How is atopic dermatitis treated?

Treatment involves a partnership among the patient, family members, and doctor. The doctor will suggest a treatment plan based on the patient's age, symptoms, and general health. The patient and the patient's family play a large role in the success of the treatment plan by carefully following the doctor's instructions. Some of the primary components of treatment programs are described below. Most patients can be successfully treated with proper skin care and lifestyle changes and do not require the more intensive treatments discussed.

Goals of treatment

The doctor has three main goals in treating atopic dermatitis:

1. Healing the skin and keeping it healthy
2. Preventing flares
3. Treating symptoms when they do occur

Much of caring for the skin and preventing flares has to do with:

• Developing skin care routines
• Identifying factors that make symptoms worse
• Avoiding circumstances that trigger the skin's immune system and the itch-scratch cycle.

It is important for the patient and his or her family to note any changes in skin condition in response to treatment, and to be persistent in identifying the most effective treatment strategy.

Skin care

Bathing and applying lubricants

Healing the skin and keeping it healthy are of primary importance as part of both preventing further damage and enhancing quality of life. Developing and sticking with a daily skin care routine is critical to preventing flares. Key factors are proper bathing and the application of lubricants, such as creams or ointments, within three minutes of bathing. People with atopic dermatitis should avoid hot or long (more than 10 to 15 minutes) baths and showers. A lukewarm bath helps to cleanse and moisturize the skin without drying it excessively. Because soaps can be drying to the skin, the doctor may recommend limited use of a mild bar soap or nonsoap cleanser. Bath oils are not usually helpful.

Once the bath is finished, the patient should air-dry the skin, or pat it dry gently (avoiding rubbing or brisk drying), and apply a lubricant immediately. Lubrication restores the skin's moisture, increases the rate of healing, and establishes a barrier against further drying and irritation. Several kinds of lubricants can be used. Lotions have a high water or alcohol content and evaporate more quickly, so they generally are not the best choice. Creams and ointments work better at healing the skin. Tar preparations can be very helpful in healing very dry, lichenified area. Whatever preparation is chosen, it should be as free of fragrances and chemicals as possible.

Avoiding and treating skin infections

Another key to protecting and restoring the skin is taking steps to avoid repeated skin infections. Although it may not be possible to avoid infection altogether, the effect of an infection may be minimized if it is identified and treated early. People with atopic dermatitis and their families should learn to recognize signs of skin infections, including tiny pustules (pus-filled bumps) on arms and legs, appearance of oozing areas, or crusty yellow blisters. If symptoms of a skin infection develop, the doctor should be consulted and treatment should begin as soon as possible.

Treating atopic dermatitis in infants and children

• Give brief, lukewarm baths.
• Apply lubricant immediately following the bath.
• Keep child's fingernails filed short.
• Select soft cotton fabrics when choosing clothing.
• Consider using antihistamines to reduce scratching at night.
• Keep the child cool; avoid situations where overheating occurs.
• Learn to recognize skin infections and seek treatment promptly.
• Attempt to distract the child with activities to keep him or her from scratching.

Medications and phototherapy

If a flare of atopic dermatitis does occur, several methods can be used to treat the symptoms. The doctor will select a treatment according to the age of the patient and the severity of the symptoms. With proper treatment, most symptoms can be brought under control within three weeks. If symptoms fail to respond, this may be due to a flare that is stronger than the medication can handle, a treatment program that is not fully effective for a particular individual, or the presence of trigger factors that were not addressed in the initial treatment program. These factors can include a reaction to a medication, infection, or emotional stress. Continued symptoms may also occur because the patient is not following the treatment program instructions.

Corticosteroid creams and ointments

Corticosteroid creams and ointments are the most frequently used treatment. Sometimes over-the-counter preparations are used, but in many cases the doctor will prescribe a stronger corticosteroid cream or ointment. The doctor will take into account the patient's age, location of the skin to be treated, severity of the symptoms, and type of preparation (cream or ointment) when prescribing a medication. Sometimes the base used in certain brands of corticosteroid creams and ointments is irritating for a particular patient. Side effects of repeated or long-term use of topical corticosteroids can include thinning of the skin, infections, growth suppression (in children), and stretch marks on the skin.

Antibiotics, antihistamines and antifungal medications

Some treatments reduce specific symptoms of the disease. Antibiotics to treat skin infections may be applied directly to the skin in an ointment, but are usually more effective when taken by mouth. Certain antihistamines that cause drowsiness can reduce nighttime scratching and allow more restful sleep when taken at bedtime. This effect can be particularly helpful for patients whose nighttime scratching makes the disease worse. If viral or fungal infections are present, the doctor may also prescribe medications to treat those infections.

