THE CANADIAN MEDICAL ASSOCIATION

BEN KANEE, M.D.,* Vancouver, B.C.

T HE effectiveness of corticosteroids topically has
revolutionized the therapeutic approach to a
great many dermatoses. These agents have given
relief to many distressed patients through an
antipruritic effect, coupled with anti-inflammatory
and antiphlogistic actions. Refinements in the
topical use of corticosteroids in ointments, creams,
lotions, sprays and foams have been sought in an
endeavour to enhance their efficacy and reduce
the cost of therapy. The development of synthetic
corticosteroids for topical therapy, when used in
conjunction with an "occlusive dressing"1 3 presently to be described, has resulted in remarkable
clinical responses in dermatoses that heretofore
were unaffected by the topical hydrocortisone
preparations. The following is a renort on the local
use of fluocinolone acetonide in the treatment
of psoriasis vulgaris, pustular and paronychial
psoriasis, neurodermatitis disseminata, keratoderma
climacterium, neurodermatitis circumscripta, lupus
erythematosus (chronic discoid) and lichen planus.
MATERIALS AND METHODS
Fluocinolone acetonide cream in a 0.025% concentration was applied thinly four times a day in
the treatment of neurodermatitis disseminata, to
flexural lesions of psoriasis, and to warm moist
areas, such as areas of lichen plarnis or psoriasis
on the glans penis. In cases of psoriasis vulgaris of
the glabrous (non-flexural) skin and in localized
neurodermatitis, it was used with various modifications of the "occlusive dressing." The customary
method followed in this investigation consisted of
applying a thin layer of cream to the lesion, covering it with a moistened single layer of cloth (old
sheeting), and then with a layer of a thin impervious film (Saran-wrap - Dow Chemical, Cellophane,
or plastic clothes bags) with the edges sealed with
Elastoplast (waterproof adhesive) or Scotch tape.
If reactions developed to the adhesive, the dressing
*Associate, Department of Dermatology, Vancouver General
Hospital, Vancouver, B.C.

ABSTRACT
Fluocmolone acetonide cream is a new,
potent topical corticosteroid. When used in
conjunction with an occlusive plastic film
dressing, herein described, it is highly effective in the treatment of psoriasis of the
glabrous skin, pustular and paronychial
psoriasis, neurodermatitis, and lichen planus.
Psoriasis of the intertriginous areas responds

to the local use of the fluocinolone cream

alone. Relapses on cessation of treatment
respond as a rule to retreatment.
Indications, limitations, reactions and contraindications to this form of treatment are
discussed.

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Canad. Med. Ass. J.

May 18, 1963, vol. 88

KA..: TREATMENT OF DERMATOSES

linear psoriasis, a 3-year-old boy, showed initial

improvement, only to flare up despite continued
treatment.
One patient with psoriasis of 'the fingers, palms,
lips, natal cleft and glans penis had mixed longterm results. The hand lesions initially cleared up
entirely on fluocinolone acetonide occlusive dressings; however, relapses on the hands did not
respond to further occlusive treatment. The natal
cleft, lip and genital lesions continued to respond
to open treatment with the cream alone, applied
three times daily (Figs. 1 and 2).
A patient with pustular paronychial psoriasis
showed a most remarkable response to the fluocinolone acetonide occlusive treatmen't (Figs. 3
and 4). This 75-year-old woman's pustular paronychial psoriasis had been present for three years
at the time of study. Formerly she had been considered to be suffering from acrodermatitis chronica
of Hallopeau or dermatitis repens of the nail beds
and paronychial areas. Involved areas included the
first, second and fourth right fingers and first,
second and third left fingers. She had a past history
of duodenal ulcer (15 years previously) and recurring furuncles and "styes" for 10 years. No
response to systemic antibiotic therapy was seen.
When pustular paronychial psoriasis was diagnosed,
the patient was started on oral triamcinolone, 4
mg. four times daily. A very favourable response
ensued; however, this treatment was eventually
stopped, owing to the reactivation of her duodenal
ulcer. After treatment with oral triamcinolone was
discontinued, the affected fingers flared. A dramatic
response followed the local use of fluocinolone
acetonide 0.025% in combination with a wet clothglove, over which the patient wore a rubber glove
continuously for 24 hours a day. Dressings were
changed every 24 hours. At present, improvement
is maintained while these applications are used
only overnight. When the treatment was limited to
fluocinolone acetonide and the wearing of plastic
gloves only, the response was not satisfactory.
Neurodermatitis dissemiriata. - Seven patients
with this disorder were treated by the open method,
which consisted of application of a very thin film
of fluocinolone acetonide cream four times a day
and left uncovered. The results were uniformly
satisfactory, and often superior to those of previous
topical corticosteroid preparations. In cases where
the cream base proved too drying, the application
of salad oil over the cream proved effective. In
such cases, a petrolatum molle vehicle should prove
to be an ideal base.
Keratoderma climacterium. - One patient with
keratoderma climacterium was treated, a 60-yearold woman with a two-year history of painful,
fissured, hyperkeratotic lesions of palms and soles.
Initially, marked clinical and subjective improvement occurred with the occlusive dressing. Unfortunately, her skin lesions reverted to the
original painful condition despite continued
therapy.

