Atopic Dermatitis in Emergency Medicine Medication
- Author: Cassandra Bradby, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
Drug regimens for eczema should be tailored to the individual patient to reduce the frequency and severity of exacerbations.
Topical steroids are very effective when used in the induction of remission and in the acute exacerbation of atopic dermatitis. Low- to medium-potency steroids should be used routinely, with medium-to-high potency steroids for more severe rashes.
Triamcinolone topical is a medium-potency topical steroid. It treats inflammatory dermatoses responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.
Hydrocortisone topical is an example of a low-potency topical steroid available over the counter. It is an adrenocorticosteroid derivative suitable for application to skin or external mucous membranes. It has mineralocorticoid and glucocorticoid effects resulting in anti-inflammatory activity.
Topical calcineurin Inhibitors
Topical immune suppressants that block early T-cell activation, degranulation of mast cells, and multiple cytokines.
Pimecrolimus was the first nonsteroid cream approved in the United States for mild-to-moderate atopic dermatitis. It is derived from ascomycin, a natural substance produced by fungus Streptomyces hygroscopicus var ascomyceticus. It selectively inhibits the production and release of inflammatory cytokines from activated T cells by binding to cytosolic immunophilin receptor macrophilin-12. The resulting complex inhibits phosphatase calcineurin, thus blocking T-cell activation and cytokine release. Cutaneous atrophy was not observed in clinical trials, a potential advantage over topical corticosteroids. It is indicated only after other treatment options have failed.
The mechanism of action of tacrolimus in atopic dermatitis is not known. It reduces itching and inflammation by suppressing the release of cytokines from T cells. It also inhibits transcription for genes that encode IL-3, IL-4, IL-5, GM-CSF, and TNF-alpha, all of which are involved in the early stages of T-cell activation. Additionally, it may inhibit the release of preformed mediators from skin mast cells and basophils, and down-regulate the expression of FCeRI on Langerhans cells. Tacrolimus ointment can be used in patients as young as 2 years. Drugs of this class are more expensive than topical corticosteroids. It is available as an ointment in concentrations of 0.03% and 0.1%. It is indicated only after other treatment options have failed.
Oral immunosuppressive agents
Oral immunosuppressive agents are for use in severe refractory atopic dermatitis.
Cyclosporine is an 11-amino acid cyclic peptide and a natural product of fungi. It acts on T-cell replication and activity. Cyclosporine is a specific modulator of T-cell function and an agent that depresses cell-mediated immune responses by inhibiting helper T-cell function. Preferential and reversible inhibition of T lymphocytes in the G0 or G1 phase of cell cycle is suggested. It binds to cyclophilin, an intracellular protein, which, in turn, prevents the formation of interleukin 2 and the subsequent recruitment of activated T cells.
Cyclosporine has about 30% bioavailability, but there is marked interindividual variability. It specifically inhibits T-lymphocyte function with minimal activity against B cells. Maximum suppression of T-lymphocyte proliferation requires that the drug be present during first 24 hours of antigenic exposure.
Cyclosporine suppresses some humoral immunity and, to a greater extent, cell-mediated immune reactions (eg, delayed hypersensitivity, allograft rejection, experimental allergic encephalomyelitis, and graft vs host disease) for a variety of organs.
Antihistamines are used for the sedating effects. They help to prevent scratching during sleep.
Hydroxyzine hydrochloride antagonizes H1-receptors in the periphery. It also may suppress histamine activity in the subcortical region of the CNS. It is a sedating antihistamine.
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