Treatment
At present there are no known cures for Atopic dermatitis, and current therapy is largely symptomatic. Certain therapeutic measures can be instituted that will dramatically reduce symptoms and control the overall skin condition.
Environmental Control
Environmental control measures, in the form of minimizing both allergen exposure and pruritic stimuli, should be instituted in all patients with Atopic dermatitis. Minimization of extreme fluctuations of temperature and humidity results in less pruritus. Sweating will induce pruritus in many patients with Atopic dermatitis; therefore, a moderate temperature environment should be maintained. Clothing should be loose and free of wool. Cotton fabrics are generally the best tolerated. Coarse fabrics in clothing and bedding should be avoided. Complete rinsing of detergents, soaps and bleach from clothing and bedding will also minimize their irritant potential. Occupational aggravating agents such as chemicals, irritants and solvents should be avoided by older patients with Atopic dermatitis. Minimization of emotional stress will also lessen the potential for pruritus.
Avoidance of known aeroallergens should be instituted when possible. The most easily avoided allergens are dust mites and animal danders. Dust mite-sensitive patients should institute full dust mite-avoidance procedures consisting of the following: plastic orhypoallergenic covers encasing mattresses and pillows, removal of all feather pillows and stuffed animals from the patient’s room, frequent high-temperature washing of the bedding and removal of carpeting and draperies from the patient’s room when practical. Animals (especially cats and dogs) should be removed from the home, and contact should be minimized. Practical avoidance of other aeroallergens (e.g., avoidance of cut grass) should be attempted.
Dietary Restriction
In patients with food hypersensitivity, food-allergen avoidance results in improvement of Atopic dermatitis. Sampson and coworkers have shown that following a strict avoidance diet of relevant food allergens patients experience symptomatic relief of pruritus and clearing of skin rash. Because of the high false-positive rate of prick skin testing and standard radioallergosorbent for food allergens, an elimination diet followed by a blinded (single- or double-blind) or open food challenge should be performed to confirm clinical reactivity to a particular food, unless a convincing history of anaphylaxis is obtained. An exception to this rule is when an elevated CAP-FEIA is obtained that demonstrates a greater then 90-95% likelihood that a patient will have a positive food challenge. Several investigators have shown the utility of this test for the diagnosis of food allergy without the need for food challenge. Improvements have been made regarding assessment for the development of tolerance among food-allergic patients. Perry and collegues have recently suggested new decision point guidelines for food re-introduction and challenge dependent on CAP-radioallergosorbent level in previously known food-allergic patients. Extensive elimination diets should not be prescribed on the basis of skin test positivity alone because of the obvious nutritional complications. The period of dietary restriction is allergen dependent, but generally should last for 1-2 yr before reintroduction or rechallenge with the implicated food. For some allergens, such as peanuts, a much longer elimination period may be necessary. In fact, new data suggests that approx 20% of children less than 5 yr with peanut allergy will outgrow the peanut allergy.
Skin Care
General measures to reduce skin trauma resulting from scratching should be instituted. Appropriate bedding and clothing can help minimize itching. In infants and children, gloves and socks can be used to reduce scratching, especially during sleep. Fingernails should be trimmed to minimize skin trauma from scratching.
Skin hydration is an extremely important measure in controlling the rash and pruritus associated with Atopic dermatitis. Although some clinicians feel that frequent or routine bathing is contraindicated in Atopic dermatitis, many others institute frequent bathing as part of the treatment protocol. Bathing hydrates the chronically dry skin of Atopic dermatitis and may reduce the likelihood of bacterial superinfection, which will reduce pruritus and activation of lesions. In addition, swimming has long been recognized by patients with Atopic dermatitis as soothing therapy. Patients should bathe in lukewarm water for 30 min once or twice a day (depending on the severity of disease). Burow’s solution, oatmeal or oils (i.e., Alpha-Keri) maybe added to the bath water to further reduce pruritus. Hydrating body wraps with water-soaked towels may be used in addition to bathing to maximize hydration of severely affected areas. Showers are inadequate in the management of Atopic dermatitis because of the lack of hydration obtained. Mild soaps (i.e., Dove or Basis) should be used for cleansing. Harsh soaps may be drying and serve to increase pruritus.
Lubricants should be applied to the skin immediately following bathing and other times during the day with a minimal application of twice daily. Lubricants will counteract dryness and “seal in” the hydration obtained from the prolonged bathing experience. Lubricants should be free of alcohols and perfumes, both of which can be irritating and drying. Effective lubricants include Vaseline, Unibase (oil-in-water preparation), Eucerin or Aquaphor (water-in-oil preparations) plus others.
