Treatment for atopic dermatitis
When controlling and treating atopic dermatitis, applying skin-care ointments and creams to your skin is very important. With localised inflammation, your GP, paediatrician or dermatologist will prescribe you weak to moderate topical corticosteroids or immunomodulators in combination with antihistamines. When the inflammation affects large portions of your skin, we can no longer speak of localised inflammation. In this case, you will have to take systemic corticosteroids for a short period of time or you will be prescribed systemic immunomodulators or UV therapy. Both types of inflammation are often accompanied by secondary infections, which are treated with antibiotics, antimycotics and or antivirus drugs. We are currently on the brink of receiving new biological medications for atopic dermatitis, which will help ease the severest forms of the condition.
Life with atopic dermatitis is extremely energy-draining. Because the currently available treatment options often don’t bring the desired results in alleviating atopic dermatitis, more and more patients turn to alternative medicine. If you discover an alternative treatment that works for you, simply stick to it. Determined, unabated and endless search for deliverance from pain or unbearable itching is perfectly understandable. Regardless, each alternative treatment should be critically evaluated and followed carefully only when sufficient information on it has been gathered.
At this point, it’s important to keep in mind that a miracle cream for atopic dermatitis doesn’t exist. At least not yet. If you are being offered a cream without proper certification that promises incredible results and contains natural ingredients, be very careful when using it. Such creams often contain potent corticosteroids the long-term use of which can have a serious impact on your health. When looking for treatment options for atopic dermatitis, stick to the following principle: if something is too good to be true, it probably is.
Skincare for atopic dermatitis patients
Proper skin care is key to controlling atopic dermatitis. In milder forms of the illness, the correct skincare can get you out of topical corticosteroid and topical immunomodulatory treatment. The skincare solution used by atopic dermatitis patients is oil- and water-based. It’s either a water-suspended-in-oil or an oil-suspended-in-water emulsion. Creams are of the later type while ointments are of the former type. The more water a cream contains, the larger the amount that needs to be applied to the skin. The water and oil solutions supply the skin with the necessary fat while preventing water evaporation. Moisturising creams without oil can only dry out the skin further. On the other hand, ointments and creams with larger quantities of oil can be irritating for the skin. If your skin is dry, you should apply proper skincare products to it at least twice a day.5
Don’t use alkaline soap when washing your body but pH neutral syndets instead. If you or your child have been prescribed baths for atopic dermatitis, the bathing time should be short (from 10 to 20 minutes). Simply add the suitable mixture to the water to make your bath. During acute inflammation, baths aren’t advised. After having washed your skin, wipe it gently while leaving it moist. Then, apply your skincare cream or ointment no later than three minutes after wiping (the 3-Minute Rule). Using skincare products helps bolster the skin’s function as a barrier against allergens and microbes. This leads to less inflammation and reduced itching.5,13,47,49
Each person’s skin with atopic dermatitis will react differently to different skincare products. What has worked for someone else may not be ideal for you or your child or may even worsen the symptoms. If no worsening of the symptoms occurs after using a skincare cream or ointment, continue using the product for at least 3 to 4 weeks, testing its efficacy and your reaction to it. It often happens that a cream which has been working well for you suddenly causes the state of your skin to deteriorate.
During acute inflammation, it’s advisable to use zinc ointments and wrap the affected skin in wet clothing or gauze (wet wrap therapy).
Drug therapy for atopic dermatitis
Topical corticosteroids have been used for atopic dermatitis for several decades. In Europe, topical corticosteroids are divided into 4 groups according to their potency. In the USA, there are 7 groups. According to the European criteria, only mild to moderate topical corticosteroids should be used in the treatment of atopic dermatitis. Systemic corticosteroids should only rarely be prescribed. Topical corticosteroids are effective against inflammation and itching. They reduce the production of inflammatory cytokines and stimulate the production of anti-inflammatory peptides. The treatment duration depends on (I) the potency of the topical corticosteroid, (II) the location and extent of the inflammation and (III) the patient’s age. Long-term use of topical corticosteroids can lead to topical or systemic unwanted side effects, which is why their application is limited.5,6,16,34 After applying topical corticosteroids to your skin, it’s advisable to avoid excess sunlight, ultraviolet light and solarium sunbathing. Before using a topical corticosteroid, always read the instructions for use and follow them.
Topical immunomodulators (calcineurin inhibitors)
Topical immunomodulators appeared in 1990 and represent a huge advance in the treatment of atopic dermatitis. Two calcineurin inhibitors are currently permitted for treating atopic dermatitis: pimecrolimus and tacrolimus. Both drugs have an anti-inflammatory effect, reduce itching, don’t cause the atrophy of the skin and should have no systemic side effects for the patients. In Europe and the USA, the drugs are approved for use in children after the second year of age although they are prescribed to babies as well.5,6,13,16,34,35 After the application of topical immunomodulators, it’s advisable to avoid excess sunlight, ultraviolet light and solarium sunbathing.
