Atopic dermatitis: Treatments

• Emollients for dry skin.
• Topical or sistemical anti-inflammatory or immunomodulatory therapy for eczema/inflammation.
• Disinfectants in case of a bacterial infection.

Despite using all of them, due to the complex physiopathology of atopic pruritus it may persist, so symptomatic antipruritic therapies will be necessary.

The choice of emollient depends on the individual patient. It is generally recommended that a thick (with a high fat content) cream or ointment is used for the driest skin, whereas creams and lotions with a higher water content are used only for very mild eczema. Such creams must be applied several times a day because of their rapid absorption into the skin. It is important to recommend an emollient without perfume or other potential allergens as they may provoke secondary allergic sensitization. Those with chronic, dry eczema benefit from tar preparations in the form of creams and occlusive bandages.

II. Bathing and showering practices, including bath additives

Bathing or showering daily, for about 5-10 minutes, may hydrate the skin and remove scales, crusting, irritants and allergens, which may be useful for patients with AD. However, letting water evaporate from the skin will cause a higher loss of transepidermal water, so it is recommended to apply moisturisers shortly after bathing or showering to keep the skin well hydrated.

If any area of the skin is significantly swollen, it is recommended to soak it in running water for 20 minutes, and then immediately apply an anti-inflammatory pharmacological treatment, such as CTs, without drying it with a towel. This technique is called "Soak and Seal," and it may improve the response in cases where only applying a topical antiinflammatory is not appropriate.

It is recommended to limit the use of cleansers without soap containing low or neutral pH, or that are hypoallergenic or unscented.

III. Wet wrap therapy

Wet wrap therapy (WWT) is a method to quickly reduce the severity of AD, and it is usually used, both in ambulatory or hospitalized patients, for significant outbreaks of the disease. In general, the technique consists of applying a topical agent and covering it by a moist first layer of tubular bandages, gauze or a cotton suit, followed by a dry second outer layer. When the condition is generalized, two layers of non-irritant clothes may be applied in a similar way. WWT seems to help with occlusion of the topical agent to increase penetration, reduce water loss and provide a physical barrier against scratchings.

The wrap may be used from several hours to up to 24 hours, depending on the patient's tolerance. In general, it is suggested to use it for several days, although some studies regarding this technique continued it for up to two weeks.

IV. Phototherapy

As most patients affected by AE improve during the sunny summer season, artificial UV radiation is frequently employed in the treatment of AE. Phototherapy can improve and even clear AE; it can decrease bacterial colonization and reduce the strength and/or the amount of topical anti-inflammatory drugs needed, but the beneficial effects vary from person to person.

I. Topical corticoids

The use of anti-inflammatory topical corticoids (CTs) may lead to the improvement or resolution of acute outbreaks in a matter of days. CTs are used in the treatment of AD both in adults and children, and they are the foundation of anti-inflammatory therapy. They act on a variety of immune cells, including T lymphocytes, monocytes, macrophages and dendritic cells, interfering with the processing of antigens and suppressing the release of proinflammatory cytokines. They are usually introduced in the treatment regimen after lesions do not respond to good skin care and regular use of moisturisers as monotherapy.

II. Topical calcineurin inhibitors

Topical calcineurin inhibitors (TCIs) are a second line of treatment for moderate-to-severe AD in patients. They inhibit the calcineurin-dependent T cell activation, blocking the production of proinflammatory cytokines and mediators of the inflammatory reaction of AD.

B. Systemic agents

Systemic immunomodulatory drugs are a common option for the treatment of chronic and/or serious inflammatory diseases. These agents are indicated and recommended for atopic dermatitis (AD) in patients in which optimized topical treatments and/or phototherapy cannot properly control the disease, or when quality of life has been substantially affected.

C. Treatment of bacterial infections

Although it is not recommended to use systemic antibiotics in the treatment of non-infected AD, they may be applied in patients with clinical evidence of bacterial infection.