Atopic dermatitis, which also goes by “atopic eczema,” is a chronic inflammatory skin problem that can produce severely, persistently itchy lesions. This condition affects 15-20% of children and 2-3% of adults in the US. The itching can disrupt sleep and other daily activities. Thus, patients often ask about atopic dermatitis treatment options that can keep the lesions away for good.
Generally, atopic dermatitis gets better for most patients but can linger throughout life for a few. Fortunately, we live in a time when people can choose from a vast array of therapies for this type of eczema. This article discusses atopic dermatitis treatments and what you can do to maximize the benefits of each.
What Causes Atopic Dermatitis?
Understanding how atopic dermatitis treatments work requires knowledge of its causes.
“My mother has atopic dermatitis and asthma. My brother once got itchy blisters on his leg after camping with Dad,” said MC, a teenage girl who came to the clinic for itchy rashes on her inner elbow surfaces. From her story, it sounds like she has risk factors for atopic dermatitis.
Atopic eczema is multifactorial, though heavily influenced by heredity. People with this skin condition have inherently defective skin barrier function and immune hyperreactivity. Barrier defects make the skin vulnerable to moisture loss and entry of irritants. Immune reaction to the irritants starts a vicious itch-scratch cycle.
Individuals with atopic dermatitis typically have dry skin. Recent atopic eczema lesions are red and blistery. Older ones look darker, with some having thickened skin, scratch marks, and evidence of skin picking (excoriations).
The itchiness usually accompanying these lesions is widely attributed to inflammation, as it resolves with anti-inflammatory medication use. People with atopic eczema usually have heritable allergy-related conditions, such as asthma and allergic rhinitis.
What Causes Atopic Eczema to Flare Up?
The triggers of atopic dermatitis include but are not limited to the following:
- Dust mites
- Animal danders
- Emotional stress
- Infectious microbes
- Certain foods
- Temperature extremes
- Irritants like detergents and harsh soaps
Trigger identification and avoidance are essential to atopic eczema treatment.
When Should You See a Doctor About Atopic Dermatitis?
Atopic dermatitis can present as early as infancy. Babies usually develop itchy rashes on the cheeks and outer joint areas, making them quite fussy. Older children and adults are more likely to have lesions on the inner joint surfaces.
Initially, patients may treat the lesions with over-the-counter steroid creams and antihistamines. Some individuals respond, but others don’t. Consult a doctor if a lesion does not get better with topical corticosteroids or other prescribed outpatient treatments, especially when complications like bleeding or infection arise.
How Do You Grade Atopic Dermatitis Severity, and Why Is It Important to Know?
Evaluating your symptoms’ severity helps your healthcare provider determine the appropriate treatment for your condition and, later, monitor your response. Various scoring tools can help them accomplish that. Your provider will base their assessment on lesion extent, degree of activity disruption, presence of oozing or bleeding, skin dryness, and other factors.
What Is Considered Severe Atopic Dermatitis?
What constitutes severe atopic dermatitis differs in every scoring system. For example, in the Eczema Area and Severity Index (EASI), the condition is severe if the lesions are large, widespread, and appear as a mix of new and old lesions. In the Patient-Oriented Eczema Measure (POEM), the lesions would also have bleeding, oozing, or cracking. Other severe eczema symptoms include loss of sleep and skin dryness.
What Is the Best Treatment for Atopic Dermatitis?
Not all atopic eczema treatments work for everyone. Trigger avoidance and patient education help prevent flare-ups. However, active medical treatment is necessary when new lesions appear. Patients usually require a combination of different therapeutic approaches to shorten eruptive episodes and prolong remissions.
Below is a list of both widely accepted and investigational atopic dermatitis treatments.
Identifying and eliminating triggers help prevent the itch-scratch cycle. The following measures are useful:
- Avoid long, hot baths and harsh, allergenic personal products. Read product labels to know if at least one ingredient can cause a flare.
- Clean up your home and workplace regularly.
- Stay away from polluted, humid, and hot places.
- Don’t eat foods that trigger your symptoms.
- Minimize emotional stress by doing yoga, breathing exercises, and other relaxation techniques.
Some people may find it difficult to identify their triggers. A board-certified dermatologist can perform a patch test to help patients identify potential irritants.
