Treatment Triangle

Consider that treatment decisions are not built solely on high quality evidence based medicine. There may not be clinical trial evidence to support treatment or to optimize combination therapy. Drugs that commonly find favor with doctors and patients have frequently not been subjected to randomized double blind studies. This does not prevent their use by the caring physician nor does it mean that they are ineffective medications. About a third of patients claim that their medication is “not at all effective.”
(Clin Pediatri 2002;41:323-332)

This may be in part related to inadequate exploration of treatment options as well as poor compliance to the recommended therapy. It is clear that we need buy in from our patients in terms of treatment in order to achieve compliance.

The three points of the Treatment Triangle:

1) Evidence Based Medicine In Eczema:

  • Topical corticosteroids
  • Topical immunomodulators
  • Interferon gamma
  • Cyclosporine
  • UVB
  • PUVA

2) Treatment Based On Evidence And Clinical Experience:

  • Moisturize
  • Avoid irritants
  • Topical corticosteroids
  • Topical immunomodulators(TIMS)
  • Topical antibiotics
  • Oral antibiotics
  • Oral antihistamines

Resistant cases:

  • UVB
  • PUVA
  • Cyclosporine
  • Methotrexate
  • Oral or IM steroids

3) Patient Preference:

Not all skin is created equal. There are variable factors contributing to eczema and it is probably a spectrum of disease involving a number of different genes in different skin types. Therefore treatment has to be tailored to each individual. The lack of compliance can be a significant factor in the response to therapy. Working with the patient preferences rather than the doctor always dictating the specifics of brands and bases can have a positive effect on outcome. A survey by the National Eczema Association shows that about 30% of patients claim that their drugs simply “not at all effective”. (Paller et al Clin Pediatric 2002;41:323-332)

Moisturizers and cleansers:
Some are unable to tolerate sticky moisturizers and other find that some will cause itching or burning from certain brands. Some have preferences for certain cleansers.

There is variable response to the same strength corticosteroid or base.

Cortisone phobia:
A large minority of patients have a fear of cortisone. Most of these do not have personal experience of side effects but it is rather a fear of thinning the skin and concerns about systemic effects. Some patients will have developed thinning of the skin or will experience purpura. These side effects are real and have developed as a result of inappropriate use of the medication. Either the drug was too strong, used in the wrong location or simply too much used for too long.

Immunomodulators (TIMS):
These medications are steroid free. Cost may inhibit some potential users. The quantity of the these products used by the patient diminishes with improvement of the condition.

Past experience may determine what seems to be the most effective antihistamine for some patients. Extra sensitivity to sedation or jobs that require an early start may be considerations as to the type and dose of antihistamines.

Oral Antibiotics:
The antibiotics used have good anti-staphylococcal activity. There are no studies clearly showing benefits but clinically these drugs are found to be useful in calming down stubborn eczema.

Systemic Drugs:
It is important to discuss side effects in detail with patients.