Atopic dermatitis: treatment and cure
Atopic dermatitis (AD) is a chronic condition that is difficult to manage therapeutically. Given its chronic-recurrent course, treatment must be planned with a long-term perspective and must take into account the multiple aspects of the disease
The real therapeutic challenge lies in managing exacerbations of atopic dermatitis
The ability to effectively control acute phases in the short term is crucial to improve adherence to recommendations and therapy.
The aim of AD therapy is to
- induce remission of symptoms
- achieve long-term stabilisation
- prevent flare-ups
- limit side effects caused by chronic therapy.
In combination with drug therapy, it is essential to educate patients and parents of young patients about skin hygiene and emollient therapy.
What is the treatment of atopic dermatitis based on?
The treatment of AD is based on:
- Correct skin hygiene
The skin must be cleansed with hypoallergenic and non-irritating cleansers, perhaps in oily formulations or in the form of cleansing creams for their greater moisturising power.
Specific cleansers for atopic skin gently cleanse the skin without damaging the already compromised skin barrier, favouring natural hydration and avoiding dehydration, respecting the physiological skin pH. Bathing should be short (max. 5 min) and carried out with lukewarm water.
Drying should be gentle, without rubbing, but patting the skin gently with a towel.
- Moisturising the skin with emollients
Emollients, which are essential for maintaining remission and preventing recurrence, are mostly emulsions (milks and balms), sometimes thicker (creams) or rich in fat (ointments).
The choice is based on the stage of AD and the tolerability and pleasantness of the product.
Thanks to their components (ceramides, polyunsaturated fatty acids, glycyrrhetinic acid, bisabolol, vitamin E), emollients are an integral part of the therapy by favouring repair of the skin barrier, reduction of inflammation, reduction of xerosis and itching as well as the use of topical corticosteroids.
- Local anti-inflammatory therapy
In the presence of lesions, the application of emollients must be combined with local anti-inflammatory therapy, which aims to ‘switch off’ the inflammation.
The anti-inflammatory therapy of first choice is based on the application of topical corticosteroids which, although characterised by a good speed of action, are burdened by side effects (such as skin atrophy) when applied long-term.
The choice of corticosteroid strength and formulation is based on the type of eczema, site and age of the patient.
Itching is the symptom to consider when assessing response to treatment, and therapy should not be reduced until itching has disappeared.
Gradual discontinuation of therapy through progressive dose reduction is recommended.
Long-term intermittent use of corticosteroids (twice/week) in the areas most prone to relapse, combined with the application of emollient creams is termed ‘proactive treatment’ and is an effective and safe mode of disease control.
Emollient creams with anti-inflammatory substances of natural origin are less effective than corticosteroid therapies but are safer in long-term use and in more delicate areas such as the face and are a valuable support in maintenance therapy.
- Sedation of itching
Controlling itchy symptoms is essential in the management of AD.
Recent scientific evidence shows that the major component of itching associated with atopic dermatitis is histamine-independent.
This is why the most recent guidelines for the treatment of AD do not recommend the use of antihistamines for the treatment of itching.
Sedative anti-H1 antihistamines (hydroxyzine, loratadine, cetirizine) may only be useful for their sedative effect to promote sleep in cases of very intense itching.
Therapy to reduce itching should be based on reducing xerosis through the application of emollients and reducing inflammation through the use of topical corticosteroids.
- Infection treatment and prevention
Patients with a high colonisation of Staphylococcus aureus may benefit from the use of topical antiseptics (chlorhexidine) and the combined topical treatment of corticosteroids and antibiotics (fusidic acid).
Treatment with systemic antibiotics is only justified in the presence of AD flare-ups associated with clinical signs of overinfection.
- Care of the environment and removal of food and inhalant allergens
The correlation between atopic dermatitis and food allergies remains controversial; only in a few cases does removal of the allergen help control the disease.
A food diet in atopic dermatitis should only be applied when there is documented evidence of a food allergy.
A beneficial effect of environmental prophylactic measures has been reported; a drastic reduction of household exposure to dust mites is an effective measure in preventing flare-ups of the disease.
What to do in the case of severe or topically resistant atopic dermatitis?
In the case of extensive AD and/or resistant to topical therapy, phototherapy (narrow-band UVB) 2-3 sessions/week may be considered, especially in chronic itchy and lichenified forms in adults.
Systemic therapy should be considered in severe forms refractory to topical treatment.
Systemic corticosteroids should be used for short periods due to long-term side effects and the risk of rebound effect upon discontinuation.
Cyclosporine is a rapidly effective immunosuppressive drug and can be considered for treatments lasting 3-6 months with monitoring of blood pressure and renal function for the risk of renal damage.
Treatment of atopic dermatitis, what’s new?
For the systemic treatment of moderate to severe adult atopic dermatitis from 2018 dermatologists are provided with a new weapon: the biologic drug dupilumab, a human monoclonal antibody that has the ability to simultaneously inhibit interleukin-4 (IL-4) and interleukin-13 (IL-13) signalling, the two inflammatory molecules mainly involved in the pathogenesis of AD.
In Italy, dupilumab is reimbursed by the National Health Service for the treatment of severe atopic dermatitis in adult patients for whom treatment with cyclosporine is contraindicated, ineffective or not tolerated.
Dupilumab represents an innovation in the therapeutic landscape of adult atopic dermatitis and a new hope for patients whose quality of life is severely compromised by severe and disabling AD.
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