Atopic Dermatitis (cont.)
How is atopic dermatitis treated?
Treatment involves a partnership between the doctor and the patient and
his or her family members. The doctor will suggest a treatment plan based on the patient's
age, symptoms, and general health. The patient and family members 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 managed with
proper skin care and lifestyle changes and do not require the more
intensive treatments discussed. Much of the improvement comes from homework, including lubricating generously especially right after showers or baths.
The doctor has three main goals in treating atopic dermatitis: healing the skin and keeping it healthy;
preventing flares, and treating symptoms when they do occur. Much of
caring for the skin involves developing skin-care routines, identifying exacerbating factors, and avoiding circumstances
that stimulate the skin's immune system and the itch-scratch cycle. It is
important for the patient and family members to note any changes in skin
condition in response to treatment and to be persistent in identifying the
most effective treatment strategy.
Skin care: A simple and basic regimen is key. Staying with one recommended soap and one moisturizer is very important. Using multiple soaps, lotions, fragrances, and mixes of products may cause further issues and skin sensitivity.
Healing the skin and
keeping it healthy are of primary importance both in preventing
further damage and enhancing the patient's quality of life.
Developing and following a daily skin care routine is critical to preventing recurrent
episodes of symptoms. 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. The doctor may recommend limited use of a mild bar soap or non-soap cleanser
because soaps can be drying to the skin. 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 generally are not the best choice because they have a
high water or alcohol content and evaporate quickly.
Creams and ointments work better at healing the skin. Tar preparations can be very
helpful in healing very dry, lichenified areas. Whatever preparation is
chosen, it should be as free of fragrances and chemicals as possible.
Another key to protecting and restoring the skin is taking steps to avoid repeated skin infections.
Although it may not be possible to avoid infections altogether, the effects of
an infection may be minimized if they are identified and treated early.
Patients and their families should learn to recognize the signs of
skin infections, including tiny pustules (pus-filled bumps) on the
arms and legs, appearance of oozing areas, or crusty yellow blisters. If
symptoms of a skin infection develop, the doctor should be consulted to begin
treatment as soon as possible.
Treating atopic dermatitis in infants and children
- Give brief, lukewarm baths.
- Apply lubricant immediately following the bath.
- Keep a 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 recurrence of atopic dermatitis occurs, several methods can
be used to treat 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 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. Occasionally, the base used
in certain brands of corticosteroid creams and ointments is irritating for a particular patient and
a different brand is required. 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.
Tacrolimus (Protopic) and pimecrolimus (Elidel) ointments are powerful topical medicated creams (drugs that are applied to the skin) that
are used for the treatment of atopic dermatitis. These new drugs are referred to as "immune modulators." They were first and are still commonly used internally (oral form) to help patients with kidney and liver transplants avoid rejecting the organs they received. They work by suppressing the immune system. When these drugs are used in limited and small quantities on intact skin to externally to treat the skin, they are not thought to significantly weaken or change the body's immune system. Also, unlike topical steroids (cortisone creams), these new medications don't cause thinning of the skin and breaking of superficial blood vessels (atrophy). However, over the recent few years, there has been concern and a positional change by the Food and Drug Administration (FDA). A special warning has been placed on these two immune modulator drugs with potential caution regarding cancers and other immune-system suppression issues. While dermatologists and other physicians have continued to safely prescribe many of these drugs for children and adults, it is important to discuss these possible concerns and precautions with your physician when beginning a treatment regimen.
A newer class of drugs for improving barrier function in both pediatrics and adults includes Atopiclair and MimyX. These creams may be used in combination with topical steroids and other emollients to help repair the overall dryness and broken skin function.
Additional available treatments may help to 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 in pill form. 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 aggravates the disease. If viral or fungal infections are present, the doctor may also prescribe medications to treat those infections.
Phototherapy is treatment with light that uses ultraviolet A or B light waves or a combination of both. This
treatment 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 in treating the symptoms
of atopic dermatitis, he or she will use the minimum exposure necessary
and monitor the skin carefully.
When other treatments are not effective, the doctor may prescribe systemic corticosteroids, drugs that 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 are 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, and 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.
Previous clinical trials using drugs like self-injectable interferon treatments demonstrated mixed results and have not become mainstream treatments. The most common side effects with interferon involve mild injection-site reactions and possible fever or flu-like symptoms. These drugs maybe used in severe or challenging situations that don't respond to more traditional treatments.
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 by blocking
the production of some immune cells and curbing the action of others. The
side effects of cyclosporine can include high blood pressure,
nausea, vomiting, kidney problems, headaches, tingling or numbness, and
a possible increased risk of cancer and infections.
There is also a risk of relapse after the drug is discontinued. 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 or immunosuppressive drugs should be
referred to a dermatologist or an allergist specializing in the care of atopic dermatitis to
help identify trigger factors and alternative therapies.
In extremely rare cases, when no other treatments have been successful, the patient may have to be hospitalized. A
five-
to seven-day hospital stay allows intensive skin-care treatment and
reduces the patient's exposure to irritants, 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 an adequate skin-care program at home.
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 keys to an improved quality of life are education, awareness, and developing a
partnership among the patient, family, and doctor. Good communication is essential for all involved. It is important that
the doctor provides understandable information about the disease and its
symptoms to the patient and family and demonstrate any treatment measures
recommended to ensure that they will be properly carried out.
When a child has atopic dermatitis, the entire
family situation 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 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. Structured activity that
keeps their 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
- Lubricate the skin frequently.
- Avoid harsh soaps and cleansers.
- 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.
Next: What is the hope for long-term management of atopic
dermatitis? »
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