Eczema medical therapy: Difference between revisions

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__NOTOC__
{{Eczema}}
{{Eczema}}
{{CMG}}, {{AE}} [[User:Edzelco|Edzel Lorraine Co, D.M.D., M.D.]]
{{CMG}}, {{AE}} [[User:Edzelco|Edzel Lorraine Co, D.M.D., M.D.]]


==Overview==
==Overview==
[[Topical corticosteroids]] are the mainline treatment for [[eczema]]. Different potencies of steroids are rendered specifically for the severity of [[eczema]]. Other drug treatments oftenly used for [[eczema]] include [[topical calcineurin inhibitors]],[[crisaborole]], [[antimicrobials]], and [[antifungals]].
[[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==
==Medical Therapy==
===Pharmacotherapy===
===Pharmacotherapy===
====Moisturizing====
*[[Moisturizers]]
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.  
**[[Eczema]] can be exacerbated by dryness of the [[skin]].  
[[Soap]]s 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.  
**[[Moisture]] content is the main factor that determines the occurrence of [[eczema]].
** European [[emollients]] such as''Oilatum'', ''Balneum'', ''Medi Oil'', ''Diprobase'', ''Sebexol'', ''Epaderm'' [[ointment]], ''Eucerin'' lotion, bath oils and aqueous cream can relieve [[eczema]] itchiness.
** [[Topical]] application of [[sulfur]] gains popularity as an alternative treatment to steroids. However, no evidence-based publications are available yet on this matter. <ref>{{cite web |title=Sulfur |url=http://www.umm.edu/altmed/articles/000328.htm |date=4/1/2002 |publisher=University of Maryland Medical Center |accessdate=2007-10-15}}</ref>


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.
*[[Corticosteroids]]
**Mild to moderate [[eczema]] - a weak [[steroid]] may be used (e.g. [[hydrocortisone]] or [[desonide]]).
**Severe [[eczema]] - high [[potency]] [steroid]] (e.g. [[clobetasol propionate]]). <ref name="pmid11134919">{{cite journal |author=Hoare C, Li Wan Po A, Williams H |title=Systematic review of treatments for atopic eczema |journal=Health technology assessment (Winchester, England) |volume=4 |issue=37 |pages=1–191 |year=2000 |pmid=11134919 |doi=}}</ref>
**Possible side effects such as [[atrophy]] of the [[skin]] may occur if overused.<ref name="pmid14576221">{{cite journal |author=Atherton DJ |title=Topical corticosteroids in atopic dermatitis |journal=BMJ |volume=327 |issue=7421 |pages=942–3 |year=2003 |pmid=14576221 |doi=10.1136/bmj.327.7421.942 |url=http://www.bmj.com/cgi/content/full/327/7421/942}}</ref>
**Use a low [[potency]] [[steroid]] for face and other thin skin- lined areas. <ref name="Lee">{{cite journal |author=Lee NP, Arriola ER |title=Topical corticosteroids: back to basics |journal=West. J. Med. |volume=171 |issue=5-6 |pages=351–3 |year=1999 |pmid=10639873 |doi= |url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=10639873 |format="Scanned & PDF"}}</ref>


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 [[emollient|cream]]s are easy to apply, they are quickly absorbed into the skin, and therefore need frequent reapplication. [[Ointment]]s, with less water content, stay on the skin for longer and need fewer applications, but they can be greasy and inconvenient.
*[[Immunomodulators]]
** These include [[pimecrolimus]] (Elidel and Douglan) and [[tacrolimus]] (Protopic). <ref>{{cite web |author= |title=FDA Issues Public Health Advisory Informing Health Care P
*UK [[dermatologists]] recommend the use of these new drugs. <ref name=BAD2002">{{cite web |author=N H Cox and Catherine H Smith |title=Advice to dermatologists re topical tacrolimus |url=http://www.bad.org.uk/healthcare/guidelines/Advice_re_topical_tacrolimus.doc |format=DOC |year=2002 |month=December |work=Therapy Guidelines Committee |publisher=British Association of Dermatologists}}</ref>
*However, [[adverse drug reactions]] of these [[drugs]] include [[flushing]], and [[photosensitivity]]. <ref name="Martins">{{cite journal |author=Martins GA, Arruda L| title=Systemic treatment of psoriasis - Part I: methotrexate and acitretin |language=English translation |journal=An. Bras. Dermatol |year=2004 |month=June | volume=79 |issue=3 |pages=263-278 |url=http://www.anaisdedermatologia.org.br/artigo_en.php?artigo_id=159}}</ref>


