atopic%20dermatitis
ATOPIC DERMATITIS
Atopic dermatitis or atopic eczema is a chronic, relapsing, familial, symmetric and pruritic inflammatory skin disease that commonly presents during early infancy and childhood, but can persist or start in adulthood.
It is commonly associated with elevated serum immunoglobulin E levels and a personal or family history of allergies, allergic rhinitis and asthma.
It is one of the most common skin diseases afflicting both children and adults.

Pharmacotherapy

Topical Corticosteroids

  • Used as 1st-line treatment for mild to severe atopic dermatitis and when non-pharmacological interventions have been unsuccessful 
  • Rapid symptomatic relief for acute flare-ups; also used for prevention of relapses
  • Choice of product will depend on severity of flare-up, distribution and site of lesions, patient’s age and preference, and other factors eg humidity
  • Anti-inflammatory and antipruritic activity through several mechanisms
    • Alteration in leukocyte number and activity
    • Suppression of mediator release (histamine, prostaglandins)
    • Enhanced response to agents that increase cyclic adenosine monophosphate (prostaglandin E2 and histamine via the histamine-2 receptor)
  • Follow the recommended restrictions regarding intensity and duration of use especially in children on delicate skin areas (eg face, neck and skin folds)
    • Intermittent use in combination with moisturizers is historically the standard therapy for atopic dermatitis
    • Continuous use can lead to adverse effect
  • Available in different potencies from mildly potent to very potent
    • Potency is also affected by the vehicle the product is formulated in (eg ointment, cream, lotion in decreasing order of efficacy)
    • Potency of topical corticosteroid does not relate to percentage stated (eg Hydrocortisone 2.5% versus Betamethasone dipropionate 0.05%)
    • Least potent but effective product should be used, especially if for long-term use
    • May use mid- and high-potency preparations (except when lesions are on face, groin or axillae) to control acute flares and then follow with lower potency preparations after clinical improvement is seen
    • 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

Solutions

  • Useful for the scalp or other hirsute areas
  • Alcohol content may be irritating when used on inflamed lesions

Lotions

  • Useful for minimal application to a large area or on hirsute areas
  • May also be used on exudative lesions and in hairy areas
Creams
  • Usually preferred for moist/weeping lesions
  • May be preferred during periods of excessive heat or humidity
  • Easier to apply but may be less effective

Ointments

  • Generally used for dry, scaly or lichenified lesions or if a more occlusive effect is needed (most occlusive vehicle)
  • Usually less additives are used
  • Evaporative losses are decreased

Systemic Corticosteroids

  • Should only be considered in treatment-resistant atopic dermatitis, acute severe exacerbations and as a bridge therapy to other steroid-sparing systemic treatments
  • Improve lesions but rebound flare-up usually occurs upon discontinuation
  • Use short-term and decrease chance of rebound effect by tapering oral form slowly while increasing topical corticosteroid treatment and continuously hydrating the skin
  • Various oral corticosteroids are available. Please see prescribing information for specific formulations in the latest MIMS.

Calcineurin Inhibitors - Topical Immunomodulators

  • Steroid-sparing agents for acute and maintenance therapy, topical calcineurin inhibitors inhibit inflammatory cytokine transcription in activated T cells and other inflammatory cells through inhibition of calcineurin
  • May be used on all body locations for extended periods of time, especially the face, hands and feet
  • All preparations are of a standard potency
  • There is no evidence of causal link between the use of calcineurin inhibitors and cancer
  • Preferred over topical corticosteroids when atopic dermatitis is unresponsive to steroid therapy, with presence of atrophy or telangiectasia secondary to steroid use, when affected areas are either the face, anogenital area, and/or skin folds, and for long-term treatments
  • Also used in patients with inadequate response to other topical therapeutic agents or when such treatments are not advised

Pimecrolimus

  • Safety and efficacy have been shown in children >2 years of age and adults with mild-moderate atopic dermatitis
    • Pruritus relief has been seen as early as day 3 of use; does not cause atrophy
    • Prevents flare-ups and 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

