Are you worried about itchy skin allergies that keep coming back out of the blue? You are probably suffering from a skin condition called atopic dermatitis (AD) better known as eczema. This common and chronic inflammatory skin disease is also associated with other atopic diseases like asthma and allergic rhinitis.

Atopic dermatitis has seen a sharp rise with the spread of industrialization and its associated lifestyle. What’s more, it affects more women than men and around 65% of patients first develop atopic dermatitis during childhood. Moreover, unlike other childhood diseases that improve with puberty, 40% of atopic dermatitis cases either relapse or recur after reaching adulthood. Its primary causes are generally associated with heredity, environmental interactions, skin barrier disorders, or immunological reactions. There are two types of eczema, namely intrinsic (or non-allergic) and extrinsic (or allergic).

The detection of atopic dermatitis involves tracing its onset in its three age-related phases of infantile, childhood and adult eczema. Diagnosis must also take into consideration its other features like heredity, its chronically relapsing aspect, association with atopic diseases, its characteristic itchiness, basic biology, etc.

Prevention is always better than cure, so the first step in the management of atopic dermatitis is reducing the symptoms by identifying the triggers (allergens) and hence avoiding them. This apart, the therapeutic approach is aimed at restoring the skin barrier functions with hydration. In eczema, a skin barrier disorder occurs due to an abnormality in skin lipids, which in turn results in greater transepidermal water loss. This is caused by genetic alterations of the epidermal barrier protein filaggrin.

Standard treatments of atopic dermatitis are the use of emollients to hydrate the skin combined with topical corticosteroids. Wet dressings, antibiotics for infections and antihistamines are also used. In acute cases where other treatments fail, systemic therapies are often implemented. Stress management and patient counseling can also be a vital part of therapy.

Corticosteroids and their usage in atopic dermatitis

Topical corticosteroids are anti-inflammatory drugs with different potencies. The use of topical corticosteroids combined with moisturizer-based emollients has been the standard procedure in atopic dermatitis prevention and treatment for almost 50 years now. This hydrating combination increases the anti-inflammatory potential of the topical steroids.

The dosage of corticosteroids for eczema

The common recommendation is to start with the use of the least-potent topical steroid combined with a good skin care routine. Thereafter more potent topical steroids should be used until the patient gains noticeable improvement in their skin condition.

The topical steroids should first be used continuously for a few weeks and then around twice a week. Practitioners generally prescribe its application twice daily at first and immediately after a bath. This is a dosage recognized by the European Academy of Dermatology and Venereology. Dosages are then tapered down to less frequent application to reach the minimum required to maintain remission of the eczema.

Maintenance doses should be of low-potency. Mid to high potency steroids should be restricted to the treatment of flares. The associated skin itchiness (pruritis) is an effective marker in the success of therapy and the dosage can be decreased (it should be done gradually to avoid flares) until the discomfort is nil. In children with mild eczema, one can only use brief and alternating doses of strong steroids. This is as safe and effective as the sustained use of milder topical steroids.

Contraindications of corticosteroids

It is very important to know how and where to apply a corticosteroid and this must be an integral part of patient counseling. This is determined by how much of it is being absorbed into the skin, which in turn is dependent on the surface area of the skin, the thickness of the epidermis, the preparation used, drug potency and the use of occlusive dressing.

Here are a few safeguards:

• Avoid Class 1 to 5 topical steroids in body locations with thinner skin, such as the eyelids, face, mucous membranes, genitalia and intertriginous areas. These body areas have a greater risk of transepidermal corticosteroid absorption.
• It is safe and necessary to use more powerful topical steroids on the palms and soles, which have a much thicker epidermis.
• Children are more vulnerable to side effects since they have a low body volume to skin surface area proportion, which leaves scope for more absorption of corticosteroids. Hence, strong steroids should be avoided in kids.

Moreover, the longer the usage and the stronger the topical steroids, the greater are the risk of side effects. The local side affects of corticosteroids are:

• Skin striae (lines in the skin)
• Skin atrophy (thinning)
• Telangiectasias (blood vessel formation)
• Perioral dermatitis (eczema around the mouth)
• Erythema (inflamed skin)
• Acne
• Glaucoma (eye condition)
• Cataracts (eye condition)

Possible systemic side effects are:

• Growth retardation in children
• Repression of the hypothalamic-pituitaryadrenal axis
• Osteoporosis (bone thinning)

Advantages of corticosteroids

The benefits of using topical steroids are:

• Cost effectiveness
• Large range of usage mediums like creams, lotions, ointments, solutions, gels and foams
• Established clinical efficacy

How to select a corticosteroid for atopic dermatitis

There are a few rules while making a choice of corticosteroids:

• Ointments are more effective than creams because of better absorption potential.
• The area of application is also a pointer. For instance, foams and lotions are easier to apply than ointments on hairy regions.
• Occlusive dressings are a good option in acute cases as they improve the absorption and hence enhance therapeutic results. However, since they also increase chances of side effects they should be restricted to short spans of use.
• The selection process should also take into account the individual needs and preferences of a patient at the backdrop of drug potency, preparation, the body location of the lesions, age, season, environment, socioeconomic condition, medical history and infections if any.

Corticosteroid combination therapies

One of the latest developments in atopic dermatitis treatment has been topical calcineurin inhibitors. They are steroid-free anti-inflammatory medications and can be used along with topical corticosteroids for fewer side effects from the latter.

What’s more, topical steroids are also often used simultaneously with psoralen plus UVA (PUVA) therapy that helps reduce dependence on the former and its side effects.