Atopic dermatitis (AD), popularly known as eczema, is a common and chronic inflammatory skin disease that has seen a rapid rise over the last few years. Industrialization, urbanization and the associated lifestyle has propelled its rise.

This disease that is closely associated with other atopic diseases like asthma and allergic rhinitis, affects more women than men. Moreover, it relapses with age with an estimated 40% of AD cases re-occurring even after attaining adulthood. Its primary causes could be associated with heredity, environmental interactions, skin barrier disorders or immunological reactions.

The management and treatment of AD involves the following steps:

• Identification of the triggers (allergens) and avoiding them.
• Restoring the skin barrier functions with standard treatments of eczema such as the use of emollients combined with topical corticosteroids, wet dressings, antibiotics for infections and antihistamines.
• In acute cases where other treatments fail, systemic therapies are often implemented.
• Stress management and patient counseling is also an integral part of therapy.

Types of systemic therapy for atopic dermatitis

Though they come with mixed results and side effects, there are varieties of systemic therapies for the treatment of atopic dermatitis. They have been extensively researched and the most prevalent are:

1. Oral antihistamines
2. Oral steroids
3. Systemic immunomodulators
4. Phototherapy
5. Antimicrobials

Oral antihistamines

There are two of its kind - sedating and non-sedating - that are used for the treatment of atopic dermatitis. They have been found to be selectively effective in the treatment of eczema. On one hand, they have not proven to be successful in reducing itchiness (pruritus) in most cases of atopic dermatitis. On the other hand, they have proved effective on patients, who suffer from atopic dermatitis-related sleep disorders (secondary to pruritus, dermatographism, or allergic rhinitis), dermatographism, urticaria, or allergic rhinitis.

Systemic steroids

They are best used on a short-term basis in case of acute atopic dermatitis. However, they are associated with serious side effects and a rebound flare after discontinuing usage. See our page on corticosteroid treatments for eczema for more details.

Immunomodulators

Immunomodulators are generally used in severe and unmanageable atopic dermatitis cases. However, the patient must be kept under close observation to monitor side effects. Moreover, they should be used for a short span to minimize side effects. The various immunomodulators and their functions are:

• Cyclosporine works speedily in about 2 weeks and has proved successful in the treatment of irrepressible AD. Renal toxicity, hypertension, nausea, and abdominal pain are some of its possible side effects. It should be used for a short span and the condition may revert after the drug is discontinued. Its adult and pediatric prescription is 3 to 5 mg/kg daily.
• Azathioprine is administered in case of unmanageable atopic dermatitis. It is an anti-inflammatory and antiproliferative drug, which is slow in its activity taking about 4 to 6 weeks to show results. Its contraindications (cases when the drug should not be used) are bone marrow suppression, hepatotoxicity, hypersensitivity reactions, pancreatitis, squamous cell carcinoma of the skin, and non-Hodgkins lymphoma. Its adult and pediatric prescription is 2.5 mg/kg daily.
• Myclophenolate mofetil is prescribed in an adult dose of 2 g daily for the treatment of AD. Its side effects include bone marrow suppression though this can be minimized with its short-term usage.

Ultraviolet (UV) light therapy

Ultraviolet (UV) light therapy or simply phototherapy works as an anti-inflammatory agent on the cells of the immunity system of the body, thus proving its worth in the treatment of complex atopic dermatitis. It works well and is popular with patients. The various types of UV therapy are:

• Psoralen plus UVA (PUVA)
• A combination of broadband UVB/UVA light treatment
• Broadband UVA exposure
• Broad-band UVB exposure
• Narrowband UVB (311 nm)
• UVA-1 (340-400 nm)

PUVA should be restricted to acute and complex atopic dermatitis. It can also be used in combination with topical steroids to minimize the use of the latter and hence its side effects. Among the other phototherapies, broadband UVB is the least effective of the lot.

The side effects of phototherapy are stinging, burning, premature ageing of the skin, pigmentation and the risk of squamous cell carcinoma and melanoma. Moreover, there are chances of a relapse generally within 3 months after phototherapy is stopped.

Antimicrobials

Antimicrobials in the form antibiotic drugs are prescribed in the case of microbial aggravation of atopic dermatitis. Microbes such as bacteria, viruses, fungi and yeast can worsen an atopic dermatitis condition. Antibiotics are a must for cases with a S. aureus infection, with a preference for systemic antibiotics and first generation cephalosporins. Antimicrobial therapy with acyclovir is vital in atopic dermatitis patients with (generally life threatening) eczema herpeticum infection.

Eczema molluscatum infections generally heal on their own, but with treatment the condition can be improved and proliferation deterred by autoinoculation.