Atopic Dermatitis (Eczema)
Diagnosis and Treatment
Learning the cause of atopic dermatitis isn’t always easy due to the number of possible triggers and the many types of the condition. However, in all cases, a doctor will use the location of the initial rash as a first clue.
For contact dermatitis, a doctor may perform patch testing, which consists of placing small patches on the skin. These patches contain substances typically known to cause the condition. This type of testing can be difficult to interpret as doctors need to select which substances to test, and the results may not always be accurate.
With atopic dermatitis, a physician will explore your medical history and often whether your family members have allergies. This will help identify possible triggers.
For neurodermatitis, your doctor will look to discover any underlying psychological stressors, allergies, or, depending on the rash location, other underlying medical conditions, such as fungal infections, warts or psoriasis.
Although no cure exists for atopic dermatitis, a number of treatment options are available for relieving the inflammation and itching that it causes. The treatments range from lifestyle changes and skin-care strategies to medication.
Lifestyle changes and skin-care strategies
Keeping your skin hydrated is one way to control atopic dermatitis. It is best to hydrate when you wash because bathing allows rough skin to soften, take in water, and better absorb the topical treatments you apply. When bathing or showering, use lukewarm water (not hot). After bathing or showering, lightly pat your skin with a towel. Then apply your prescription ointments or creams and, once they’ve been absorbed, a good moisturizer.
There are many classes of moisturizers. The least effective are lotions or creams; the most effective moisturizers are ointments. It’s usually best to use ointment-type moisturizers during a flare-up and only after you've applied your prescription ointment. When the skin is clear, you can move back to a fragrance-free lotion.
Short, frequent, gentle bathing or showering also washes away Staphylococcus aureus, a bacterium that is found on everyone’s skin and seems to be attracted to atopic dermatitis. Some people with atopic dermatitis can also develop an allergic reaction to this bacterium, which can worsen their condition.
Preventing flare-ups is another effective way to control the condition. Here are some tips to help you to avoid triggering symptoms:
Treatments for atopic dermatitis generally fall into two categories: those that control symptoms such as itching or dryness, and those that modify the immune system or decrease inflammation. Proper skin care and over-the-counter treatments, as described above, may be enough to control mild cases of atopic dermatitis. If these fail, your doctor may prescribe a topical treatment, such as a medicated cream or ointment, for moderate atopic dermatitis, or a systemic treatment (in pill form) for severe or widespread cases.
Topical treatments (creams, lotions, ointments)
Calcineurin inhibitors are found in creams or ointments containing tacrolimus or pimecrolimus, both of which are immune-modifying drugs. These drugs work by reducing inflammation in the skin. A thin layer of the cream is applied to the affected area twice daily. To avoid rare side effects, these products should not be used continuously over a long period of time, or in children under age 2. You should also minimize exposure to natural (e.g., sunshine) and artificial (e.g., tanning beds) ultraviolet light. Common side effects include a burning feeling or warmth at the application site, which is of short duration and usually disappears after the first week of use.
Corticosteroids are synthetic versions of hormones made in the body. When applied to the skin, they reduce inflammation in the area, making them useful treatments for some forms of atopic dermatitis. Apply the cream sparingly to the affected skin with a gentle massage, 3-4 times each day. Decrease or discontinue the use once the condition is under control. Side effects include dryness, itching, burning and local irritation. Excessive use of corticosteroids (i.e., for an extended period of time over a large area of skin) may cause hormonal problems in rare cases. It is important to follow any instructions your doctor gives you.
Emollient creams/ointments are over-the-counter topical products used to soften and moisturize the skin and help preserve its function as a barrier to water loss. These products may be soothing and help remove dry, scaling skin, as well as increase the effectiveness of other topical treatments. These can be applied generously to affected and unaffected areas.