Antipruritics
Of major importance in the successful treatment of Atopic dermatitis is interruption of the itch-scratch cycle. In addition to the methods mentioned previously, antihistamines and occasionally sedatives provide valuable relief of symptoms. Hydroxyzine (2 mg/kg/d divided every 6 h or given at bedtime; maximum adult dose 600 mg/d) and diphenhydramine (5 mg/kg/d divided every 6 h or given at bedtime; maximum adult dose 400 mg/d) have been shown to dramatically reduce itching and reduce sleep disturbance in patients with Atopic dermatitis. Other nonsedating antihistamines (e.g., loratidine and cetirizine) may also be useful for daytime use to relieve pruritus when a sedating medication is prohibitive. In young children with severe disease, short-term sedation with chloral hydrate (50 mg/kg/d given at bedtime) may be needed until control of symptoms can be obtained. Topical application of doxepin cream also provides relief of pruritus, but poses a greater risk for side effects because of its systemic absorption. Doxepin should be used with close observation in all patients, especially children and patients with large skin surface areas affected.
Corticosteroids
Corticosteroids are used in Atopic dermatitis to control inflammation. These preparations are very effective in controlling skin lesions of Atopic dermatitis, but should be used wisely. There is little role for systemic corticosteroids in the management of Atopic dermatitis except in the most severe cases. When used, oral corticosteroids should be prescribed for only a limited time and should be tapered judiciously. The skin disease will typically clear quickly with the use of oral corticosteroids, but frequently relapse once their use is discontinued. In addition, the side effects associated with use of systemic corticosteroids are well known and generally preclude their use.
Topical corticosteroid use in Atopic dermatitis is the mainstay of therapy. The potency of topical steroids used is dependent on the severity of the skin disease and the location of skin lesions. In general, topical steroid potency is related to the vehicle and the chemical preparation. Gel preparations penetrate more effectively, but are drying and therefore not of great benefit in Atopic dermatitis. Ointments penetrate well and enhance hydration, but feel occlusive and may be poorly tolerated during periods of high temperature (i.e., summer). Creams and lotions are less potent and penetrate less effectively than gels or ointments, but are more comfortable to some patients. Except in mild cases, ointments should be used because of their higher penetrance and potency. The lowest strength that gives adequate results should be used. Halogenated corticosteroid preparations, such as 0.1% betamethasone (Valisone), 0.025% fluocinolone (Synalar), and 0.1% or 0.025% triamcinolone (Aristocort, Kenalog), have potent anti-inflammatory properties and can be used sparingly on affected body lesions. These preparations should not be used on the face and neck. Hydrocortisone cream or ointment, 1%, can be used sparingly on the face and neck, but stronger preparations should be avoided. Topical steroids should be applied twice daily after application of lubricating creams or ointments as discussed. These preparations will penetrate the lubricant and reach the affected skin. Although generally safe from systemic absorption, diffuse application of topical steroids over long periods can have the adverse effects of striae, atrophic thinning of skin, ulcerations, hirsutism, acne, and telangectasia. In addition, cases of adrenal suppression secondary to use of topical steroids have been reported. Although these complications are rare with prolonged use of low-potency topical steroids, their use in children and adults with severe disease should be monitored.
Tar Preparations
Coal tar preparations have been used for many years in the management of Atopic dermatitis. Although topical corticosteroids have generally replaced the routine use of these keratolytic agents, they are still effective in the management of chronic, lichenified skin lesions that respond poorly to corticosteroids. The mechanism by which coal tar preparations work is unknown, but clinical evidence has shown that they have both anti-inflammatory and antipruritic effects. These preparations are will tolerated, but prolonged use may lead to folliculitis and photosensitivity. Shampoos containing tars are especially useful in the patient with scalp involvement (i.e., as in both Atopic dermatitis and seborrhea).
Antibiotics
As previously stressed, patients with Atopic dermatitis have a high degree of bacterial colonization of both affected and unaffected skin. The risk and occurrence of bacterial superinfection of the Atopic dermatitis skin is therefore high, most commonly with Staphylococcus aureus and strep-tococcal organisms. In addition, Leung and others have shown that some patients with Atopic dermatitis produce specific immunoglobulin E antibodies to various exotoxins produced from S. aureus. Because of these factors, antistaphylococcal and antistreptococcal antibiotics should be used liberally in the Atopic dermatitis patient with documented or suspected bacterial superinfection. Skin cultures can be helpful in documenting the type of organism present and the antibiotic sensitivities of the organism. From a clinical standpoint, exudative, crusted or excoriated lesions should raise the clinical index of suspicion for secondary bacterial infection. Appropriate antibiotic therapy should be instituted for 10-14 d. In cases of limited distribution of infected skin lesions, topical antibiotic therapy with preparations such as Bactroban ointment may be adequate. For most cases, systemic antibiotics will be required to eradicate the infection. An increased skin care regimen with more frequent bathing may also help to reduce the bacterial load.