Learning More About Your Condition
“I worry whenever my child has these rashes. She throws tantrums, saying she can’t stand the itching. She can’t sleep at night and wants to skip school the next day. I don’t know what to do,” said CP, the mother of an eight-year-old girl with atopic dermatitis. CP doesn’t have the condition, although the child’s father had it as an infant.
Parents often feel frustrated when caring for children with atopic dermatitis, especially if they don’t have the condition themselves. Similarly, adults affected by this skin problem may experience feelings of helplessness, unsure of how to manage it.
However, knowledge is power, especially when treating and preventing atopic dermatitis relapses. At the BHSkin Dermatology clinic, we always emphasize the importance of the following measures to our patients:
Good hygiene and skin care
Body hygiene is important. However, long, hot showers can deplete skin barrier lipids, especially if you use harsh soaps. Adjust your shower’s temperature to lukewarm, and use synthetic (non-soap) or moisturizing cleansers. Moisturize your skin to replenish your skin barrier’s lipids after showering and at other times of the day.
Atopic dermatitis can cause emotional stress and vice-versa in affected individuals. Caregivers may also share patients’ distress. Relaxation is most helpful. Biofeedback and counseling have also allowed patients and caregivers to cope with this illness’ effects.
Prompt skin infection treatment
Common skin microbes like Staphylococcus aureus can irritate the skin if its barrier function is compromised. Besides good hygiene and regular moisturization, prompt treatment of skin infections also helps shorten acute eczema episodes.
Avoiding rash-triggering foods
Patients with atopic dermatitis may be sensitive to either peanuts, eggs, chicken, dairy, or other food types. Avoid foods that trigger your symptoms. Prevention spares you from aggressive treatments and saves you hours distracted by itchy rashes.
Atopic dermatitis treatments are tailored to each patient’s needs. What works for other people may not work for you. Adhering to your prescribed regimen helps shorten flare-up duration.
If you have other atopic dermatitis-specific skincare questions, give our offices a call. Your specialists at BHSkin Dermatology are always ready to answer your queries about this skin condition.
Topical treatment is the first-line option for mild-to-moderate atopic dermatitis symptoms. These products also work in conjunction with UV light therapy and immunosuppressants in treating severe cases. Most patients respond to topical treatment, especially if combined with good skincare habits.
“I love SkinStyle moisturizers, which are specially formulated for sensitive skin. They’re not only fun to use, but they also make my skin glow,” says JM, a young woman who recently switched to our dermatologist-formulated products.
Besides trigger avoidance, emollients are the mainstays of atopic eczema treatment. These products restore and preserve the skin barrier while reducing the need for anti-inflammatory medications. Hypoallergenic formulations are best.
Triple-lipid therapies—products with optimized ceramide, cholesterol, and free fatty acid ratios—have been proven to be as effective as the mid-potency steroid fluticasone in reducing atopic dermatitis symptoms. Ceramides are large, complex lipids that cement skin cells together and tend to be deficient in atopic dermatitis skin.
Topical steroid cream formulations suppress the skin’s immune activity and are the first-line topical anti-inflammatory treatment for atopic eczema. These medications may be applied on lesions frequently during eruptions and twice weekly on flare-prone areas once the acute episode is controlled.
Wet wrap therapy enhances topical steroid skin penetration in patients with severe symptoms. Essentially, it entails wrapping a topical steroid-treated area with a damp cloth for a few hours or overnight. Patients must not overuse this technique because it can result in skin maceration—or the skin looking shriveled up—and make it infection-prone.
Additionally, topical corticosteroid creams can cause local symptoms such as skin thinning, stretch marks, rashes around the lips, and acne rosacea. Adrenal suppression—a condition marked by severe blood sugar and pressure reduction—is a potential systemic complication of long-term topical corticosteroid treatment.
Moreover, topical steroids are generally effective and safe when used appropriately. However, side effects can occur when thin skin is highly exposed to high-potency formulations, especially in children. Matching potency with skin thickness, e.g., using low-potency steroids on thin skin, maximizes these medications’ benefits while reducing their risks.
