Eczema is an umbrella term that entails several medical conditions that affect the skin.
The most prevalent of these is atopic dermatitis (AD), which is our main topic.
Other types of eczema include:
- Contact dermatitis
- Seborrheic dermatitis
- Stasis dermatitis
In this article, we will briefly define atopic dermatitis, review its causes, and thoroughly cover the management plan for patients with AD
What is atopic dermatitis?
Atopic dermatitis is a common dermatological condition that’s characterized by chronic inflammation of the skin.
Over the past few years, the prevalence of this disease has been exponential, which alerted experts to categorize AD as a major public health problem.
The most frustrating aspect of atopic dermatitis is its chronic and relapsing nature that negatively affects the lives of patients.
Interestingly, AD is more prevalent in high socioeconomic countries, which may be explained by the hygiene hypothesis.
If you’re not familiar with this hypothesis, it is a description that scientists came up with to explain why low-income citizens are less likely to develop autoimmune diseases.
Since underdeveloped countries already suffer from several epidemics and have lower hygiene standards, the immune system of these individuals is always fighting pathogens to protect the host.
On the other hand, people from developed countries rarely deal with serious infections, and if they do, antimicrobial medications are readily available for treatment.
As a result, the immune system is in a relatively “dormant” condition, which may be the reason it overreacts to harmless antigens and causes autoimmune diseases, such as asthma and atopic dermatitis.
Causes of atopic dermatitis
Typically, AD starts in infancy, and it’s believed to be the result of the classic “nature and nurture” diagram.
The nature part
This is believed to be the result of genetic predisposition, as patients with AD often have a family history of different types of eczema and other allergic conditions.
Furthermore, patients themselves may be diagnosed with other allergic illnesses, such as rhino-conjunctivitis, asthma, food allergies, and less often, eosinophilic esophagitis.
The nurture part
The nurture part represents the environmental factors that trigger the first flare-up of atopic dermatitis. Usually, this is caused by viral infections, pharmacological drugs, chemicals, and certain foods.
In summary, for an individual to develop AD, he/she must have a genetic predisposition, as well as an environmental trigger to stimulate the disease process.
Can atopic dermatitis spread?
The short answer is no.
Atopic dermatitis is an autoimmune disease, which means that the patient has a dysfunctional immune system that’s attacking the skin.
This condition is not infectious and belongs to the same category that includes asthma, allergic rhinitis, and multiple sclerosis.
In fact, the combination of these three conditions (atopic dermatitis, asthma, allergic rhinitis) makes up the notion of atopy, which reflects the susceptibility of an individual to develop autoimmune diseases.
Treatment of atopic dermatitis
In this section, we will discuss several entities in the treatment of atopic dermatitis.
For years, atopic dermatitis treatment was designed to target the occasional flareups with short-term therapy. This approach was popular since AD is a chronic, relapsing disease, so there was no point in trying a long-term management plan. However, we are seeing a new approach today.
Dermatologists have adopted a proactive plan that includes long-term maintenance therapy, which can modify the overall disease course and prevent any atopic-associated complications.
The new plan includes the education of patients, special skincare routine, the use of moisturizes, and the prescription of anti-inflammatory drugs to manage the subclinical inflammation and flareups.
Some forms of atopic dermatitis may require phototherapy or systemic pharmacological treatment in association with topical therapy.
Educating patients and their families about the necessary measures to manage atopic dermatitis has become a cornerstone of maintenance therapy.
Several studies demonstrated that a better understanding of the disease course, triggers, appropriate use of therapies, and the short and long-term goals of the treatment increase therapeutic adherence and reduce irrational fear and misconceptions.
This process also reduces the chances of getting misled by scams and advertisements that target desperate patients with AD. One challenging aspect that parents face is accepting that AD is a chronic condition that can be controlled but not cured. However, after explaining to them the benefits and improvement of symptoms when the treatment is started, they tend to become more resilient.
Additionally, online resources such as theNational Eczema Associationcan provide valuable information about AD and the available treatments. Psychological interventions to aid in coping with AD may have benefit, with reported approaches including biofeedback, cognitive-behavioral therapy, and stress management.
Topical corticosteroids are the first-line treatment for atopic dermatitis. These drugs possess anti-inflammatory, immunosuppressive, and vasoconstrictive properties, with a special action on cutaneous immune cells (e.g. T cells, macrophages, dendritic cells).
There are more than 100 randomized clinical trials that support the efficacy of topical corticosteroids in the management of AD. This efficacy is observed during acute and chronic inflammation, which helps reduce the severity and frequency of itching. For this reason, these drugs are prescribed to treat acute flareups, as well as maintenance therapy for potential relapses.
When it comes to choosing the right medication, several factors are involved, including the location of the lesion, its type, thickness, and extent of the damage. The drug should have an appropriate potency to rapidly tamper down the flareup while being effective as maintenance therapy to stop the inflammation and reduce the risk of a rebound.