  • Rapidly decreases the signs and symptoms of atopic dermatitis in adults and children >2 years of age
    • Improvement is seen within 3-7 days of therapy and sustained for at least 12 months
    • Well-tolerated with transient skin burning/irritation; less incidence of atrophy compared to steroids
  • Studies have confirmed the efficacy of Tacrolimus 0.03% compared to low-potency topical corticosteroids in children and the efficacy of Tacrolimus 0.1% compared to mid-potency topical corticosteroids in adults

Skin Infections

  • Clinical infections at treatment sites should be cleared before starting anti-inflammatory agents
  • May need to treat reservoirs of the disease to prevent recurrence (eg nose, groin)
  • Various antibiotics, antivirals and antifungals are available. Please see prescribing information for specific formulations in the latest MIMS

Bacterial Infections

  • Staphylococcus aureus is commonly cultured from eczematous skin and is often the cause of localized infections
  • Topical therapy
    • May be used to treat localized areas
    • Fusidic acid, Mupirocin, Neomycin and 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 and 2nd generation cephalosporins, and Clindamycin are treatment options

Viral Infections

  • Patients may develop secondary herpes infections inclusive of eczema herpeticum and Kaposi’s varicelliform eruption and may require systemic Acyclovir treatment in a hospital setting
  • Prophylactic oral antiviral agents may be used to suppress recurrent cutaneous herpetic infections
  • Cryotherapy, topical KOH, Imiquimod or immunostimulatory agents may be used for eczema molluscatum

Fungal Infections

  • May be considered as a possible complication of atopic dermatitis
  • Superficial dermatophytosis and Pityrosporum ovale may be treated with systemic or topical antifungals
Antihistamines
  • Oral sedating antihistamines are typically used for soporific effect to facilitate sleep and to prevent increase of itch intensity 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 with associated urticaria
  • Topical antihistamines are usually not helpful in relieving pruritus and may cause allergic contact dermatitis
  • Various oral antihistamines are available. Please see prescribing information for specific formulations in the latest MIMS
Alitretinoin
  • A derivative of Isotretinoin with anti-inflammatory effects used for severe chronic hand atopic dermatitis unresponsive to 1st-line treatments

Immunosuppressants - Oral

Ciclosporin (Cyclosporin A)

  • Effective for short-term use in severe refractory disease in children and adults
    • 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 and renal and liver dysfunction
  • Various oral immunosuppressants are available. Please see prescribing information for specific formulations in the latest MIMS

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 and has been used long-term
    • Most children respond to low doses
    • There is increasing evidence supporting its efficacy in severe refractory atopic dermatitis
  • May cause nausea, fatigue, myalgia, liver dysfunction and bone marrow depression in patients deficient in thiopurine methyltransferase

Other Systemic Immunosuppressants

  • Methotrexate, Mycophenolate mofetil and Interferon gamma may be considered for refractory atopic dermatitis but further studies are needed to confirm efficacy

Other Pharmacotherapeutic Options:

  • Leukotriene antagonists
  • Probiotics
  • Topical phosphodiesterase inhibitors (eg Apremilast)
  • Topical sodium cromoglycate
  • Vitamin D

Non-Pharmacological Therapy

Avoidance of Trigger Factors

  • Avoidance of aeroallergens, eg house dust mites, may result in improved symptoms
    • Use dust mite-proof encasings on pillows, mattresses and box springs
    • Wash bedding weekly in hot water (>58°C)
    • Remove bedroom carpeting and curtains
    • Decrease indoor humidity to levels below 60%
    • Evidence suggests that allergen-specific immunotherapy may be an option in treating select patients with sensitivity to aeroallergens
  • In most cases, trigger factors cannot be specifically identified
    • Apply holistic approach to avoidance since trigger factors are usually multiple

Common Trigger Factors

  • Wool clothing, pollen, extreme temperature, sweat, products with perfumes or preservatives, foods, cigarette smoke and animal dander

Other Factors

  • Psychological factors
    • Emotional factors (eg anxiety, stress and anger) cause disease exacerbation, induce immune activation and increase pruritus and scratching
    • Psychological evaluation and counseling should be considered in patients who have difficulty with emotional triggers or who have psychological problems

