eMedicine Specialties > Ophthalmology > Dermatologic Disorders

Dermatitis, Atopic: Treatment & Medication

Author: R Scott Lowery, MD, Assistant Professor of Ophthalmology, Department of Pediatric Ophthalmology and Strabismus, University of Arkansas for Medical Center, Arkansas Children's Hospital
Contributor Information and Disclosures

Updated: Apr 10, 2009

Treatment

Medical Care

  • No cure exists, and treatment is aimed at the multifactorial nature of the disease.6
  • The most commonly used treatments include stress control, avoidance of allergens (most commonly dust mites, peanuts, egg, milk, fish, rice, soy, and wheat), and irritants (particularly chemicals, soaps, heat, humidity, wool, and acrylic).
  • Atopic dermatitis frequently can be controlled with topical steroids.
  • Management of atopic dermatitis and AKC is similar to management of vernal keratoconjunctivitis (VKC), but the chronic nature of AKC requires more prolonged treatment.
  • The treatment regimen for AKC typically consists of topical steroids, mast cell stabilizers, systemic antihistamines, and systemic and topical antibiotics.7
  • Recent studies have shown that patients with eye involvement may have an increased likelihood of food sensitivity.

Consultations

Ophthalmic consultation is recommended if eye involvement is noted. Dermatology consultation may be necessary to confirm a diagnosis of atopic dermatitis.8

Diet

Patients with known atopic disease may have various food allergies that trigger or exacerbate their disease. Avoidance of these foods is essential.

Medication

The most commonly used treatment strategies include antibiotics, corticosteroids, antihistamines, and, less commonly, immunosuppressives (other than steroids), UV light, and hospitalization (rare). For most cases of atopic dermatitis (without AKC), application of topical steroids to the affected area is usually sufficient. Eye involvement may be treated with topical steroids alone, or if symptoms persist, additional mast cell stabilizers (topical), and oral antihistamines (eg, over-the-counter diphenhydramine). AKC may require all of these, and some ophthalmologists recommend that an oral antibiotic be given in addition to a topical antibiotic for the affected eye(s). Antibiotic treatment should target S aureus, the most likely pathogen, and should be chosen based on the patient's allergies and compliance. Immunosuppressives, other than steroids, will only very rarely be required, and these likely will not be prescribed by the ophthalmologist.

Corticosteroids

As anti-inflammatory and immunosuppressive agents, corticosteroids are beneficial in treating atopic dermatitis. Dexamethasone, fluorometholone, hydrocortisone, and prednisolone are the most commonly available preparations of ophthalmic steroids in the United States. Preparations range from 0.05-2.5%. For most topical purposes, a 0.5% preparation of prednisolone, cortisone, or hydrocortisone is adequate.


Prednisolone (AK-Pred, Pred Forte, Inflamase Forte)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Adult

Dosage depends on severity of disease
For AKC, a higher concentration for a longer period may be required
1-2 gtt bid/qid, not to discontinue prematurely; reevaluate in 2 d if symptoms fail to improve

Pediatric

Not established

Decreases effects of salicylates and toxoids (for immunizations); phenytoin, carbamazepine, barbiturates, and rifampin decrease effects of corticosteroids

Documented hypersensitivity; viral, fungal, or tubercular skin infections; glaucoma; immunosuppression; myopathy

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes, and myasthenia gravis; long-term treatment with high-dose steroids has been shown to cause posterior subcapsular cataracts; hypokalemic alkalosis has been observed; glaucoma, myopathy, psychosis or mood disorders, corneal and scleral thinning, secondary infection, and retardation of wound healing are possible; with prolonged steroid treatment, pediatric patients may develop growth retardation, Cushing syndrome, striae, osteoporosis, avascular necrosis, myopathy, hypertension, ulcers, acne, fluid and electrolyte imbalance, mood alterations, and diminished immunity; pseudotumor cerebri may result on discontinuation; may increase IOP; prolonged use may result in glaucoma

Mast cell stabilizers

May be useful as prophylaxis against exacerbation of the disease.


Lodoxamide (Alomide)

Inhibits degranulation of mast cells and helps prevent histamine release.

Adult

1-2 gtt qid for 10 d to affected eye(s); not to use >3 mo

Pediatric

<2 years: Not established
>2 years: Administer as in adults

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Not for injection; often experience transient burning or stinging from instillation; soft contact lens wearers should refrain from using them while under treatment


Cromolyn (Crolom, Opticrom)

Inhibits degranulation of sensitized mast cells following exposure to specific antigens.

