Medication Summary
A potent-to-intermediate potency steroid may be applied 2-4 times daily to the affected areas. They are most effective when used in ointment form (rather than cream) and applied to damp skin. Once lesions improve, a lower-potency steroid or moisturizer should be prescribed to avoid skin atrophy.
If the patient has an overt infection, a combination of a topical antibiotic and a steroid ointment applied twice daily is usually very effective. This therapy decreases inflammation and colonization by staphylococci.
Use of sedating antihistamines at night helps with sleep.
Severe or generalized flares may be treated with tap water–moistened dressings on top of the steroid ointment. Oral or parenteral steroids may be used in severe flares, followed by topical therapy.
Oral antibiotics, such as dicloxacillin, cephalexin, or erythromycin, should be used in cases of secondary infection.
Corticosteroids
Class Summary
Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, they modify the body's immune response to diverse stimuli.
Triamcinolone topical (Aristocort) Cream or Ointment
Triamcinolone topical is used for inflammatory dermatosis responsive to steroids; it decreases inflammation by suppressing migration of PMN leukocytes and reversing capillary permeability. It is a good choice once lesions stabilize and the threat of secondary infection has passed. Use 0.025-0.1% strength.
Prednisone (Deltasone, Meticorten, Orasone)
Prednisone is for severe generalized flares. It may decrease inflammation by reversing increased capillary permeability and suppressing PMN leukocyte activity.
Clobetasol (Clarelux, Clobex, Clobex Spray)
Clobetasol propionate is a class I superpotent topical steroid; it suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction. Clobetasol propionate decreases inflammation by stabilizing lysosomal membranes, inhibiting PMN and mast cell degranulation.
Immune modulators
Class Summary
Immune modulators reduce inflammation.
Pimecrolimus 1% cream (Elidel)
Pimecrolimus is 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. Pimecrolimus 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. Pimecrolimus is indicated only after other treatment options have failed.
Tacrolimus 0.03% or 0.1% ointment (Protopic)
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, tacrolimus may inhibit the release of preformed mediators from skin mast cells and basophils, and down-regulate expression of FCeRI on Langerhans cells. It can be used in patients as young as 2 years. Drugs of this class are more expensive than topical corticosteroids. Tacrolimus is available as an ointment in concentrations of 0.03 and 0.1%. It is indicated only after other treatment options have failed.
Antihistamines
Class Summary
Antihistamines used to help with sleep. Caution must be used because even the traditionally nonsedating classes may cause somnolence.
Hydroxyzine (Atarax, Vistaril, Vistazine)
Hydroxyzine antagonizes H1 receptors in the periphery. It may suppress histamine activity in the subcortical region of the CNS. Hydroxyzine is a piperazine type of antihistamine that has fewer sedating effects compared with diphenhydramine and is effective. It is usually well tolerated in most individuals.
Antibiotics
Class Summary
Antibiotics are used for severe exudative flares with infection. Empiric antimicrobial therapy should cover S aureus and other likely pathogens in the context of the clinical setting.
Sulfamethoxazole and trimethoprim (Bactrim)
Sulfamethoxazole and trimethoprim combination agent inhibits bacterial growth by inhibiting the synthesis of dihydrofolic acid. The antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa. It is also used for MRSA infections.
Dicloxacillin (Dynapen, Pathocil, Dycill)
Dicloxacillin binds to one or more penicillin-binding proteins, which, in turn, inhibits the synthesis of bacterial cell walls. Dicloxacillin is used for the treatment of infections caused by penicillinase-producing staphylococci. It may be used to initiate therapy when staphylococcal infection is suspected.
Erythromycin (E.E.S., E-Mycin, Eryc)
Erythromycin inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. It is used for the treatment of staphylococcal and streptococcal infections.
In children, age, weight, and severity of infection determine proper dosage. When twice-daily dosing is desired, half the total daily dose may be taken every 12 hours. For more severe infections, double the dose.
Cephalexin (Biocef, Keflex, Keftab)
Cephalexin is a first-generation cephalosporin that arrests bacterial growth by inhibiting the synthesis of bacterial cell walls. It has bactericidal activity against rapidly growing organisms. Its primary activity is against skin flora. Cephalexin is used for skin infections or prophylaxis in minor procedures.
Interleukin Inhibitors
Dupilumab (Dupixent)
Dupimumab is a monoclonal antibody that blocks interleukins 4 and 13, which have been shown to be important mediators in atopic dermatitis. It has been shown to be helpful in many other diseases including asthma, prurigo nodularis and eosinophilic esophagitis.
Calcineurin Inhibitors
Cyclosporine (Gengraf, Neoral, Sandimmune)
Oral immune suppressant formerly used in solid organ and bone marrow transplants. Suppresses the immune system. Use is limited due to renal toxicity and patients must be monitored aggressively with bloodwork and blood pressure.
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Dry, scaling plaque of nummular dermatitis (size, 3 X 5 cm) on the shin.
