Treatment of Atopic Dermatitis

RENNU PRIAKSHAN VIVEGANANDARAJAHGROUP 14, 4th COURSE

• Atopic dermatitis is a chronic, pruritic inflammatory skin disease that occurs most frequently in children, but also affects many adults. It follows a relapsing course.  AD is often associated with elevated serum immunoglobulin (IgE) levels and a personal or family history of type I allergies, allergic rhinitis, and asthma.  Atopic eczema is synonymous with AD.• The often protracted nature of AD necessitates setting several

long-term treatment goals: prevention of continued outbreaks, management of co-morbidities and secondary complications that arise, and minimizing adverse effects while trying to maximize positive outcomes.• Before treating use tests to diagnose and scales and indexes

like SCORAD to asses the severity

According to the American academy of dermatology clinical guide lines, there are three main groups of treatment

Topical therapyDisease flares and adjunctive

therapyPhototherapy and

systemic agent

1.Non pharmacologic interventions 2.Topical corticosteroids 3.Topical Calcineurin inhibitors4.Topical antimicrobial and antiseptics 5.Topical antihistamines

1.Phototherapy2.Systemic immunomodulatory agents3.Systemic antimicrobials4Systemic antihistamines

1.Prevention of flares2.Educational interventions3.Coexisting allergic disease and allergy testing4.Dietary interventions5.Environmental 6.modifications

1.Non pharmacologic interventions• The application of moisturizers should be an integral part of the

treatment of patients with AD as there is strong evidence that their use can reduce disease severity and the need for pharmacologic intervention.

• Bathing is suggested for patients with AD as part of treatment and maintenance; however, there is no standard for the frequency or duration of bathing appropriate for those with AD.

• Moisturizers should be applied soon after bathing to improve skin hydration in patients with AD.

• Limited use of non soap cleansers (that are neutral to low pH, hypoallergenic, and fragrance free) is recommended.

• Use of wet-wrap therapy with or without a topical corticosteroid can be recommended for patients with moderate to severe AD to decrease disease severity and water loss during flares.

2.Topical Corticosteroids • A variety of factors should be considered when

choosing a particular topical corticosteroid for the treatment of AD, including patient age, areas of the body to which the medication will be applied, and other patient factors such as degree of xerosis, patient preference, and cost of medication.• TCS are grouped into 7 classes, from very low/ lowest

potency (VII) to very high potency (I), based on vasoconstriction assays.

Class Drug Dosage Form(s) Strength (%)

I Very high potency

Augmented betamethasone dipropionate

Ointment 0.05

II High Potency Amcinonide Cream, lotion, ointment

0.1

III-IV. Medium Potency

Fluocinolone acetonide

Cream, ointment

0.025

V Lower-Medium Potency

Hydrocortisone butyrate

Cream, ointment, solution

0.1

VI  Low Potency Alclometasone dipropionate

Cream, ointment

0.05

VII Hydrocortisone Cream, lotion, ointment, solution

0.25, 0.5, 1

TCI are recommended and effective for acute and chronic treatment, along with maintenance, in both adults and children with AD, and are particularly useful in selected clinical situation

Clinical situations in which topical calcineurin inhibitors may be preferable to topical steroids

Recalcitrance to steroidsSensitive areas (e.g., face, anogenital, skin folds)Steroid-induced atrophyLong-term uninterrupted topical steroid use

Pimecrolimus cream and tacrolimus 

4.Topical antimicrobial and antiseptics In patients with moderate to severe AD and clinical signs of secondary bacterial infection, bleach baths and intranasal mupirocin may be recommended to reduce disease severity.5. The use of topical antihistamines for the treatment of patients with atopic dermatitis is not recommended because of the risk of absorption and of contact dermatitis.

3.Topical Calcineurin inhibitors

6. Phototherapy1.Phototherapy is a second line treatment, after failure of first-line treatment (emollients, topical steroids, and topical calcineurin inhibitors).

2.Phototherapy can be used as maintenance therapy in patients with chronic disease.

3Phototherapy treatment of all forms should be under the guidance and ongoing supervision of a physician knowledgeable in phototherapy techniques.

4.The light modality chosen should be guided by factors such as availability, cost, patient skin type, skin cancer history, patient use of photosensitizing medications, etc.

5.The dosing and scheduling of light should be based upon minimal erythema dose (MED) and/or Fitzpatrick skin type.

7. Systemic immunomodulatory agents Systemic immunomodulatory agents are indicated for the subset of adult and pediatric patients in whom optimized topical regimens and/or phototherapy do not adequately control the signs and symptoms of disease.

