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1. Introduction
2. Pathogenesis
3. ClinicalFeatures
4. History
5. Diagnosis
Management of Atopic Dermatitis
a.) Avoidance of precipitating factors
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The first step in management is identification and avoidance as far as is possible of “trigger” factors of atopic eczema. Where stress might be a precipitating factor, stress management must be taught and family therapy instituted. Hospitalisation for brief periods (removes patient from daily stresses or environmental factors) may also be helpful. Patients with severe atopic dermatitis should ideally avoid stressful occupations (e.g. police work, nursing, etc) and be advised against choosing careers or jobs which will expose them to wet, messy conditions e.g. hairdressing, motor mechanics and laboratory technology.
b.) Treatment with Corticosteroids
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Topical steroid therapy remains the mainstay of treatment in atopic eczema. The relative potency of topical steroids is listed in Table 2. In general, use the least potent steroid that controls the patient’s symptoms in order to minimise side effects. Used correctly, topical steroids will usually suffice for lesions on the trunk and limbs, and 1% hydrocortisone for the face. In small children only 1% hydrocortisone or dilute strengths (e.g. 10%) of the mid-potency steroids should be used. Occasionally, more potent steroids are required to suppress acute exacerbations and for treatment of lichenified lesions. Strong steroids should be used for short periods only, but never on the face or delicate flexures because of the risk of side effects (e.g. skin atrophy, striae and steroid rosacea, hypothalamic-pituitary adrenal suppression and Cushing’s syndrome due to systemic absorption). The choice of cream or ointment is also important. Cream bases are more acceptable to certain patients, e.g. in warm, humid conditions, though they tend to dry the skin; ointment bases, which are greasy, are more suitable as they lubricate dry skin. In general, oral corticosteroids should be avoided when treating atopic eczema because it is difficult to wean patients off these drugs and tolerance may develop.
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Tar is a traditional remedy for atopic dermatitis and relatively safer than topical corticosteroids. Pastes containing tar are applied under stockinette; for the limbs, tar paste bandages are a suitable alternative. Tar preparations are highly effective for lichenified lesions. Drawbacks of tar are its unpleasant odour and tendency to irritate dry skin.
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Emollients are an essential form of treatment. They should be applied frequently, as a soap substitute, bath additive or applied to the whole body while still wet after a bath. This helps to lubricate dry skin. The choice of cream or ointment depends on the patient’s preference. Ointments e.g. emulsifying ointment have the advantage of lasting longer than creams but may not be favoured by some because they are greasy. Creams e.g. aqueous cream and E45 are less greasy but need to be applied more frequently.
d.) Treatment with Evening Primrose Oil
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Evening primrose oil (Epogam®) is one of the most controversial therapies of recent years. Some clinicians believe it has no value but proponents of this treatment claim that primrose oil may be of benefit (may improve dryness and itching) as adjunct treatment in selected patients with atopic eczema. Determining which patients might benefit is a costly exercise. Adults need eight to 12 capsules a day for 6-10 weeks to assess efficacy. The treatment is not cost-effective for patients with mild eczema.
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Choice of antibiotic treatment for infected eczema is easy. About 95% of infected lesions are colonised by S. Aureus, the remainder by streptococci or both organisms together.
For minor or localised lesions apply antiseptics e.g. betadine, two to three times a day. Mupirocin (Bactroban®) 2% ointment can be used as an alternative to betadine. However, bacterial resistance has been reported during eczema treatment with this agent and thus it should not be routinely used for prolonged periods. Mupirocin should be used with caution in infants because of a risk of renal toxicity if this agent is applied to extensive surface areas. Parents may use mupirocin on a trial basis as the sole agent in very localised secondary infections. For more widespread or severe infection betadine paste dressings can be applied daily and an antibiotic should be prescribed. Erythromycin is probably the antibiotic of choice, though staphylococci may be resistant to this drug. The second choice would be flucloxacillin. Cefadroxil and the newer macrolides (clarithromycin and azithromycin) may be used as alternative to flucloxacillin. These newer drugs require less frequent dosage and shorter courses but are more expensive than fludoxacillin or erythromycin. Recurrent infection may be prevented by using antiseptics e.g. potassium permanganate in the patient’s bath water or low-doses of antibiotics for a prolonged period. Failure to treat an infective component is one of the most common reasons for failed treatment in atopic eczema.For localised herpes simplex lesions use topical antiseptic treatment to prevent secondary bacterial infection. In patients with eczema herpeticum treatment with acyclovir, orally or intravenously, is usually necessary.
f) Treatment with Chinese Herbs
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Chinese herbs is another area of controversy, partly because their pharmacology is not clear, but there are anecdotal reports of some excellent responses. Traditionally, each patient is assessed and treated with an individual herb mixture. However, collaborative studies between Western dematologists and Chinese practitioners are in progress in an attempt to create a standardised preparation based on some of the most frequently used herbs. Cases of severe hepatoxicity have been reported after herbal medicines, even when used responsibly.
g.) Treatment of Chronic, Severe
and Unresponsive Atopic Dermatitis
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A vast majority of patients will respond to the measures previously described, but some have recalcitrant atopic eczema which defies all conventional treatment. These patients are usually greatly incapacitated by their disease and cannot lead a normal life. Patients with recalcitrant eczema must be referred to a dermatologist as they may require hospitalization or highly-specialised forms of treatment (e.g. UV therapy, immunosuppressive therapy).
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A simple explanation of the nature of eczema (including prognosis) and key advice on its management should be discussed with patients and/or parents (Table 3). General measures which may be applied to reduce pruritis (Table 4) and great emphasis must be placed on the role of emollients including a demonstration of their application. Potency and side-effects of topical steroids must also be discussed. Simple dressing techniques should be demonstrated, including the application of paste bandages (wet wraps). Parents should be advised that skin problems do promote taunts from fellow school children, that occasionally children with eczema have to attend with bandaging, and that both these situations should be anticipated and dealt with by the teacher. It should be emphasised that the condition is not contagious. Written information on eczema and instructions on treatment must also be given.
Table 3
Key advice on eczema management
- Protection against scratching
- Functions of creams, ointments and bandages
- Correct and appropriate use of creams, ointments and bandages
- Care of the home to reduce environmental risk of eczema ‘flare-up’
- Appropriate clothing
- Use and effects of antihistamines
- Sunlight and eczema (eg. on holidays and while swimming)
- Bathing/showering
- Effects of eczema on the family
- Elimination diets (may be relevant in infants)
Table 4
Suggested general measures to reduce pruritus and scratching
- Finger nails should be trimmed short. Cotton gloves may be worn at night.
- Bath in tepid water, avoid soap and pat dry with soft absorbant towel.
- Avoid woollen and acrylic clothing. Loose cotton clothes and blankets are recommended.
- Clothes should be washed with enzyme-free washing powders and doubly rinsed to remove all residual detergent.
- Keep bedroom cool.