient multicenter trial, they randomized participants to 10-30 g/day of clobetasol tapered over a 4-month period or to their earlier regimen of 40 g/day for a full year. The investigators showed that the rate of death or life-threatening adverse events in the 134 patients with moderate disease was reduced by nearly half with the milder regimen (J. Invest. Dermatol. 2009;129:1681-7).

He reported having no relevant financial disclosures.