J. Bergman, MD, FRCPC and D. R. Thomas, MD, FRCPC
Faculty of Medicine, University of British Columbia, Vancouver, Canada
Diagnostic Features of Eczema or Atopic Dermatitis (AD)
Diagnostic Features of Eczema or Atopic Dermatitis (AD): a chronic relapsing condition in patients with a personal or family history of atopy. Usually starts before the age of 2 years and usually improves or resolves in older children and adults.
- Itching must be present to make the diagnosis
- Dry Skin is always present
- Typical Rash Location varies with age of patient. Infants: face usually involved. Diaper area and axilla usually clear. Extensor arms and legs involved due to friction from crawling. Children 4-10 years: flexures, sides of the neck, earlobes.
- Inflammed Skin usually seen
- Secondary Infection – Staphylococcus aureus very common, molluscum and herpes infections often more extensive
Treatment: Self-help and Medical Treatments
1. Patient Self-help – Patients may not improve if triggers are not removed
Aggravating/Trigger Factors to be Avoided
- Skin irritants such as soap, bubble bath, detergents, fabric softeners and perfumed products.
- Frequent bathing, especially if not followed by moisturizers. Sweating may exacerbate pruritus.
- Skin infection will tend to promote AD
- Food allergies can play a role in a small percentage of young patients with AD (e.g. eggs, milk, nuts, peanuts, fish, shellfish,
- wheat, and soy account for over 90% of food allergies)
- Environmental allergens such as house dust mites
Self-Help
1. Use a mild cleanser; 2. Moisturize often; 3. Hydrocortisone; 4. Cool bathing; 5. Use perfume free products; 6. Oral antihistamines; 7. Avoid triggers
Mild Cleansers
- Mild soap or nonsoap cleanser like Spectrojel®, Spectroderm®, Cetaphil®, plain white Dove®
- Emulsifying ointment USP (ask pharmacist)
Moisturizers
Use at least 250mg of cream/ week. Must be thick like butter or greasy like petroleum (e.g., Vaseline® Petroleum Jelly, Aquaphor® ointment, Creamy Vaseline®, 25% water in Hydrophilic Petrolatum, Aqueous cream, Aveeno® cream, unscented cold cream, Eucerin® cream, Cetaphil® cream, Cliniderm® cream)
2. Medical Treatment
Relief and suppression of eczema flares check list:
- Itch Relief – Dry Skin Therapy – Inflammation Suppression
- with anti-inflammatories
- Infection Control
Itch Relief
Oral-sedating antihistamines at bedtime. Hydroxyzine, Benadryl®, start at low dose and increase as tolerated. Moisturize and use topical anti-inflammatory. Wet compresses using gauze or face cloth dipped in tepid water, rung out and then laid on oozing skin is soothing.
Long-term Control by Preventing New Flares
Control of a flare may be easier than motivating a patient to continue intermittent use of an anti-inflammatory or to regularly moisturize the skin and avoid triggers. Using anti inflammatory topicals at the first signs and symptoms can minimize the use of medication and give smoother control of the disease.
Dry Skin
Frequent moisturizing especially within 2-5 minutes after bathing and when skin is wet. Most patients under moisturize. Check the quantity used. Use a minimum of 250mg/week (more if possible).
Anti-inflammatory Drugs
Corticosteroids and Calcineurin inhibitors are useful for shortand long-term use.
Topical Corticosteroids (TCS)
- Gold standard of treatment for AD
- Quick acting anti-inflammatory action. Potency from mild to very potent.
- General rule is that one uses the lowest potency possible for control of the disease. Goal is to be off the steroid more often than on the steroid.
- Useful for flare prevention.
- In conjunction with calcineurin inhibitors, they have a role
- as rescue medication when severe flares develop.
- Low potency corticosteroids are best used in the skin folds, face and neck.
- Moderate potency steroids are needed for thick lichenified eczema in older children and for acute flares on the body.
