Corticosteroids (Topical)

• Used as 1st-line treatment for mild to severe atopic dermatitis
• Moderately potent & potent corticosteroids should be used for the treatment of clinical exacerbation over short periods of time
• Mildly potent corticosteroids are recommended for maintenance therapy
• Anti-inflammatory & antipruritic activity through several mechanisms
  • Alteration in leukocyte number & activity
  • Suppression of mediator release (histamine, prostaglandins)
  • Enhanced response to agents that increase cyclic adenosine monophosphate (prostaglandin E₂ & histamine via the histamine-2 receptor)
• Rapid symptomatic relief of acute flare-ups
• Continuous use can lead to adverse effects
• Follow the recommended restrictions regarding intensity & duration of use on delicate skin areas (eg face, neck & skin folds)
• Topical corticosteroids are available in different potencies from mild to very potent
  • Potency is also affected by the vehicle the product is formulated in (eg cream, ointment)
• Choice of product will depend on severity of flare-up, distribution of lesions & other factors (eg humidity)
• Least potent but effective product should be used
• Rebound flaring can occur if higher potency preparations are discontinued abruptly
  •  A gradual decrease in potency should follow use of higher potency preparations
•  Therapy-resistant lesions may require potent topical corticosteroid used under occlusion for a short period of time & under close supervision

Calcineurin Inhibitors (Topical)

• Inhibit inflammatory cytokine transcription in activated T cells & other inflammatory cells through inhibition of calcineurin
• May be used on all body locations for extended periods of time, especially the face, hands & feet
• All preparations are of a standard potency
• Not recommended for patient <2 years of age

Pimecrolimus

• Safety & efficacy has been shown in infants & children w/ mild-moderate atopic dermatitis
  • Pruritus relief has been seen as early as day 3 of use
  • Prevents flare-ups & results in significant steroid-sparing effect when used for up to 12 months
• When used in early stages of disease, it has shown to be therapeutically advantageous over typical moisturizers plus topical corticosteroids in long-term use

Tacrolimus

• Indicated for moderate-severe atopic dermatitis
  • May be used for up to 1 year w/o loss of effectiveness, increase in infection risk or other non-application-site adverse effects
  • Well-tolerated w/ transient skin burning/irritation
• Studies have confirmed the efficacy of Tacrolimus 0.03% compared to low potency topical corticosteroids in children

Skin Infections¹

• Clinical infections at treatment sites should be cleared before starting anti-inflammatory agents
• May need to treat reservoirs of the infection to prevent recurrence (eg nose, groin)

Bacterial Infections

• S aureus is commonly cultured from eczematous skin & is often the cause of localized infections
• Topical therapy
  • May be used to treat mild & localized secondary infection
  • Fusidic acid, Mupirocin, & Retapamulin are treatment options
  • Neomycin may cause allergic contact dermatitis
  • Retapamulin is recommended for children ≥ 9 months
• Oral therapy
  •  Usually necessary to treat widespread infected lesions
  •  Anti-staphylococcal penicillins, macrolides, 1st & 2nd generation cephalosporins & Clindamycin are treatment options

Viral Infections

• Patients may develop secondary herpes infections inclusive of eczema herpeticum (Kaposi’s varicelliform eruption) & may require systemic Acyclovir treatment in a hospital setting
• Prophylactic oral antiviral agents may be used to suppress recurrent cutaneous herpetic infections

Fungal Infections

• Role of fungi in atopic dermatitis is questionable
• Superficial dermatophytosis & Pityrosporum ovale may be treated w/ systemic or topical antifungals

Viral Infections

• Patients may develop secondary herpes infections inclusive of eczema herpeticum (Kaposi’s varicelliform eruption) & may require systemic Acyclovir treatment in a hospital setting
• Prophylactic oral antiviral agents may be used to suppress recurrent cutaneous herpetic infections

Fungal Infections

• Role of fungi in atopic dermatitis is questionable
• Superficial dermatophytosis & Pityrosporum ovale may be treated w/ systemic or topical antifungals

Antihistamines¹

• Oral sedating antihistamines may be useful if the patient has comorbidities (allergic rhinitis, urticaria or dermatographism) & sleep disturbance
  • They are best used at bedtime since pruritus is typically worse at night
• Studies of oral non-sedating antihistamines have shown variable results in controlling pruritus, however they may be useful in a small group of patients w/ associated urticaria
•  Topical antihistamines are usually not helpful in relieving pruritus & may cause allergic contact dermatitis