Skin Care

  • Hydration of skin with emollients is essential to treatment of atopic dermatitis

Bathing

  • Soap substitutes with minimal defatting activity, fragrance-free, hypoallergenic, and a neutral to low 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 and apply moisturizer within 3-5 minutes of bath
  • Studies have shown a decrease in bacterial infection (eg staphylococcal, methicillin-resistant Staphylococcus aureus), disease severity, and flare-ups in patients taking regular bleach baths (1:1200 dilution of 6% hypochlorite bleach; 10-minute soak, 3x/week)
    • Bleach baths with intranasal Mupirocin are highly recommended for patients with moderate-severe disease with recurrent secondary bacterial infection
  • 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
  • Various products are available. Please see prescribing information for specific formulations in the latest MIMS

Moisturizers

  • Water-in-oil emollients are preferred; occlusive agents and humectants also used
    • Useful for the treatment of active disease and both prevention and maintenance therapy
    • Helps reestablish and preserve the stratum corneum
  • Reports of studies suggest that the use of emollients in infants might prevent atopic dermatitis development in high-risk patients
  • Patient preference and treatment area will determine formula used in moisturizers [eg Ceramides, Hydroxypalmitoyl sphinganine, Palmitoylethanolamide (PEA), Liquid paraffin, Mineral oils, Glycerin, Hyaluronic acid, Shea (Butyrospermum parkii) butter, Telmesteine, Glycyrrhetinic acid, Lactic acid]
  • Effects:
    • Emollients provide lubrication and helps soften skin surface
    • Occlusive agents provide a physical barrier against water evaporation
    • Humectants help retain moisture in
  • Can decrease the need for topical corticosteroids
  • Should be applied all over at least twice daily regardless of the presence of active dermatitis
  • Avoid products with preservatives or fragrances
  • If product stings, seek expert advice
  • Various products are available. Please see prescribing information for specific formulations in the latest MIMS

Wet Dressings

  • May be used for chronic and refractory lesions or for moderate-severe weeping lesions
    • Cools inflamed skin, maintains hydration, and decreases scratching
    • Can help reduce water loss and disease severity in patients with moderate-severe atopic dermatitis
  • Combined with topical corticosteroids can be effective in treating refractory cases

Phototherapy

  • Considered in patients with recalcitrant disease or when 1st-line therapy with topical agents has been unsuccessful
  • Broad-band UVB and UVA, narrow-band UVB and UVA-1 or combined UVA and UVB can be useful
    • Treats chronic lichenified forms of moderate-severe disease; high doses of UVA-1 may be given for acute flares
    • Effectively reduces colonization of S aureus and Malassezia sp and mediate cytokine production
  • Photochemotherapy with Psoralens and UVA should be restricted to patients with widespread severe atopic dermatitis
  • High doses of UVA-1 may be combined with corticosteroids and emollients in phases of acute flares
  • Relapse after therapy cessation frequently occurs
  • Adverse reactions:
    • Short-term: Erythema, skin pain, pigmentation, itching
    • Long-term: Premature skin aging and potential cutaneous malignant diseases
Editor's Recommendations
Most Read Articles
08 Oct 2017
Treatment with vismodegib does not appear to increase the risk of subsequent squamous cell carcinoma (SCC) in comparison with standard surgical treatment of basal cell carcinoma (BCC), a recent study suggests.
Stephen Padilla, 10 Oct 2017
Secukinumab has shown efficacy and safety for patients with extensive moderate-to-severe scalp psoriasis, according to a recent study.
09 Oct 2017
Use of voriconazole appears to increase the risk specifically for squamous cell carcinoma (SCC) in the allogeneic haematopoietic cell transplantation (HCT) population, according to a recent study.
27 Sep 2017
Poor sleep quality is not uncommon among patients with psoriatic disease, suggests a recent study. Poor sleep is associated with fatigue, anxiety and lower EQ-5D. It is also associated with actively inflamed joints in patients with psoriatic arthritis (PsA).