Atopic dermatitis medical therapy
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Atopic dermatitis Microchapters |
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Diagnosis |
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Treatment |
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Atopic dermatitis medical therapy On the Web |
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American Roentgen Ray Society Images of Atopic dermatitis medical therapy |
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Risk calculators and risk factors forAtopic dermatitis medical therapy |
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Atopic dermatitis Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Atopic dermatitis medical therapy On the Web |
|
American Roentgen Ray Society Images of Atopic dermatitis medical therapy |
|
Risk calculators and risk factors forAtopic dermatitis medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shalinder Singh, M.B.B.S.[2]
Overview
The mainstay of treatment for atopic dermatitis depends upon the severity of the disease and is treated with a combination of conservative and medical therapy. The goals of treatment include elimination of aggravating factors, skin barrier function repair, maintaining skin hydration and pharmacologic treatment of skin inflammation.
Medical Therapy
To combat the severe dryness associated with eczema, a high-quality, dermatologist approved moisturizer should be used daily. Moisturizers should not have any ingredients that may further aggravate the condition. Moisturizers are especially effective if applied within 5-10 minutes after bathing.
Most commercial soaps wash away the oils produced by the skin that normally serve to prevent drying. Using a soap substitute such as aqueous cream helps keep the skin moisturized. A non-soap soap can be purchased usually at a local drug store. Showers should be kept short and at a lukewarm/moderate temperature.
If moisturizers on their own don't help and the eczema is severe, a doctor may prescribe topical steroid ointments or creams. Steroid creams have been traditionally been considered the most effective method of treating severe eczema. Disadvantages of using steroid creams include stretch marks and thinning of the skin. Higher-potency steroid creams must not be used on the face or other areas where the skin is naturally thin; usually a lower-potency steroid is prescribed for sensitive areas. Along with creams, antibiotics are often prescribed if an infection is suspected. If the eczema is especially severe, a doctor may prescribe prednisone or administer a shot of cortisone. If the eczema is mild, over-the-counter hydrocortisone can be purchased at the local drugstore.
The immunosuppressant Tacrolimus or pimecrolimus can be used as a topical preparation in the treatment of severe atopic dermatitis instead of traditional steroid creams. However, there can be unpleasant side effects in some patients such as intense stinging or burning.
Alternative medicines may (illegally) contain very strong steroids [1].
Conservative Therapy
| Elimination of exacerbating factors | Maintaining skin hydration | Controlling pruritus |
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Medical Therapy
- Pharmacologic medical therapies for atopic dermatitis can be classified according to the several severity scales( (i.e SCORAD index, the eczema area and severity index [EASI], and the patient-oriented eczema measure [POEM]) which includes characteristics of the rash, questions about itch, sleep, impact on daily activities, and persistence of disease.
Atopic dermatitis
- MIld atopic dermatitis:
- Topical corticosteroids and emollients - mainstay therapy
- Adult
- Preferred regimen (1): desonide 0.05% top. q12h-q24h for 14-28 days
- Preferred regimen (2): hydrocortisone 2.5% top. q12h-q24h for 14-28 days
- Preferred regimen (3): fluocinolone acetonide 0.01% top. q12h-q24h for 14-28 days
- Alternative regimen (1) tacrolimus 0.1% top. q8h (0.03% for adults who do not tolerate the higher dose)
- Alternative regimen (2): pimecrolimus 1% top. q8h
- Alternative regimen (3) crisaborole 2% top.
- Pediatric
- Preferred regimen (1): desonide 0.05% top. q12h-q24h for 14-28 days
- Preferred regimen (2): hydrocortisone 2.5% top. q12h-q24h for 14-28 days
- Preferred regimen (3): fluocinolone acetonide 0.01% top. q12h-q24h for 14-28 days
- Alternative regimen (1) tacrolimus 0.03% top. q8h (Children (>2years)
- Alternative regimen (2): pimecrolimus 1% top. q8h
- Alternative regimen (3): crisaborole 2% top.
- Adult
- Topical corticosteroids and emollients - mainstay therapy
- Moderate atopic dermatitis
- Topical corticosteroids and emollients are the mainstay of therapy
- Adult
- Preferred regimen (1): fluocinolone0.025%. q12h-q24h for 14-28 days
- Preferred regimen (2): triamcinolone 0.1% top. q12h-q24h for 14-28 days
- Preferred regimen (3): fluocinolone acetonide 0.025% top. q12h-q24h for 14-28 days
- Alternative regimen (1) tacrolimus 0.1% top. q8h (0.03% for adults who do not tolerate the higher dose)
- Alternative regimen (2): pimecrolimus 1% top. q8h
- Alternative regimen (3) crisaborole 2% top.
