Management of atopic dermatitis requires the elimination of exacerbating factors, restoration of the skin barrier function and hydration of the skin, patient education, and pharmacologic treatment of skin inflammation.
- Exacerbating factors in atopic dermatitis that further disturb the already abnormal epidermal barrier include excessive bathing not followed by adequate moisturization, low humidity environments, emotional stress, xerosis (dry skin), overheating of skin, and exposure to solvents and detergents. Avoiding these triggers is vital for acute flares as well as for long-term management.
-The role of environmental or food allergies in exacerbating atopic dermatitis remains controversial.
-Individuals with atopy are are more prone to develop allergic contact dermatitis (ACD) to many components of topical treatments (eg, fragrances, preservatives etc.)
-Skin hydration is vital for the overall management of patients with atopic dermatitis. Lotions, which have a high water and low oil content, can worsen xerosis via evaporation and induce a flare of the disease. In contrast, thick creams (eg, Eucerin), which are low in water, or ointments (eg, petroleum jelly, Vaseline), which have zero water content, better protect against xerosis, but are greasy. To maintain skin hydration, emollients should be applied at least two times per day and immediately after bathing or hand-washing. Atopic skin is known to be deficient in lipids (especially ceramide), so using moisturizers that contain those ingredients may be beneficial.
Topical steroids, and emollients are the mainstay of therapy. The choice of the steroid potency is determined based upon the patient’s age, body area involved, and degree of skin inflammation. Topical calcineurin inhibitors may be an alternative to topical corticosteroids, in particular for the treatment of the face, including the eyelids, neck, and skin folds.
Topical corticosteroids:
For patients with mild atopic dermatitis, a low potency corticosteroid cream or ointment, like the one you’re using (like Cutivate, generic fluticasone propionate) is recommended. Application once or twice per day for two to four weeks. Emollients should be abundantly used multiple times per day in conjunction with topical corticosteroids.
For patients with moderate disease, medium to high potency steroids (eg, triamcinolone 0.1%, betamethasone dipropionate 0.05%) are recommended. In patients with acute flares, topical steroids (can be used for up to two weeks and then replaced with lower potency preparations until the lesions resolve.
The face and skin folds are areas that are at high risk for atrophy with corticosteroids. Initial therapy in these areas should start with a low potency steroid (such as desonide 0.05% ointment. High potency topical corticosteroids are generally avoided in skin folds and on the face.
Maintenance therapy: after induction of remission, intermittent therapy with moderate to high potency topical steroids applied once daily to previously affected skin areas for two consecutive days per week (ie, weekends) for up to 16 weeks is recommended, in parallel with emollients many times per day.
You may want to shift to a more potent topical steroid such as a Betamethasone-based cream (e.g. Betnovate®) to control the eczema, then back to Cutivate for maintenance therapy.
Topical calcineurin inhibitors
These are nonsteroidal agents that locally (on the skin level) modulate the response of the immune system. Unlike steroids, they do not lead to skin atrophy. They can be used as an alternative to topical steroids for the treatment of mild to moderate atopic dermatitis involving the face, including the eyelids, neck, and skin folds. The most widely used and effective topical calcineurin inhibitors are Tacrolimus ointment and pimecrolimus cream are applied twice a day. Tacrolimus comes in two strengths; the 0.1% formulation is appropriate initial therapy for adults. In patients who do not tolerate tacrolimus because of burning or stinging, pimecrolimus may be better tolerated.
-Individuals with atopy are are more prone to develop allergic contact dermatitis (ACD) to many components of topical treatments (eg, fragrances, preservatives etc.)
-Skin hydration is vital for the overall management of patients with atopic dermatitis. Lotions, which have a high water and low oil content, can worsen xerosis via evaporation and induce a flare of the disease. In contrast, thick creams (eg, Eucerin), which are low in water, or ointments (eg, petroleum jelly, Vaseline), which have zero water content, better protect against xerosis, but are greasy. To maintain skin hydration, emollients should be applied at least two times per day and immediately after bathing or hand-washing. Atopic skin is known to be deficient in lipids (especially ceramide), so using moisturizers that contain those ingredients may be beneficial.
Topical steroids, and emollients are the mainstay of therapy. The choice of the steroid potency is determined based upon the patient’s age, body area involved, and degree of skin inflammation. Topical calcineurin inhibitors may be an alternative to topical corticosteroids, in particular for the treatment of the face, including the eyelids, neck, and skin folds.
Topical corticosteroids:
For patients with mild atopic dermatitis, a low potency corticosteroid cream or ointment, like the one you’re using (like Cutivate, generic fluticasone propionate) is recommended. Application once or twice per day for two to four weeks. Emollients should be abundantly used multiple times per day in conjunction with topical corticosteroids.
For patients with moderate disease, medium to high potency steroids (eg, triamcinolone 0.1%, betamethasone dipropionate 0.05%) are recommended. In patients with acute flares, topical steroids (can be used for up to two weeks and then replaced with lower potency preparations until the lesions resolve.
The face and skin folds are areas that are at high risk for atrophy with corticosteroids. Initial therapy in these areas should start with a low potency steroid (such as desonide 0.05% ointment. High potency topical corticosteroids are generally avoided in skin folds and on the face.
Maintenance therapy: after induction of remission, intermittent therapy with moderate to high potency topical steroids applied once daily to previously affected skin areas for two consecutive days per week (ie, weekends) for up to 16 weeks is recommended, in parallel with emollients many times per day.
You may want to shift to a more potent topical steroid such as a Betamethasone-based cream (e.g. Betnovate®) to control the eczema, then back to Cutivate for maintenance therapy.
Topical calcineurin inhibitors
These are nonsteroidal agents that locally (on the skin level) modulate the response of the immune system. Unlike steroids, they do not lead to skin atrophy. They can be used as an alternative to topical steroids for the treatment of mild to moderate atopic dermatitis involving the face, including the eyelids, neck, and skin folds. The most widely used and effective topical calcineurin inhibitors are Tacrolimus ointment and pimecrolimus cream are applied twice a day. Tacrolimus comes in two strengths; the 0.1% formulation is appropriate initial therapy for adults. In patients who do not tolerate tacrolimus because of burning or stinging, pimecrolimus may be better tolerated.
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