Topical Calcineurin Inhibitors
“My sister advised me to use over-the-counter topical steroids on my son’s rashes, but they didn’t work. Our skin doctor replaced it with tacrolimus, which did wonders to his skin,” said ST, the mother of a teenage boy with atopic eczema.
Subsequently, healthcare providers frequently use topical calcineurin inhibitors, such as tacrolimus and pimecrolimus, to treat moderate-to-severe atopic eczema. They typically prescribe these nonsteroidal immunomodulators for regular use during exacerbations and suggest thrice-weekly applications for maintenance after a flare-up.
Unlike some treatments, topical calcineurin inhibitors do not lead to skin thinning. However, it’s important to note they carry an FDA black box warning due to a potential increase in skin cancer and lymphoma risks. Despite this warning, real-world studies have not shown an increased incidence of tumors in patients using these inhibitors for atopic dermatitis.
Crisaborole is an FDA-approved boron-based anti-inflammatory medication indicated for mild-to-moderate atopic eczema. No serious adverse events were reported in crisaborole clinical trials. This medication’s most common side effect is a mild stinging sensation on the application site.
Coal tar has anti-inflammatory properties that make it useful in treating skin disorders like eczema and psoriasis. Although less potent than topical steroids, this medication can reduce steroid requirements. Coal tar shampoo helps relieve scalp itching and crusting in patients with scalp dermatitis.
The topical treatment of severe atopic dermatitis has been the focus of drug development of late. For example, the JAK inhibitor delgocitinib has been recently FDA-approved for topical use in moderate-to-severe manifestations of this skin disease.
Meanwhile, inherited sensitivity to bacterial products has been found to be associated with severe eczema flare-ups in some families. Thus, the intense research into the potential of topical antibacterials like omiganan in atopic dermatitis treatment.
Interestingly, UV light is an effective immunomodulator, which is why sunlight can help atopic eczema symptoms improve. However, simple sun exposure in a humid or hot environment can cause sweating and itching. Outpatient UVB and psoralen-UVA (PUVA) phototherapy control such external factors, making these procedures valuable in moderate-to-severe atopic dermatitis treatment.
UV light therapy has minor short-term side effects that include redness, mild burning sensation, slight itching, and skin darkening. Potential long-term complications like skin cancer and premature skin aging can be avoided by giving patients the minimum effective UV light exposure duration and dose.
Generarally, systemic therapy is typically considered when topical medication or UV light therapy alone doesn’t improve moderate-to-severe atopic dermatitis. Drugs in this category modulate the immune system. Some have severe side effects.
Dupilumab is an antibody that blocks immune-cell activation. This drug is injected every other week. Side effects are minor and include injection site pain and non-infectious conjunctivitis. Dupilumab does not increase infection or malignancy risk, unlike many other biologics.
Conversely, systemic steroids typically produce dramatic clinical improvement followed by rebound symptoms. Dose tapering reduces rebound risk. Patients are given short courses of oral prednisone. Long-term steroid use causes adrenal suppression, immunosuppression, weight gain, osteoporosis, and skin changes.
Cyclosporine can induce remission of severe disease in patients unresponsive to other therapies. This drug is given in brief periods as it can cause kidney failure, hypertension, and severe interactions with other medications. Symptom rebound may occur after cyclosporine withdrawal, but many individuals experience long remissions.
Methotrexate, mycophenolate mofetil, and azathioprine suppress immune cell proliferation. These medications have severe side effects and are considered only if other systemic treatments don’t work.
Bone marrow suppression—which lowers all blood cell counts—is a potentially fatal adverse effect of these three drugs. Methotrexate can damage the liver. Mycophenolate mofetil can cause pregnancy loss, eye infection, and brain injury. However, careful screening and monitoring throughout the treatment helps patients avoid serious complications.
Investigational Immunomodulatory Therapy
Additionally, treatments falling under this category are drugs and procedures that can modulate immune responses but have not shown consistent results in clinical trials. Drugs include interferon-gamma, omalizumab, probiotics, and oral vitamin D. Procedures include allergen immunotherapy and extracorporeal photopheresis.
Allergen immunotherapy desensitizes patients from atopic dermatitis triggers. Extracorporeal photopheresis treats the white blood cells with UVA light.