- Adult
- Pediatric
- Preferred regimen (1): fluocinolone0.025%. q12h-q24h for 14 days
- Preferred regimen (2): triamcinolone 0.1% top. q12h-q24h for 14 days
- Preferred regimen (3): fluocinolone acetonide 0.025% top. q12h-q24h for 14-28 days
- Alternative regimen (1) tacrolimus 0.03% top. q8h (Children (>2years)
- Alternative regimen (2): pimecrolimus 1% top. q8h
- Alternative regimen (3) crisaborole 2% top.
- Topical corticosteroids and emollients are the mainstay of therapy
- Severe atopic dermatitis
- Phototherapy or systemic immunosuppressant treatment is the mainstay of therapy
- Adult
- Preferred regimen (1): Phototherapy Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
- Preferred regimen (2): cyclosporine PO 3-5 mg/kg o.d. for 6 weeks (monitor BP and serum creatinine q2 weeks for three months, f/u q month)
- Alternative regimen (1) methotrexatePO
- Alternative regimen (2): azathioprine PO
- Alternative regimen (3) mycophenolate mofetil PO
- Alternative regimen (3) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
- Pediatric
- Preferred regimen (1):
- Preferred regimen (2): cyclosporine PO 3 to 5 mg/kg per day o.d. for 6 weeks (monitor BP and serum creatinine q2 weeks for three months, f/b q month)
- Alternative regimen (1) Phototherapy Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
- Alternative regimen (2): azathioprine PO
- Alternative regimen (3) mycophenolate mofetil PO
- Alternative regimen (3) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
- Adult
- Phototherapy or systemic immunosuppressant treatment is the mainstay of therapy
- Severe refractory atopic dermatitis
- Adult
- Preferred regimen (1): Intensive topical therapy
- Soak and smear: Soak for 15 minutes in a tub of water. Apply desoximetasone 0.25% top. to the whole body, except the groin, axillae, and face
- Wet wrap therapy: desoximetasone 0.25% top. then occluded with wet wraps q12h
- Alternative regimen (1) Phototherapy: narrowband ultraviolet B or psoralen plus ultraviolet A two to three times per week
- Alternative regimen (2): cyclosporine PO 2.5 to 5 mg/kg o.d. (C/I - abnormal renal function, uncontrolled hypertension or infection, and malignancy)
- Alternative regimen (3): prednisone 40 to 60 mg o.d. for one week, then taper the dose over the following two to three week
- Alternative regimen (4): methotrexate 7.5 to 25 mg single weekly dose with folic acid 1 mg o.d.
- Alternative regimen (5): azathioprine 2 to 3 mg/kg
- Alternative regimen (6): mycophenolate mofetil 1 to 2 g/day
- Alternative regimen (7): mycophenolic acid 720 to 1440 mg/day
- Alternative regimen (8) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
- Preferred regimen (1): Intensive topical therapy
- Pediatric
- Preferred regimen (1): Intensive topical therapy
- Wet wrap therapy: desoximetasone 0.05% top. then occluded with wet wraps q12h-q24h for 2 to 14 days
- Alternative regimen (1) Phototherapy: narrowband ultraviolet B (UVB) 3 times per week (older children > 6 years)
- Alternative regimen (2): cyclosporine PO 2.5 to 5 mg/kg o.d. for 2-4 months (monitor renal and hepatic function)
- Alternative regimen (3): methotrexate 0.5 mg/kg PO single weekly dose with folic acid 1 mg o.d.(up to a maximum of 25 mg per week)
- Alternative regimen (4): methylprednisolone 0.5 mg/kg o.d. for 1-2 weeks tapered over one month
- Preferred regimen (1): Intensive topical therapy
- Adult
Management of Infection:
- Bacterial infections: (most common bacteria - Staphylococcus. aureus)
- Clinically infected skin:
- Mupirocin 2% top. BID for one to two weeks
- More extensive infection: oral antibiotic therapy with cephalosporins or penicillinase-resistant penicillins X two weeks
- Clinically uninfected skin:
- liquid chlorine bleach- 0.5 cup or 120 ml of 6% bleach in a full bathtub [40 gallons or 150 L] of lukewarm water
- Clinically infected skin:
- Viral infections:
- Herpes simplex:
- Acyclovir 200 or 400 mg PO five times daily
- Famciclovir 750 mg BID for one day or 1500 mg as a single dose
- molluscum contagiosum :
- cryotherapy, curettage, cantharidin, and podophyllotoxin as first-line therapeutic options
- Herpes simplex:
- Fungal infections:
- Dermatophyte infections- topical or oral antifungals
Controlling pruritus:
- Preferred regimen:
- Sedatives: diphenhydramine, hydroxyzine, and cyproheptadine
- Nonsedatives: fexofenadine, cetirizine or loratadine
- Alternative regimen:
- Topical doxepin
- Topical calcineurin inhibitors
- Pimecrolimus 1% cream or tacrolimus 0.03% to 0.1%
References
- ↑ Ramsay H M, Goddard W, Gill S, Moss C. Herbal creams used for atopic eczema in Birmingham, UK illegally contain potent corticosteroids. Archives of Disease in Childhood 2003; 88:1056-1057