Treatment is more effective when a partnership develops that includes the patient, family members, and doctor. The doctor will suggest a treatment plan based on the patient’s age, symptoms, and general health.
The patient or family member providing care plays a large role in the success of the treatment plan by carefully following the doctor’s instructions and paying attention to what is or is not helpful. Most patients will notice improvement with proper skin care and lifestyle changes.
The doctor has two main goals in treating atopic dermatitis: healing the skin and preventing flares.
These may be assisted by developing skin care routines and avoiding substances that lead to skin irritation and trigger the immune system and the itch-scratch cycle. It is important for the patient and family members to note any changes in the skin’s condition in response to treatment, and to be persistent in identifying the treatment that seems to work best.
Medications: New medications known as immunomodulators have been developed that help control inflammation and reduce immune system reactions when applied to the skin. Examples of these medications are tacrolimus ointment ( Protopic ) and pimecrolimus cream ( Elidel ). They can be used in patients older than 2 years of age and have few side effects (burning or itching the first few days of application). They not only reduce flares, but also maintain skin texture and reduce the need for long-term use of corticosteroids.
Corticosteroid creams and ointments have been used for many years to treat atopic dermatitis and other autoimmune diseases affecting the skin. Sometimes over-the-counter preparations are used, but in many cases the doctor will prescribe a stronger corticosteroid cream or ointment. When prescribing a medication, the doctor will take into account the patient’s age, location of the skin to be treated, severity of the symptoms, and type of preparation (cream or ointment) that will be most effective. Sometimes the base used in certain brands of corticosteroid creams and ointments irritates the skin of a particular patient. Side effects of repeated or long-term use of topical corticosteroids can include thinning of the skin, infections, growth suppression (in children), and stretch marks on the skin.
When topical corticosteroids are not effective, the doctor may prescribe a systemic corticosteroid, which is taken by mouth or injected instead of being applied directly to the skin.
An example of a commonly prescribed corticosteroid is prednisone. Typically, these medications are used only in resistant cases and only given for short periods of time. The side effects of systemic corticosteroids can include skin damage, thinned or weakened bones, high blood pressure, high blood sugar, infections, and cataracts. It can be dangerous to suddenly stop taking corticosteroids, so it is very important that the doctor and patient work together in changing the corticosteroid dose.
Antibiotics to treat skin infections may be applied directly to the skin in an ointment, but are usually more effective when taken by mouth. If viral or fungal infections are present, the doctor may also prescribe specific medications to treat those infections.
Certain antihistamines that cause drowsiness can reduce nighttime scratching and allow more restful sleep when taken at bedtime. This effect can be particularly helpful for patients whose nighttime scratching makes the disease worse.
In adults, drugs that suppress the immune system, such as cyclosporine, methotrexate, or azathioprine, may be prescribed to treat severe cases of atopic dermatitis that have failed to respond to other forms of therapy. These drugs block the production of some immune cells and curb the action of others. The side effects of drugs like cyclosporine can include high blood pressure, nausea, vomiting, kidney problems, headaches, tingling or numbness, and a possible increased risk of cancer and infections. There is also a risk of relapse after the drug is stopped. Because of their toxic side effects, systemic corticosteroids and immunosuppressive drugs are used only in severe cases and then for as short a period of time as possible. Patients requiring systemic corticosteroids should be referred to dermatologists or allergists specializing in the care of atopic dermatitis to help identify trigger factors and alternative therapies.
In rare cases, when home-based treatments have been unsuccessful, a patient may need a few days in the hospital for intense treatment.
Phototherapy: Use of ultraviolet A or B light waves,
alone or combined, can be an effective treatment for mild
to moderate dermatitis in older children (over 12 years
old) and adults. A combination of ultraviolet light
therapy and a drug called psoralen can also be used in
cases that are resistant to ultraviolet light alone. Possible
long-term side effects of this treatment include premature skin aging and skin cancer.
Treating Atopic Dermatitis in Infants and Children
Give lukewarm baths.
Apply lubricant immediately following the bath.
Keep child’s fingernails filed short.
Select soft cotton fabrics when choosing clothing.
Consider using sedating antihistamines to promote sleep and reduce scratching at night.
Keep the child cool; avoid situations where overheating occurs.
Learn to recognize skin infections and seek treatment promptly.
Attempt to distract the child with activities to keep him or her from scratching.
If the doctor thinks that phototherapy may be useful to treat the symptoms of atopic dermatitis, he or she will use the minimum exposure necessary and monitor the skin carefully.
Skin Care: Healing the skin and keeping it healthy are important to prevent further damage and enhance quality of life. Developing and sticking with a daily skin care routine is critical to preventing flares.
A lukewarm bath helps to cleanse and moisturize the skin without drying it excessively. Because soaps can be drying to the skin, the doctor may recommend use of a mild bar soap or nonsoap cleanser. Bath oils are not usually helpful.
After bathing, a person should air-dry the skin, or pat it dry gently (avoiding rubbing or brisk drying), and then apply a lubricant to seal in the water that has been absorbed into the skin during bathing. In addition to restoring the skin’s moisture, lubrication increases the rate of healing and establishes a barrier against further drying and irritation. Lotions that have a high water or alcohol content evaporate more quickly, and alcohol may cause stinging. Therefore, they generally are not the best choice. Creams and ointments work better at healing the skin.
Another key to protecting and restoring the skin is taking steps to avoid repeated skin infections. Signs of skin infection include tiny pustules (pus-filled bumps), oozing cracks or sores, or crusty yellow blisters. If symptoms of a skin infection develop, the doctor should be consulted and treatment should begin as soon as possible.
Protection from Allergen Exposure: The doctor may suggest reducing exposure to a suspected allergen. For example, the presence of the house dust mite can be limited by encasing mattresses and pillows in special dust-proof covers, frequently washing bedding in hot water, and removing carpeting. However, there is no way to completely rid the environment of airborne allergens.
Changing the diet may not always relieve symptoms of atopic dermatitis. A change may be helpful, however, when the medical history, laboratory studies, and specific symptoms strongly suggest a food allergy. It is up to the patient and his or her family and physician to decide whether the dietary restrictions are appropriate. Unless properly monitored by a physician or dietitian, diets with many restrictions can contribute to serious nutritional problems, especially in children.
Revision date: July 3, 2011
Last revised: by Andrew G. Epstein, M.D.