Adult

Not to exceed 1-2 gtt in each eye 4-6 times/d at regular intervals

Pediatric

Not established

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Often experience transient burning or stinging from instillation; soft contact lens wearers should refrain from using them while under treatment

Oral antihistamines

Useful in decreasing itching and scratching associated with atopic dermatitis.


Hydroxyzine (Atarax, Vistaril, Vistazine)

Antagonizes H1 receptors in periphery; may suppress histamine activity in subcortical region of CNS; may assist in sleep.

Adult

25 mg PO/IM tid/qid

Pediatric

<6 years: 50 mg/d PO divided into several doses
>6 years: 50-100 mg/d PO divided into several doses

May potentiate CNS depressants such as alcohol, narcotics, barbiturates, and other analgesics (reducing dose in combination with these is necessary)

Documented hypersensitivity; early pregnancy

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Associated with clinical exacerbations of porphyria (may not be safe for porphyric patients); ECG abnormalities (alterations in T waves) may occur; may cause drowsiness requiring avoidance of driving, operating heavy machinery, and alcohol use

Topical antibiotics

Atopic conjunctivitis requires the use of topical antibiotics that particularly target S aureus, the most common pathogen. Since most ophthalmic antibiotics will target this bacterium, physician discretion, reference to package inserts, and the ophthalmic Physicians' Desk Reference are recommended. Patients' allergies and compliance should be considered.


Gatifloxacin ophthalmic (Zymar)

Fluoroquinolone with activity against streptococci, staphylococci, Corynebacterium propinquum, and Haemophilus influenzae; inhibits bacterial DNA synthesis and, consequently, growth.

Adult

2 gtt q15min for the first 6 h, then 2 gtt q30min for remainder of first day
Day 2: 2 gtt qh
Days 3-14: 2 gtt q4h

Pediatric

Not established

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Serious anaphylactic reactions have occurred; superinfections and opportunistic infections may occur; contact lenses should be removed before instillation; white crystalline precipitates may occur

More on Dermatitis, Atopic

Overview: Dermatitis, Atopic
Differential Diagnoses & Workup: Dermatitis, Atopic
Treatment & Medication: Dermatitis, Atopic
Follow-up: Dermatitis, Atopic
References
Further Reading
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References

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  3. Jung T, Stingl G. Atopic dermatitis: therapeutic concepts evolving from new pathophysiologic insights. J Allergy Clin Immunol. Dec 2008;122(6):1074-81. [Medline].

  4. Bezan DJ. Eye itch. In: Bezan DJ, Larussa FP, Nishimoto JH, et al, eds. Differential Diagnosis in Primary Eye Care. Boston: Butterworth-Heinemann; 1999:67-71.

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  16. Liesegang TJ. Atopic keratoconjunctivitis. In: Pepose JS, Holland GN, Wilhelmus KR, eds. Ocular Infection and Immunity. St. Louis: Mosby; 1996:376-390.

  17. Roy FH. Ocular Differential Diagnosis. 7th ed. Philadelphia: Williams & Wilkins; 2002.

  18. Shelley WB, Shelley EB. Atopic dermatitis. In: Advanced Dermatologic Diagnosis. Philadelphia: WB Saunders Co; 1992:285-291.

  19. Uchio E, Miyakawa K, Ikezawa Z, Ohno S. Systemic and local immunological features of atopic dermatitis patients with ocular complications. Br J Ophthalmol. Jan 1998;82(1):82-7. [Medline].

  20. Weisbecker CA, Fraunfelder FT, Rhee D. Physicians' Desk Reference for Ophthalmology. 28th ed. Oradell, NJ: Medical Economics Co; 2000.

  21. Zimmerman TJ, Kulkarni PS, Meredith TA. Steroids in ocular therapy, antibiotics and antifungals, antiallergic therapies. In: Zimmerman TJ, Kooner KS, Shariv M, Fechtner RD, eds. Textbook of Ocular Pharmacology. Philadelphia: Lippincott-Raven; 1997:61-74, 363-385, 609-633,683-701, 801-804.

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Keywords

atopic dermatitis, atopic eczema, Besnier prurigo, prurigo Besnier, Besnier's prurigo, atopy

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Contributor Information and Disclosures

Author

R Scott Lowery, MD, Assistant Professor of Ophthalmology, Department of Pediatric Ophthalmology and Strabismus, University of Arkansas for Medical Center, Arkansas Children's Hospital
R Scott Lowery, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.

Medical Editor

Jack L Wilson, PhD, Distinguished Professor, Department of Anatomy and Neurobiology, University of Tennessee at Memphis
Jack L Wilson, PhD is a member of the following medical societies: American Association of Anatomists, American Association of Clinical Anatomists, and American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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