eMedicine Specialties > Emergency Medicine > Dermatology
Dermatitis, Atopic: Treatment & Medication
Updated: Jun 30, 2009
- Overview
- Differential Diagnoses & Workup
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Treatment
Emergency Department Care
Many patients with atopic dermatitis (AD) present to the ED during acute exacerbation. Therapy is targeted toward alleviation of pruritus and prevention of scratching. ED physicians must also look for signs and symptoms of bacterial superinfection and treat accordingly.
Practice guidelines on the management of atopic dermatitis are available from the Joint Task Force on Practice Parameters for Allergy and Immunology.8
- Skin care
- In the acute setting patients should be instructed to bathe once-to-twice daily using mild soaps (eg, Dove). There is no preference over showers or baths, whichever makes the patient most comfortable.
- The patient should dry quickly and immediately (within 3 min) lubricate the skin. Many creams and lotions are available, and the optimal one is the greasiest the patient can tolerate.
- Creams (eg, Eucerin, Cetaphil) are preferred over lotions, as they have lower or no water content and will not evaporate off of the skin during the day. Parents may use petroleum jelly on infants, but most children and adults will not tolerate the texture.
- Topical steroids
- Acute attacks should be treated by mid-high strength topical steroids for up to 2 weeks. Medium-to-high potency topical steroids should not be used on the face or neck area because of the potential adverse effects. These are preferred over low-mid strength medications, as they better control exacerbations. Patients should apply the ointment within 5 minutes of twice-daily bathing.
- Inform the patient about adverse effects of topical steroids (eg, atrophy, hypopigmentation, striae, telangiectasia, thinning of the skin).
- Antihistamines: Physicians have been prescribing antihistamines for years to control the pruritus associated with acute atopic dermatitis. Little evidence exists that antihistamines help with the itching in an awake patient; however, the use of sedating antihistamines is supported to control scratching while the patient is asleep.9
- Systemic steroids: The use of systemic steroids in the treatment of acute exacerbation of atopic dermatitis is controversial. Most authors reserve oral prednisone (at least 20 mg/d for 7 d) for the most severe cases, although it seems the disease quickly relapses once the medication is discontinued. Patients also tend to discontinue topical steroid creams and other treatment as they feel better, which contributes to the relapse after oral steroids are done.
- Topical calcineurin inhibitors: Topical calcineurin inhibitors (pimecrolimus 1% and tacrolimus 0.03%, 0.1%) are available for patients older than 2 years. These medications may be used all over skin surfaces (including face, neck, and hairline) because they do not have the side effects seen with topical steroids. Evidence supports the twice-daily use of these creams during acute exacerbation of atopic dermatitis, and some evidence exists to support use up to 4 years. The long-term side effects (including the possibility of increased risk for malignancy) have not fully been elucidated. For these reasons, the US Food and Drug Administration (FDA) does not recommend long-term use yet. Side effects of tacrolimus include burning and stinging on broken skin.
- Oral immunosuppressive agents: Patients with refractory atopic dermatitis may benefit from oral immunosuppressive agents, such as cyclosporine A. This medication is effective in treating severe atopic dermatitis in the acute setting. It is not recommended for long-term use.
- Phototherapy with PUVA, UVA, or UVB is successful in controlling atopic dermatitis but is expensive and may lead to increased risk of melanoma and nonmelanoma skin cancer. Studies evaluating the role of several proposed disease-modifying agents continue to be conducted. Results of studies on IL-4 neutralizing antibody and mast cell depleters are promising, whereas the evidence for probiotics,10,11 primrose oil, sodium cromolyn, topical caffeine, and dietary exclusion is inconclusive and requires more research.
Consultations
In cases of uncertain diagnosis or severe atopic dermatitis that is resistant to conventional therapy, patients may be referred to a specialist such as a dermatologist or an allergist.
Medication
Drug regimens for eczema should be tailored to the individual patient to reduce the frequency and severity of exacerbations.
Topical steroids
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 (Aristocort)
A medium potency topical steroid. Treats inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult
Apply bid to affected area
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; fungal, viral, and bacterial skin infections
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
A percentage of topical drug might be absorbed systemically; if application is repeated, there may be some systemic effects of the corticosteroids
Hydrocortisone (CortaGel, Cortaid, Dermacort, Westcort)
An example of a low-potency topical steroid available OTC. An adrenocorticosteroid derivative suitable for application to skin or external mucous membranes. Has mineralocorticoid and glucocorticoid effects resulting in anti-inflammatory activity.
Adult
Apply bid to affected areas
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; viral, fungal, and bacterial skin infections
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
Prolonged use, applying over large surface areas, application of potent steroids, and using occlusive dressings may increase systemic absorption of corticosteroids and may cause Cushing syndrome, reversible HPA axis suppression, hyperglycemia, and glycosuria
Topical calcineurin Inhibitors
Topical immune suppressants that block early T-cell activation, degranulation of mast cells, and multiple cytokines.
Pimecrolimus (Elidel cream)
First nonsteroid cream approved in the US for mild-to-moderate atopic dermatitis. Derived from ascomycin, a natural substance produced by fungus Streptomyces hygroscopicus var ascomyceticus. Selectively inhibits 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. Indicated only after other treatment options have failed.