A few reports have addressed the issue of secondary infection caused by fungal infections, such as Pityrosporum ovale, in which investigators have advocated the use of topical agents such as Sebulex or Selsun shampoo, to fight fungal growth. Others have recommended the use of oral antifungal agents when fungal organisms are documented or highly suspected. Experience to date is relatively empiric and not well established.
Phototherapy
Ultraviolet light therapy with UVA rays has been offered to some Atopic dermatitis patients for control of lesions. Rajka has reported favorable results in a small series of Atopic dermatitis patients when phototherapy was provided to eczematous skin lesions and maintenance therapy was sustained. This method of therapy has been proposed for the patient who is poorly responsive to conventional therapy or in whom severe Atopic dermatitis is present. Rajka also notes that phototherapy may be beneficial in children with severe disease requiring systemic steroids to reduce the potential side effects of long-term corticosteroids. Most commonly, ultraviolet therapy must be given at least weekly and sustained over long periods to prevent relapse. This regimen raises the issue of adverse effects of long-term ultraviolet light exposure, such as induction of malignant disease and chronic skin changes. Most clinicians feel that the risk-benefit ratio is too high to encourage this form of therapy for the average Atopic dermatitis patient. Phototherapy should therefore be reserved for the complicated case that is poorly responsive to other forms of therapy.
Recently, omalizumab, a humanized IgGl monoclonal antibody against immunoglobulin E has been shown to be effective in treatment of allergic asthma and allergic rhinitis. As such, this therapy could potentially decrease the effects of immunoglobulin E in Atopic dermatitis, but the high serum immunoglobulin E levels seen in Atopic dermatitis may limit its utility. However, omalizumab may have a role in treatment of food-induced Atopic dermatitis. In apopulation of peanut-allergic patients, the threshold of sensitivity to peanuts on oral food challenge was significantly increased after treatment wiht anti-immunoglobulin E, suggesting protection against unintented ingestion of the food allergen.
Immunotherapy
Although allergen immunotherapy has been useful in some atopic conditions (i.e., allergic rhinitis), its role in the treatment of Atopic dermatitis has been limited. In clinical practice, immunotherapy will frequently exacerbate the condition of Atopic dermatitis rather than provide relief. Some clinicians advocate the use of immunotherapy, especially in older patients with significant aeroallergen hypersensitivity, but recommend initiating therapy with a much smaller dilution of allergen extract than in standard therapy for allergic rhinitis. The dose of extract needed to induce tolerance is often greater than the dose tolerated by the patient with Atopic dermatitis, thereby precluding its use in most patients.
Immunomodulatory Therapy
As previously discussed, Atopic dermatitis is associated with abnormalities of the immune system, especially with regard to cytokine production and immunoglobulin E regulation. In particular, many investigators have shown a predominance of TH2-type lymphocytes, which produce excess amounts of IL-4 and therefore upregulate immunoglobulin E production. These patients are noted to have little IFN-y production in comparison. Some of these same investigators have also shown that IFN-y suppresses immunoglobulin E production in vitro and has effects on immune effector cell function. Several immunomodulatory agents, including recombinant IFN-y, cyclosporin A, and tacrolimus (FK506), have been used in clinical trials of Atopic dermatitis.
A recent, double-blind, placebo-controlled, multicenter trial was conducted to examine the effects of recombinant IFN-y (rIFN-yg) administration to patients with chronic Atopic dermatitis. Patients treated with IFN-y had a significant reduction in symptoms and a mean reduction in circulating eosinophils when compared to the placebo-treated group. A previous trial of 23 patients also showed a significant fall in immunoglobulin E synthesis in rIFN-y treated patients. In another trial of 15 patients (adult and pediatric) treated for aminimum of 22 mo, patients had a significant reduction in mean body surface involvement of Atopic dermatitis from 61.6% at baseline to 18.5% at 24 mo.
