Eczema: What’s the Best Treatment for You?Mar 06, Author: Topical steroids should be applied only non steroidal topical cream for eczema areas of acute exacerbations, whereas emollients should be used over the remainder of the skin. The regular use of emollients in children with mild-to-moderate atopic dermatitis reduces the symptom severity; they should be considered first-line treatment. The various topical steroid formulations, in ascending order of occlusiveness, include lotions, creams, gels, and ointments. The proactive wet-wrap method with diluted corticosteroids has been advocated.
A non-steroid approach to eczema
Mar 06, Author: Topical steroids should be applied only to areas of acute exacerbations, whereas emollients should be used over the remainder of the skin. The regular use of emollients in children with mild-to-moderate atopic dermatitis reduces the symptom severity; they should be considered first-line treatment. The various topical steroid formulations, in ascending order of occlusiveness, include lotions, creams, gels, and ointments.
The proactive wet-wrap method with diluted corticosteroids has been advocated. Lotions contain water and may be drying because of the evaporative effect; thus, they are used mostly in scalp and beard areas where drying effects are not as problematic. Lotions containing alcohol may cause a burning sensation upon application, especially on skin with fissured or ulcerated areas. Lotions may contain preservatives, solubilizers, and fragrances that can irritate the skin. Creams are generally well tolerated but are less moisturizing than ointments.
Creams are popular for their nongreasy appearance on treated skin and are more convenient during hot weather because they cause less occlusion of eccrine sweat glands than ointments and gels.
As with lotions, creams may contain preservatives, solubilizers, and fragrances that can irritate the skin. Gels are highly occlusive, but the propylene glycol base is irritating to the skin and promotes dryness. Therefore, gels, similar to lotions, are used mostly in scalp and beard areas where the drying effects are not as problematic. They are very effective in the management of acute weeping or vesicular lesions of atopic dermatitis.
Ointments are the most moisturizing of the topical steroid vehicles, but their occlusiveness may not be well tolerated because of their interference with sweat gland function and resultant development of sweat retention dermatitis, especially in warm humid climates.
Ointments are the preferred vehicle for thickened, lichenified plaques of atopic dermatitis. Systemic corticosteroids have been used in severe chronic atopic dermatitis, but use has been limited in the pediatric population because of the risk of severe adverse effects associated with chronic usage, including growth retardation and immune suppression. Oral antihistamines are effective as systemic antipruritics, sedatives, and mild anxiolytics.
These are beneficial especially at nighttime because pruritus is usually worse at night. Commonly used oral antihistamines include diphenhydramine, hydroxyzine, and doxepin. Pramoxine is a topical antipruritic agent and can be found as Prax, Pramosone, or PrameGel. Coal tar topical preparations have antipruritic and anti-inflammatory effects.
They are effective as second-line agents for subacute, chronic, and lichenified atopic dermatitis. Tar shampoos, such as Neutrogena T-Gel, are effective for scalp involvement.
Adverse effects may include folliculitis and photosensitivity. Topical calcineurin inhibitors eg, tacrolimus, pimecrolimus are the newest class of topical medications for atopic dermatitis. These nonsteroidal immunomodulators act by down-regulating the mediator release or cytokine expression of various cells, including Th1 helper cells, Th2 helper cells, mast cells, eosinophils, keratinocytes, and Langerhans cells.
Calcineurin inhibitors may be especially useful for treating face, groin, or axillary areas, where steroid-sparing treatments are preferred. The safety of pimecrolimus has been stressed for infants and other children, with the conclusion made that labeling restrictions be lifted.
Several studies have documented the rapid and prolonged improvement in clinical severity scores in children and adults with a range of severity of atopic dermatitis treat with topical calcineurin inhibitors. Research has shown the beneficial effect of topical calcineurin inhibitors in patients refractory to topical corticosteroid therapy.
In January , the Food and Drug Administration FDA approved a black box warning for tacrolimus and pimecrolimus topical medications. The warning emphasized the lack of long-term safety data and a possible link to malignancies. No causal link between these agents and the development of malignancies has been established.
Long-term studies on the safety of these agents in humans are not yet available, and the black box warning was based on case reports in humans and on animal studies. An analysis of tacrolimus ointment use in patients with atopic dermatitis over 4 years did not show any increased risk of infections or cancer. The safety of pimecrolimus has been stressed; labeling restrictions may be unnecessary. Establishing the long-term safety profile of topical calcineurin inhibitors is of paramount importance because they appear to provide an effective alternative to topical corticosteroid treatment in certain patients.
Furthermore, pimecrolimus has been shown to improve the epidermal skin barrier without the concurrent risk of local skin atrophy commonly seen with topical corticosteroid treatment. At the present time, physicians are advised to use the following guidelines when prescribing topical immunomodulators such as tacrolimus and pimecrolimus [ 50 , 51 ]:. Oral cyclosporine has proven beneficial in patients with severe atopic dermatitis refractory to treatment with topical steroids.
Discontinuation of cyclosporine frequently results in rapid relapse of skin disease. Significant adverse effects eg, nausea, abdominal discomfort, hypertrichosis, paresthesias, hypertension, hyperbilirubinemia, renal impairment have diminished enthusiasm for this drug, especially with the advent of the topical immunomodulators mentioned above. Experimental treatments for atopic dermatitis have included trials of gamma-interferon and IL-2; both are inhibitors of Th2 cell functions and have been promising.