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.
*[[Antibiotics]]
**Dry and cracked [[skin]] allows entry of [[bacteria]].  
**[[Skin infection]] may arise and could irritate the [[skin]].
**[[Antibiotics]] should be prescribed to cover the [[microorganism]].


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.<ref>{{cite web |title=Sulfur |url=http://www.umm.edu/altmed/articles/000328.htm |date=4/1/2002 |publisher=University of Maryland Medical Center |accessdate=2007-10-15}}</ref> Of course, if used in homeopathic doses, no actual sulphur atoms would be present.
*[[Immunosuppressants]]
 
**These work by dampening the [[immune system]] to improve [[eczema]].  
====Eczema and skin cleansers====
** Commonly used [[immunosuppressants]] for [[eczema]] include [[ciclosporin]], [[azathioprine]], and [[methotrexate]].  
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.
**Laboratory workup such as a complete [[blood test]] must be done by the [[patient]] since [[drug]] side effects may develop.
 
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, [[detergent]]s and [[soap]]s 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").<ref name="pmid15898995">{{cite journal |author=Corazza M, Virgili A |title=Allergic contact dermatitis from ophthalmic products: can pre-treatment with sodium lauryl sulfate increase patch test sensitivity? |journal=Contact Derm. |volume=52 |issue=5 |pages=239–41 |year=2005 |pmid=15898995 |doi=10.1111/j.0105-1873.2005.00606.x}}</ref>
 
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,<ref name="pmid15115531">{{cite journal |author=Murphy LA, White IR, Rastogi SC |title=Is hypoallergenic a credible term? |journal=Clin. Exp. Dermatol. |volume=29 |issue=3 |pages=325–7 |year=2004 |pmid=15115531 |doi=10.1111/j.1365-2230.2004.01521.x}}</ref> 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 drug]]s, 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]]'').
 
<!-- 'More recently, researchers have found signs that the scratching syndrome in some forms of dermatitis is enabled through itching signal transmission in the neural system.[[Dexamethasone]], [[tacrolimus]], ' - sorry don't understand this - itching is a response to a nerve signal received, in turn as a result of tissue irritation.  Was the intension to suggest that the agents listed help through a direct effect on the nerves, vs their existing known effect on tissue inflammation ?  This should be on the talk page. -->
[[Capsaicin]] applied to the skin acts as a counter irritant (see [[Gate control theory of pain|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|clobetasone butyrate]] (Eumovate) or [[Betamethasone|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.<ref name="pmid11134919">{{cite journal |author=Hoare C, Li Wan Po A, Williams H |title=Systematic review of treatments for atopic eczema |journal=Health technology assessment (Winchester, England) |volume=4 |issue=37 |pages=1–191 |year=2000 |pmid=11134919 |doi=}}</ref>
 