- Pimecrolimus, 1%, is suitable for mild-to-moderate atopic dermatitis. It’s anti-inflammatory and reduces itching and the need for topical corticosteroids. It can be used over longer periods of time and is safe for use in children.
- Tacrolimus, 0,03% and 1%, is suitable for moderate-to-severe atopic dermatitis. It has an effect similar to corticosteroids but absorbs more slowly due to its greater molecular mass. It can be used over longer periods of time.
Side effects of topical immunomodulators (especially frequent with Protopic) mostly involve a burning sensation after application that fades over time. Before using a topical immunomodulator, always read the instructions for use and follow them.
Sedating and non-sedating antihistamines
Antihistamines are prescribed for atopic dermatitis in combination with topical corticosteroids or topical immunomodulators. The drugs are divided into 3 generations according to their sedating properties. They effectively alleviate symptoms of allergic rhinitis (hay fever), urticaria (hives) and asthma, but it’s questionable whether they can successfully reduce the itching sensation of the affected skin. Histamine isn’t the main inflammatory modulator that triggers itching, and thus antihistamines can’t prevent the itch from occurring. However, research conducted in 2015 by Japanese scientists shows that second-generation antihistamines can help lessen the itchy sensation.5,12,13,16
Before using an antihistamine always, read the instructions for use and follow them.
Systemic immunosuppressants are used in patients with severe forms of atopic dermatitis who didn’t respond positively to any other treatment course. The task of immunosuppressants is to suppress the activity of the immune system. The most frequently used immunosuppressants for atopic dermatitis are systemic corticosteroids and cyclosporine A. 5,12,16,52
Systemic corticosteroids are only rarely needed in the treatment of atopic dermatitis, but in practice they are very frequently prescribed. The use of systemic corticosteroids is questionable, as there isn’t any research made on the long-term beneficial effects of the drugs (e.g. long-term remission of atopic dermatitis). In comparison to systemic corticosteroids, cyclosporine A is much more effective long-term.
Cyclosporine A is a very effective and very frequently used drug for treating atopic dermatitis in child and adult patients alike. The treatment usually lasts from 3 to 12 months. Some patients can even tolerate low doses of cyclosporine A for longer periods of time. The maximum treatment duration is 2 years. The drug has many unwanted side effects that make regular blood and blood pressure tests necessary.
Other immunosuppressants are azathioprine, methotrexate, mycophenolate mofetil, etc.
Before using systemic immunosuppressant drugs, always read the instructions for use and follow them.
UV therapy is the standard therapy for atopic dermatitis, psoriasis and other inflammatory skin diseases. It’s anti-inflammatory and antimicrobial. There are different types of UV therapy:
- Heliotherapy (the use of natural UV rays)
- Broadband UVB phototherapy (280—320 nm)
- Narrowband UVB phototherapy (311—313 nm)
- UVA phototherapy (320—400 nm)
- UVA 1 phototherapy (340—400 nm)
- Chemophototherapy (PUVA)
Phototherapy is used in adults with the chronic type of atopic dermatitis. It unsuitable for the treatment of the acute phase of the illness and for patients that don’t tolerate sunlight well.5,16
Antibiotic, antimycotic and antivirus drugs
The skin of patients with atopic dermatitis is more prone to infections with bacteria (e.g. Staphyloccocus aurens, group A Streptococcus), viruses (e.g. Herpes simplex, Varicellela zoster, Pox viruses) and fungi (e.g. Malassezia furfur, Candida albicans). The secondary skin infections of the inflamed skin need to be treated with antibiotics, antimycotics and/or antiviral drugs.5,16,51
New medications for atopic dermatitis
In December 2016, FDA approved a new topical drug,for the use in atopic dermatitis patients that contains crisaborole. The ointment (2%) has a boric base (i.e. it is based on the chemical element boron) and, according to research, effectively alleviates the signs and symptoms of mild-to-moderate atopic dermatitis. It’s mode of action is distinct from topical corticosteroids and topical immunomodulators.
Crisaborole is a local inhibitor of the inflammatory enzyme phosphodiesterase E-4 (PDE4)8 the levels of which are raised in patients with atopic dermatitis. By inhibiting the enzyme, the drug helps decrease the production of inflammatory peptides, which in turn reduces the intensity of inflammatory processes. The ointment containing crisaborole can be used in adults and children aged 2 or more.
Biological medicine for atopic dermatitis
In Slovenia, patients with atopic dermatitis can be treated with biological medicine as of December 2019. The medicine is suitable for treating adolescents and adults with moderate-to-severe atopic dermatitis. It was approved by FDA at the beginning of 2017 and represents a breakthrough in the treatment of atopic dermatitis. The medicine contains monoclonal antibodies derived in an ethical manner from human cells. The antibodies bind to the alpha subunits of the IL-4 receptors and thus prevent the binding of interleukins IL-4 and IL-13. You can read more about the biological medicine for atopic dermatitis tukaj.