Optimizing the treatment of atopic dermatitis in children: a review of the benefit/risk ratio of methylprednisolone aceponate

Atopic dermatitis (AD) is a chronic, recurring, pruritic, inflammatory skin condition which has its onset in early childhood in most cases. A stepped approach to therapy, starting with emollients and adding first mild and then more potent topical medications is recommended. For more than 50 years, topical corticosteroids (TCs) have been the gold standard in AD therapy. Increasingly potent TCs have tended to come with increasing risk of adverse events, however. Calculating the benefit/risk ratio [or therapeutic index (TIX)] for TCs when treating children and infants is more challenging in this population. Not only does their increased surface area to volume ratio as a result of their small size mean that they are likely to absorb a greater proportion of any active agent applied to their skin, but drug metabolism is slower than in adults and the systemic effects of corticosteroids are more pronounced (in particular reduction of serum cortisol levels through suppression of the hypothalamic-pituitary-adrenal axis). Unlike traditional TCs, topical calcineurin inhibitors are not associated with the systemic effects and have shown good efficacy in treating AD in children. Parental/Carer concerns about their long-term use can limit their acceptance for treatment in the paediatric population, however. Modifications to the structure of fourth generation corticosteroids mean that increased potency is not accompanied by increased risk of adverse events and hence they have an improved TIX. Methylprednisolone aceponate is a potent fourth generation corticosteroid which has demonstrated efficacy and safety in acute and maintenance programmes in infants and children. It is licenced for once-daily use, and is available in four formulations - ointment, fatty ointment, cream and milk, which combine with its improved TIX to meet the needs of young patients and their carers.