There is currently no cure for dermatitis. The chronic nature of the condition often leads to misconceptions regarding treatment. However, the vast majority of patients can be successfully managed. The key to success is to learn about the best medication and preventive steps, and then implement them.

Introduction

Any chronic disease is difficult to manage, and atopic dermatitis is certainly one of these. Once the diagnosis has been firmly established, you should take time to discuss a management plan with your family physician. There is presently no cure for atopic eczema, and it's therefore most important to adapt preventive measures that have proven effective.

We now know the peculiarities of the atopic skin: it is dry, itchy and red where it's inflamed. It's more susceptible to irritation than normal skin, and scratching tends to break the natural defense barrier against invading bacteria that it normally possesses.

Avoiding or reducing provoking factors

The patient and caregivers need to be constantly aware of products that irritate the skin, especially so-called skin care products, or irritant clothing such as woolens. Cotton clothing is recommended, instead. Patients should beware of habits such as excessive hand washing with soaps and detergents that remove natural lipids from the skin surface; this is important, as all eczema patients already have dry skin.

To minimize the risks of itching, extremes of temperature should be avoided, especially overheating (including clothing and bedding or caused by physical exercise). Emotional stress must also be considered as a risk factor for increased itch. Nails should be kept short to avoid scratching, especially in infants.

Patients or their parents should regularly watch for signs of infection, such as crusting and weeping, or punched-out erosions (ulcers). These signs may indicate infection with Staphylococcus or the Herpes simplex virus, and they require consultation with family physician without delay -- the appropriate treatment is an antibiotic or antiviral medication. Ill patients with fever and a rash suggestive of Herpes must be hospitalized to receive an intravenous antiviral drug.

Hydrate the (dry) skin

Bathing is hydrating the skin only if a moisturizer (also called an emollient ) is applied within 3 minutes after the bath , to keep water in the superficial skin layer, thereby ensuring the skin remains soft and flexible. If an emollient is not applied on atopic skin within a few minutes the skin dries up quickly, with a higher risk for the occurrence of fissures, itching or infection. Bathing should be permitted as often as necessary but, again, extremes of temperature should be avoided and one should be mindful of the mechanical irritation of the skin by showering. There are many types of soaps recommended for atopic skin, but the 3-minutes rule is more important than the choice of soap.

Moisturizers create a surface lipid film that retards evaporative water loss, and also provides some protection against external irritants. Use of moisturizer 'lotions' is not recommended. In general, the oilier the moisturizer preparation is, the better the emollient effect. However, the greasiest preparations may be judged by some as too messy for routine use. There are many different emollient preparations to choose from, so one should find one or two that are effective and cosmetically acceptable, and stick with them. They should be applied sufficiently often to effectively relieve and prevent recurrence of symptoms, with twice a day as a minimum.

Topical corticosteroids

The topical steroids are effective in reducing inflammation, one of the main signs of atopic eczema. Their chronic use or abuse may cause skin atrophy. There are rules that govern the safe application of topical steroids, which should be known by every patient with dermatitis:

• lower potency preparations do not work well against inflammation. Their use may lead to chronic use of an ineffective, useless treatment.
• mid-strength topical steroids applied within 3 minutes after a bath on the inflamed areas, are usually effective within a week of starting daily application. They can be used intermittently thereafter, being progressively replaced by moisturizers.
• steroids cause skin atrophy if used daily for more than 3 weeks, but their daily use for a long time is really not necessary. Twice-weekly application, restricted to areas with inflammation, seems safe in the majority of patients.

The age of the patient, the site to be treated, the extent of the disease, the type of preparation, and the method of application may all play a role in effectiveness and safety. Dosage and potency are especially important in infants; on the palms and soles dosage and potency may be higher because skin is thicker and the surface to be treated is generally small; both ointments and creams are available; and topical applications may use wraps or bandaging for areas affected by severe dryness with fissures or lichenification.

The following dosage recommendation - the fingertip method -- can generally be used; it's easy to employ and to remember:

On the face, the principal risk of side effect is telangiectasia (appearance of small, red, spider-like veins in the skin), whereas striae atrophicae (stretch marks) may occur on the breasts, abdomen, upper arms, and thighs when potent preparations are used.

The use of topical corticoids containing antibiotics is generally not recommended. Evidence shows that they are no better than corticoids alone, and they should be reserved for cases where clinical infection of eczema is documented.

Other therapies

Antihistamines have no effects at all on the disease or on the itch itself, but those with sedative properties may be useful in combating itch.

New non-steroid therapies, which inhibit skin inflammation but don't contain corticoids, are available for subjects 2 years of age or older who suffer from mild to moderate atopic eczema. These will be the subject of future articles in this series, as they have the prospect of reducing the need to use topical corticoids while at the same time reducing the clinical severity of the symptoms.

A small percentage of patients (around 15%) require more aggressive treatment, such as coal tars, phototherapy, or intravenous administration of a drug acting on the immune system. These treatments require hospitalization.

Allergen avoidance

Control of the house-dust mite brings clinical benefits to patients with atopic eczema. Positive skin testing or RAST reports can show if you are allergic to one or several substances. For practical purposes, only substances (whether they come from food or air) that are known by the patient or caregiver to cause real symptoms should be prevented from making contact with the skin.

It is not known for certain if dietary manipulations, prolonged breast-feeding in predisposed infants, or dietary restrictions during lactation in mothers of predisposed infants are effective. Allergen avoidance will be the subject of further articles in this series.

Conclusions

Atopic dermatitis can be treated by following a few basic rules regarding skin hydration, use of a moisturizer, and topical steroid applications to reduce inflammation. Further articles in this series will review the evidence for effectiveness of novel non-steroid therapies, especially if they allow a reduction or suppression for the need to use topical corticoids.

Source

Update on therapy of atopic dermatitis. JM. Hanifin, SJ. Tofte, J Allergy Clin Immunol, 1999, vol. 104, pp. 123--125

Atopic eczema. C. Charman, BMJ, 1999, vol. 318, pp. 1600--1604

Fortnightly review: Management of atopic eczema. PM. McHenry, HC. Williams, EA. Bingham, BMJ, 1995, vol. 310, pp. 843--847

Links

• The Diagnosis of Atopic Dermatitis
• Dermatology Online Atlas