Atopic Dermatitis is challenging condition, here we will review management and treatment options.
Skin Hydration-Eczema is characterized by impaired skin barrier function, moisture application particularly after soaking in water can hlep retain water and improve barrier function. There is very little data comparing barrier creams with one another.
Topical Steroids-For non-mild atopic dermatitis, moisturizing alone may not be sufficient. Topical steroids can be applied one to two times daily to calm both itch and inflammation. They though must be used with caution in thin skin areas. Once improved, low potency steroids should be used to minimize side effects.
Topical Calcineurin Inhibitors-These represent another class of anti-inflammatory medications without the adverse side effect profile. Tacrolimus and pimecrolimus inhibit the activation of key cells in eczema. Common side effects are local burning of the skin, which wears off after a few days. These medications do not cause skin atrophy and are favored for facial use. Procactive therapy with twice weekly application has been shown to reduce flares. Despite the black box warnings, studies have shown since 2006 no increase in lymphomas.
Antihistamines-Studies have shown little effectiveness besides their high usage. This is the case because histamine is not the only mediator involved in pruritis. But patients with concomitant hives or allergies may find it beneficial.
Vitamin D-There is controversy about Vitamin D supplementation. Eczema is worse in the wintertime, leading some to believe this is due to Vitamin D deficiency because lack of sun exposure. This is a relatively benign therapy that may help some patients.
Treatment of Infections– Staphyloccus aureus has been know to play a significant role in eczema, causing infection and inflammation, even as a colonizer. They may be severe and recurrent. When an infection is present, a short course of oral antibiotics is warranted. Dilute bleach baths have been shown to reduce severity. Mixing 1/4 of plain household bleach in a 40 gallon bath and soaking twice weekly and lead to a dramatic improvement.
Wet Dressings-For difficult to manage patients, wet wraps in combo with topical steroids represent a powerful therapy. This entails soaking the skin, applying a topical steroid, and then applying a damp layer of gauze or clothing followed by a dry layer. Wet dressing appear to be safe for up to 14 days and actually decrease steroid usage.
Trigger Elimination-A range of trigger factors are soaps, chemical and fabrics. Other proteins can be dust mites. Food triggers are often suspected and up to 1/3 of patients with moderate to severe eczema have them. Testing for food allergy is recommended for children younger than 5 years old who have persistent eczmea.
Other Treatments-For refractory disease other possibilities include, phototherapy, methotrexate, cyclosporine, mycophenolate and azathioprine.
For the majority of patients the above therapies allow for excellent disease control. Frequent follow up and education of patients allow for the best disease management. Future therapies are being studied to aim for the best treatment pathways.