The prolonged use of an inadequately potent medication can lead to a higher risk of adverse effects and the loss of symptom control.
Systemic Anti-Inflammatory Therapy
The use of systemic anti-inflammatory drugs may be necessary for patients with moderate to severe symptoms of AD who did not respond to topical therapy. Before prescribing these drugs, your doctor will measure the risk-benefit profile to determine whether it’s an appropriate choice. Moreover, patients taking immunosuppressive drugs must be closely monitored for any adverse effects.
This drug is a potent monoclonal antibody that blocks the action of proinflammatory cytokines to suppress the action of T cells. Dupilumab is FDA-approved for the treatment of AD in patients who do not respond to optimized topical therapy. It is subcutaneously administered every other week in association with topical corticosteroids. Fortunately, this drug has mild side effects, which makes it a favorite for dermatologists.
Cyclosporine is a common immunosuppressor that’s prescribed in several medical conditions. Once this drug is administered, symptoms of AD significantly improve; however, the prolonged use of this medication carries some serious side effects (e.g. kidney damage, blood hypertension), hence the need to stop it after a while.
Similar to the other drugs on this list, methotrexate has anti-inflammatory and immunosuppressive properties and has been shown to effectively reduce the symptoms of AD in children and adults. Typically, this drug is combined with folic acid supplements to avoid serious side effects.
Mycophenolate mofetil (MMF) blocks certain metabolic pathways to halt the activity of lymphocytes. Treatment usually lasts for 2–3 months to observe maximum efficacy.
This option is left for severe and debilitating flareups of AD that failed to respond to other therapies.Note that the chronic use of corticosteroids is not recommended due to the heavy side effect profile and rebound.
How to treat atopic eczema naturally
Wet wrap therapy
Wet wrap therapy can help patients during severe flareups and in AD resistant to pharmacological treatment. If you’re not familiar with wet wraps, they are moist dressings that increase skin hydration, protect the dermal layers from scratching, and improve the penetration of corticosteroids.
Note that these wraps should be used carefully if the patient is receiving potent corticosteroids, as it would increase the concentration of the drug in the bloodstream, leading to adverse effects such as skin bacterial infections. These wraps are applied after topical corticosteroids for 8-24 hours per day, with a maximum duration of 2 weeks.
Taking frequent baths can hydrate the skin and remove the extra scale, crust, and other irritants.
Current guidelines suggest that patients should take a daily bath for around 5-10 minutes in warm water. It is also recommended to use a fragrance-free, non-soap cleanser, with a neutral to low pH. Applying the moisturizer, corticosteroids, and other anti-inflammatory agents should take place after bathing.
Follow this order:
Bathing→ topical corticosteroids/anti-inflammatory agent→ moisturizer
Why moisturizing creams are important to treat atopic eczema
Researchers found that the daily application of moisturizes can prevent dry skin and reduce transepidermal water loss, which is a crucial step for proper AD management.
The frequent use of moisturizers reduces itchiness, erythema (redness), fissuring, and the thickening of the skin.
As a result, patients will need less potent anti-inflammatory medications to control their symptoms. The reason why moisturizes are effective is attributed to their content in emollient agents that lubricate the skin, and the occlusive agents that stop water loss. When choosing the proper moisturizer, you should opt for products that are free of dyes, fragrances, and food-derived allergens.
Many clinical studies supported the effectiveness of combined UV light (UVB, UVA, UVA1) in reducing the symptoms of atopic dermatitis associated with itching.
This effect is mediated via T-cell apoptosis, reduction of dendritic cells, and the downregulation of cytokines expression.
Moreover, phototherapy can reduce the number of bacteria that colonize the dermal flora, which improves skin health and reduce the risk of bacterial infections.
For optimal results, phototherapy is often combined with topical corticosteroids, especially during the initial phase of therapy. Perhaps the most advantageous aspect of using phototherapy is the low profile of side effects compared to systemic immunosuppressive medications. Nevertheless, here are some side effects that you can expect:
- Potentially higher risk of skin cancer
Unfortunately, traveling every week to a phototherapy center might interfere with school or professional life, making this option less favorable for long-term use.
Atopic dermatitis is a challenging condition to deal with for both physicians and patients. This disease has complex pathophysiology that we don’t fully understand.
AD is chronic and often relapsing, which may affect the patient’s psychological status, hence the need to educate them and their family about the course of the disease, treatment options, and goals of receiving therapy.
Every year, hundreds of studies around atopic dermatitis pathogenesis and treatment effectiveness are published, which may help us comprehend this illness and potentially develop a curative treatment. Hopefully, you have a better understanding of AD, as well as the possible treatment options.
Read more about things you can do at home to treat your eczema here: https://itsitchy.com/stay-at-home-treatments-of-atopic-dermatitis/
Written by Zac Hyde M.D.