Dermatológica 153:236-242 (1976)
Onset of the Vasoconstrictor Effect of Diflucortolone Valerate, Betamethasone Valerate, and Fluocinolone Acetonide Ointments Applied for Varying Periods under Occlusive Dressings J. Szadurski, F. R enz and D. G asser Dermatological Clinic of the Cantonal Hospital of Basel (Director: Prof. R. S chuppli), and Department of Clinical Research of F. Hoffmann-La Roche & Co., Basel
Key Words. Topical corticoids • Diflucortolone valerate ointment • Betamethasone valerate ointment • Fluocinolone acetonide ointment • Vasoconstrictor effect (onset) • Occlusive dressing • Application time Abstract. Evaluation of cutaneous vasoconstriction after applications of varying dura tion of topical corticoids on the flexor surfaces of the forearms of 20 patients with intact skin shows a significantly faster blanching effect with diflucortolone valerate ointment than with fluocinolone acetonide and betamethasone valerate ointments. Furthermore, the test shows that even for a highly active preparation, such as the diflucortolone valerate ointment, an application time of less than 3 h only exceptionally leads to vasoconstriction in the healthy skin.
Received: March 1, 1976; accepted: May 29, 1976.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:27:33 PM
Corticosteroid preparations have gained wide acceptance in therapy because of their efficacy in the treatment of inflammatory skin conditions. The antiallergic and anti-inflammatory effectiveness of the preparations has been enhanced during development to the point where the concentration needed for topical application is but a fraction of the dose used in the past [2], Corticosteroid treatment has the particular virtue of shortening the acute early phase of the disease. Exudation, inflammation, swelling and distressing pruritus disappear in a few hours or days. The duration of the skin disease is considerably shortened [‘fast motion effect’ according to K orting , 3, and L aetsch-K ammermeier, 4]. Various new test methods, and their numerous
S zadurski/R enz/G asser
237
modifications, have been developed and applied in order to determine the efficacy of new preparations with the greatest possible accuracy [1, 5-7], How ever, a direct correlation between the therapeutic effect and the blanching effect under occlusion with steroids is not yet proven, although the blanching test has shown itself to be a useful screening test. It should also be added in this connection that, whereas the various cutaneous vasoconstriction tests (CVCT) supply information on the intensity and decline of the vasoconstric tor activity of topical corticoids, they do not, in principle, allow any proper assessment of the rapidity of onset and the attainment of maximum effect [4], According to W eirich and L utz [7], the application procedure and site conditions lead to synchronization of the blanching effect, and for this reason the maximum effect of a 16-hour application - although varying in strength is observed with fair uniformity 3-4 h after the dressing is removed. The authors’ own modification of the CVCT, which is explained below, is an attempt to determine with greater precision the time of onset - a factor of importance in evaluating the action of topical corticoids - without too great a departure from the conditions of therapeutic practice.
Method
Reading o f results. 1 h after removal of the dressing, and every subsequent hour until the 8th hour after the start of the experiment, the blanching reaction was assessed with the naked eye in diffuse daylight near the window or at the bedside in the case of bedridden patients.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:27:33 PM
Mode o f application. Special plaster strips containing seven pairs of perforations (Micropore 3M) were affixed to the flexor surfaces of both forearms. With a 1-ml syringe, 0.05 ml of a steroid ointment was deposited in each perforation of 10 mm diameter, covered with a fleece disc of the same size (Webril 2401), and fixed with a nonirritant sealing plaster (Blenderm 3M) so as to exclude air, care being exercised to ensure that the plaster was accurately and durably fixed and that there was no dragging, folding, or pressure. A randomized pattern of application was used in the test so as to eliminate as far as possible any influence of the site (right-left, distal-proximal). The different ointments numbered 1, 2, 3 and 4 for identification were applied laterally, medially, and proximally and distally to the left and right forearms in accordance with a location plan prepared in advance for each test subject (see location plan, fig. 1). Subsequently, the individual plaster strips were removed at 1-hour intervals also in randomized order, the duration of application thus ranging from a minimum of 1 h to a maximum of 7 h per strip. After each of these occlusive strips was taken off, the remains of the ointment were removed with a cottonwool swab, the number of the strip removed was marked on the skin with a dermatograph, and the treated sites left open. The whole test was double blind.
