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Therapeutic Strategies

Atopic Dermatitis

Timothy Berger Bruce Wintroub

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.

First Steps

Limited Hair Loss

  1. Hydration: Cool-to-tepid baths twice daily, for 15-20 minutes. Gently pat-dry with a soft towel. 
  2. 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 used. 
  3. Suppression of pruritus: Oral antihistamines (hydroxyzine, initially 10 mg to 75 mg nightly, and lesser doses as needed during the day).

Ancillary Steps

  1. 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. 
  2. General measures:
    1. 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 moisturizing. 
    2. Avoid wool clothing. 

Subsequent Steps (After Rash Abates, Usually in 7-10 days)

  1. 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 skin. 
  2. Suppression of inflammation: Switch to an intermediate-potency topical steroid (eg, triamcinolone 0.1%), which is applied twice daily. 
  3. Suppression of pruritus: Continue antihistamines at maximum tolerated dosage indefinitely. 
  4. Other measures:
    1. Phototherapy: Narrowband or broadband UVB three times weekly.
    2. Photochemotherapy (PUVA) twice weekly is highly effective. 
    3. 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 UVB. 
    4. Tacrolimus ointment 0.1% or pimecrolimus cream 1% may be used on thin-skinned areas or combined with steroids in refractory cases. 
    5. 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 response. 
    6. 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.
    7. 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.

Pitfalls

  1. 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. 
  2. Atopic dermatitis tends to flare during the winter months unless hydration regimens are enhanced during this period. 
  3. 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. 
  4. 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.

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