Phototherapy and photochemotherapy

Phototherapy (treatment with light) that uses ultraviolet A or B light waves, or both together, can be an effective treatment for mild to moderate dermatitis in older children (over 12 years old) and adults. Photochemotherapy, a combination of ultraviolet light therapy and a drug called psoralen, can also be used in cases that are resistant to phototherapy alone. Possible long-term side effects of this treatment include premature skin aging and skin cancer. If the doctor thinks that phototherapy may be useful to treat the symptoms of atopic dermatitis, he or she will use the minimum exposure necessary and monitor the skin carefully.

Systemic corticosteriods

When other treatments are not effective, the doctor may prescribe systemic corticosteroids. These drugs are taken by mouth or injected into muscle instead of being applied directly to the skin. An example of a commonly prescribed corticosteroid is prednisone . Typically, these medications are used only in resistant cases and only given for short periods of time. The side effects of systemic corticosteroids can include:

• Skin damage
• Thinned or weakened bones
• High blood pressure
• High blood sugar
• Infections
• Cataracts

It can be dangerous to suddenly stop taking corticosteroids, so it is very important that the doctor and patient work together in changing the corticosteroid dose.

Immunosuppressive drugs

In adults, immunosuppressive drugs, such as cyclosporine , are also used to treat severe cases of atopic dermatitis that have failed to respond to any other forms of therapy. Immunosuppressive drugs restrain the overactive immune system. The side effects of cyclosporine can include:

• High blood pressure
• Nausea
• Vomiting
• Kidney problems
• Headaches
• Tingling or numbness
• A possible increased risk of cancer and infections.

There is a risk of relapse after the drug is stopped. Because of their toxic side effects, systemic corticosteroids and immunosuppressive drugs are used only in severe cases and then for as short a period of time as possible. Patients requiring systemic corticosteroids should be referred to dermatologists or allergists specializing in the care of atopic dermatitis. They can help identify trigger factors and alternative therapies.

Hospitalization

In rare cases, when no other treatments have been successful, the patient may have to be hospitalized. A 5- to 7-day stay in the hospital allows intensive skin care and reduces the patient's exposure to irritants and allergens and the stresses of day-to-day life. Under these conditions, the symptoms usually clear quickly if environmental factors play a role or if the patient is not able to carry out adequate skin care at home.

Experimental medications

A number of promising experimental medications are being tested for atopic dermatitis. These medications affect the immune system and offer additional options for patients with difficult-to-treat symptoms. Researchers are also actively pursuing the development of alternative treatments for atopic dermatitis.

Tips for working with your doctor

• Provide complete, accurate medical information about yourself or your child.
• Make a list of your questions and concerns in advance.
• Be honest and share your point of view with the doctor.
• Ask for clarification or further explanation if you need it.
• Talk to other members of the health care team, such as nurses, therapists, or pharmacists.
• Don't hesitate to discuss sensitive subjects with your doctor.
• Discuss changes to any medical treatment or medications with your doctor before making them.

Atopic dermatitis and quality of life

Despite the symptoms caused by atopic dermatitis, it is possible for people with the disorder to maintain a high quality of life. The key to quality of life lies in education, awareness, and developing a partnership among patient, family, and doctor. Good communication is essential, both within the family and among the patient, the family, and the doctor. It is important that the doctor provide understandable information about the disease and its symptoms to the patient and family. He or she should demonstrate any treatment measures recommended to ensure that they will be properly carried out.

Children

When a child has atopic dermatitis, the entire family may be affected. It is important that families have additional support to help them cope with the stress and frustration associated with the disease. The child may be fussy and difficult, and often is unable to keep from scratching and rubbing the skin. Distracting the child and providing as many activities that keep the hands busy is key, but requires much effort and work on the part of the parents or caregivers. Another issue families face is the social and emotional stress associated with disfigurement caused by atopic dermatitis. The child may face difficulty in school or other social relationships and may need additional support and encouragement from family members.

Adults

Adults with atopic dermatitis can enhance their quality of life by caring regularly for their skin and being mindful of other effects of the disease and how to treat them. Adults should develop a skin care regimen as part of their daily routine, which can be adapted as circumstances and skin conditions change. Stress management and relaxation techniques may help decrease the likelihood of flares due to emotional stress. Developing a network of support that includes family, friends, health professionals, and support groups or organizations can be beneficial. Chronic anxiety and depression may be relieved by short-term psychological therapy.

Recognizing the situations when scratching is most likely to occur may also help. For example, many patients find that they scratch more when they are idle, so structured activity that keeps the hands occupied may prevent further damage to the skin. Occupational counseling also may be helpful to identify or change career goals if a job involves contact with irritants or involves frequent hand washing, such as kitchen work or auto mechanics.

Controlling atopic dermatitis

• Prevent scratching or rubbing whenever possible.
• Protect skin from excessive moisture, irritants, and rough clothing.
• Maintain a cool, stable temperature and consistent humidity levels.
• Limit exposure to dust, cigarette smoke, pollens, and animal dander.
• Recognize and limit emotional stress.