Neurodermatitis circumscripta.-In this category

seven patients have been fully evaluated. One
patient who had genital lesions showed no relief.
Three with hypertrophic lesions responded in a
highly satisfactory manner to the full occlusive
dressing method (Figs. 5-7). Three responded to
fluocinolone acetonide cream and Saran dressings
only, with clearing of lesions after two to three
treatments.
Lupus erythematosus (discoid) .-Two patients
with discoid lupus showed a favourable response
to the occlusive treatment with near involution after
two to four treatments. Since such lesions are on
the face, this type of treatment is not very practical.
Lichen Planus.-One patient with lichen planus
of the glans penis showed involutions of the lesions
after three weeks of open treatment.
A second patient with lichen planus on the back
used fluocinolone acetonide cream applied thinly
four times a day. There was immediate symptomatic relief and the lesions gradually involuted over
a period of eight weeks.
DIscussIoN

Topical 0.025% fluocinolone acetonide cream

proved to be very effective in the treatment of
neurodermatitis disseminata and neurodermatitis
circumscripta, for which it was often superior to
1% hydrocortisone preparations.
In psoriatic patients it was found that occlusive
dressing treatment with fluocinolone acetonide was
very effective. Lesions cleared as a rule within two
weeks, depending on their thickness. Results were
enhanced by instructing patients to cleanse off the
thickened scales with soap and water before applying the medication. It was also evident that
only the treated lesions responded. Remissions in
psoriasis usually lasted one to three weeks, and
most responded to further treatment. Treatment of
psoriatic lesion on the glabrous skin with occlusive
dressings alone (without corticosteroids), or with
corticosteroid cream alone, proved ineffective. Here
it is believed that the moisture which develops
under the enclosed dressing acts as a water transport, carrying the active therapeutic agent into the
depth of the epidermis and the upper layers of the
dermis, resulting in clinical improvement.
Psoriasis of the scalp is favourably influenced by
the continued local use of fluocinolone acetonide
cream applied at bedtime and covered with a
plastic shower cap worn overnight or longer. The
resulting moist scalp quickly dries on exposure to
air. The scalp is then washed with a tar shampoo
once or twice weekly, or as frequently as desired.
It is interesting to observe that in cases of
flexural psoriasis, lesions in the axillae, the retroauricular, inframammary, inguinal and crural folds,
and on the natal cleft, glans penis and perineum
do equally well with the open treatment, in contradistinction to the occlusive closed method. In
other words, application of a thin film of fluoci-

K..l.EE:

Fig. I

TREATMENT OF DERMATOSES

Fig. 2

Fig. 3Fig. 4
Fig. 1.-Flexural psoriasis of the natal cleft and perianal areas before treatment. Fig. 2.Natal cleft and perianal psoriasis showing striking clinical improvement, after nine days of
open treatment with fluocinolone acetonide cream.
Fig. 3.-Paronychial and pustular psoriasis of the fingers and thumb before treatment.
Fig. 4.-Paronychial and pustular psoriasis of the fingers and thumb, one week after the
closed, occlusive-dressing type of treatment with fluocinolone acetonide cream.

1001

Canad. Med. Ass. J.

May 18, 1963, vol. 88

Figs. 5, 6 and 7

Fig. 5 (top left).-Persistent neurodermatitis circumscripta

of the right leg despite various topical treatments, x-ray
therapy and intralesional injections of steroid, and before
fluocinolone acetonide occlusive dressing.

Fig. 6 (top right).-Neurodermatitis circumscripta of right

leg show ng the closed, occlusive dressing in place.

Fig. 7 (right).-Neurodermatitis circumscripta of right leg

showing clinical response to seven weeks of the closed
occlusive treatment with fluocinolone acetonide cream.

KANEE:

Canad. Med. Ass. J.

May 18, 1963, vol. 88

nolone acetonide cream four times a day, without

superimposed dressings, is followed by early dramatic improvement at these sites. Later, treatment
is reduced to three times a day and then twice a
day, or as required as a maintenance regimen. While
psoriatic lesions in the flexural areas are dry and
do not show the presence of sweating, the sweat
from the adjacent uninvolved skin acts as the water
transport, and the apposing skin forms a sort of
occlusive dressing. Any associated pruritus is also
promptly brought under control with this form of
treatment. The results in cases of psoriasis are
comparable to those of intralesional injections with
corticosteroids, without the risk of atrophy, infection and systemic reactions. These observations
confirm the findings of Scholtz,2'4 and Tye and
Schiff.5 Similarly, neurodermatitis and lichen planus
of intertriginous sites do equally well with open
treatment. Neurodermatitis and lichen planus in
other areas and without any great degree of thickness of the lesions, did well with application of
fluocinolone acetonide plus the plastic film without
the wet cloth.
Patients were forewarned about the odour that
develops under the occlusive dressings due to the
action of surface bacteria on the higher fatty acids
in the sweat. however, this did not preclude continuation of treatment by any patient. During the
hot weather, pustular miliaria sometimes developed
under the occlusive closed dressings. This quickly
disappeared on washing and exposing the affected
skin to the air. Subsequent use of the occlusive
treatment was withheld until cooler weather or was
limited to a few hours overnight. Some patients
developed reactions to the Elastoplast adhesive or
plain adhesive tape; in such cases we were able to
continue treatment using stockinette or Ace crepe
bandage to keep the dressings in place. The abovedescribed treatment was limited to those patients
who were free of bacterial or viral infection, and
whose disease was not generalized or in an acute
exudative state. Muller and Kitzmiller6 caution
against the use of flammable plastic films, and cite

