Eczema Essentials: More than Skin Deep

Although eczema is not curable, it is controllable.

More than 30 million Americans have eczema (atopic dermatitis),¹ and the incidence is increasing.² According to the Centers for Disease Control and Prevention, eczema in children nearly doubled between 2000 and 2010.³

Eczema is characterized by itching, redness, papules/vesicles, crusts or lichenifications, spongiosis, keratosis, and skin thickening.⁴ It is neither contagious nor curable, but it is controllable.^1,4 Management is challenging, however, trying to control acute symptoms and prevent flares while avoiding adverse effects (AEs).⁴ Topical corticosteroids (TCs) are the mainstay of pharmacologic treatment, but calcineurin antagonists may be preferred for certain applications.⁴ Liberal use of moisturizers is universally recommended,⁵ and multiple topicals with different mechanisms of action may be used concomitantly.⁵ Systemic treatment is generally reserved for severe or difficultto- treat cases.⁴ The American Academy of Dermatology notes that clinical judgment needs to be used, as there is still much to be discovered.⁵

Hydrating the Skin

A dysfunctional epidermal barrier is a key eczema feature.^4,5 Moisturizers can be the primary treatment for mild disease and should be part of all regimens.⁷ They improve hydration and decrease both irritation and the need for prescription medications.⁵ Ideal amounts and frequencies have not been studied, but regular and generous application is generally recommended.⁵ Prescription emollients, such as Biafine, Kerol, and EpiCeram, mimic natural compounds; they have a structural role as a skin barrier rather than a pharmacologic effect.⁵

Bathing is both treatment and maintenance. Although it can hydrate and remove irritants, water evaporation may cause greater moisture loss. It is not clear if baths or showers are better.⁵ Bleach baths may help, and do not cause antibiotic resistance.⁵ Wet wraps, which can be worn up to 24 hours, decrease flares and are well tolerated.^4,5 Instruct patients to towel dry.⁵

Topical Corticosteroids Are the Gold Standard

TCs are the mainstay of therapy; they suppress inflammation and relieve itching, and may be needed for months or even years.^4-6 Patients often have fear or anxiety associated with using TCs, particularly regarding skin thinning, systemic absorption, and effects on growth and development.⁶ Over 70% of patients expressed concern, and 24% admitted nonadherence because of those concerns, according to study results.^5,6 A common misconception is that TCs are the same as anabolic or oral steroids.⁶ Addressing concerns with facts may improve adherence and efficacy.⁵

TCs come in a wide variety of potencies and formulations (Online Table 1) and can be applied to inflamed skin as needed.^4,5,7 There is no clear superior agent or regimen, and quantities and frequencies of use are highly varied. Sometimes a short course of a high-potency agent with a quick taper is used; other times, a low-potency agent is used first and dosing is increased or a stronger agent is used, as needed. During severe flares, short courses of mid-or high-potency TCs can provide rapid relief, but less potent agents are preferred for long-term treatment. ⁵ Twice-daily dosing is most common,⁷ but once-daily dosages may be just as effective.⁵ More frequent administration does not improve efficacy.⁷ Pulse application of potent agents (eg, only weekends, every other week), drug holidays, and use of steroid-sparing drugs may decrease systemic effects.⁸

Table 1: Relative Potencies of Topical Corticosteroids

Lowest Potency (VII)

Mild (VI)

Lower Mid-strength (V)

Mid-strength (IV)

Upper Mid-strength (III)

Potent (II)

Superpotent (I)

Dexamethasone cream 0.01%

Alclometasone ointment, cream 0.05% (Aclovate)

Betamethasone dipropionate lotion 0.05% (Diprosone, Maxivate)

Fluocinolone ointment 0.025% (Synalar)

Amcinonide 0.1% cream or lotion (Cyclocort)

Amcinonide 0.1% ointment, lotion, cream (Cyclocort)

Betamethasone dipropionate ointment and cream 0.05% (Diprolene, Diprosone)

Hydrocortisone acetate 0.5%-2.5% (Hytone, Cortaid, etc)

Betamethasone valerate lotion 0.05% (Valisone)

Betamethasone valerate cream, lotion 0.01% (Valisone)

Flurandrenolide ointment 0.05% (Cordran)

Mometasone ointment 0.1% (Elocon)

Desoximetasone cream or ointment 0.25%, or gel 0.05% (Topicort, Ibaril)

Clobetasol ointment, cream 0.05% (Temovate, Clobex, Cormax, Embeline, Olux)

Methylprednisolone 1%

Desonide cream 0.05% (Desowen, Verdeso, Desonate)

Fluocinolone oil 0.01% (Derma-Smoothe)

Halcinonide cream 0.025% (Halog)

Betamethasone valerate ointment, foam 0.1% (Valisone, Luxiq 0.12%)