238
Szadurski/R enz/G asser Right forearm
Left forearm
Fig. 1. Location plan showing the randomized application for varying periods of time of four corticoid ointments in a comparative assay (subject 17). Strip No. = duration of application in hours; encircled figures = No. of the corticoid ointment to be applied.
The blanching effects recorded on the test sheet were graded as follows: 0 = no vaso constriction; 1 = distinct blanching in the area of application; 2 = distinct and sharply demarcated blanching in the area of application, and 3 = marked blanching in the area of application spreading to the adjacent areas of skin. Subjects. The subjects tested comprised patients from the ward with an intact skin at the site where ointment was applied in the test. In order to recreate normal practice conditions as faithfully as possible, purposive selection of test subjects (special skin types, responsiveness, etc.) was dispensed with. Preparations tested. The test was made on fluocinolone acetonide (FA), betamethasone valerate (BV) and diflucortolone valerate (DV)1 ointments in their normal commercial forms which were supplied to the investigators in neutral tubes numbered 1, 2, 3 and 4 for the CVCT.
1 Temetex®, F. Hoffmann-La Roche & Co. Ltd., Basle; Distribution in Switzerland: Laboratoires Sauter S.A., Vernier-Genève.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:27:33 PM
Statistical evaluation. Only the initial onset of the vasoconstrictor action was taken into account, irrespective of duration and intensity. Since major differences in responsiveness to
Onset of the Vasoconstrictor Effect of Diflucortolone Valerate
239
Time of read-off
Fig. 2. The number of positive reactions in the cutaneous vasoconstriction test after applications of varying duration of four topical corticoids plotted against the time of reading.------ = DV 1 ; --------= DV 3 ; --------= BV 4 ; ......... = FA 2.
topical corticoids were expected from one subject to another, evaluation had to be restricted to ascertaining whether, after a given period of application, the onset of each individual’s response to DV was faster than, as fast as, or slower than to the other preparation. McNemar’s sign test for colligated random samples was used for the calculations.
Table I shows the results obtained after application of the McNemar test. Each column corresponds to a specific period of application (from 1 to 7 h). The results obtained by two investigators (I and II) are available for the 6th and 7th hours of the application. Three comparisons are shown in table I; namely, DV versus FA, DV versus BV, and DV 1 versus DV 2 (as a check on the reproducibility of the results). After 1 or 2 h of application of the ointments, only 2-6 of the application sites react, and this precludes any meaningful interpretation of the results with the NcNemar test. From the 3rd hour of application onwards, the
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:27:33 PM
Results
240
Szadurski/R enz/G assïr
Table I. Cutaneous vasoconstriction test Onset of action
Duration of application 1 h* 2 h 1 3 h l
4 h1 5 h1 6 hl
6 h2 7 h1
7 h2
0
4 12
3 9
2
1 4
D V versus FA DV + FA equally fast DV faster than FA FA faster than DV
0
0
2 0
3
0 11 1
2
1 10
14
1 16
3 6
0 4
0 3
11 1
18
1 16
McNemar a
-
-
D V versus BV DV + BV equally fast DV faster than BV
0 1
0 4
1 12
BV faster than DV
1
0
18
16
-
-
0.008 0.052 0.109 0.021 0.317 0.011
1
1 2
6
4
10
5 9
6 1
5 2
13 3 1
2
3
2
3
Absent in both cases
Absent in both cases McNemar a
8
5
2
0.013 0.109 0.001 0.000 0.013 0.020 0.035
3
1
4
3
1
10 2
10 3
10 1
6 2
6
5
6
5
6
5 9
3 7
0 6
0 7 0.034
D V 1 versus D V 2 DV 1 + DV 2 equally fast DV 1 faster than DV 2 DV 2 faster than DV 1 Absent in both cases McNemar a
1 0
3
3 5
18
14
6
-
-
11
0.739 0.439 0.157 0.480
0.655
picture changes: the faster onset of response to DV is significant as compared with FA and highly significant as compared with BV. Although at the 5th hour DV shows a distinct numerical superiority over the two comparative preparations (10:3 and 10:2, respectively), the differ ence is registered by means of the McNemar test only with a level of signif icance of just on 11 and 5.2%, respectively. As for the 5th, 6th and 7th hours, the superiority of DV over FA is significant or highly significant, likewise for
