Comparison of the effect of topical triamcinolone 0.1% cream with sulfur 2.0% cream in the treatment of patients with hand eczema: A randomized controlled trial

Hand eczema (HE) is a common and heterogeneous condition. It has a wide range of etiologies and clinical manifestations. In this study the efficacy of triamcinolone 0.1% cream and sulfur 2% creams was compared in treating patients with HE.

be endogenous, such as atopy, or exogenous, such as irritant and/ or allergic contact dermatitis. 3The disease in 50% and 15% of the patients is caused by irritant contact dermatitis (ICD) and allergic contact dermatitis, respectively. 6The severity of the HE is measured by Hand Eczema Severity Index (HECSI). 7The HECSI scoring system is similar to scoring systems for psoriasis and atopic dermatitis which incorporates both extent and intensity of the disease.The scoring system is shown in Table 1. 8 There is no FDA-approved treatment for the long-term control of CHE, particularly for moderate-to-severe cases. 9HE is recurred in about 65% of patients after 5 years using topical creams. 1,102][13] Various skin conditions are treated with triamcinolone, which is a glucocorticoid. 2,146][17][18][19][20][21] The aim of this study was to compare triamcinolone 0.1% and sulfur 2% topical creams in treating patients with HE.Patients' satisfaction with treatment was measured with a VAS questionnaire.In addition, pictures before and after therapy for the evaluation of treatment were taken (Figure 1).Data were analyzed by SPSS software (ver.20), and the paired t-test and repeated measure ANOVA test were used.A p-value <0.05 was considered statistically significant.

| RE SULTS
The effect of two creams, triamcinolone (0.1%) and sulfur (2.0%), was evaluated and compared on 140 hands (including 70 patients) with diagnosed chronic eczema.All the patients had ICD.The hands were randomly divided into two groups, and each group was provided with a special therapeutic regimen for 4 weeks.The data was collected at the beginning of the study, after the treatment, and at the end of the fourth week of the follow-up period.
In this study, 28 male and 42 female patients participated.The mean age of participants was 34.64 years.Results showed that triamcinolone (0.1%) cream could significantly reduce the scores of HECSI, itching, dryness, burning sensation, and erythema, after 4 weeks of therapy (Table 2).In addition, after the 4-week followup, the scores of HECSI, itching, dryness, burning sensation, and erythema were significantly lower than before treatment with TA B L E 1 Hand eczema severity index (HECSI) score. 8
triamcinolone (Table 2).Similar findings were observed using sulfur (2.0%) cream.All parameters including HECSI, itching, dryness, burning sensation, and erythema were significantly reduced immediately after treatment (Table 3; Figure 1).On the other hand, the therapeutic effects of sulfur cream continued after follow-up period (Table 3).
Our result showed that HECSI score was not significantly different between the two groups at the beginning of the study (p > 0.05); however, at the end of the 4-week treatment, the sulfur cream is more effective than triamcinolone cream (p < 0.05).After follow-up, the efficacy of two creams was not significantly different (p > 0.05) (Table 4; Chart S1).
Itching, dryness, and erythema were more significantly reduced by sulfur cream than by the triamcinolone cream immediately after treatment (p < 0.05); however, burning sensation was not significantly different between the two groups (Table 4; Chart S2-S5).On the other hand, there was no significant difference between triamcinolone and sulfur cream effects after follow-up period (p > 0.05) (Table 4).Patients' satisfaction with both treatments was the same (p > 0.05) (Table 4).
Our data showed that sulfur cream (2.0%) is as effective as triamcinolone (0.1%) in the treatment of HE and even more effective in some cases (in reducing HECSI, itching, dryness, and erythema).
There was no adverse reaction reported for using sulfur cream during this study.

| DISCUSS ION
HE is a heterogonous and multifactorial condition.ICD, allergic contact dermatitis (ACD), and atopic HE are three main classification of HE. 2,22 Changes in severity and appearance of HE manifestations are observed over time.Manual work is affected by cracks and blisters, and results in sick leave and economic loss. 23Although HE is highly prevalent (up to 10% of general population), there is no treatment except for topical and short-term systemic corticosteroids. 10,24ng-term use of triamcinolone have some side effects including Skin thinning which can worsen skin damage.
In this study, we investigated the effectiveness of a sulfur cream (2.0%) in treating HE.Our results showed that using sulfur cream is as effective as triamcinolone topical cream, and is even more effective on reducing some manifestations of HE.Sulfur, used in treating several dermatological disorders, has antifungal, antibacterial, anti-inflammatory, and keratolytic properties. 17  On the other hand, it was reported that topical sulfur products (5%-10%) are safe, even in children, and complications because of topical sulfur cream are rare and mainly involve mild local reactions. 17,27In our study, no adverse reaction to sulfur cream was observed.

| CON CLUS ION
Topical sulfur cream (2.0%) is as effective as triamcinolone (0.1%) cream in the treatment of HE without significant adverse reactions (during four-week treatment and follow-up).

TA B L E 4
The results of comparison of two treatment regimen of hand eczema.a,b This randomized, triple-blind clinical trial was performed on 70 patients with CHE referred to the dermatology clinic of Al-Zahra and Sedigheh Tahereh Hospitals (Isfahan, Iran).Inclusion criteria were the clinical diagnosis of HE by a dermatologist.Patients did no have treatment for a month prior to study.All the participants gave informed consent.Patients with drug-induced eczema, without informed consent or treatment non-adherence were excluded from the study.Two creams used In this study were triamcinolone 0.1% cream as a traditional therapy for HE and sulfur 2.0% cream as a new treatment.The creams were packaged with labels number 1 or 2 and no additional information.Each participant randomly selected the number 1 or 2 treatment package for their left or right hand (randomization).In a triple-blind design, none of the participants, therapists, and biostatisticians were informed about the type of the creams used in the left or right hand.Confounding parameters such as the history of atopy, use of detergents, and environmental contacts were considered.The patients were treated with these two creams twice a day (every 12 h) for 4 weeks.The follow-up visit was 4 weeks after treatment termination.In cases with severe side effects, treatment terminated and the participant was excluded from the study.Data was collected by the demographic questionnaire, and VAS (Visual Analog Scale) questionnaire for itching, burning sensation, erythema, and dryness in addition to HECSI.All measurements were taken three times during the study including at the beginning, immediately after topical therapy (after 4 weeks of treatment), and at the end of the fourth week after stopping treatment (end of follow-up period).
,25,26 Nitric oxide and prostaglandin E2 production, and the expression of the proinflammatory cytokines tumor necrosis factorα, interleukin-1β, and interleukin-6 in lipopolysaccharide-activated macrophages is inhibited by the sulfur compounds. 26F I G U R E 1 The healing effect of sulfur cream (2.0%) after 4 weeks of treatment.TA B L E 2 Comparison of the triamcinolone (0.1%) cream efficacy in treating hand eczema between end of treatment and end of the follow-up period.a,b Triamcinolone (0.1%), (n = 70) Beginning of study End of treatment, (effect size, p-value)

TA B L E 3
Comparison of the sulfur (2.0%) cream efficacy in treating hand eczema between end of treatment and end of the follow-up period.a,b Sulfur (2.0%), (n = 70) Beginning of study End of treatment, (effect size, p-value)

End of follow-up, (effect size, p-value)
a Repeated measure ANOVA (pairwise comparisons).b Data was shown as Mean ± SD. c The Hand Eczema Severity Index (HECSI).d Measured by Visual Analog Scale (VAS).e Statistically significant.