Emergency Care for Atopic Dermatitis
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.
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. [12]
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.
A study by Reitamo and Allsopp determined that twice-weekly tacrolimus ointment was effective in patients with moderate-to-severe atopic dermatitis. [13]
Topical phosphodiesterase-4 (PDE-4) inhibitors
Crisaborole topical ointment 2% (Eucrisa) was approved by the FDA in December 2016 for mild-to-moderate atopic dermatitis in adults and children aged 2 years or older. The approval was based on two placebo-controlled trials (n=1522). Patients who received crisaborole achieved greater response with clear or almost clear skin after 28 days compared with vehicle-treated patients (P< .001). [14]
Probiotics
The role of probiotics in the treatment of atopic dermatitis remains controversial. Gerasimov et al determined that the administration of a probiotic mixture containing Lactobacillus acidophilus DDS-1, Bifidobacterium lactis UABLA-12, and fructo-oligosaccharide was associated with significant clinical improvement in children with atopic dermatitis. [15] However, the efficacy of probiotic therapy in adults requires further study.
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
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, [16, 17] primrose oil, sodium cromolyn, topical caffeine, and dietary exclusion is inconclusive and requires more research.
Inpatient care
Few patients with atopic dermatitis will require hospitalization. Patients with cellulitis or severe secondary infection may require intravenous antibiotics and sedation.
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.
Prevention
Breastfeeding has indisputable benefits in infant nutrition, but no strong evidence suggests a protective effect against the development of atopic dermatitis, even in children with a family positive history. [18]
The mainstay of treatment of atopic dermatitis is prevention of outbreaks. Patients should continue to take short showers/baths followed by immediate hydration of skin with emollients even during rash-free times. They should also continue to avoid any triggers that may exacerbate atopic dermatitis.
Long-Term Monitoring
Atopic dermatitis is chronic and relapsing. The main goal of treatment is control of the disease, not a cure. Patient education about management of flare and recognition of superinfection is paramount.
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Irritation around mouth of an infant with atopic dermatitis.
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Typical atopic dermatitis on the face of an infant.
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Flexural involvement in childhood atopic dermatitis.