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]]).<ref name="pmid14576221">{{cite journal |author=Atherton DJ |title=Topical corticosteroids in atopic dermatitis |journal=BMJ |volume=327 |issue=7421 |pages=942–3 |year=2003 |pmid=14576221 |doi=10.1136/bmj.327.7421.942 |url=http://www.bmj.com/cgi/content/full/327/7421/942}}</ref> 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 [[Occlusive dressing|occlusion]], may be significantly absorbed into the body, causing [[hypothalamic-pituitary-adrenal axis]] suppression (HPA Axis suppression).<ref name="Lee">{{cite journal |author=Lee NP, Arriola ER |title=Topical corticosteroids: back to basics |journal=West. J. Med. |volume=171 |issue=5-6 |pages=351–3 |year=1999 |pmid=10639873 |doi= |url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=10639873 |format="Scanned & PDF"}}</ref>  Finally by their immunosuppressive action they can, if used without [[antibiotic]]s or [[antifungal drug]]s, lead to some skin infections ([[fungal]] or [[bacteria]]l). Care must be taken to avoid the eyes, as topical corticosteroids applied to the eye can cause [[glaucoma]].<ref>{{cite web |title= neomycin and polymyxin b sulfates and bacitracin zinc with hydrocortisone acetate (Neomycin sulfate and Polymyxin B Sulfate, Bacitracin zinc and Hydrocortisone Acetate) ointment -- Warnings|url=http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=1932#nlm34071-1| publisher=[[FDA]]}}</ref>
 
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.<ref name="pmid10354080">{{cite journal |author=Van Der Meer JB, Glazenburg EJ, Mulder PG, Eggink HF, Coenraads PJ |title=The management of moderate to severe atopic dermatitis in adults with topical fluticasone propionate. The Netherlands Adult Atopic DermatitisStudy Group |journal=Br. J. Dermatol. |volume=140 |issue=6 |pages=1114–21 |year=1999 |pmid=10354080 |doi=}}</ref>
 
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 [[immunomodulator]]s 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,<ref>{{cite web |author= |title=FDA Issues Public Health Advisory Informing Health Care Providers of Safety Concerns Associated with the Use of Two Eczema Drugs, Elidel and Protopic  |url=http://www.fda.gov/bbs/topics/ANSWERS/2005/ANS01343.html |date=March 10, 2005 |publisher=FDA |accessdate=2007-10-16}}</ref> 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.<ref name=BAD2002">{{cite web |author=N H Cox and Catherine H Smith |title=Advice to dermatologists re topical tacrolimus |url=http://www.bad.org.uk/healthcare/guidelines/Advice_re_topical_tacrolimus.doc |format=DOC |year=2002 |month=December |work=Therapy Guidelines Committee |publisher=British Association of Dermatologists}}</ref> 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.<ref>{{cite journal|author= |title=Pimecrolimus cream for atopic dermatitis |journal=Drug and Therapeutics Bulletin |date=May 2003 |volume=41 |pages=33-6 |url=http://dtb.highwire.org/cgi/content/abstract/41/5/33 |accessdate=2007-10-16}}</ref>
*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.<ref name="Martins">{{cite journal |author=Martins GA, Arruda L| title=Systemic treatment of psoriasis - Part I: methotrexate and acitretin |language=English translation |journal=An. Bras. Dermatol |year=2004 |month=June | volume=79 |issue=3 |pages=263-278 |url=http://www.anaisdedermatologia.org.br/artigo_en.php?artigo_id=159}}</ref>
 
====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===
[[Phototherapy|Light therapy]] using [[ultraviolet]] light can help control eczema.<ref name="pmid15752127">{{cite journal |author=Polderman MC, Wintzen M, le Cessie S, Pavel S |title=UVA-1 cold light therapy in the treatment of atopic dermatitis: 61 patients treated in the Leiden University Medical Center |journal=Photodermatology, photoimmunology & photomedicine |volume=21 |issue=2 |pages=93–6 |year=2005 |pmid=15752127 |doi=10.1111/j.1600-0781.2005.00150.x}}</ref> [[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.<ref>{{cite news |author=Stöppler MC |title=Psoriasis PUVA Treatment Can Increase Melanoma Risk |url=http://www.medicinenet.com/script/main/art.asp?articlekey=548 |date=31 May 2007 |publisher=MedicineNet |accessdate=2007-10-17}}</ref>
*When [[light therapy]] alone is found to be ineffective, the [[treatment]] is performed with the application (or ingestion) of a substance called [[psoralen]].  
 
