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  Atopic eczema, irritant dermatitis and contact dermatitis
 
 
 

COMMON TREATMENT OPTIONS FOR ATOPIC DERMATITIS OVERVIEW

Treatment for Atopic Dermatitis (AD or eczema) is multidimensional, involving four main aims. These are improving the skin barrier function, reducing or containing the inflammation, identifying the responsible triggers and preventing any secondary infection.

The skin barrier function is impaired, firstly, due to reduction in skin lipids, causing moisture loss, and secondly due to mutation of the skin barrier gene filaggrin. Emollients have been a standard medication in atopic dermatitis and when used with steroids they have an anti-inflammatory effect.

Topical therapy

There are a number of treatment options that can be applied to affected areas of skin topically.

Topical corticosteroids

Corticosteroids have been, largely, the first choice of medication in atopic dermatitis for the last 50 years. They come in 7 levels of potency. The more potent ones produce more adverse side effects. So do longer duration therapies. Amount of absorption of corticosteroids depends on the skin thickness. Generally, the less potent corticosteroids are used on areas with thinner skins, such as, eyes, genitalia and face. Palms and soles may need more potent corticosteroids since the skin at these places is thicker.

In children, who have a low body volume to skin surface area ratio, the chances of more corticosteroid absorption is higher. Therefore potent corticosteroids are avoided in children, because of side effects. Low potency corticosteroids are generally used at the beginning of treatment and for maintenance therapy, whereas, higher potency corticosteroids are used when there are flares.

The advantages of corticosteroids are many. They are cheaper than most other drugs, are available in a variety of preparations and have proven clinical effectiveness. They are available as creams, lotions, ointments, solutions gels and foams.

However, the use of corticosteroids is limited by some very adverse effects they produce. The local side effects can include, skin atrophy, acne, glaucoma and cataracts. The systemic side effects include growth suppression and osteoporosis.

Calcineurin inhibitors

These drugs have been recently introduced for treating eczema and have been approved for treating children over 2 years of age. They have anti-inflammatory effects and do not contain any steroids. They can be used along with topical corticosteroids. These medications have been found to be as or more efficacious than some of the higher potency corticosteroids. Calcineurin inhibitors do not have the more serious side effects of corticosteroids and can therefore be used in places where the skin is thinner. The most common side effect is burning at the application site. Other side effects include photosensitivity, erythema and itching.

Coal tar

Coal tar and its derivatives have been used to treat atopic dermatitis for decades and are as effective as the highest potency steroids. They have anti-itching and anti-inflammatory effects and are recommended for use in chronic cases of atopic dermatitis. Coal tar can be used singly or in combination with topical steroids. Side effects of coal tar are photosensitivity and folliculitis, but the major drawbacks are its odor and dark color which stains clothes.

Systemic therapy

The medications in the systemic therapy of atopic dermatitis include oral antihistamines, oral steroids, systemic immunomodulators, phototherapy and antimicrobials.

Antihistamines and steroids

Sedating and non-sedating oral antihistamines are not good at relieving itching in most cases, but they may provide some relief to patients having sleep disorders (secondary to itching or allergic rhinitis), urticaria or allergic rhinitis. Systemic steroids are normally used to treat the more severe cases and that too for short durations. Use of systemic steroids raises concerns about side effects, the more serious one being recurrence of the condition after discontinuation of their use.

Immunomodulators

In more refractory cases of eczema, immunomodulators are used, but constant monitoring is required to detect any side effects. Long term use of immunomodulators is not advised but patients may have a relapse if the medication is discontinued. Some immuno-modulators work quickly in two weeks, in the more severe cases, but produce several side effects. These include renal toxicity, hypertension and nausea. A slow acting immuno-modulator, known as, Azathioprine, has been developed but has side effects, such as, bone marrow suppression, hypersensitivity reactions and pancreatic.

Phototherapy

Ultraviolet light therapy is another method for treating the refractive cases of eczema. This therapy has an anti-inflammatory effect on the cells of the immune system. There are various kinds of UV phototherapy for treating various kinds of atopic dermatitis. Topical steroids may be used with some types of UV therapy, with option later to reduce steroid dosage.

Side effects include singing, burning, premature ageing of skin and pigmentation.

Antimicrobials

Antibiotics are preferred, especially, when there is a heavy infection of staphylococcus bacteria associated with the eczema. Currently, systemic antibiotics are preferred because of increasing cases of resistant staphylococcus. Topical steroids and calcineurin inhibitors can also reduce staphylococcus count. Antiviral treatment is critical in cases with eczema herpeticum, as it can become life threatening.