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:27:33 PM
1 Investigator I. 2 Investigator II.
Onset of the Vasoconstrictor Effect of Diflucortolone Valerate
241
the 6th and 7th hours in the case of the second investigator. Again, in the comparison between DV and BV, only a trend can be ascertained for the 4th hour although in numerical terms DV is distinctly favored. The 6th and 7th hours are clearly significant in the case of one investigator but only the 7th hour in the case of the other. Even so, the agreement between the two investigators may be regarded as satisfactory. The agreement between DV 1 and DV 3 may also be regarded as satisfactory, for even the difference in the numerical relations of the 5th hour are shown by the McNemar test to lie within the limits of random deviation. A graph plotting the number of positive results against the time of read ing and disregarding whether in the individual case the onset of the action of DV was faster than that of the other product shows that the response to the application of DV was more frequent and rapid than to that of FA and BV. The two DV curves show good agreement, and the patterns of the FA and BV curves are also largely congruent. In terms of cumulative frequency, where the onset of a reaction is recorded independently of the point of time and the duration of application, the following might be said: as each of the 4 types of ointment was given 7 times to each of 20 patients, the onset of vasoconstriction could theoretically be observed a maximum of 140 times per type of ointment. In fact, the onset of reaction was observed 76 and 75 times in the case of DV. There were 21 onsets of reaction for FA and a total of 30 for BV (fig. 2).
Acknowledgement The authors wish to thank Prof. R. S c h u p p l i , Director of the Dermatological Clinic of the Cantonal Hospital of Basel for his cooperation and support in this study. Thanks are also due to Dr. A m r e in , Clinical Department of F . Hoffmann-La Roche & Co. Ltd., for the randomization plan he prepared specially for our purposes.
References 1 B u r d ic k , K.H.: Various vagaries of vasoconstriction. Archs Derm. 110: 238-242 (1974).
2 J e n n y , D. und S c h u p p l i , R .: Fortschritte in der Therapie der Ekzeme. Praxis 59:
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:27:33 PM
589-592 (1970). 3 Körting , G .W . : Therapie der Hautkrankheiten; 2. Aufl. (Schattauer, Stuttgart 1970).
242
Szadurski/R enz/G assi:r
4 L aetscu-K ammermeier, C.: Einige Aspekte der lokalen Corticosteroidtherapie. Diss.
'. J. Szadurski, Abteilung für klinische Forschung der Firma F. HolTmann-La Roche Co. AG, Grenzacherstrasse 124, CH-4002 Basel (Schweiz) Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:27:33 PM
O
Zürich (1971). 5 P lace, V.A.; V elazquez, J.G., and Burdick , K.H.: Precise evaluation of topically applied corticosteroid potency. Archs Derm. 101: 531 537 (1970). 6 Poulsen, B.J.; Burdick , K., and Bessler, S .: Paired comparison vasoconstrictor assays. Archs Derm. 109: 367-371 (1974). 7 W eirich, E.G. und L utz , U.: Der Hautvasokonstriktionstest am Menschen als Prüf methode für Externkortikoide. Dermatológica 147: 353-375 (1973).