TREATMENT OF DERMATOSES

1003

the need for observation to detect the development

of superficial skin infections under the occlusive
dressings, particularly in hospital-treated patients.
In the series described in this report there was no
clinical evidence of systemic corticosteroid effect,
nor was there any evidence of allergy or primary
irritation to fluocinolone acetonidc cream. It proved
to be readily acceptable to all patients as a nonstaining, highly effective, anti-inflammatory and
antipruritic preparation. When used with the
occlusive dressing, it should prove quite economical. Comparable satisfactory clinical results have
been obtained with the use of 0.05% flurandrenolone acetonide cream.
SUMMARY

Fluocinolone acetonide cream, in 0.025% concentration, was used with marked success, both as an open
treatment and a closed occlusive dressing in the treatment of the following dermatoses: psoriasis vulgaris,
pustular paronychial psoriasis, neurodermatitis disseminata, neurodermatitis circumscripta (localized), and
lichen planus. In one case of keratoderma climacterium
the treatment proved unsuccessful after initial improvement. In patients with chronic discoid lupus erythematosus of the face, the occlusive treatment was
temporarily effective but the lesions relapsed quickly.
This form of therapy has definite limitations in such
cases.
The author wishes to express his thanks to Dr. Kenneth
J. Dumas, Medical Director of Syntex Laboratories, Inc.,
Palo Alto, Califomia, U.S.A., for the supply of 0.025%

fluocinolone acetonide (Synalar Cream) used in this

clinical investigation.

REFERENCES

1. GARB, J.: A.M.A. Arch. Derm., 81: 606, 1960.

2. SCHOLTE, J. R.: Arch. Derm. (Chic.). 84: 1029, 1961.

3. WITTEN V. H. AND SULZBERGER, M. B.: Med. Olin. N.
Amer., 45: 857, 1961.
4. ScHoLTz J. R., GoLDMAN, L. AND ROBINSON, H. M., JR.:
Recent advances in corticosteroid topical therapy.
Scientific Exhibit, The Twelfth International Congress
of Dermatology, Washington. D.C., September. 1962.
5. TYE, M. J. AND ScHIFF, B. L.: J. Invest. Derm., 38: 321,
1962.
6. MULLER, S. A. AND KITZMILLER, K. W.: Arch. Derm.
(Chic.), 86: 478, 1962.

3195 Granville Street,

Vancouver 9, B.C.

PAGES OUT OF THE PAST: FROM THE JOURNAL OF FIFTY YEARS AGO
POST-OPERATIVE PERITONITIS
In Dr. Chipman's patient the result of the operation
[high enterostomy in postoperative diffuse-spreading peritonitis] showed that her very ave condition was due
to the obstruction toxaemia rat.er than to the streptococcus toxaemia. She immediately improved when the tube
was put in. I was present in Ottawa when MeKenna's paper
was read, and I decided to try it if the occasion arose.
Since that time I have tried it in two cases. I remember
two previous cases in which I performed enterostomy for
a similar condition, but not purposely high up. In both
I opened the abdomen and took a chance coil of small
bowel which was well down in the jejunum or the ileum.
In these two cases the procedure had practically no effect
at all, the bowel remaining flaccid, nothing came through
it and the patients died. But I have to report that the
two other cases in which I introduced the tube into the
jejunum, close to the duodenum, died also. I report these
particularly in order to show that in some instances at least,

the method cannot he counted upon with certainty. These

patients were also in extremis. There were postoperative
adynamic obstructions with moderate peritoneal infection.
In both I introduced a Paul's tube. In one a coil of the
bowel was brought out upon the abdomen, in the other
only an inch or so. In neither of these cases did I succeed
in getting that free drainage which I hoped for; the
amount evacuated was clearly insufficient. The exhihition
of hormonal in one was without effect.
The work of Hartwell, published in the American Journal
of Medical Sciences last March, went to show fairly conclusively that the toxaemia in such cases is very largely
original in the duodenum and upper jejunum. McKenna
advises washing out with saline so as to get rid of these
toxines. The whole subject is fascinating because it promises
so much and yet is still rather unclear.-E. W. Archibald,
in discussion of a case presented at a meeting of the Montreal Medico-Chirurgical Society, Caned. Med. Ass. 1., 3:
259, 1913.