There are many aspects to treatment. The dermatitis is controlled primarily with topical steroids, calcineurin inhibitors are second line therapy. Emollients are used to control the dry skin component of the disease. Topical or oral antibiotics may be required for secondarily infected dermatitis. Antihistamines help control itching and have a calming effect at bedtime. An allergist may be required to control allergic rhinitis and asthma.
Topical steroids are the mainstay of therapy. An agent of appropriate strength must be used to rapidly control inflammation. Weak topical steroids are ineffective and allow the inflammation to progress. Dermatitis that persists and is scratched may become infected. Adults respond to a group 2-4 topical steroid in a cream base such as desoximetasone 0.25 or triamcinalome 0.1. This medication is applied twice each day for 7-21 days until the skin is smooth.
Lesions that have become thick from scratching are often found in crease areas. These appear around the wrists, ankles, and inside the elbows and knees. These difficult lesions may respond to the application of the topical steroid that is then covered by a plastic wrap such as Saran wrap. This treatment may be conveniently used at bedtime. The Saran wrap is removed in the morning.
Emollients are then applied to the moist skin. This program is repeated each night until the skin is smooth. This type of inflammation with thickened skin can’t easily recur. The routine use of emollients can discourage recurrence. Skin that is occluded with plastic wrap is more prone to infection. Stop treatment if pustules occur.
Children are treated in a similar fashion. Weaker topical steroids such as fluticasone cream are safe, effective and well tolerated. They may be used for short periods of time such as 3-6 days on the face. Weaker topical steroids such as 1% hydrocortisone cream are often not effective and allow the dermatitis to progress.
Oral and topical antibiotics
Oral antibiotics such as cephalexin may produce rapid improvement in secondarily infected disease.
Topical antibiotics such as mupirocin are affective for localized secondarily infected areas. Neomycin-containing topical antibiotics are sensitizers and should be avoided for long-term use.
Oral steroids such as prednisone 20 mg taken twice a day are sometimes indicated for patients with extensive, widespread inflammation. The dosage of prednisone is tapered once control is achieved and then topical steroids may be used to control the disease flare that often follows when oral steroids are stopped.
Topical calcineurin inhibitors
Elidel (pimecrolimus) and Protopic (tacrolimus) are nonsteroidal anti-inflammatory agents. Elidel is a little stronger than 1% hydrocortisone. Protopic has about the same anti-inflammatory activity as triamcinolone cream 0.1. These agents are used less frequently than in the past because of their immunosuppressive properties. They may be considered for short-term use in patients with difficult to control inflammation that requires almost constant use of a topical steroid. A typical program would be to apply topical steroids twice a day for 2-4 weeks and then use Protopic or Elidel to suppress flares in unstable patients.
Sedating antihistamines such as diphenhydramine (Benadryl) help control itching and encouraged sleep. The anti-itch affect is unfortunately only mild-to-moderate. Nonsedating antihistamines such as cetirizine have similar effects to control itching.
Coal tar creams and ointments were the mainstay of treatment prior to the 1950s when topical steroids were not available. These were very effective in some patients and may be considered today as a steroid sparing medication. They are safe and available over-the-counter. A coal tar bath oil (Balnetar) is especially soothing. Add two caps to warm bath water and soak for 20 minutes or apply directly to inflamed skin.
The routine use of emollient creams and lotions are an essential part of the treatment program. Atopic patients have a hereditary tendency to have dry skin. Scratching, excessive bathing and cold weather easily irritate this compromised barrier. Emollients can be applied at any time but are especially effective when applied to moist skin that has been padded dry after bathing. There are numerous products that are all effective. Lotions are easy to apply and encourage compliance. Creams are more effective but a bit messier.
Very thick ointments such as Aquaphor have a longer lasting effect. Bath oils such as Keri are soothing and effective for repairing the skin barrier. Ammonium lactate containing lotions such as Lac-Hydrin and AmLactin have special lubricating qualities. Sometimes these lotions sting.
Some patients discover that eliminating certain foods, for example, wheat, completely controls the disease. Food testing by allergists is not an exact science. However patients with widespread persistent inflammation should be referred for possible diet testing.
Breast-feeding for at least 4 months may lower the incidence of atopic dermatitis.