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Author: Dr Amy Stanway, Department of Dermatology, Waikato Hospital, Hamilton, New Zealand, February 2004. Updated by Hon A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand, July 2016.
There is no known cure for atopic dermatitis (eczema). As a large part of the tendency towards eczema is genetic, there is unlikely to be a cure anytime in the foreseeable future. There is, however, ongoing research and very effective treatments.
Several treatments are available that will control eczema so the skin looks and feels healthy.
Most people with eczema use topical treatments (lotions, creams and ointments). When the surface of the skin is inflamed, cracked or raw, many of these stings or burns when first applied. This irritation will lessen as eczema improves. It is worth persevering for at least a few days. If the stinging persists beyond this or causes welts or eczema gets worse, stop the treatment and consult your doctor.
Emollients provide moisture to the skin and help prevent further water loss. They should be used in almost everyone with eczema in an attempt to restore skin barrier function. Emollients are a very important part of eczema management, even (especially) when the eczema is well controlled. Remove the emollient from the pot using a clean spoon to avoid contamination. Note: clothing soaked in paraffin-based emollients becomes a fire hazard.
Topical steroids are the mainstay of treatment for mild to moderate eczema. They are also used in severe atopic dermatitis to reduce the dose of oral treatments and phototherapy. They are very effective and safe if used correctly. Despite this, many people are concerned about potential side effects from topical steroids. The trick is to use the correct strength of steroid for the severity of eczema and be prepared to change treatment as the severity of the eczema changes.
As eczema tends to be persistent, most people will have to use topical steroids on and off for many years. If used continuously topical steroids may lose their effectiveness after a few weeks (this is known as tachyphylaxis). Tachyphylaxis can be avoided by reducing the strength and frequency of the topical steroid as eczema comes under control.
The topical calcineurin inhibitors, pimecrolimus cream (Elidel™) and tacrolimus ointment (Protopic™, which is not yet available in New Zealand), are particularly useful for mild to moderate atopic dermatitis. They are anti-inflammatory immunomodulators and, unlike topical steroids, do not thin the skin or affect its barrier function.
Crisaborole (Eucrisa®) is a non-steroidal topical anti-inflammatory PDE-4 inhibitor reducing the production of inflammatory cytokines used for the treatment of mild to moderate atopic dermatitis. The FDA approved the drug in December 2016. It is not yet available in New Zealand (2019).
Antiseptic solutions can also be helpful in infected eczema as long as the concentration is not too high or they can have an irritant effect on the skin. Apply an emollient as well.
Coal tar, pine tar and ichthammol preparations are available as creams, bandages and bath additives. Although reducing itch and inflammation, they can be smelly and messy and do not appear as effective as topical steroids.
‘Wet wraps’ are wet bandages applied over emollients +/- topical steroids. Tubular elastic bandages are convenient. Wet wraps are used in acute red, hot, weeping eczema and usually require admission to hospital. They can quite quickly gain control of eczema and appear to work by cooling and moisturising the skin. They also protect the skin from damage due to scratching. They can be repeated for several days or longer, reapplied as they dry out.
The following oral medications are reserved for severe eczema.
Despite the potential long-term side effects of immunosuppressive agents, most patients who take them for severe eczema are very happy with the result as it frees them from otherwise disabling eczema. Immunosuppressant agents are not intended for indefinite use but if severe eczema relapses every time they are stopped they may be needed at least intermittently for many years.
Biologic medications are being developed for atopic dermatitis. A monoclonal antibody that targets Th2 cytokines interleukin (IL)-4 and IL-13 (responsible for reduced barrier function and inflammation), dupilumab (Dupixent®), was approved by the for the treatment of atopic dermatitis in March 2017. The results of Phase 2 trials for nemolizumab have been reported.
Scratching damages the skin, aggravating eczema, which then itches even more. Some scratching is just a bad habit or stress reaction. Behavioural therapy can be helpful to develop strategies to reduce scratching (habit reversal) thus leading to improvement in eczema.
So-called cures for atopic dermatitis abound, with many examples found readily on the Internet. Most are ineffective. Some are potentially hazardous. Insufficient evidence exists to recommend probiotics, leukotriene inhibitors, essential fatty acids or traditional Chinese medicines. Allergen immunotherapy may be useful in a small number of individuals with proven sensitisation to inhalant allergens.
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