*[[PUVA]] (Psoralen + UVA) combination [[therapy]] also known as [[photo-chemotherapy]] can increase the [[sensitivity]] to [[UV light]], which can lead to [[skin cancer]].<ref name="pmid11312420">{{cite journal |author=Stern RS |title=The risk of melanoma in association with long-term exposure to PUVA |journal=J. Am. Acad. Dermatol. |volume=44 |issue=5 |pages=755–61 |year=2001 |pmid=11312420 |doi=10.1067/mjd.2001.114576}}</ref>
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.<ref name="pmid11312420">{{cite journal |author=Stern RS |title=The risk of melanoma in association with long-term exposure to PUVA |journal=J. Am. Acad. Dermatol. |volume=44 |issue=5 |pages=755–61 |year=2001 |pmid=11312420 |doi=10.1067/mjd.2001.114576}}</ref>


===Diet and nutrition===
===Herbal Medicine===
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. <ref name="pmid15984300">{{cite journal |author=Kanny G |title=[Atopic dermatitis in children and food allergy: combination or causality? Should avoidance diets be initiated?] |language=French |journal=Annales de dermatologie et de vénéréologie |volume=132 Spec No 1 |issue= |pages=1S90–103 |year=2005 |pmid=15984300 |doi=}}</ref>
Some of these topical [[remedies]] include:
 
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.<ref>{{cite web |author= |title=New Skin-healing Chemicals |url=http://www.sciencedaily.com/releases/2007/08/070827184713.htm |date= August 30, 2007 |publisher=Science Daily |accessdate=2007-10-06}}</ref>
 
====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''
*''Potentilla chinensis''
*''Aebia clematidis''
*''Aebia clematidis''
Line 96: Line 46:
*''[[Rehmannia glutinosa]]''
*''[[Rehmannia glutinosa]]''
*''[[Paeonia lactiflora]]'' (Chinese Peony)
*''[[Paeonia lactiflora]]'' (Chinese Peony)
*''Schizonepeta tenuifolia'' (Neem)
*''Schizonepeta tennuifolia''
*''Lophatherum gracile''
*''Lophatherum gracile''
*''[[Calamine]]''
*''[[Oatmeal]]''
*''[[Glycyrrhiza uralensis]]''
*''[[Glycyrrhiza glabra]]'' (Licorice)
*''[[Burdock]]''
*''[[Rooibos]]''
*''Dictamnus dasycarpus''
*''Dictamnus dasycarpus''
*''[[Tribulus terrestris]]''
*''[[Tribulus terrestris]]''
*''[[Glycyrrhiza uralensis]]''
*''[[Glycyrrhiza glabra]]'' (Licorice)
*''Schizonepeta tenuifolia'' (Neem)
*''Schizonepeta tennuifolia''
*''[[Azadirachta indica]]''
*''[[Azadirachta indica]]''
*''Evening primrose oil''
*''Evening primrose oil''
*''[[Tea tree oil]]''
*''[[Tea tree oil]]''
*''[[Burdock]]''
*''[[Rooibos]]''
*''[[Linseed oil]]''
*''[[Linseed oil]]''
*''[[Calamine]]''
*''[[Oatmeal]]''
*''[[Cod liver oil]]''
*''[[Cod liver oil]]''
*''[[Neem oil]]''
*''[[Neem oil]]''
Line 119: Line 69:
*''Guto Kola''
*''Guto Kola''


===Behavioural approach===
===2014 Clinical Practice Guidelines for the Management of [[Eczema]] by American Academy of Dermatology <ref name="pmid24813302">{{cite journal| author=Eichenfield LF, Tom WL, Berger TG, Krol A, Paller AS, Schwarzenberger K | display-authors=etal| title=Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. | journal=J Am Acad Dermatol | year= 2014 | volume= 71 | issue= 1 | pages= 116-32 | pmid=24813302 | doi=10.1016/j.jaad.2014.03.023 | pmc=4326095 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24813302  }} </ref> ===
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.<ref>{{cite journal |author=Bridgett C |title=Psychodermatology and Atopic Skin Disease in London 1989-1999 - Helping Patients to Help Themselves |journal=Dermatology and Psychosomatics |volume=1 |issue=4 |year=2000}}</ref><ref name="pmid17147570">{{cite journal |author=Bridgett C |title=Psychocutaneous medicine |journal=Journal of cosmetic dermatology |volume=3 |issue=2 |pages=116 |year=2004 |pmid=17147570 |doi=10.1111/j.1473-2130.2004.00047.x}}</ref>
 
