Atopic Dermatitis (Eczema)

Introduction

Atopic dermatitis (eczema) is a chronic, pruritic, inflammatory skin disease that occurs most frequently in children but also affects many adults.

The lifetime prevalence of atopic eczema is 20%; begins in 90% between 3 months and 5 years of age. It persists into adult life in at least one quarter of cases.

Clinical features of atopic dermatitis include

Skin dryness
Erythema
Oozing and crusting
Lichenification

Affected individuals often have a family history of asthma, hay fever and/or type 1 food allergy (anaphylactoid reactions).

Management

Identify and, if possible, avoid possible triggers including

Irritants, e.g. abrasive clothing, soaps/detergents (including bubble bath), raised temperatures, sweating, heavily chlorinated pools or spas
Allergens, e.g. preservatives, fragrances, lanolin, nickel, aeroallergens (e.g. house dust mites, animal dander), foods (only avoid if confirmed by testing)

The goals of treatment are to reduce symptoms (pruritus and dermatitis), prevent exacerbations and minimize therapeutic risks.

Standard treatment modalities for the management of these patients are centred around the use of topical antiinflammatory preparations and moisturization of the skin, but patients with severe disease may require phototherapy or systemic treatment.

Phototherapy with narrowband ultraviolet B results in significant improvement in most patients with atopic dermatitis.

Maintaining Skin Hydration

Skin hydration is a key component of the overall management of patients with atopic dermatitis.

To maintain hydration, emollients should be applied at least 2 times per day, particularly after bathing, even when eczema is under control.
Although ointments are generally more effective than creams or lotions, choice often depends on patient preference.

Replace soaps, bubble baths, and shower gels with nonsoap fragrance-free cleansers with neutral to low pH to help prevent irritant or allergic reactions.

Topical Treatments

Topical anti-inflammatory therapy with topical corticosteroids (first-line treatment) or topical calcineurin inhibitors (e.g. pimecrolimus 1% and tacrolimus 0.03% or 0.1%) is effective in controlling pruritus.

Select potency of topical corticosteroid based on factors such as severity, patient age, location of atopic dermatitis, patient preference and cost.
Use a topical calcineurin inhibitor on flaring areas for specific clinical situations

Recalcitrance to corticosteroids
Sensitive areas (face, anogenital, skin folds)
Steroid-induced atrophy
Long-term uninterrupted topical steroid use

Treat all areas of inflammation aggressively until the skin is completely clear to avoid recurrence.

NOTE: Topical calcineurin inhibitors may be used as either monotherapy or combination therapy with corticosteroids for the treatment of eczema. Initial concerns about potential long-term carcinogenic effects, based on its mechanism of action, have not been substantiated.

Crisaborole, a topical phosphodiesterase 4 (PDE4) inhibitor approved for the treatment of mild to moderate atopic dermatitis in patients aged ≥3 months, appears to be effective in reducing pruritus.

It can be expensive and can cause irritation or stinging (particularly at the start of treatment).

Systemic Treatments

Oral antihistamines are widely used as therapeutic adjuncts in patients with atopic dermatitis to alleviate pruritus, but the evidence supporting their use is relatively weak.

Less sedating drugs, for example cetirizine or loratadine, are given during the day.
Sedating antihistamines, for example chlorpheniramine, promethazine or cyproheptadine, are given at night if sleep disturbance is a problem.

In adolescents and adults, an acute exacerbation of chronic atopic dermatitis can sometimes be aborted by a short course of systemic glucocorticoids (e.g., prednisone 40 to 60 mg/day for three to four days, then 20 to 30 mg/day for three to four days).

To avoid rebound flare, topical therapy should be resumed while tapering systemic glucocorticoids.

For patients with severe atopic dermatitis refractory to other treatments, consider systemic treatment with 1 of the following.

Immunosuppression

Cyclosporine - short-term treatment options for patients with moderate to severe atopic dermatitis (up to 2 years) due to the significant risk of renal impairment, hypertension and the potential for serious infections.
Off-label: Methotrexate, mycophenolate mofetil, azathioprine

Dupilumab - A fully human monoclonal antibody inhibiting IL-4 and IL-13; is given as a fortnightly subcutaneous injection, for indefinite use.
Upadacitinib - oral Janus kinase (JAK) inhibitor; can cause acne, cytopenias and elevation of lipid levels.

Supplements

There is insufficient evidence to recommend treatment of atopic dermatitis with fish oil, evening primrose oil, vitamin E or probiotics.

Summary

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