Treatment option of Eczema
Atopic dermatitis is not curable but it can be controlled. To manage it, we need medications and must avoid triggers.
Most doctors use antihistamines to minimize itching and topucal steroids to control skin inflammation. To manage atopic dermatitis well, we need to minimize exposure to allergens, to avoid irritating factors, to learn to care for our skin and keep it hydrated, and to follow the prescription when using drugs.
In other words, the principles of eczema care are as follows:
- Avoid exacerbating factors
- Proper skin care. Keep skin hydrated.
- Treat secondary infection early
- Treat exacerbations by appropriate topical steroids
Skin care (Emollient therapy and skin care)
Cleansing and bathing
- The skin must be cleansed thoroughly, but gently and carefully to get rid of crusts and mechanically eliminate bacterial contaminants in the case of bacterial super-infection.
- Cleansers with or without antiseptics (the duration of action of antiseptics is very limited, thus mechanical cleansing is probably more important) in nonirritant and low allergen formulas available in various galenic forms (syndets, aqueous solutions) may be used.
- For infants, it is easier to perform this first stage of gentle cleansing of skin on the nappy mattress rather than directly in the bathtub. A further cleansing followed by a rapid rinse is performed in the bath (27–30 C).
- Regarding cleansing, many people believe that hot water can relieve itchiness. But this is wrong. In fact, hot water will wash away natural oils, and the moisture in the skin will go away even sooner, making the skin drier and the condition of eczema worse. Having showers for too long or too frequently will lead to the same problem. To avoid skin dehydration, the bath should be of short duration (only 5 min). Use bath oils at the end (last 2 minutes of bathing).For patients with severe condition, they may choose to take a shower every other day. The shorter the bath duration, the better it is. Water should not be over 40 degree.
- European dermatologists recommended in 2012 the use of bleach water during bath to inhibit bacteria. Adding half a cup of Sodium hypochlorite (bleach water) to a full standard bath tub of water has been shown to reduce eczema related itching in children.
- Salt baths may be beneficial when skin becomes scale-like by removing the dead keratolytic material.
Use of Emollients
Dry skin is one of the main symptoms of eczema; inflammation will follow if the skin barrier is broken. Emollient therapy is the mainstay of maintenance therapy in eczema treatment. It softens the skin, aid in restoring the impaired barrier function of the epidermis, reduce the itch of dry skin, increase the efficacy of topical corticosteroids and have a steroid sparing action. Emollients replace the natural surface oils which tend to be deficient in atopic eczema and which are essential both in preventing irritant materials, infection and allergy- inducing substances from entering the skin and water from leaving the skin. However, one has to bear in mind that the direct use of emollients on inflamed skin is poorly tolerated. So, it is important to treat the acute flare first.
- For maintenance therapy, hydration of the skin is usually maintained by at least twice daily application of moisturizers with a hydrophilic base, e.g. 5% urea.
- The use of barrier ointments, bath oil, shower gel, emulsions or micellar solutions enhancing the barrier effect is also recommended. No matter what preparation, choose high-quality ones, i.e. those low in contact allergens and expect a high consumption (sometimes up to 150-250g per week in young children, up to 500 g in adults). Many patients underestimate the quantity needed and frequency of application to achieve maximal effect.
- Continual treatment with complete emollient therapy (combinations of cream, ointment, bath oil and emollient soap substitute) will help provide maximal effect.
- Topical emollients are usually applied directly after a bath or a shower following gentle drying when the skin is still slightly humid. Use a full cotton towel to dry the skin. Be gentle when drying.
- In winter time more lipid ingredients are preferable. Glycerol seems better tolerated than urea plus sodium chloride. For children aged less than 2 years, propylene glycol and emollients containing allergens such as peanut or oat should be avoided as they are irritating to skin and may increase the risk of skin sensitization and allergy.
- Crude lanolin is a weak sensitizer. However, the sensitizing potential of hypoallergenic ultra-purified lanolin has been shown to be minimal.
- The emollient should be applied smoothly in the general direction of growth of body hair in order to prevent accumulation at hair bases which might predispose to folliculitis.
- Emollients can become contaminated with bacteria. The use of pump dispensers minimizes the risk of microbial contamination. If the emollient is in a pot the required amount should be removed with a clean spoon or spatula. Fingers should not be inserted into pots. Emollients should not be shared with others.
- Even when eczema is under control, emollients need to be applied regularly onto dry skin.
- Intensive use of emollients will reduce the need for topical steroids. The quantity and frequency of use of emollients should be far greater than that of other therapies given.
- A general rule of thumb is that emollient use should exceed steroid use by 10: 1 in terms of quantities used for most patients.