Adult
Apply topically to affected areas bid, short-term and intermittent use only
Pediatric
<2 years: Not established
>2 years: Administer as in adults, short-term and intermittent use only
None reported
Documented hypersensitivity
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
Potential exacerbation of existing infection at site of application; may cause burning and irritation; caution with conditions that suppress the immune system (eg, AIDS, cancer); possible risk of lymph node or skin cancer based on animal studies and a small number of patients; may increase risk of viral infections; other adverse effects include headache, sore throat, flulike symptoms, fever, and cough
Tacrolimus (Protopic)
The mechanism of action of tacrolimus in atopic dermatitis is not known. Reduces itching and inflammation by suppressing the release of cytokines from T cells. 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, may inhibit release of preformed mediators from skin mast cells and basophils, and downregulate expression of FCeRI on Langerhans cells. Can be used in patients as young as 2 years. Drugs of this class are more expensive than topical corticosteroids. Available as an ointment in concentrations of 0.03% and 0.1%. Indicated only after other treatment options have failed.
Adult
Apply thin layer to affected skin areas bid and rub in gently and completely; continue treatment for 1 wk after clearing of signs and symptoms; use short-term and intermittent use only
Pediatric
<2 years: Not established
2-15 years: Apply 0.03% ointment bid to affected area(s)
>15 years: Administer as in adults; use short-term and intermittent use only
None reported
Documented hypersensitivity to tacrolimus or components of ointment
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
Patients may experience a burning sensation during first few days of application; skin can become photosensitive, and patients should be cautioned about exposure to direct or artificial sunlight and to use sunscreen; safety and efficacy in infected atopic dermatitis is not known; application under occlusion, which may promote systemic exposure, has not been evaluated (do not use tacrolimus ointment with occlusive dressings); absorption of tacrolimus following topical applications of tacrolimus ointment is minimal (relative to systemic administration), but tacrolimus is excreted in human milk and, thus, a decision should be made whether to discontinue breastfeeding or to discontinue drug, taking into account importance of drug to mother (potential for serious adverse reactions in breastfeeding infants from tacrolimus should also be a concern)
Caution with conditions that suppress the immune system (eg, AIDS, cancer); possible risk of lymph node or skin cancer based on animal studies and a small number of patients; may increase risk of viral infections; other adverse effects include headache, sore throat, flulike symptoms, fever, and cough
Oral immunosuppressive agents
For use in severe refractory atopic dermatitis.
Cyclosporine (Neoral, Sandimmune)
An 11-amino acid cyclic peptide and natural product of fungi. Acts on T-cell replication and activity.
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 G0 or G1 phase of cell cycle suggested.
Binds to cyclophilin, an intracellular protein, which, in turn, prevents formation of interleukin 2 and the subsequent recruitment of activated T cells.
Has about 30% bioavailability, but there is marked interindividual variability. Specifically inhibits T-lymphocyte function with minimal activity against B cells. Maximum suppression of T-lymphocyte proliferation requires that drug be present during first 24 h of antigenic exposure.
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.
Adult
5 mg/kg/d PO qd
Pediatric
Not established
Carbamazepine, phenytoin, isoniazid, rifampin, and phenobarbital may decrease cyclosporine concentrations; azithromycin, itraconazole, nicardipine, ketoconazole, fluconazole, erythromycin, verapamil, grapefruit juice, diltiazem, aminoglycosides, acyclovir, amphotericin B, and clarithromycin may increase cyclosporine toxicity; acute renal failure, rhabdomyolysis, myositis, and myalgias increase when taken concurrently with lovastatin; methylprednisolone and cyclosporine mutually inhibit one another resulting in increased plasma levels of each drug
Documented hypersensitivity; uncontrolled hypertension or malignancies; do not administer concomitantly with PUVA or UVB radiation in psoriasis since it may increase risk of cancer
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
Evaluate renal and liver functions often by measuring BUN, serum creatinine, serum bilirubin and liver enzymes; may increase risk of infection and lymphoma; reserve IV use only for those who cannot take PO
Antihistamines
Used for the sedating effects. Help to prevent scratching during sleep.
Hydroxyzine hydrochloride (Atarax, Vistaril)
Antagonizes H1-receptors in the periphery. Also may suppress histamine activity in the subcortical region of the CNS. A sedating antihistamine.
Adult
25-50 mg PO q4-6h prn
Pediatric
0.5 mg/kg PO q4-6h prn
CNS depression may increase with alcohol or other CNS depressants
Documented hypersensitivity
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
More on Dermatitis, Atopic |
| Overview: Dermatitis, Atopic |
| Differential Diagnoses & Workup: Dermatitis, Atopic |
 Treatment & Medication: Dermatitis, Atopic |
| Follow-up: Dermatitis, Atopic |
| Multimedia: Dermatitis, Atopic |
| References |
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References
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Further Reading
Keywords
dermatitis, atopic dermatitis, atopy, atopic disease, dry skin, eczema, allergy, dermatitis treatment, dermatitis causes, dermatitis symptoms, ichthyosis vulgaris, keratosis pilaris, hand and foot dermatitis, keratoconus, chronic pruritic skin condition, fishlike scales, horny follicular papules, fissuring of the palms, fissuring of the soles, facial erythema, pityriasis alba, increased palmar linear markings, infraorbital fold, Dennie-Morgan line, pilaris, perioral pallor