Diflorasone ointment 0.05% (Florone)

Diflorasone ointment 0.05% (Psorcon)

Prednisolone

Fluocinolone cream, solution 0.01% (Synalar, Derma-Smoothe)

Flurandrenolide cream 0.05% (Cordran)

Hydrocortisone valerate ointment 0.2% (Westcort)

Diflorasone cream 0.05% (Florone, Psorcon)

Fluocinonide ointment, cream, gel 0.05% (Lidex)

Halobetasol ointment, cream 0.05% (Ultravate)

Fluticasone cream 0.05% (Cutivate)

Mometasone cream, lotion 0.1% (Elocon)

Fluticasone ointment 0.005% (Cutivate)

Halcinonide cream, ointment, shampoo 0.1% (Halog)

Fluocinonide cream 0.1% (Lidex)

Hydrocortisone butyrate cream, ointment, gel 0.1% (Locoid)

Triamcinolone ointment 0.1% (Kenalog, Aristocort)

Fluocinonide cream 0.05% (Lidex)

Triamcinolone ointment 0.5% (Kenalog)

Desonide ointment 0.05% (Desowen)

Fluocinolone cream 0.025% (Synalar)

Triamcinolone ointment, cream 0.1% (Aristocort)

Prednicarbate cream 0.1% (Dermatop)

Hydrocortisone valerate cream 0.2% (Westcort)

Triamcinolone cream 0.05% (Aristocort)

Fluocinolone cream 0.025% (Synalar, Derma-Smoothe)

Desoximetasone emollient cream 0.25% (Topicort)

Desoximetasone Cream 0.05% (Topicort)

Triamcinolone lotion, cream 0.1% (Kenalog)

Betamethasone valerate lotion 0.01% (Valisone, Luxiq)

Triamcinolone diacetate cream 0.1% (Aristocort)

^{Adapted from references 5, 10, 11, 14.}

AEs such as atrophy, striae, telangiectasia, purpura, blanching, acneiform and rosacea-like eruptions, and abnormal hair growth are related to potency, amount used, duration of use, patient age, occlusive dressing use, administration vehicle, and addition of other forms of corticosteroids (inhaled, intranasal, and systemic).^5,7,8 Skin thinning is more likely with higher-potency medications, the use of occlusive dressings, and use on thinner skin (such as with elderly patients).^5,8 Potent or very potent TCs are more likely to decrease adrenal function; however, faster restoration of skin integrity decreases systemic effects.⁴ Pituitary suppression is low, and hyperglycemia and hypertension are rare.⁵ Cushing’s symptoms are also rare, and mostly reported in infants.⁸ Effects on children’s final height are not clear at this time.⁵ Cataracts and glaucoma have been reported with systemic steroid use, but have not been noted with topical corticosteroids.⁵ Contact dermatitis may occur with TC use^7,9; consider the possibility if patients are not getting relief, particularly if the application area does not heal or worsens.⁹ Inactive ingredients (particularly propylene glycol or preservatives) may be to blame.⁵ AEs are mostly reversible (within months) with discontinuation of TCs,⁵ with the exception of striae.⁷ Rebound dermatitis has been reported with abrupt discontinuation.⁷

Itch is the primary symptom used to evaluate the success of TCs; do not taper therapy until itching has resolved. To avoid rebound, taper gradually by reducing the frequency and/or the potency of the TC used.⁴

Calcineurin Inhibitors

Topical calcineurin inhibitors, tacrolimus (Protopic) and pimecrolimus (Elidel), are second-line options; they reduce flares and the need for TCs.^4,5,10,11 Tacrolimus 0.03% or pimecrolimus can be used in children as young as 2 years.^10,11 Tacrolimus 0.1% is the most efficacious⁵—it is on par with a medium-potency TC—but is only approved for patients 15 years and older.10

Stinging and burning are common AEs, but lessen after several applications.⁵ They also do not cause skin atrophy.⁵ Cancers were rarely reported, and causality is unclear.^5,10,11

Other Topical Medications

Infections may trigger inflammation and additional skin damage.⁵ Up to 90% of patients with eczema have Staphylococcus aureus; treatment may improve symptoms, but will not cure eczema.⁴ A 2010 Cochrane review did not find clear benefits to using topical antibiotics, antiseptics, antibacterial soaps, or bath additives.⁵ Topical antihistamines, however, may provide temporary itch relief.⁵ Topical antistaphylococcals are of questionable value.⁵ Coal tar products work for other inflammatory skin diseases, but efficacy in eczema is unknown.⁵

Systemic Treatment

Although systemic antihistamines are commonly used for itching, sedating antihistamines may be preferred because they may improve the amount of sleep patients can get. Newer nonsedating antihistamines have not showed much effect on eczema.⁴ Systemic corticosteroids work quickly, but use is limited to a few weeks to avoid AEs. Cyclosporine also works quickly, but has a narrow therapeutic index, and close monitoring for renal dysfunction is needed. Azathioprine works slowly and may not be well tolerated. Mycophenolate (Cellcept) and methotrexate lack efficacy data.⁴ Small trials of probiotics showed some efficacy in children.^12,13 See Online Table 2 for the pros and cons of various eczema treatments.

