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Eczema treatment evolves over time for each individual patient. What works for you at one point in time might not work in a different season or 10 years from now. This can affect whether you need more or less therapy. You have to work very closely with your team of caregivers to ensure your treatment is best tailored for any given situation.
That baseline skin care — which includes engaging in healthy bathing practices, and the use of gentle products, moisturizers, and emollients — can also help as you taper off some medicines, which is really important as we look at your overall care. In regard to topical therapies, among our first-line medications are topical corticosteroids, because they provide excellent effects for inflammation and itch. They can also combat dryness, depending on the thickness of emollient used.
Topical steroids are divided into seven classes, which range in potency from Class 1 very potent steroids to Class 7 very weak steroids. For example, in ointment form, mometasone falls in a high-potency class, but when you use the very same steroid as a cream, it falls in the medium-potency class.
But one of the strongest topical steroids has a listed concentration of 0. In terms of their chemical structure, steroids are divided into classes, A, B, C, and D. Those within the same class have a similar chemical structure. The Consensus Statement on the Management of Eczema, published in sections in the Journal of the American Academy of Dermatology, gives us guidance regarding choice of topical steroids.
We use very different steroids on infant skin than we do on adult skin, for example. Certainly, the degree of dryness can impact whether we might want to use an ointment or a cream preparation as well. Patient preference is another important consideration.
Finally, cost plays a part in steroid choice. Some insurance companies cover different steroids at different degrees, and some steroids are, unfortunately, a little harder to get than others. We take that into account when selecting the best steroid option for a patient. Side effects of topical steroids most commonly initially present on the skin with signs such as increased blood vessels or thinning of the skin. We provide physical exams to monitor for skin side effects.
If we see a lot of side effects on the skin, then we also begin to think about how systemic side effects may affect the body internally. As a general rule of thumb, we use the fingertip unit of measurement to decide how much of a steroid we need to apply.
The fingertip unit refers to the amount of steroid in a small strip on that very last portion of your finger from the last joint to the fingertip. That one fingertip unit will be enough medication to cover the skin on two adult hands.
From there, we scale the amount up or down accordingly. This has been found to be more effective than just using emollients alone. Another category of topical treatments consists of the calcineurin inhibitors, tacrolimus and pimecrolimus. They also work to reduce inflammation, improve itch, and can combat dryness—especially when used in an ointment formulation.
I like to have an up-front talk with my patients about this potential risk and explain to them that our use is topical, in limited focal areas, and that I find along with the American Academy of Dermatology and many other providers these topicals to be very safe for long-term use in a controlled manner for eczema. In many situations, the use of a topical calcineurin inhibitor is preferred over that of a topical steroid.
One instance is when the skin has become resistant to steroid use in sensitive areas, such as the eyelid or the lips. A topical calcineurin inhibitor may also be the best choice when side effects from topical steroids begin to show in the folds of the skin, where you might have too much steroid absorption. Topical calcineurin inhibitors can also be helpful in places that are already showing signs of steroid-induced changes such as atrophy.
Topical antimicrobials and antiseptics are medicines that are applied topically in efforts to reduce bacteria, though the Consensus Statement on the Management of Eczema designates only specific scenarios where they are recommended for eczema, specifically, in patients who have moderate to severe eczema and signs of infection on top of their eczema called secondary bacterial infection or superinfection.
For these patients, dilute bleach baths and mupirocin used intranasally to reduce the colonization of bacteria on the skin are often recommended to reduce the severity of eczema. Topical antihistamines also help many patients, but the Consensus Statement does not recommend their use for eczema specifically, mainly due to the risks of absorption and contact dermatitis that patients can develop from them.
Many patients do bene t from them, however, so this is another one of those situations where individual patient preferences and conditions must be taken into account. Other topical treatments available that have been used for eczema include tar, biologic devices, and others in development.
There are biologic devices, such as Epaderm and Atopiclair, which are prescription-only topicals designed to work on the skin barrier. There are also topicals in development such as the phosphodiesterase inhibitors, which may be used to treat eczema in the future. Phototherapy is the controlled delivery of ultraviolet UV light for anti-inflammatory purposes. With this in mind, when patients start phototherapy, their first treatments are sometimes as short as 15 seconds of exposure.
Over time, the length of sessions in the phototherapy unit gradually increases. There are different types of wavelengths of light that can be delivered, including UVB, UVA1, or a combination of ultraviolet lights.
Often patients start out with three sessions a week, and typical phototherapy courses last three to five months. I tell my patients to expect to undergo 15 treatments for a duration of at least five weeks before considering whether it is helpful.
Sometimes patients are prescribed psoralen, which is a photo-activating medication that can be taken orally or applied topically before light exposure; it gives patients an extra boost of a response.