Onset of the Vasoconstrictor Effect of Diflucortolone Valerate, Betamethasone Valerate, and Fluocinolone Acetonide Ointments Applied for Varying Periods under Occlusive Dressings J. Szadurski, F. R enz and D. G asser Dermatological Clinic of the Cantonal Hospital of Basel (Director: Prof. R. S chuppli), and Department of Clinical Research of F. Hoffmann-La Roche & Co., Basel
Key Words. Topical corticoids • Diflucortolone valerate ointment • Betamethasone valerate ointment • Fluocinolone acetonide ointment • Vasoconstrictor effect (onset) • Occlusive dressing • Application time Abstract. Evaluation of cutaneous vasoconstriction after applications of varying dura tion of topical corticoids on the flexor surfaces of the forearms of 20 patients with intact skin shows a significantly faster blanching effect with diflucortolone valerate ointment than with fluocinolone acetonide and betamethasone valerate ointments. Furthermore, the test shows that even for a highly active preparation, such as the diflucortolone valerate ointment, an application time of less than 3 h only exceptionally leads to vasoconstriction in the healthy skin.
Received: March 1, 1976; accepted: May 29, 1976.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:27:33 PM
Corticosteroid preparations have gained wide acceptance in therapy because of their efficacy in the treatment of inflammatory skin conditions. The antiallergic and anti-inflammatory effectiveness of the preparations has been enhanced during development to the point where the concentration needed for topical application is but a fraction of the dose used in the past [2], Corticosteroid treatment has the particular virtue of shortening the acute early phase of the disease. Exudation, inflammation, swelling and distressing pruritus disappear in a few hours or days. The duration of the skin disease is considerably shortened [‘fast motion effect’ according to K orting , 3, and L aetsch-K ammermeier, 4]. Various new test methods, and their numerous
S zadurski/R enz/G asser
237
modifications, have been developed and applied in order to determine the efficacy of new preparations with the greatest possible accuracy [1, 5-7], How ever, a direct correlation between the therapeutic effect and the blanching effect under occlusion with steroids is not yet proven, although the blanching test has shown itself to be a useful screening test. It should also be added in this connection that, whereas the various cutaneous vasoconstriction tests (CVCT) supply information on the intensity and decline of the vasoconstric tor activity of topical corticoids, they do not, in principle, allow any proper assessment of the rapidity of onset and the attainment of maximum effect [4], According to W eirich and L utz [7], the application procedure and site conditions lead to synchronization of the blanching effect, and for this reason the maximum effect of a 16-hour application - although varying in strength is observed with fair uniformity 3-4 h after the dressing is removed. The authors’ own modification of the CVCT, which is explained below, is an attempt to determine with greater precision the time of onset - a factor of importance in evaluating the action of topical corticoids - without too great a departure from the conditions of therapeutic practice.
Method
Reading o f results. 1 h after removal of the dressing, and every subsequent hour until the 8th hour after the start of the experiment, the blanching reaction was assessed with the naked eye in diffuse daylight near the window or at the bedside in the case of bedridden patients.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:27:33 PM
Mode o f application. Special plaster strips containing seven pairs of perforations (Micropore 3M) were affixed to the flexor surfaces of both forearms. With a 1-ml syringe, 0.05 ml of a steroid ointment was deposited in each perforation of 10 mm diameter, covered with a fleece disc of the same size (Webril 2401), and fixed with a nonirritant sealing plaster (Blenderm 3M) so as to exclude air, care being exercised to ensure that the plaster was accurately and durably fixed and that there was no dragging, folding, or pressure. A randomized pattern of application was used in the test so as to eliminate as far as possible any influence of the site (right-left, distal-proximal). The different ointments numbered 1, 2, 3 and 4 for identification were applied laterally, medially, and proximally and distally to the left and right forearms in accordance with a location plan prepared in advance for each test subject (see location plan, fig. 1). Subsequently, the individual plaster strips were removed at 1-hour intervals also in randomized order, the duration of application thus ranging from a minimum of 1 h to a maximum of 7 h per strip. After each of these occlusive strips was taken off, the remains of the ointment were removed with a cottonwool swab, the number of the strip removed was marked on the skin with a dermatograph, and the treated sites left open. The whole test was double blind.