{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightCyan"| [[AAD guidelines classification scheme#Strength of Recommendation|Class A]]
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''1.'''Use of [[moisturizers]]. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: I]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''2.'''Use of [[topical corticosteroids]]. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: I]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''2a.'''Need for consideration of side effects with use. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: I]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''3.'''Use of [[topical calcineurin inhibitors]] ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: I]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''3a.'''Use as [[steroid]] sparing agents. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: I]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''3b.'''Off-label use of [[topical calcineurin inhibitors]] in those age less than 2 years. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: I]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''3c.'''Proactive use of [[topical calcineurin inhibitors]] for maintenance. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: I]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''3d.'''Routine monitoring of [[topical calcineurin inhibitors]] blood levels not needed. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: I]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''4.'''Against routine use of [[topical]] anti-''[[Staphylococcal]]'' [[treatment]]. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: I]])'' <nowiki>"</nowiki>
|}
 
 
{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightCyan"| [[AAD guidelines classification scheme#Strength of Recommendation|Class B]]
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''1.'''Application of [[moisturizers]] after bathing. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: II]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''2.'''Wet-wrap [[therapy]]. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: II]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''3.'''Frequency of application of [[topical corticosteroids]]. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: II]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''3a.'''Proactive use of [[topical corticosteroids]] for maintenance. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: II]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''3b.'''Need for monitoring for [[cutaneous]] side effects with potent [[topical corticosteroids]]. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: III]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''3c.'''Addressing fears with use. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: III]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''4.'''Counseling on local reactions with [[topical calcineurin inhibitors]] and the preceding use of [[topical corticosteroids]]. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: II]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''4a.'''Concomitant [[topical corticosteroids]] and [[topical calcineurin inhibitors]] use.''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: II]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''5.'''Bleach baths and [[intranasal]] [[mupirocin]] for those with moderate to severe [[AD]] and [[clinical infection]]. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: I]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''6.'''Against use of [[topical antihistamines]]. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: II]])'' <nowiki>"</nowiki>
|}
 
 
{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightCyan"| [[AAD guidelines classification scheme#Strength of Recommendation|Class C]]
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''1.'''Bathing and bathing practices ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: III]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''2.'''Limited use of nonsoap cleansers. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: III]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''3.'''Against use of bath additives, acidic spring water. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: III]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''4.'''Consideration of a variety of factors in [[topical corticosteroids]] selection. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: II]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''4a.'''Specific routine monitoring for [[systemic]] [[side effects]] with [[topical corticosteroids]] not needed. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: III]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''5.'''Informing [[patients]] regarding theoretical risk of [[cutaneous]] [[viral infections]] with use. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: III]])'' <nowiki>"</nowiki>


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.
|-
| bgcolor="Beige"|<nowiki>"</nowiki>'''6.'''Awareness of black-box warning of [[topical calcineurin inhibitors]]. ''([[AAD guidelines classification scheme#Strength of Recommendation|Level of Evidence: III]])'' <nowiki>"</nowiki>
|}


==References==
==References==
{{reflist|2}}
{{Reflist|2}}
[[category:Up to Date]]

Latest revision as of 18:32, 14 July 2022

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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

  • Moisturizers
    • Eczema can be exacerbated by dryness of the skin.
    • Moisture content is the main factor that determines the occurrence of eczema.
    • European emollients such asOilatum, Balneum, Medi Oil, Diprobase, Sebexol, Epaderm ointment, Eucerin lotion, bath oils and aqueous cream can relieve eczema itchiness.
    • Topical application of sulfur gains popularity as an alternative treatment to steroids. However, no evidence-based publications are available yet on this matter. [1]

Light therapy

Herbal Medicine

Some of these topical remedies include:

