Saturday, January 01, 2011
Therapy of adult atopic dermatitis may be approached as
management of either acute or chronic dermatitis. In addition,
therapy should be based on the extent of skin involvement (ie,
generalized versus localized disease). The therapies for these
variations are discussed together with specific comments directing
treatment in the different scenarios.
Limited Hair Loss
- Hydration: Cool-to-tepid baths twice daily, for 15-20 minutes.
Gently pat-dry with a soft towel.
- Suppression of inflammation: For the trunk and extremities,
apply a thin film of high-potency or superpotent fluorinated
steroid ointments to the affected areas immediately after the bath
(within 3 minutes). For the face, groin, and eyelids, topical
tacrolimus 0.03% or 0.1% ointment, pimecrolimus 1% cream, or a
low-potency steroid (hydrocortisone 1%, for example) may be
- Suppression of pruritus: Oral antihistamines (hydroxyzine,
initially 10 mg to 75 mg nightly, and lesser doses as needed during
- Treatment of secondary infection: Colonization with S.
aureus is common, although often not apparent. Thus, even in
the absence of obvious infection, treat patients with acute
dermatitis who have tenderness, crusts, pustules, and/or oozing
empirically with an appropriate antibiotic (eg, cephalexin or
dicloxacillin 1-2 g per day for 7-10 days). Obtain baseline culture
and sensitivity to confirm that the infecting organism is sensitive
to the antibiotic given.
- General measures:
- Advise the patient to use mild soaps or a soapless cleanser.
Soap need be applied only to intertriginous sites (groin and
axillae). If the patient is not soaking in a tub, then bathing
should consist of a short, tepid shower followed by immediate
- Avoid wool clothing.
Subsequent Steps (After Rash Abates, Usually in 7-10
- Hydration: Reduce bathing frequency to once daily and for
shorter duration. Emolliate the entire skin surface (except the
face) with a water-in-oil (ointment) preparation (eg, petrolatum).
Note: Lotions or creams can exacerbate underlying dry
- Suppression of inflammation: Switch to an intermediate-potency
topical steroid (eg, triamcinolone 0.1%), which is applied twice
- Suppression of pruritus: Continue antihistamines at maximum
tolerated dosage indefinitely.
- Other measures:
- Phototherapy: Narrowband or broadband UVB three times
- Photochemotherapy (PUVA) twice weekly is highly
- Tar (with or without UVB): Compounded LCD 10% (liquor carbonis
detergens) or 20% in petrolatum may be applied once or twice daily.
It may be used to augment the response to topical steroids or
- Tacrolimus ointment 0.1% or pimecrolimus cream 1% may be used
on thin-skinned areas or combined with steroids in refractory
- For localized areas on the trunk or extremities refractory to
topical therapy, intralesional triamcinolone acetonide (3-5 mg per
cc) or occlusion of the topical steroid with saran wrap may enhance
- In severe adult atopic dermatitis, systemic immunosuppressives
may be of great value to control the disease. The most rapid
response is seen with oral cyclosporine A at a dose of 3-5 mg per
kg per day. Azathioprine or mycophenolate mofetil is also effective
but has a slower onset of action and may not be as effective as
cyclosporine in the acute setting.
- In acute atopic dermatitis triggered by a specific situation
(contact dermatitis, systemic viral infection [not herpes simplex])
and where that inciting event has been removed, systemic steroids
may be of value, starting at 0.75-1 mg per kg per day and tapering
over 3-4 weeks. Chronic systemic steroids are not recommended for
atopic dermatitis, except in the most extreme circumstances.
- As noted above, colonization with S. aureus is common,
often unapparent, and often the trigger for fresh exacerbations of
disease. If erosive lesions are present, the possibility of eczema
herpeticum (or Kaposi's varicelliform eruption) must be considered,
and appropriate viral cultures and fluorescent antibody tests
should be performed.
- Atopic dermatitis tends to flare during the winter months
unless hydration regimens are enhanced during this
- Although antihistamines can be sedating, tachyphylaxis to the
soporific effects occurs within a few days, allowing higher and
higher doses, if necessary. Initially, however, patients must be
warned about the risks of operating motor vehicles and additive
sedation from alcohol intake. Nonsedating second-generation
antihistamines are of minimal to no value in suppressing the
pruritus of atopic dermatitis.
- Systemic steroids are not generally necessary and should be
avoided in atopic dermatitis. Although they are extremely
effective, patients tend to become overly dependent and side
effects of chronic steroid therapy often result.