Systemic corticosteroids¹

• Should only be considered in treatment-resistant atopic dermatitis
• Improves lesions but rebound flare-up usually occurs upon discontinuation
• Use short-term & decrease chance of rebound effect by tapering oral form slowly while increasing topical corticosteroid treatment & continuously hydrating the skin

Immunosuppressants (Oral)¹ 

Ciclosporin

• Effective for short-term use in severe refractory disease
  • Condition tends to return after discontinuation of therapy but not always at the original severity level
•  Long-term use is not justified because of risks of hypertension & renal dysfunction

Azathioprine

• Used for severe/refractory disease
• Thiopurine methyltransferase (TMPT) levels should be monitored while patient is on Azathioprine to test for myelosuppression
• Safer than Ciclosporin & has been used long-term
  • Most patients respond to low doses
• Adverse reactions: Nausea, fatigue, myalgia, liver dysfunction & bone marrow depression in patients deficient in thiopurine methyltransferase

¹Various antibiotics, antifungals & antivirals are available. Please see prescribing information for specific formulations in the latest MIMS.

Avoidance of Trigger Factors

All irritants

• Lipid solvents (soaps, detergents)
  • New clothes should be laundered before wearing to decrease levels of formaldehyde & other chemicals added
  • When washing, use liquid instead of powder detergent, & do another rinse cycle to remove detergent completely from clothes
• Disinfectants (swimming pool chlorine)
•  Occupational irritants
•  Household fluids (meats, juices from fresh fruits)

Contact & aeroallergens

• Dust mites
  • Avoidance include use of dust mite-proof encasings on pillows & mattresses, washing bedding in hot water weekly remove bedroom carpeting & curtains, decrease indoor humidity level by air conditioning, avoid upholstered sofa
• Furry animals (cats, dogs)
•  Molds
•  Human dander (dandruff) resulting in overgrowth of yeast

Others

• Foods
  • Flaring/occurrence of atopic dermatitis w/ a specific food may warrant elimination diet in patients w/ moderate-severe atopic dermatitis
  • Skin prick tests (SPT) & measurement of specific immunoglobulin E (IgE) are used to determine sensitization to a particular food
  • Dietary restriction of eggs may be beneficial in patients w/ IgE reactivity to egg
• Climate
  •  Consider temp & humidity control to avoid increased pruritus due to heat & perspiration
  •  Prolonged sun exposure may increase evaporative losses due to sweating
•  Hormones (menstrual cycle)
•  Psychological factors
  •  Emotional factors (eg anxiety & anger) cause disease exacerbation, induce immune activation & increase pruritus & scratching
  •  Psychological evaluation & counseling should be considered in patients who have difficulty w/ emotional triggers or who have psychological problems

Skin Care

• Hydration of skin w/ emollients is essential in atopic dermatitis treatment

Bathing¹

• Soap substitutes w/ minimal defatting activity & a neutral pH are preferred
• If possible, limit soap use to hands, feet, genitalia, axillae
• Limit bathing to once daily for 5-10 minutes using warm water
• Pat dry after bath & apply moisturizer w/in 3-5 minutes of bath
• Oatmeal products added to bath may be soothing but do not increase water absorption by the skin
• Topical medications are best applied after bathing because of greater penetration of hydrated skin

Moisturizers¹

• Water-in-oil emollients are preferred
• Patient preference & treatment area will determine formula used in emollients (eg palmitoylethanolamide (PEA), liqd paraffin, mineral oils, glycerin, etc)
• Effects: Moisturizers help re-establish & preserve the stratum corneum
  • Can decrease the need for topical corticosteroids
• Should be applied all over at least twice daily or as often as possible, regardless of the presence of active dermatitis
•  Avoid products w/ preservatives or fragrances
•  If product stings, it should not be used

Wet Dressings

• May be used on weeping lesions or severely affected areas
  • Discomfort, folliculitis & impetigo reported as common adverse effects
•  
  •  Temporary increased systemic absorption of corticosteroids reported

Phototherapy

• Broad-band ultraviolet B (UVB) & ultraviolet A (UVA), narrow-band UVB & UVA-1 or combined UVA & UVB can be useful in atopic dermatitis
• Relapse following cessation of therapy frequently occurs
• Photochemotherapy w/ Psoralens & UVA should be restricted to patients w/ widespread severe atopic dermatitis
• UV therapy should be restricted to patients >12 years except when absolutely necessary
• Adverse reactions:
  • Short-term: Erythema, skin pain, pigmentation, itching
  • Long-term: Premature skin aging & potential cutaneous malignant diseases