Finally, in some parts of the country the Goeckerman Therapy regimen is used. In this therapy, tar is applied to the skin lesions, which also makes patients more sensitive to the light from phototherapy. Selection between these options depends on local availability.
Cost is also an issue, as many insurance companies, unfortunately, are charging co-pays with every phototherapy visit. Patient skin type, current medications, and whether patients have had skin cancer in the past are also factors in how light therapy impacts skin.
All of these factors must be taken into consideration. According to the Consensus Statement, phototherapy is considered a second-line treatment. If the use of emollients, topical steroids, and topical calcineurin inhibitors fail, then phototherapy can be used as a maintenance therapy. Phototherapy should be performed under the supervision of a doctor who is experienced in managing the treatment.
Additionally, phototherapy units are sold for home use, and can deliver the therapy safely as well. This may be due to a combination of natural sunlight and summer activities, such as spending more time in the swimming pool something that may deliver a bleach bath-like effect. Antibiotics, antihistamines, and many anti-inflammatory medicines are used as oral medications for eczema.
Antibiotics can be particularly helpful if there is clear evidence of active Staph infection, as an antibiotic may help alleviate oozing and painful skin. For those patients who improve with frequent administration of antibiotics which signals they may have a high burden of bacteria that may be aggravating their eczema , I often suggest regular dilute bleach baths or other decontamination measures. Antihistamines tend to work for eczema by helping to induce sleep and reduce loss of sleep.
Antihistamines can also help patients who have eczema and allergies or eczema and hives concurrently. In the absence of hives, non-sedating antihistamines are not recommended for the management of eczema. Systemic anti-inflammatories are generally indicated for patients who do not respond to the optimal topical regimens and have tried many different iterations of topical steroids. For these patients, working closely with their doctor to tailor treatment for their needs is important.
I always start by talking about systemic corticosteroids or oral prednisone because so many patients tell me that they were on prednisone for either their skin, or asthma, or another reason, and found that their skin improved quickly. However, they can be used for a short period of time in order to help transition to another medication or phototherapy to get the disease under control. In terms of other systemic treatment options, there is evidence-based data for a number of medicines.
The Consensus Statement addresses four of them: It was developed as an immunosuppressive medication used to prevent rejection of organs after transplantation. In my experience, Cyclosporine works very quickly and we think of it as a rescue medication to be used for a short period of time to get skin under control. I think about which medications it may interact with and whether the patient has an underlying cancer, since cyclosporine impacts the immune system. Some side effects of cyclosporine include hypertension and elevating lipids, so we monitor patients very closely with monthly labs in order to minimize these potential side effects.
We also try to keep this medication course very short: Methotrexate was initially discovered as a compound similar to folic acid and has also been around for quite a long time. In the late s, it was used for children with leukemia, and at high doses methotrexate is still used as a chemotherapy. Methotrexate is given once weekly, and can be given orally or by injection. It does have serious medication interactions and affects fertility.
It can also cause side effects in both the liver and the lungs, so we monitor patients regularly, especially as the dose is being adjusted. Azathioprine is another serious medication that was initially developed as a cancer drug in the late s. Because it interferes with the synthesis of DNA, azathioprine relies on the body to metabolize it. We all have an enzyme in our bodies called thiopurine methyltransferase TPMT , and for patients who have low levels of this enzyme naturally, azathioprine can build up in the bloodstream and cause serious unwanted effects.
For these reasons, we always check for the levels of this enzyme before using azathioprine so we know whether the medicine is safe to take. Most people know mycophenolate mofetil by the brand name CellCept, a drug tolerated without difficulty by many patients. Though it targets the same DNA synthesis pathway as azathioprine with far fewer side effects, it still causes serious side effects, which require monitoring. The most common side effects include gastrointestinal issues, like nausea or irregular bowels.
For patients taking this drug, we monitor for bone marrow and liver toxicity as well, in order to make sure the medication is being tolerated safely. It is also harmful during pregnancy. Another drug, Interferon gamma, has been shown to be effective in many trials.
Unfortunately, it has side effects which sometimes limit its use. And, of course, I want to mention Dupilumab, which is the new medication I recently read about and discussed previously.
Many supplements are being tested for benefit for eczema, along with some new moisturizers. Though the pathways are different, we are starting to see whether biologics relevant to psoriasis might be helpful in eczema. There are many more drugs in development. Of course, we love scaling down, getting back to that baseline foundation whenever we can. Getting your atopic dermatitis symptoms under control will be much easier if you take it step by step Atopic dermatitis can look different on a range of skin tones, and research shows that certain ethnic groups are more at risk.