2014 Clinical Practice Guidelines for the Management of Eczema by American Academy of Dermatology [7]

Class A
"1.Use of moisturizers. (Level of Evidence: I) "
"2.Use of topical corticosteroids. (Level of Evidence: I) "
"2a.Need for consideration of side effects with use. (Level of Evidence: I) "
"3.Use of topical calcineurin inhibitors (Level of Evidence: I) "
"3a.Use as steroid sparing agents. (Level of Evidence: I) "
"3b.Off-label use of topical calcineurin inhibitors in those age less than 2 years. (Level of Evidence: I) "
"3c.Proactive use of topical calcineurin inhibitors for maintenance. (Level of Evidence: I) "
"3d.Routine monitoring of topical calcineurin inhibitors blood levels not needed. (Level of Evidence: I) "
"4.Against routine use of topical anti-Staphylococcal treatment. (Level of Evidence: I) "


Class B
"1.Application of moisturizers after bathing. (Level of Evidence: II) "
"2.Wet-wrap therapy. (Level of Evidence: II) "
"3.Frequency of application of topical corticosteroids. (Level of Evidence: II) "
"3a.Proactive use of topical corticosteroids for maintenance. (Level of Evidence: II) "
"3b.Need for monitoring for cutaneous side effects with potent topical corticosteroids. (Level of Evidence: III) "
"3c.Addressing fears with use. (Level of Evidence: III) "
"4.Counseling on local reactions with topical calcineurin inhibitors and the preceding use of topical corticosteroids. (Level of Evidence: II) "
"4a.Concomitant topical corticosteroids and topical calcineurin inhibitors use.(Level of Evidence: II) "
"5.Bleach baths and intranasal mupirocin for those with moderate to severe AD and clinical infection. (Level of Evidence: I) "
"6.Against use of topical antihistamines. (Level of Evidence: II) "


Class C
"1.Bathing and bathing practices (Level of Evidence: III) "
"2.Limited use of nonsoap cleansers. (Level of Evidence: III) "
"3.Against use of bath additives, acidic spring water. (Level of Evidence: III) "
"4.Consideration of a variety of factors in topical corticosteroids selection. (Level of Evidence: II) "
"4a.Specific routine monitoring for systemic side effects with topical corticosteroids not needed. (Level of Evidence: III) "
"5.Informing patients regarding theoretical risk of cutaneous viral infections with use. (Level of Evidence: III) "
"6.Awareness of black-box warning of topical calcineurin inhibitors. (Level of Evidence: III) "

References

  1. ↑ "Sulfur". University of Maryland Medical Center. 4/1/2002. Retrieved 2007-10-15. Check date values in: |date= (help)
  2. ↑ Hoare C, Li Wan Po A, Williams H (2000). "Systematic review of treatments for atopic eczema". Health technology assessment (Winchester, England). 4 (37): 1–191. PMID 11134919.
  3. ↑ Atherton DJ (2003). "Topical corticosteroids in atopic dermatitis". BMJ. 327 (7421): 942–3. doi:10.1136/bmj.327.7421.942. PMID 14576221.
  4. ↑ Lee NP, Arriola ER (1999). "Topical corticosteroids: back to basics" ("Scanned & PDF"). West. J. Med. 171 (5–6): 351–3. PMID 10639873.
  5. ↑ Martins GA, Arruda L (2004). "Systemic treatment of psoriasis - Part I: methotrexate and acitretin". An. Bras. Dermatol (in English translation). 79 (3): 263–278. Unknown parameter |month= ignored (help)
  6. ↑ Stern RS (2001). "The risk of melanoma in association with long-term exposure to PUVA". J. Am. Acad. Dermatol. 44 (5): 755–61. doi:10.1067/mjd.2001.114576. PMID 11312420.
  7. ↑ Eichenfield LF, Tom WL, Berger TG, Krol A, Paller AS, Schwarzenberger K; et al. (2014). "Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies". J Am Acad Dermatol. 71 (1): 116–32. doi:10.1016/j.jaad.2014.03.023. PMC 4326095. PMID 24813302.
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