Medication Summary
The most commonly used treatment strategies include antibiotics, corticosteroids, antihistamines, and less commonly, immunomodulating therapy, UV light, and hospitalization (rare). [35] For most cases of atopic dermatitis (without AKC), application of topical steroids to the affected area is usually sufficient. Ocular involvement may be managed with topical mast cell stabilizers, topical calcineurin inhibitors (e.g. Restasis or Verkazia), topical steroids, or if symptoms persist, oral antihistamines (e.g. over-the-counter diphenhydramine) and oral steroids. [33] 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). [33] Antibiotic treatment should target S. aureus, the most likely pathogen, and should be chosen based on the patient's allergies and cultures. [33] Immunomodulatory therapy will only very rarely be required, and these will unlikely be prescribed by the ophthalmologist. [35]
Fore more detailed discussion on medical treatment, please see the "Treatment" section.
Corticosteroids
Class Summary
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 ophthalmic (Omnipred, Pred Forte, Pred MIld)
Based on weight, prednisolone has 3-5 times the anti-inflammatory potency of hydrocortisone. Glucocorticoids inhibit edema, fibrin deposition, capillary dilatation and proliferation, phagocytic migration of the acute inflammatory response, deposition of collagen, and scar formation.
Fluorometholone (Flarex, FML, FML Forte, FML Liquifilm)
Fluorometholone inhibits edema, fibrin deposition, capillary dilatation, and phagocytic migration of acute inflammatory response and capillary proliferation, collagen deposition, and scar formation. Used topically, this agent can elevate intraocular pressure (IOP) and cause steroid-response glaucoma. However, in clinical studies of documented steroid responders, fluorometholone demonstrated a significantly longer average time to produce a rise in IOP than dexamethasone phosphate. In a small percentage of individuals, a significant rise in IOP occurred within 1 week. The ultimate magnitude of the rise was equivalent.
Mast cell stabilizers
Class Summary
May be useful as prophylaxis against exacerbation of the disease.
Lodoxamide (Alomide)
Inhibits degranulation of mast cells and helps prevent histamine release.
Cromolyn
Inhibits histamine and slow-releasing substance of anaphylaxis (SRS-A) release from mast cells but has no intrinsic anti-inflammatory, antihistamine, or vasoconstrictive effects.
Nedocromil ophthalmic (Alocril)
Nedocromil interferes with mast cell degranulation, specifically with release of leukotrienes and platelet activating factor.
Oral antihistamines
Class Summary
Useful in decreasing itching and scratching associated with atopic dermatitis.
Hydroxyzine (Vistaril)
Antagonizes H1 receptors in periphery; may suppress histamine activity in subcortical region of CNS; may assist in sleep.
Diphenhydramine (Benadryl, Benadryl Dye-Free Allergy, Complete Allergy Relief, Q-Dryl, Diphen)
Diphenhydramine is for symptomatic relief of urticaria symptoms caused by the release of histamine in allergic reactions.
Loratadine (Alavert, Allergy Relief, Claritin, Loratadamed)
Loratadine selectively inhibits peripheral histamine H1 receptors.
Desloratadine (Clarinex)
Desloratadine is a long-acting tricyclic histamine antagonist that is selective for H1 receptors. This agent is a major metabolite of loratadine, which, after ingestion, is extensively metabolized to active metabolite 3-hydroxydesloratadine.
Fexofenadine (Allegra Allergy, Allegra Allergy 24 Hour, Mucinex Allergy)
Fexofenadine competes with histamine for H1 receptors in the GI tract, blood vessels, and the respiratory tract, reducing hypersensitivity reactions.
Antibiotics, Ophthalmic
Class Summary
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 (Zymaxid)
Fluoroquinolone with activity against streptococci, staphylococci, Corynebacterium propinquum, and Haemophilus influenzae; inhibits bacterial DNA synthesis and, consequently, growth.
Calcineurin Inhibitors
Class Summary
Inhibit calcineurin, an enzyme involved in T cell activation, thereby decreasing the level of inflammatory cells and mediators on the ocular surface.
Restasis (cyclosporine ophthalmic emulsion, 0.05%)
Restasis is available in single-use or multidose vials, and is commonly used in the treatment of:
1) VKC:1 drop four times a day, treatment can be discontinued once signs/symptoms have resolved and can be restarted once signs/symptoms recur
2) Keratoconjunctivitis sicca: therapeutic by increasing tear production, 1 drop twice daily
3) Corneal melting syndromes of known or presumed immunologic etiology, e.g. Mooren's ulcer
4) Prevention of graft rejection, in high risk patients, especially after penetrating keratoplasty
5) Keratoconjunctivitis: useful adjunctive treatment in cases of HSV stromal keratitis
Verkazia (cyclosporine ophthalmic emulsion, 0.1%)
FDA approved in June 2021 for the treatment of VKC in children and adults. Verkazia was studied in two randomized, multicenter, double-masked, vehicle-controlled clinical trials: the VEKTIS study and NOVATIVE study, and showed improvement in corneal inflammation and ocular itching in both studies. The most common adverse reactions (>5% of patients) included (usually) transient eye pain and pruritis. Verkazia can be started and stopped as signs/symptoms of VKC have started and have resolved, respectively.
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Typical atopic dermatitis on the face of an infant.
