Eczema medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Edzel Lorraine Co, D.M.D., M.D.

Overview

Topical corticosteroids are the mainline treatment for eczema. Different potencies of steroids are rendered specifically for the severity of eczema. Other drug treatments often used for eczema include topical calcineurin inhibitors, crisaborole, antimicrobials, and antifungals.

Medical Therapy

Pharmacotherapy

Moisturizing

Eczema can be exacerbated by dryness of the skin. Moisturizing is one of the most important self-care treatments for sufferers of eczema. Keeping the affected area moistened can promote skin healing and relief of symptoms. Soaps and harsh detergent should not be used on affected skin because they can strip natural skin oils and lead to excessive dryness. Instead, the use of moisturizing body wash, or an emollient like aqueous cream, will maintain natural skin oils and may reduce some of the need to moisturize the skin. Another option is to try bathing using colloidal oatmeal bath treatments. In addition to avoiding soap, other products that may dry the skin (such as powders or perfume) should also be avoided.

Moistening agents are called 'emollients'. In general, it is best to match thicker ointments to the driest, flakiest skin. Light emollients like aqueous cream may not have any effect on severely dry skin.

Some common European emollients for the relief of eczema include Oilatum, Balneum, Medi Oil, Diprobase, bath oils and aqueous cream. Sebexol, Epaderm ointment and Eucerin lotion or cream may also be helpful with itching. Lotions or creams may be applied directly to the skin after bathing to lock in moisture. Moisturizing gloves (gloves which keep emollients in contact with skin on the hands) can be worn while sleeping. Generally, twice-daily applications of emollients work best. While creams are easy to apply, they are quickly absorbed into the skin, and therefore need frequent reapplication. Ointments, with less water content, stay on the skin for longer and need fewer applications, but they can be greasy and inconvenient.

For unbroken skin, direct application of waterproof tape with or without an emollient or prescription ointment can improve moisture levels and skin integrity which allows the skin to heal. This treatment regimen can also help prevent the skin from cracking; as well as putting a stop to the itch cycle. The end result is reduced lichenification (the roughening of skin from repeated scratching). Exfoliated skin under the tape loosens the contact after 3 days and the lesion can then be cleaned and aired for one day. The skin may appear dappled in areas not affected by eczema. Repeat the tape coverage for another 4 days and discontinue. Treat the same area promptly when the itch returns and cover it with tape once for 3 days. Taping works best on skin away from joints.

An alternative treatment which was fashionable in the Victorian and Edwardian eras was the topical application of sulfur. Recently sulfur has regained some popularity as a homeopathic alternative to steroids and coal tar. However, there is currently no scientific evidence for the claim that sulfur treatment relieves eczema. Of course, if used in homeopathic doses, no actual sulphur atoms would be present.

Eczema and skin cleansers

The first and primary recommendation is that people suffering from eczema shouldn't use detergents of any kind on their skin unless absolutely necessary. Eczema sufferers can reduce pruritus by using cleansers only when water is not sufficient to remove dirt from skin.

However, detergents are so ubiquitous in modern environments in items like tissues, and so persistent on surfaces, "safe" soaps are necessary to remove them from the skin in order to control eczema. Although most eczema recommendations use the terms "detergents" and "soaps" interchangeably, and tell eczema sufferers to avoid both, detergents and soaps are not the same and are not equally problematic to eczema sufferers. Detergents, often made from petrochemicals, increase the permeability of skin membranes in a way that soaps and water alone do not. Sodium lauryl sulfate, the most common household detergent, has been shown to amplify the allergenicity of other substances ("increase antigen penetration").

Unfortunately there is no one agreed-upon best kind of skin cleanser for eczema sufferers. Different clinical tests, sponsored by different personal product companies, unsurprisingly tout various brands as the most skin-friendly based on specific properties of various products and different underlying assumptions as to what really determines skin friendliness. The terms "hypoallergenic" and "doctor tested" are not regulated, and no research has been done showing that products labeled "hypoallergenic" are in fact less problematic than any others.