PDE4 inhibitors are enzymes that help to regulate inflammation in your body. When you have atopic dermatitis, PDE4 enzymes may be overactive in your skin cells. This can lead to inflammation of the skin. The only approved drug of this type is Eucrisa (crisaborole), the first topically applied PDE4 inhibitor to be approved by Health Canada for use for adults and kids as young as 2 years old living with atopic dermatitis. It was developed as a small-molecule, boron-based, selective PDE4 inhibitor that can be used topically. Unlike PDE4 inhibitors that act systemically, this treatment does not cause significant gastrointestinal adverse effects. The most common side effect is stinging and burning when the product is applied to the skin.
Systemic treatments (for very severe atopic dermatitis)
Corticosteroids can also be injected. When taken in this manner, they alter the body’s immune response, reducing inflammation in the skin and elsewhere. As with the topical creams, corticosteroids can cause changes in the body’s hormone production if used excessively. Your doctor will carefully plan the dosing and duration of treatment to avoid this. Less severe side effects include weight gain, nausea or vomiting.
Cyclosporin, a drug used to treat people who have had transplants, has been shown to be effective in people with severe atopic eczema, especially where their lives are significantly disrupted by their condition. The drug is believed to work by suppressing severe allergic and immune reactions. Since it is very powerful, it tends only to be prescribed for a small percentage of patients.
In addition to the medications described above, new treatments not yet on the market are being tested regularly.
Biologics (or biosimilars) are medications that are produced from living cells, such as animal cells, bacteria, or yeast. They target specific parts of a person’s immune system to treat diseases such as psoriasis, psoriatic arthritis, rheumatoid arthritis, and some cancers. People can receive biologics through an injection or an intravenous (IV) infusion. The only approved drug of this type is Dupixent (dupilumab) for adult patients living with moderate to severe atopic dermatitis. Common side effects include cold sores, dry eyes and redness at the injection site.
Medications officially approved for treating other conditions/diseases have been tried in eczema with variable success. They are included here for information only.
Phototherapy is a treatment in which the skin is exposed to ultraviolet light, slowing the growth of affected skin cells. There are two forms commonly used to treat severe atopic dermatitis :
- PUVA (psoralen/ultraviolet A): a drug called psoralen is given (either as pills or applied to the skin) that sensitizes the skin cells to ultraviolet A light. Psoralen pills can cause nausea, vomiting, headaches and sensitivity to UV light (including sunlight)
- UVB (ultraviolet B): uses ultraviolet light (B form) only
Both types of phototherapy are performed at your doctor’s office. As with repeated exposure to natural UV light from the sun, repeated use of phototherapy over a long period of time can lead to drying and ageing of the skin and may increase the risk of skin cancer.
Wet wraps incorporating an emollient (moisturizer) and a low-potency steroid are used for those with moderate-to-severe atopic dermatitis, especially children, where topical applications have not helped. Wet wraps involve double layers of tubular bandages forming a body suit. They work in three ways:
- Evaporation cools the skin, reducing itching and discomfort; the bandages need to be remoistened and not allowed to dry out
- Rehydration puts moisture back into the skin as the skin absorbs large amounts of the emollient; the skin tends to be softened as a result.
- Protection by providing a barrier to little fingers that want to scratch the skin, thus providing an opportunity for the skin to heal.
Coal tar applied to affected areas has been shown to help reduce the itchiness of atopic dermatitis. But its strong smell and tendency to stain any fabric it touches make it a less appealing remedy. Coal tar can also irritate the skin in some people. It should only be used under the guidance of a doctor with experience in managing atopic dermatitis.
*All information on medical treatments on this site is provided as an overview only. For a complete and up-to-date list of side effects, warnings and precautions, read the product’s package insert and consult your doctor or a pharmacist.
**If you are considering an alternative or complementary therapy, discuss it with your doctor first, and always be sure to keep your doctor up to date about any vitamins, supplements, or other forms of alternative treatment you are taking. Like any medication, alternative therapies can interact with other medications/treatments and, in some cases, have side effects of their own. Remember that “natural” does not necessarily mean “safe.”