Two topical calcineutininhibitors, tacrolimus (FK506) and pimecrolimus, have recently been approved for the tratment of Atopic dermatitis. Both of these medications inhibit the activation of a number of key effector cells involved in Atopic dermatitis, including T-cells, dendritic cells, keratinocytes, and mast cells. The distinciton between pimecrolimus and tacrolimus is that pimecrolimus is a cream that is somewhat weaker than tacrolimus but less irritating. Short-term, multicenter blinded, vehical-controlled trials in both adults and children have shown both topical tacrolimus and pimecrolimus to be effective. The most common reported side effects for both drugs are stinging and local irritation. Long-term studies with both drugs have shown sustained efficacy and no significant side effects. Because topical calcineurin inhibitors are not atrophogenic, they can be advantageous over topical corticosteroids in some circumstances, including in patients who are poorly responsive to topical steroids or have steroid phobia and treatment of face and neck dermatitis. Although systemic absorption of these compounds is low, these drugs need or be carefully monitored in any child with extensive skin disease because of their high ratio of body surface area to weight.
Cyclosporine A, a potent T-cell suppressant, has been evaluated extensively in two recent clinical trials. In the first, 42 patients were treated for one or two 6-wk treatment periods and observed for 2 yr. A 58% reduction was noted in symptoms and Atopic dermatitis scoring with 95% of follow-up cases still in remission after 2 yr. In the second study, 100 adults with Atopic dermatitis were treated for a maximum of 48 wk in an open trial. Most (65%) patients showed complete resolution or significant reduction in their symptoms and lesions, yet most reported relapse after cessation of therapy. Tolerability of cyclosporine therapy was rated good or very good in 85% of patients.
These studies provide examples of potential immunomodulatory therapy that will likely become of more importance as our understanding of the immunopathogenesis of Atopic dermatitis expands. Further long-term evaluation of therapeutic efficacy and safety is needed, especially in pediatric populations. Other newer medications, such as phosphodiesterase inhibitors and leukotriene modifiers, may have clinical relevance for the treatment of Atopic dermatitis in the future. Currently, information on these medications is limited to in vitro analysis and anecdotal reports.
Alternative Medical Therapy
As alternative therapeutic approaches to medical care have become more popular in the United States and other Western countries, interest has developed regarding the application of some of these therapies for patients with Atopic dermatitis. Chinese herbal therapy has been evaluated in several trials, most of which are not population- or placebo-controlled. Xu and colleagues reported a reduction of inflammatory cells and markers (e.g., low-affinity immunoglobulin E receptor [CD23], plus others) in 10 patients treated for 2 mo. These authors concluded that Chinese herbal therapy is efficacious for patients with Atopic dermatitis. Other case reports and small series using different Chinese herbal therapy have drawn the same conclusions. Obviously, this form of therapy for Atopic dermatitis needs to be evaluated by blinded, controlled trials in larger studies before it can be recommended for use. In addition, in some reports, Chinese herbal therapy has been associated with significant adverse symptoms, such as cardiomyopathy, highlighting the fact that at this time Chinese herbal therapy should not be used without caution and close observation.
Another alternative therapy, known as bioresonance or biophysical information therapy (BIT), has been reported as beneficial for Atopic dermatitis in case reports and uncontrolled trials. To more rigorously test the efficacy of BIT for Atopic dermatitis, Schoni observed 32 children with Atopic dermatitis in a double-blind trial. Results showed no benefit of BIT in patients with Atopic dermatitis compared to controls, leading the authors to dismiss the role of BIT as alternative therapy for Atopic dermatitis.
The use of probiotics has been growing in popularity in recent years. Probiotics are live microorganisms that when ingested confer a health benefit on the host. Of the various organisms used as probiotics, Lactobacillus has been of particular interest in Atopic dermatitis. The use of combination lactobacilli in infants and children with Atopic dermatitis has been associated with reduction in disease, especially in younger children with allergen sensitization. In a double-blind, placebo-controlled crossover study, Rosenfeldt and coworkers found that the administration of two probiotic Lactobacillus strains to children with Atopic dermatitis caused a significant reduction in clinical severity as measured by patient reprot with the effect being more pronounced in allergic patients (high immunoglobulin E and at least one positive skin prick test). The combination of a low side-effect profile and our emerging understanding of the role of gut flora in the development of atopic disease and its relationship to the “hygiene hypothesis” make therapy with probiotics attractive. Larger scale studies are needed to advance our understanding of the role of these therapies in clinical practice.
Psychotherapy
Atopic dermatitis is a very aggravating chronic disease that can be emotionally challenging for patients and families alike. Emotional distress and problems can trigger episodes of pruritus and worsen the Atopic dermatitis. In addition, young patients and their families may have difficulty understanding and coping with this chronic condition and may need help to establish parameters for discipline without adding to the emotional tension of an already aggravated child. Older children and adolescents may also experience body image problems related to the obvious skin abnormalities. For all of these reasons, some patients and their families will benefit from social service support and/or psychological counseling to address these issues. This is particularly important in the patient with severe chronic disease.
This post has been viewed 472 times.