- Side-effects such as skin atrophy, tachyphlaxis, and adrenal suppression can occur but these are usually seen if the drug is used for too long, too often, or too much especially on the face folds, or inner thigh. Very young and old patients are more at risk. No harm will come from using potent corticosteriods for short periods, i.e., days at a time.
- Two issues of concern are steroid phobia by patients and
steroid allergy:
a) Steroid phobia — patients need to understand that the
body naturally produces steroids and that side-effects are unlikely if topical steroids are used appropriately.
b) Steroid allergy – Uncommon. Patch testing is required to confirm.
Topical Calcineurin Inhibitors
Pimecrolimus (Elidel™ 1% cream) Nonsteroid approved for short- and long-term intermittent use in mild-to-moderate AD over 2 years of age. Guidelines suggest use when other standard treatments fail or there is concern regarding risk of side-effects.
- Rapid relief (1-2 weeks) due to targeted anti-inflammatory action
- Used in practice to bring AD under control and also intermittently thereafter at first signs and symptoms of disease activity to prevent flare-ups. Topical corticosteroids can also be used but some physicians reserve them for more severe flares.
- Well-controlled studies in infants, children and adults demonstrate significant reduction in incidence of flares with the use of corticosteroids.
- Long-term studies show efficacy and safety in infants from 3-23 months, but it is not approved for this age range.
- Burning or stinging can be a problem but the likelihood is usually relative to disease severity. Patients do much better if warned of this transient effect.
- Long term safety – see Author’s Comment on recent FDA advisory.
Tacrolimus (Protopic™0.03% and 0.1%ointment) Non-steroid approved for short-term intermittent use in moderate- to-severe atopic AD over 2 years of age (0.03% >2yrs, 0.1% >15yrs). Guidelines suggest use when other standard treatments fail or concern regarding risk of side effects.
- Rapid relief (1-2 weeks) due to targeted anti-inflammatory action
- Used in practice to bring AD under control and also intermittently thereafter at first sign of disease activity or flare. TCS could be used as rescue medications for severe flares
- Long-term studies show safety and efficacy in > 2yr old.
- Burning or stinging can be a problem but the likelihood is usually relative to disease severity.
- Long term safety – see Author’s Comment on FDA advisory.
Infection Control
Clinical experience shows that AD may respond to anti Staph antibiotics even when there are no signs of a typical impetigo. Localized AD with probable secondary infection (swab if in doubt) use mupirocin cream, fucidic acid cream/ointment or oral cloxacillin or cephalosporin if widespread.
Authors’ Comments
Recently asked question: What is the role of calcineurin inhibitors in the control of eczema following the recent FDA Health Advisory?
It is the authors’ opinion that the recent Advisory about calcineurin inhibitors increasing the risk of cancer is based more on fear than fact. Granted that long-term use of oral immunosuppressive agents, such as in the transplant population, does raise the incidence of lymphoma, the degree of suppression is dose related. Rates of lymphoma and skin cancers in clinical trials and postmarketing surveillance reveal cancer rates that are much lower than would be expected in a control population. Evidence shows that both pimecrolimus and tacrolimus have very low systemic absorption when used topically as recommended for AD. Animal studies using oral formulations showed a higher rate of lymphoma, but at very high doses. What is clear is that people with AD have very significant disease that impacts most negatively on their quality of life. For the physician and patient there is no option other than to treat this disabling condition. With any medication there are always potential risks, but based on the available information the benefits of these medications far outweigh the risks. Resistant cases have been treated with UV light, azathioprine, cyclosporine, mycophenolate mofetil and systemic steroids.
It is significant that in a recent survey of leading dermatologists in North America and Europe conducted and published by Skin Therapy Letter© the majority of these doctors reported that they will not change their habit of prescribing topical calcineurin inhibitors, but are now likely to spend a little more time counseling and informing their patients who show concern.
