Pharmacotherapy
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.
Non-Pharmacological Therapy
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
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- 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