Oral mycophenolate mofetil, an inhibitor of purine synthesis, has also been shown to be an effective alternative form of treatment for severe disease. A small study of 6 patients with severe atopic dermatitis showed promising results for treatment with anti-CD20 monoclonal antibody Rituximab. Conflicting results have been reported regarding the use of probiotics eg, Lactobacillus , Bifidobacterium in preventing atopic dermatitis or in controlling symptoms in children.
Deo et al have suggested low-dose methotrexate as a treatment option in the pediatric population. Baricitinib, an oral selective inhibitor of Janus kinase JAK —1 and JAK-2, which modulates proinflammatory cytokine signaling, appears to be have efficacy and be safe in patients with moderate-to-severe atopic dermatitis when used with topical steroids.
In older children and adolescents, treat mild cases of atopic dermatitis with a low-potency class VI or VII topical steroid twice a day to decrease inflammation.
Subsequently, low-potency steroids can be used to maintain remission. For severe cases of atopic dermatitis, pulse therapy with high-potency topical steroids class II or oral steroids may be beneficial in adolescents. Use only low-potency steroids on the face, axillae, groin, and intertriginous areas because of increased absorption and increased local steroid adverse effects. If the infant has more severe atopic dermatitis, a moderate-potency steroid can be prescribed for as long as 1 week and then tapered down to a lower-potency medication for maintenance therapy.
In general, do not treat infants with topical steroids in the high-potency classes class II or above without a referral to a dermatologist. Cordran tape is a corticosteroid-impregnated polyethylene film that enhances topical steroid penetration up to fold. Occlusion of a topical steroid under plastic wrap seems to work equally well.
These methods are especially useful for chronic lichenified plaques of atopic dermatitis. In order to achieve a quick, complete remission of atopic dermatitis symptoms, adequate amounts of topical steroid must be used. Many patients initially use suboptimal amounts of topical steroid products, leading to poor control of their atopic dermatitis symptoms and ultimate discontinuation of their therapy.
Approximately 30 grams of medication is needed to cover the entire surface area of an adult body. For children, the fingertip unit FTU has been shown to accurately measure an appropriate amount of medication. The FTU is defined as the amount of topical medication that will cover the child's index finger from the tip to the metacarpophalangeal joint. Atopic dermatitis increases the risk of developing lymphoma both Hodgkin disease and non-Hodgkin lymphoma. This risk correlates with increasing severity of disease.
The risk reportedly rose with increasing potency of the topical corticosteroid and with longer duration of use. Hydrocortisone topical is an adrenocorticosteroid derivative suitable for application to skin or external mucous membranes. It has mineralocorticoid and glucocorticoid effects, resulting in anti-inflammatory activity. It treats inflammatory dermatosis that is responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.
Flurandrenolide is an intermediate-potency topical corticosteroid. Each square cm provides 4 mcg. Symptoms typically dramatically improve in the first few days of treatment with systemic steroids, only to be followed by an equally dramatic rebound flare after cessation of treatment.
Tapering oral steroids over days may mitigate this effect. In addition, an intensified focus on hydration with bathing and appropriate use of topical steroids should be emphasized to prevent rebound phenomena after discontinuation of systemic steroids. Prednisone decreases inflammation by reversing increased capillary permeability and suppressing PMN activity. Antistaphylococcal antibiotics eg, topical mupirocin or bacitracin, first-generation cephalosporins, macrolides, penicillinase-resistant extended-spectrum penicillins such as oxacillin or dicloxacillin if resistant strains of S aureus are encountered, amoxicillin-clavulanate are helpful in secondary bacterial infections.
Herpes simplex superinfections eczema herpeticum should be suspected if vesicles are present or if no improvement is observed with oral antibiotics. Treat with oral or intravenous acyclovir for 10 days. Varicella infections may become severe in the setting of atopic dermatitis, and early treatment with acyclovir is recommended. Counsel all children with atopic dermatitis as to the benefits of vaccination against varicella. Treat dermatophyte infections with topical or oral antifungals, such as topical ketoconazole cream or shampoo.
Mupirocin topical cream or ointment inhibits bacterial growth by inhibiting RNA and protein synthesis. Cephalexin is a first-generation cephalosporin that arrests bacterial growth by inhibiting bacterial cell wall synthesis.
It has bactericidal activity against rapidly growing organisms. Its primary activity is against skin flora. It is used for the treatment of staphylococcal and streptococcal infections. Oxacillin is a bactericidal antibiotic that inhibits cell wall synthesis. This drug combination treats bacteria resistant to beta-lactam antibiotics. Base dosage regimen on amoxicillin content. Patients experience less pain and faster resolution of cutaneous lesions when used within 48 hours of rash onset.
Acyclovir may prevent recurrent outbreaks. Ketoconazole is an imidazole broad-spectrum antifungal agent. It inhibits the synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.
Dicloxacillin is a bactericidal antibiotic that inhibits cell wall synthesis. It is used in the treatment of infections caused by penicillinase-producing staphylococci and may be used to initiate therapy when a staphylococcal infection is suspected. Topical local anesthetics or antihistamines topical or systemic may be used to decrease pruritus.
Pramoxine elicits anesthetic effect by blocking nerve conduction and impulses by inhibiting depolarization of neurons. Diphenhydramine can be used for symptomatic relief of symptoms caused by the release of histamine in allergic reactions.