Dermatological recommendations in choosing a soap generally include:

• Avoid harsh detergents or drying soaps
• Choose a soap that has an oil or fat base; a "superfatted" goat milk soap is best
• Use an unscented soap
• Patch test your soap choice, by using it only on a small area until you are sure of its results
• Use a non-soap based cleanser

Instructions for using soap:

• Use soap sparingly
• Avoid using washcloths, sponges, or loofahs, or anything that will abrade the skin
• Use soap only on areas where it is necessary
• Soap up only at the very end of your bath
• Use a fragrance-free barrier-type moisturizer such as vaseline or aquaphor before drying off
• Use care when selecting lotion, soap, or perfumes to avoid suspected allergens; ask your doctor for recommendations
• Never rub your skin dry, or else your skin's oil/moisture will be on the towel and not your body; pat dry instead

Itch relief

Anti-itch drugs, often antihistamine, may reduce the itch during a flare up of eczema, and the reduced scratching in turn reduces damage & irritation to the skin (the Itch cycle).

Capsaicin applied to the skin acts as a counter irritant (see Gate control theory of nerve signal transmission). Other agents that act on nerve transmissions, like menthol, also have been found to mitigate the body's itch signals, providing some relief. Recent research suggests Naloxone hydrochloride and dibucaine suppress the itch cycle in atopic-dermatitis model mice as well.

Corticosteroids

Dermatitis is often treated by doctors with prescribed glucocorticoid (a corticosteroid steroid) ointments, creams or lotions. For mild-moderate eczema a weak steroid may be used (e.g. hydrocortisone or desonide), whilst more severe cases require a higher-potency steroid (e.g. clobetasol propionate). Medium-potency Corticosteroids such as clobetasone butyrate (Eumovate) or Betamethasone Valerate (Betnovate) are also available, generally medical practioners will prescribe the less potent ones first before trying the more potent ones. In the UK, Hydrocortisone and Eumovate can be purchased 'over the counter' from a pharmacy without a prescription whilst the more potent ones are prescription-only. Corticosteroids do not cure eczema, but are highly effective in controlling or suppressing symptoms in most cases.

Corticosteroids must be used sparingly to avoid possible side effects, the most common of which is that their prolonged use can cause the skin to thin and become fragile (atrophy). Because of this, if used on the face or other delicate skin, only a low-strength steroid should be used. Additionally, high-strength steroids used over large areas, or under occlusion, may be significantly absorbed into the body, causing hypothalamic-pituitary-adrenal axis suppression (HPA Axis suppression). Finally by their immunosuppressive action they can, if used without antibiotics or antifungal drugs, lead to some skin infections (fungal or bacterial). Care must be taken to avoid the eyes, as topical corticosteroids applied to the eye can cause glaucoma.

Because of the risks associated with this type of drug, a steroid of an appropriate strength should be sparingly applied only to control an episode of eczema. Once the desired response has been achieved, it should be discontinued and replaced with emollients as maintenance therapy. Corticosteroids are generally considered safe to use in the short- to medium-term for controlling eczema, with no significant side effects differing from treatment with non-steroidal ointment.

Oral cortisosteroids such as prednisolone may also be prescribed in severe cases; while these usually bring about rapid improvements, they should not be taken for any length of time and the eczema often returns to its previous level of severity once the medication is stopped.

Immunomodulators

Topical immunomodulators like pimecrolimus (Elidel and Douglan) and tacrolimus (Protopic) were developed after corticosteroid treatments, effectively suppressing the immune system in the affected area, and appear to yield better results in some populations. The US Food and Drug Administration has issued a public health advisory about the possible risk of lymph node or skin cancer from use of these products, but many professional medical organizations disagree with the FDA's findings;

• The postulation is that the immune system may help remove some pre-cancerous abnormal cells which is prevented by these drugs. However, any chronic inflammatory condition such as eczema, by the very nature of increased metabolism and cell replication, has a tiny associated risk of cancer (see Bowen's disease).
• Current practice by UK dermatologists is not to consider this a significant real concern and they are increasingly recommending the use of these new drugs. The dramatic improvement on the condition can significantly improve the quality of life of sufferers (and families kept awake by the distress of affected children). The major debate, in the UK, has been about the cost of such newer treatments and, given only finite NHS resources, when they are most appropriate to use.
• In addition to cancer risk, there are other potential side effects with this class of drugs. Adverse reactions including severe flushing, photosensitive reactivity and possible drug interaction in patients who consume even small amounts of alcohol.

Antibiotics

When the normal protective barrier of the skin is distrupted (dry and cracked), it allows easy entry for bacteria. Scratching by the patient both introduces infection and spreads it from one area to another. Any skin infection further irritates the skin and a rapid deterioration in the condition may ensue; the appropriate antibiotic should be given.