238
Szadurski/R enz/G asser Right forearm
Left forearm
Fig. 1. Location plan showing the randomized application for varying periods of time of four corticoid ointments in a comparative assay (subject 17). Strip No. = duration of application in hours; encircled figures = No. of the corticoid ointment to be applied.
The blanching effects recorded on the test sheet were graded as follows: 0 = no vaso constriction; 1 = distinct blanching in the area of application; 2 = distinct and sharply demarcated blanching in the area of application, and 3 = marked blanching in the area of application spreading to the adjacent areas of skin. Subjects. The subjects tested comprised patients from the ward with an intact skin at the site where ointment was applied in the test. In order to recreate normal practice conditions as faithfully as possible, purposive selection of test subjects (special skin types, responsiveness, etc.) was dispensed with. Preparations tested. The test was made on fluocinolone acetonide (FA), betamethasone valerate (BV) and diflucortolone valerate (DV)1 ointments in their normal commercial forms which were supplied to the investigators in neutral tubes numbered 1, 2, 3 and 4 for the CVCT.
1 Temetex®, F. Hoffmann-La Roche & Co. Ltd., Basle; Distribution in Switzerland: Laboratoires Sauter S.A., Vernier-Genève.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:27:33 PM
Statistical evaluation. Only the initial onset of the vasoconstrictor action was taken into account, irrespective of duration and intensity. Since major differences in responsiveness to
Onset of the Vasoconstrictor Effect of Diflucortolone Valerate
239
Time of read-off
Fig. 2. The number of positive reactions in the cutaneous vasoconstriction test after applications of varying duration of four topical corticoids plotted against the time of reading.------ = DV 1 ; --------= DV 3 ; --------= BV 4 ; ......... = FA 2.
topical corticoids were expected from one subject to another, evaluation had to be restricted to ascertaining whether, after a given period of application, the onset of each individual’s response to DV was faster than, as fast as, or slower than to the other preparation. McNemar’s sign test for colligated random samples was used for the calculations.
Table I shows the results obtained after application of the McNemar test. Each column corresponds to a specific period of application (from 1 to 7 h). The results obtained by two investigators (I and II) are available for the 6th and 7th hours of the application. Three comparisons are shown in table I; namely, DV versus FA, DV versus BV, and DV 1 versus DV 2 (as a check on the reproducibility of the results). After 1 or 2 h of application of the ointments, only 2-6 of the application sites react, and this precludes any meaningful interpretation of the results with the NcNemar test. From the 3rd hour of application onwards, the
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:27:33 PM
Results
240
Szadurski/R enz/G assïr
Table I. Cutaneous vasoconstriction test Onset of action
Duration of application 1 h* 2 h 1 3 h l
4 h1 5 h1 6 hl
6 h2 7 h1
7 h2
0
4 12
3 9
2
1 4
D V versus FA DV + FA equally fast DV faster than FA FA faster than DV
0
0
2 0
3
0 11 1
2
1 10
14
1 16
3 6
0 4
0 3
11 1
18
1 16
McNemar a
-
-
D V versus BV DV + BV equally fast DV faster than BV
0 1
0 4
1 12
BV faster than DV
1
0
18
16
-
-
0.008 0.052 0.109 0.021 0.317 0.011
1
1 2
6
4
10
5 9
6 1
5 2
13 3 1
2
3
2
3
Absent in both cases
Absent in both cases McNemar a
8
5
2
0.013 0.109 0.001 0.000 0.013 0.020 0.035
3
1
4
3
1
10 2
10 3
10 1
6 2
6
5
6
5
6
5 9
3 7
0 6
0 7 0.034
D V 1 versus D V 2 DV 1 + DV 2 equally fast DV 1 faster than DV 2 DV 2 faster than DV 1 Absent in both cases McNemar a
1 0
3
3 5
18
14
6
-
-
11
0.739 0.439 0.157 0.480
0.655
picture changes: the faster onset of response to DV is significant as compared with FA and highly significant as compared with BV. Although at the 5th hour DV shows a distinct numerical superiority over the two comparative preparations (10:3 and 10:2, respectively), the differ ence is registered by means of the McNemar test only with a level of signif icance of just on 11 and 5.2%, respectively. As for the 5th, 6th and 7th hours, the superiority of DV over FA is significant or highly significant, likewise for