Systemic immunomodulatory agents are indicated when the patient’s skin disease has significant negative physical, emotional, or social impact.

All immunomodulatory agents should be adjusted to the minimal effective dose once response is attained and sustained. Adjunctive therapies should be continued in order to use the lowest dose and duration of systemic agent possible.

Insufficient data exists to firmly recommend optimal dosing, duration of therapy, and precise monitoring protocols for any systemic immunomodulation medication.

Treatment decisions should be based on each individual patient's AD status (current and historical), comorbidities, and preferences.

Cyclosporine is effective and recommended as a treatment option for patients with AD refractory to conventional topical treatment.

The use of systemic antibiotics in the treatment of non-infected AD is not recommended

Systemic antibiotics are appropriate and can be recommended for use in patients with clinical evidence of bacterial infections in addition to standard and appropriate treatments for AD disease itself (which may include the concurrent use of topical corticosteroids).

Systemic antiviral agents should be used for the treatment of eczema herpeticum.

9. Systemic Antihistamines There is insufficient evidence to recommend the general use of antihistamines as

part of the treatment of atopic dermatitis.

Short-term, intermittent use of sedating antihistamines may be beneficial in the setting of sleep loss secondary to itch, but should not be substituted for management of atopic dermatitis with topical therapies.

8. Systemic antibiotics

10. Educational Interventions Educational programs (i.e., training programs and ‘‘eczema schools’’) are

recommended as an adjunct to the conventional therapy of atopic dermatitis.

Video interventions can be recommended as an adjunct to conventional therapy.

Eczema workshops and nurse-led programs may be useful as an adjunct to conventional therapy.

11. Coexisting Allergy diseases and their management Atopic dermatitis patients have an increased rate of environmental and food

allergies, and physicians should assess for these conditions during history taking. If significant concerns for allergy are identified (ie, hives, urticaria, etc) assessment can be undertaken. Allergy testing independent of history is not recommended. 

Patch testing should be considered in patients with atopic dermatitis who have persistent/recalcitrant disease and/or a history or physical examination findings consistent with allergic contact dermatitis.

Food elimination diets based solely on the findings of food allergy, test results are not recommended for the management of AD.

If a patient has a true immunoglobulin E-mediated allergy, he or she should practice avoidance to prevent potential serious health sequelae.

Children less than 5 years of age with moderate to severe AD should be considered for food allergy evaluation for milk, egg, peanut, wheat, and soy if at least 1 of the following is met: (A) persistent AD in spite of optimized treatment or (B) having a reliable history of immediate reaction after ingestion of a specific food.

The use of probiotics/prebiotics for the treatment of patients with established AD is not recommended because of inconsistent evidence.

There is inconsistent to no evidence to recommend the use of fish oils, evening primrose oil, borage oil, multivitamin supplements, zinc, vitamin D, vitamin E, and vitamins B12 and B6 for the treatment of AD. 

12. Dietary controls

Factors that we should consider in dietary control

1. Food allergies may coexist and represent important triggers in a small subset of individuals with AD, he true frequency of food allergies causing an isolated flare of disease is probably low.

2. Elimination diets should not be initiated based on presence of AD or a suspicious history alone, If allergy is suspected as a trigger of AD, a food diary recording symptoms and intake can be helpful in identifying a specific food, a diagnostic elimination diet for up to 4 to 6 weeks with the suspected food item(s) may be initiated. If the individual’s AD remains stable or even increases in severity, it is unlikely that the food is a relevant AD trigger and additional testing is not necessary.

3. Multiple dietary restrictions and long-term dietary avoidance should only be undertaken with documented, clinically relevant food allergies, Excessively restrictive diets, especially in atopic children, have led to weight loss, poor growth, calcium deficiency, hypovitaminosis, and kwashiorkor, Proper medical supervision, nutritional counseling from a dietician, and supplementation should be included if elimination/avoidance diets are pursued for any prolonged period of time.

4. The use of probiotics/prebiotics for the treatment of patients with established AD is not recommended because of inconsistent evidence

13. Environmental ModificationsThere are less or no evidence to support to these modifications can improve the condition of the patient with AD.

And finally the treatment for Ad should be individualized, we should consider patient’s age, clinical symptoms, degree of the activity and the severity of the disease. Therapeutic measures should be aimed at eliminating the inflammatory process and as well as the extension of the state of the clinical reference and the relapse prevention.

References Eichenfield LF, Tom WL, Berger TG, Krol A, Paller AS, Schwarzenberger K, et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014 Jul;71(1):116-32.V.I.Stepanenko , Dermatology and VenerologyABC of Dermatology

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