Immunosuppresants

When eczema is severe and does not respond to other forms of treatment, immunosuppressant drugs are sometimes prescribed. These dampen the immune system and can result in dramatic improvements to the patient's eczema. However, immunosuppresants can cause side effects on the body. As such, patients must undergo regular blood tests and be closely monitored by a doctor. In the UK, the most commonly used immunosuppressants for eczema are ciclosporin, azathioprine and methotrexate. These drugs were generally designed for other medical conditions but have been found to be effective against eczema.

Light therapy

Light therapy using ultraviolet light can help control eczema. UVA is mostly used, but UVB and Narrow Band UVB are also used. Ultraviolet light exposure carries its own risks, particularly eventual skin cancer from exposure.

When light therapy alone is found to be ineffective, the treatment is performed with the application (or ingestion) of a substance called psoralen. This PUVA (Psoralen + UVA) combination therapy is termed photo-chemotherapy. Psoralens make the skin more sensitive to UV light, thus allowing lower doses of UVA to be used. However, the increased sensitivity to UV light also puts the patient at greater risk for skin cancer.

Diet and nutrition

Recent studies provide hints that food allergy may trigger atopic dermatitis. For these people, identifying the allergens could lead to an avoidance diet to help minimize symptoms, although this approach is still in an experimental stage.

Dietary elements that have been reported to trigger eczema include dairy products and coffee (both caffeinated and decaffeinated), soybean products, eggs, nuts, wheat and maize (sweet corn), though food allergies may vary from person to person.

Alternative therapies

Non-conventional medical approaches include traditional herbal medicine and others. Patients should inform their doctor/allergist/dermatologist if they are pursuing one of these treatment routes. Patients can also wear clothing designed specifically to manage the itching, scratching and peeling associated with eczema. Sulfur has been used for many years as a treatment in the alleviation of eczema, although this could be suppressive. Many patients find that swimming in the ocean will relieve symptoms and clear up the red patchy scales. Oatmeal is a common kitchen remedy to relieve itching, and can be applied topically as a cream or, as a colloid, in the bath. Add 2tbl to a square of muslin and fasten securely with elastic band. Submerge in the bath and when the organic porridge oats are saturated, squeeze. The bath water becomes opaque with a soothing scent of oats.

Pseudoceramides

On August 27, 2007, scientists led by Jeung-Hoon Lee created in the laboratory synthetic lipids called pseudoceramides which are involved in skin cell growth and could be used in treating skin diseases such as atopic dermatitis, a form of eczema characterized by red, flaky and very itchy skin; psoriasis, a disease that causes red scaly patches on the skin; and glucocorticoid-induced epidermal atrophy, in which the skin shrinks due to skin cell loss.

Herbal Medicine

Historical sources - notably traditional Chinese medicine and Western herbalism - suggest a wide variety of treatments, each of which may vary from individual to individual as to efficacy or harm. Toxicity may be present in some. Some of these remedies are for topical use.

• Potentilla chinensis
• Aebia clematidis
• Clematis armandii
• Rehmannia glutinosa
• Paeonia lactiflora (Chinese Peony)
• Lophatherum gracile
• Dictamnus dasycarpus
• Tribulus terrestris
• Glycyrrhiza uralensis
• Glycyrrhiza glabra (Licorice)
• Schizonepeta tenuifolia (Neem)
• Schizonepeta tennuifolia
• Azadirachta indica
• Evening primrose oil
• Tea tree oil
• Burdock
• Rooibos
• Linseed oil
• Calamine
• Oatmeal
• Cod liver oil
• Neem oil
• Aloe propolis cream
• Raw goat's milk
• Grapefruit seed extract (GSE)
• Hemp cream
• Guto Kola

Behavioural approach

In the 1980's, a Swedish dermatologist (Dr Peter Noren) developed a behavioural approach to the treatment of long term atopic eczema. This approach has been further developed by a dermatologist (Dr Richard Staughton) and psychiatrist (Christopher Bridgett) at the Chelsea and Westminster Hospital in London.

Patients undergo a 6 week monitored programme involving scratch habit reversal and self awareness of scratching levels. For long term eczema sufferers, scratching can become habitual. Sometimes scratching becomes a reflex (scratching without conscious awareness), and not always from the feeling of itchiness itself. The habit reversal programme is done in conjunction with the standard applied emollient/corticosteroid treatments so that the skin can heal. It also reduces future scratching, as well as reduces the likelihood of further flareups. The behavioural approach can give an eczema sufferer some control over the degree of severity of eczema.