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:27:33 PM
1 Investigator I. 2 Investigator II.
Onset of the Vasoconstrictor Effect of Diflucortolone Valerate
241
the 6th and 7th hours in the case of the second investigator. Again, in the comparison between DV and BV, only a trend can be ascertained for the 4th hour although in numerical terms DV is distinctly favored. The 6th and 7th hours are clearly significant in the case of one investigator but only the 7th hour in the case of the other. Even so, the agreement between the two investigators may be regarded as satisfactory. The agreement between DV 1 and DV 3 may also be regarded as satisfactory, for even the difference in the numerical relations of the 5th hour are shown by the McNemar test to lie within the limits of random deviation. A graph plotting the number of positive results against the time of read ing and disregarding whether in the individual case the onset of the action of DV was faster than that of the other product shows that the response to the application of DV was more frequent and rapid than to that of FA and BV. The two DV curves show good agreement, and the patterns of the FA and BV curves are also largely congruent. In terms of cumulative frequency, where the onset of a reaction is recorded independently of the point of time and the duration of application, the following might be said: as each of the 4 types of ointment was given 7 times to each of 20 patients, the onset of vasoconstriction could theoretically be observed a maximum of 140 times per type of ointment. In fact, the onset of reaction was observed 76 and 75 times in the case of DV. There were 21 onsets of reaction for FA and a total of 30 for BV (fig. 2).
Acknowledgement The authors wish to thank Prof. R. S c h u p p l i , Director of the Dermatological Clinic of the Cantonal Hospital of Basel for his cooperation and support in this study. Thanks are also due to Dr. A m r e in , Clinical Department of F . Hoffmann-La Roche & Co. Ltd., for the randomization plan he prepared specially for our purposes.
References 1 B u r d ic k , K.H.: Various vagaries of vasoconstriction. Archs Derm. 110: 238-242 (1974).
2 J e n n y , D. und S c h u p p l i , R .: Fortschritte in der Therapie der Ekzeme. Praxis 59:
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:27:33 PM
589-592 (1970). 3 Körting , G .W . : Therapie der Hautkrankheiten; 2. Aufl. (Schattauer, Stuttgart 1970).
242
Szadurski/R enz/G assi:r
4 L aetscu-K ammermeier, C.: Einige Aspekte der lokalen Corticosteroidtherapie. Diss.
'. J. Szadurski, Abteilung für klinische Forschung der Firma F. HolTmann-La Roche Co. AG, Grenzacherstrasse 124, CH-4002 Basel (Schweiz) Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:27:33 PM
O
Zürich (1971). 5 P lace, V.A.; V elazquez, J.G., and Burdick , K.H.: Precise evaluation of topically applied corticosteroid potency. Archs Derm. 101: 531 537 (1970). 6 Poulsen, B.J.; Burdick , K., and Bessler, S .: Paired comparison vasoconstrictor assays. Archs Derm. 109: 367-371 (1974). 7 W eirich, E.G. und L utz , U.: Der Hautvasokonstriktionstest am Menschen als Prüf methode für Externkortikoide. Dermatológica 147: 353-375 (1973).
