Dermatology Online Journal

Correspondence

Treatment of atopic dermatitis with zafirlukast

To the editor: Zafirlukast (Accolate, Zeneca) is a cysteinyl leukotriene inhibitor currently available in the United States for the treatment of asthma (1). There is only a single report describing the successful use of zafirlukast in four patients for the treatment of atopic dermatitis, a pruritic disease of the skin commonly associated with asthma that can be severe and disabling (2). We describe an additional 5 patients with severe, disabling atopic dermatitis, including the first report of a child, treated successfully with zafirlukast.

A 45-year-old female presented with a lifelong history of severe atopic dermatitis. Treatment with topical corticosteroid preparations, oral antihistamines and oral antibiotics was insufficient to control her disease, necessitating frequent courses of oral corticosteroids. Treatment with oral cyclosporine (Neoral) was instituted in the spring of 1998 with good response although the pruritus persisted. Cyclosporine was continued for an additional three months but hypertension and pitting edema of the lower extremities necessitated withdrawal of the drug. A severe flare of her dermatitis followed, and systemic corticosteroid therapy was initiated. Corticosteroid therapy was tapered to alternate days and zafirlukast 20 mg orally twice daily was prescribed. Within 3 days, the pruritus had abated and a marked reduction in lichenification was evident. After 10 days of zafirlukast treatment, oral corticosteroids were discontinued. She currently remains nearly free of pruritus for the first time in 25 years and has not received systemic corticosteroids for over 6 weeks. Laboratory studies, including a complete blood count and hepatocellular enzyme levels, have been normal.

A 57 year old man presented with a 30-year history of adult-onset atopic dermatitis, asthma, and chronic obstructive pulmonary disease. His dermatitis was characterized by frequent severe exacerbations requiring systemic corticosteroid therapy for control. At the beginning of the most recent flare, treatment with zafirlukast 20mg orally twice daily was initiated as monotherapy. The dermatitis completely resolved in one week and by two weeks chronically lichenified areas had diminished in thickness by over 50% and there was minimal erythema or scale. The pruritus had completely abated. No adverse side effects were noted.

A 42-year-old female presented with a life long history of atopic dermatitis and asthma, currently under marginal control with emollients, topical corticosteroid preparations, and ultraviolet light therapy. Zafirlukast 20mg orally twice a day was added. The patient reported noticeable reduction in pruritus within 24 hours, and at 2 weeks of therapy there was marked reduction in erythema and lichenification. At 4 weeks of zafirlukast therapy, pruritus was markedly reduced, allowing for weaning of ultraviolet light treatments and reduction of topical corticosteroid applications. No side effects were reported.

An 8-year-old girl with severe atopic dermatitis since birth was referred to the dermatology service for evaluation and for possible systemic cyclosporine therapy. Years of conservative therapy with topical corticosteroid preparations, emollients, and oral antihistamines failed to yield appreciable improvement. Topical tacrolimus ointment 0.05% twice a day was begun and at 2 weeks, there had been significant reduction in lichenification and inflammation although the pruritus was still present and a number of thickened areas persisted. Zafirlukast 10mg twice daily orally was initiated in addition to the topical tacrolimus. At 3 weeks, reductions in pruritus were reported, and noticeable reductions in erythema and lichenification were evident. Zafirlukast dosage was increased to 20mg twice a day, with further reductions in pruritus and erythema, although subjective dryness persisted, which was treated with mineral oil. Laboratory examination revealed an IgE level of 28,000 and hypereosinophilia, but no other abnormalities were noted. No side effects were reported. Although still symptomatic, withdrawal of zafirlukast resulted in flaring her disease, which abated when zafirlukast was restarted.

A 12-year-old girl presented with severe atopic dermatitis since infancy, currently poorly controlled with topical corticosteroids, oral antihistamines and periodic systemic corticosteroid for severe exacerbations. She also suffers from asthma and allergies. Zafirlukast 20 mg twice a day was initiated with dramatic clinical improvement within 2 weeks. Except for emollients, all other medications have been discontinued at 2 months of follow-up. No side effects were reported.

Prompt resolution of pruritus with resolution of the secondary lichenification and erythema of atopic dermatitis occurred in all 5 patients with zafirlukast. These findings corroborate those by Carucci et al, all of whose patients exhibited both objective and subjective improvement of their disease after only 2 weeks of therapy (1). The efficacy of zafirlukast in relieving signs and symptoms of atopic dermatitis suggests that it may be a satisfactory alternative to cyclosporine with a superior safety profile. The safety profile of zafirlukast has been established in adult patients with asthma (3) and as expected, we observed no complications in our patients. Even thought the drug has not yet been evaluated extensively in children, we report the first 2 cases of zafirlukast used successfully for atopic dermatitis in a child. In addition to being safer than cyclosporine, it may be more effective at reducing pruritus as was evident in one patient in this report and a similar patient of Carucci et al.

Thus, zafirlukast appears to be a potentially useful agent for patients with severe atopic dermatitis that is safer and at least as effective as either systemic corticosteroids or cyclosporine. Long term effects are unknown, however. Larger studies should be undertaken to more fully characterize the utility of zafirlukast in the treatment of atopic dermatitis.

Edward J Zabawski, Jr., DO
Clay J Cockerell, MD
Department of Dermatology
Division of Dermatopathology
University of Texas Southwestern Medical Center
Dallas, TX USA


M.A. Kahn, MD
Northeastern Ohio College of Medicine
Canton, Ohio USA


L.J.Gregg, MD
Department of Dermatology
University of Oklahoma Health Sciences Center
Oklahoma City, Oklahoma USA

References

1. Kelloway JS. Zafirlukast: the first leukotriene receptor antagonist available for the treatment of asthma. Ann Pharmacother. 1997;31-1012-1021.

2. Carucci JA, Washenik K, Weinstein A, Shupack J, Cohen DE. The leukotriene antagonist zafirlukast as a therapeutic agent for atopic dermatitis. Arch Dermatol 1998 Jul;134(7):785-786.

3. Calhoun WJ. Summary of clinical trials with zafirlukast. Am J Respir Crit Care Med 1998 Jun;157(6 Pt 2):S238-S245