Atopic Dermatitis Treatment & Management

Patients with atopic dermatitis do not usually require emergency therapy, but they may visit the emergency department for treatment of acute flares caused by eczema herpeticum and bacterial infections. For further information on treatment, see the NICE Guidelines Issued for Treating Atopic Eczema in Children.^[16]

• Moisturization in atopic dermatitis

  • Depending on the climate, patients usually benefit from 5-minute, lukewarm baths followed by the application of a moisturizer such as white petrolatum. Frequent baths with the addition of emulsifying oils (1 capful added to lukewarm bath water) for 5-10 minutes hydrate the skin. The oil keeps the water on the skin and prevents evaporation to the outside environment. In infants, 3 times a day is not a great burden; in adults, once or twice a day is usually all that can be achieved. Leave the body wet after bathing.
  • Advise patients to apply an emollient such as petrolatum or Aquaphor all over the body while wet, to seal in moisture and allow water to be absorbed through the stratum corneum. The ointment spreads well on wet skin. The active ingredient should be applied before the emollient. Newer emollients such as Atopiclair and Mimyx have been advocated as having superior results, but they are expensive and need further evaluation.
• Topical steroids in atopic dermatitis

  • Topical steroids are currently the mainstay of treatment. In association with moisturization, responses have been excellent.
  • Ointment bases are preferred, particularly in dry environments.
  • Initial therapy consists of hydrocortisone 1% powder in an ointment base applied 3 times daily to lesions on the face and in the folds.
  • A midstrength steroid ointment (triamcinolone or betamethasone valerate) is applied 2-3 times daily to lesions on the trunk until the eczematous lesions clear.
  • Steroids are discontinued when lesions disappear and are resumed when new patches arise.
  • Flares may be associated with seasonal changes, stress, activity, staphylococcal infection, or contact allergy.
  • Contact allergy is rare but accounts for increasing numbers of flares. These are seen mostly with hydrocortisone.
  • The results of a study from the Netherlands by Haeck et al suggest that the use of topical corticosteroids for atopic dermatitis on the eyelids and periorbital region is safe with the respect to induction of glaucoma or cataracts.^[17]
• Immunomodulators in atopic dermatitis

  • Tacrolimus (topical FK506) is an immunomodulator that acts as a calcineurin inhibitor. Studies have shown excellent results compared with placebo and hydrocortisone 1%. Little absorption occurs. A stinging sensation may occur following application, but this can be minimized by applying the medication only when the skin is dry. The burning usually disappears within 2-3 days. Tacrolimus is available in 2 strengths, 0.1% for adults and 0.03% for children, although some authorities routinely use the 0.1% preparation in children. Tacrolimus is an ointment and is indicated for moderate-to-severe atopic dermatitis. It is indicated for children older than 2 years.
  • Pimecrolimus 1% is also an immunomodulator and calcineurin inhibitor. It is more effective than placebo. Pimecrolimus is produced in a cream base for use twice a day; it is indicated for mild atopic dermatitis in persons older than 2 years and is particularly useful on the face.
  • A 2006 black box warning has been issued in the United States based on research that has shown an increase in malignancy in association with the calcineurin inhibitors. While these claims are being investigated further, the medication should likely only be used as indicated (ie, for atopic dermatitis in persons older than 2 y and only when first-line therapy has failed).
  • These agents are much more expensive than corticosteroids and should only be used as second-line therapy.
• Other treatments, effective and ineffective, in atopic dermatitis

  • Probiotics have been explored as a therapeutic option for the treatment of atopic dermatitis. The rationale for their use is that bacterial products may induce an immune response of the T_H 1 series instead of T_H 2 and could therefore inhibit the development of allergic IgE antibody production. Some report limited benefit in preventive and therapeutic roles.^[18] This research has yet to be proven.
  • UV-A, UV-B, a combination of both, psoralen plus UV-A (PUVA), or UV-B1 (narrow-band UV-B) therapy may be used. Long-term adverse effects of skin malignancies in fair-skinned individuals should be weighed against the benefits.
  • In patients with eczema herpeticum, acyclovir is effective.
  • In patients with severe disease, and particularly in adults, phototherapy, methotrexate (MTX), azathioprine, cyclosporine, and mycophenolate mofetil^[19] have been used with success.
  • Both hydroxyzine and diphenhydramine hydrochloride provide a certain degree of relief from itching but are not effective without other treatments.
  • Ketotifen (a calcium channel blocker) may be effective.
  • Oil of evening primrose was believed to be effective, but in a randomized controlled study, it showed no benefit in children and little improvement in adults.
  • Unsuccessful therapy with everolimus, a rapamycin-derived macrolide, has been reported in 2 patients with severe atopic dermatitis. Combination therapy with either prednisone or cyclosporine A was not effective.^[20] However, reports of the ineffectiveness of everolimus have be questioned.^[21]
  • Results with many other medications, such as thymopentin, gamma interferon, and Chinese herbs, have been disappointing. Many medications are not practical to use, and they can be expensive. Some Chinese herbal preparations contain prescription medications, including prednisone, and have been associated with cardiac and liver problems.
  • Antibiotics are used for the treatment of clinical infection caused by S aureus or flares of disease. They have no effect on stable disease in the absence of infection. Laboratory evidence of S aureus colonization is not evidence of clinical infection because staphylococcal organisms commonly colonize the skin of patients with atopic dermatitis.
  • A randomized, investigator-blinded, placebo-controlled trial including 31 patients showed that intranasal mupirocin ointment and diluted bleach (sodium hypochlorite) baths improved atopic dermatitis symptoms in patients with clinical signs of secondary bacterial infection.^[22]
• Nonmedical efforts in atopic dermatitis

  • Clothing should be soft next to the skin. Cotton is comfortable and can be layered in the winter.
  • Cool temperatures, particularly at night, are helpful because sweating causes irritation and itch.
  • A humidifier (cool mist) prevents excess drying and should be used in both winter, when the heating dries the atmosphere, and in the summer, when air conditioning absorbs the moisture from the air.
  • Clothes should be washed in a mild detergent with no bleach or fabric softener.
  • Food avoidance is discussed in Diet, below, and in Causes.

Consulting an allergist may be necessary, particularly if the patient develops asthma and/or hay fever or an acute reaction to a food.

Avoid foods that provoke acute allergic reactions (hives, anaphylaxis). Most frequently, allergic reactions occur to peanuts (peanut butter), eggs, seafood, milk, soya, and chocolate. Additionally, advise patients to apply a barrier of petroleum jelly around the mouth prior to eating to prevent irritation from tomatoes, oranges, and other irritating foods.

Advise patients to avoid activities that cause excessive sweating. Also, swimming in an outdoor pool (or wading pool for babies) in summer provides therapeutic benefit by exposing the person to the sun but avoiding the heat.