- However, sole use of emollients without sufficient topical anti-inflammatory therapy involves a considerable risk for disseminated bacterial and viral infection, which is already increased in atopic eczema patients.
- An additional approach by adding a local anaesthetic agent such as lauromacrogols to the emollient may help break the scatch-itch cycle. (Keep nails short!)
- The addition of an antiseptic to a bath emollient may reduce bacterial infection and colonization but it should not be used regularly unless the infection is widespread or recurrent to minimize the risk of resistance, according to UK expert guideline in 2009.
Table 2: Types of emollient products
|Emollient creams and ointments||These products are designed to be left on the skin. Creams soak into the skin faster than ointments.|
|Emollient soap substitutes||These products contain emollient ingredients with very mild emulsifiers. They are used instead of soap and other detergents.|
|Emollient semidispersing bath oils||These contain oils and emulsifiers that disperse the oil in the water. This combination has a cleansing effect if gently rubbed over the skin.|
|Non-dispersing emollient bath oils||These products contain oils with no emulsifying agent. The oil forms a layer on the surface of the water which is deposited on the skin on getting out of the bath.|
|Adjuvant emollient products||Some emollient products contain additional ingredient s such as antipruritics and antiseptics.|
Dressings and wet wrap treatment
A number of dressings can be used in the management of atopic eczema. It depends on the doctors’ recommendation.
Table 3; Dressings used in the management of atopic eczema
|Type of dressing||Method used|
|Dry wrap dressings||
Open-weave tubular bandage or crepe bandage used as a protective dressing e.g. to keep greasy moisturizers in place.
Patients with non-infected moderate to severe eczema may under the advice of doctor cover affected areas with dry wrap dressings to provide a physical barrier to scratching and improve retention of emollient.
|Occlusive/ semi- occlusive dressings||These include vapour-permeable films and membranes and hydrocolloid dressings. They can be used over topical preparations. Nappies, sleep suits and pyjamas may have an occlusive effect and enhance skin penetration of topical preparations.|
Sometimes, cotton bandages impregnated with a variety of drugs are used. They are applied in a special spiraling fashion. Another outer bandage is applied to keep the layers in place.
These bandages can only be used on the limbs. They cannot be applied to the trunk and face as they may tighten as they dry.
The conditions of eczema vary from one person to another. Depending on the conditions, doctors may use different medications. But topical steroids are mainly prescribed.
Steroid cream is used as a first line of treatment. It suppresses skin immunity and balances skin cells. There are many types of steroid cream, some stronger and some weaker. The type of cream depends on the conditions of a patient. Steroid cream should not be applied to festered or infected skin as this will delay healing of the affected areas. Long-term use of steroid cream may produce side effects. The stronger the cream is, the more serious the side effects will be. Since skin thickness varies throughout the body, which affects the level of penetration of the medications, it is important to choose steroid medications carefully. Many parents are afraid of the use of steroids. In spite of the side effects, steroids are the most effective medications. The application and side effects depend on the type, the quantity used and the location of application. Side effects can be minimized if the right steroid cream is chosen and used as instructed. If needed, it should be used sooner as it can reduce inflammation effectively. Delayed treatment may increase the dose or lengthen the course of treatment.
Apart from steroid cream, topical calcineurin inhibitors may also reduce the allergic reactions of the immunity system. Patients over 2 years old may use it. It is especially useful for patients who find steroid cream ineffective or when the side effects of steroid cream are too severe. This inhibitor is more costly and must be prescribed by specialists.
Under very special circumstances (severe and acute outbreaks), doctors may prescribe a short course of oral steroids which reduces inflammation and stops itching quickly. Long-term use of oral steroids is only for patients with general severe conditions. Since steroids suppress the immunity system, those who use the drug may experience virus, bacteria, or fungal infections more easily.
If there is liquid coming out from the skin, doctors will use potassium permanganate to sterilize and dry the wounds. In case of infections, antibiotics will be used.
It is important not to scratch and hurt the skin. If an infected area is hurt, doctor may prescribe antibiotics cream. The external use of the cream can prevent the skin from being infected by bacteria. In severe cases, oral antibiotics may be prescribed. Antihistamines may be used to relieve itchiness during outbreaks; this can stop the patients from scratching the itchy areas. But they have side effects such as drowsiness and dry mouth. Take note of that when using this drug.
If untreated, the areas affected by atopic dermatitis will continue to be itchy. Scratching will damage the skin and lead to secondary bacterial infections. It will also affect the quality of sleep. The skin will become thicker if it is scratched persistently. Young patients may be ridiculed by other children or adults and they may become unsettled. It is important for eczema patients to see a doctor and follow the medical advice given.