“I get bad rashes when I’m under a lot of stress. My primary care doctor told me that stress reduction could help my symptoms. True enough, the episodes became fewer when I started taking yoga classes,” said LR, a young adult male patient with controlled atopic dermatitis following up for a regular skin exam.
Alternative atopic dermatitis treatments include holistic therapies and nutritional modification. Clinical trials do not widely support these “all-natural” treatments, though patients should combine them with recommended eczema therapies to optimize their regimen. Alternative treatments that have been tried on this condition include the following:
- Acupuncture and acupressure: Guided needle insertion or body pressure relieves itchy skin.
- Hypnotherapy, relaxation, and massage: These stress-reducing measures may help prevent atopic dermatitis flares.
- Balneotherapy: Water devoid of magnesium, calcium, and bromide (soft water) prevents skin inflammation and itchiness.
- Chinese herbs: Oral preparations temporarily relieve atopic dermatitis symptoms but may cause rebound and systemic toxicity later. Some Chinese herbs have been found contaminated with steroids.
- Skin-applied oils: An example is sunflower seed oil, which is rich in linoleic acid. This essential fatty acid is a ceramide component.
- Oral oil and fatty acid supplementation: Omega-3 and -6 polyunsaturated fatty acids have anti-inflammatory properties and are important skin barrier components.
- Vitamins and minerals: Vitamins B6, B12, and E and the minerals selenium and zinc sulfate have antioxidant and anti-inflammatory properties.
Patients on alternative therapies must continue to be supervised by their healthcare provider.
When Does Atopic Dermatitis Need Hospitalization?
Importantly, good skin care and trigger avoidance help patients prevent severe symptoms requiring aggressive therapy. However, hospitalization may be considered when the condition gets out of hand. Hospitalization of individuals with atopic dermatitis may be recommended in the following situations:
- Severe atopic dermatitis symptoms resistant to outpatient therapy
- Further testing to identify triggers
- Additional testing to rule out serious conditions like cancer and HIV
Hospitalization may also address concomitant problems like infection and severe dehydration.
What Can Your Atopic Dermatitis Treatment Look Like?
Atopic dermatitis treatment regimens differ for every patient. Below is a table summarizing the severity-based management of this condition.
Table: Severity-Based Atopic Dermatitis Management
|Symptoms and Treatment Regimen
After the acute phase, patients must resume their regular skin care routine and avoid symptom triggers.
Can Atopic Dermatitis Go Away?
Atopic dermatitis has no cure. However, you can prolong periods of remission by avoiding symptom triggers and properly caring for your skin. Your healthcare provider should formulate a personalized regimen to help clear up your skin.
Atopic Dermatitis Treatment Is Unique for All Patients
Finally, every patient with atopic dermatitis requires a different approach because of their unique exposures and health factors. Prevention—by good skin care, trigger avoidance, and learning more about your condition—is still the most important part of management.
Your atopic dermatitis specialist will help you determine your best treatment option if you develop symptoms acutely. However, adherence to your personalized regimen gives you the best chance of taking the bull by the horns and quickly resuming your normal.
Usual Atopic Dermatitis Meds Not Working? Consult LA’s Best Skin Specialists
Characteristically, atopic dermatitis is a chronic skin issue that leads to itchy lesions, often so severe they can disrupt sleep. Typically, most patients resort to topical corticosteroids for treating the rashes, yet these medications aren’t effective for everyone. So, who can you turn to for help?
Moreover, at BHSkin Dermatology, our board-certified dermatologists specialize in managing atopic dermatitis. Patients are happy about how fast our skin doctors’ treatments work! Visit our Glendale or Encino clinic or use our telederm portal for your consultation.
Book your appointment today!
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- Vieira, B. L., et al. (2016, July 7). Complementary and Alternative Medicine for Atopic Dermatitis: An Evidence-Based Review. American Journal of Clinical Dermatology. 17(6). 557-581. https://doi.org/10.1007/s40257-016-0209-1
- Zhao, M., et al. (2020, March 21). Patient Education Programs in Pediatric Atopic Dermatitis: A Systematic Review of Randomized Controlled Trials and Meta-Analysis. Dermatology and Therapy. 10. 449-464. https://doi.org/10.1007/s13555-020-00365-z
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