Table 2: Quick Facts on Eczema Therapy

Type of Treatment

Pros

Cons

Practice Points

Bathing

Inexpensive; safe

Temporary; time-consuming; soap can be drying/irritating

Bathe once a day, at most; short duration (5 to 10 min); use warm water

Towel dry; use moisturizers soon after

Use hypoallergenic, fragrance-free cleaners

Adding oils, emollients, or other additives to the bath hold unknown value

Phototherapy

Very effective

Slow; time-consuming

Avoidance

Effective; safe

Difficult to adhere to

Avoid tight or very warm clothes/bedding

Keep bedroom temperatures low

Avoid soft toys that cannot be washed

Wash sheets in hot water regularly

Avoid furry pets

Keep windows closed during peak pollen season

If exercise causes flares, slowly increase the level of exertion

If exacerbated by stress, consider counseling

Moisturizers

Safe; effective

Require frequent application

Ointments can be too greasy

Lotions evaporate quickly

Increase use in cold weather

Apply 15 min before anti-inflammatories

Topical corticosteroids

Safe; effective

May require long-term use

Adverse effects (AEs) are related to potency, amount used, frequency, and duration

Use lowest strength and/or shortest duration

Always apply to hydrated skin

An “adult fingertipful”—the amount that fits from the fingertip to the first joint, or about half of 1 g—should cover an area about the size of 2 adult palms

Topical calcineurin inhibitors

Fewer AEs than corticosteroids

Little data on use with corticosteroids

No long-term safety data

Cancer risk

Apply a thin layer twice daily

Twice-daily dosing is significantly more effective than once-a-day dosing

Avoid in immunocompromised patients

Do not use with light therapy

Systemic therapy

Sedating antihistamines improve sleep

Lack of efficacy data for most agents

Nonsedating antihistamines do not have much effect

If needed, corticosteroids can be cross-tapered

Other

Vaccination is safe

Viral infections are common

Clean skin at injection site well

Untreated patients have more infections than those on corticosteroids or calcineurin inhibitors

Silver-impregnated underwear is no better than cotton underwear

It is unclear if antimicrobial silk underwear helps

^{Adapted from references 3-5, 7, 10, 11.}

Other Options

Light influences immune function and has an antimicrobial effect; most patients improve with increased sun exposure.⁴ Phototherapy helps up to 70% of patients, but requires 2 or 3 office visits a week and can take up to 2 months before any improvement is seen.¹ Risks include burns, skin aging, and skin cancer.¹

Environmental allergens, such as food, inhalants (including tobacco), and chemicals, may affect the disease course of eczema. Common contact sensitizers include metals, fragrances, neomycin, and lanolin. Allergy testing and immunotherapy may be helpful.⁴

A multidisciplinary approach involving dermatologists, pediatricians, and psychological and dietary counseling has been shown to be very effective in improving treatment and quality-of-life issues related to eczema. Educating patients may be time-consuming, but is very important. Patient fears of treatment need to be taken seriously; a professional attitude and recognizing patient beliefs about the causes of flare-ups can help with medication adherence.⁴

Debra Freiheit has been a practicing pharmacist and human services professional for over 25 years. Specializing in medical information, she has obtained a broad spectrum of experience through research for companies including Cerner and PPD, Inc. With an emphasis on clear and concise information transfer, she has built a career communicating data with medical professionals and patients. Education and knowledge have motivated her rich career of caregiving through research. Debra’s current project involves the creation of a multinational database of drug information.

References

• Eczema. National Eczema Association website. http://nationaleczema.org/eczema/. Accessed February 17, 2015.
• Madhok V, Futamura M, Thomas KS, Barbarot S. What's new in atopic eczema? An analysis of systematic reviews published in 2012 and 2013. Part 1. Epidemiology, mechanisms of disease and methodological issues. Clin Exp Dermatol 2015;40(3):238-242. doi: 10.1111/ced.12578.
• Morbidity and Mortality Weekly Report. QuickStats: percentage of children aged ≤17 years with eczema or any kind of skin allergy, by selected races/ethnicities—National Health Interview Survey, United States, 2000-2010. Centers for Disease Control website. www.cdc.gov/mmwr/preview/mmwrhtml/mm6044a9.htm. Accessed February 17, 2015.
• Darsow U, Wollenberg A, Simon D, et al; European Task Force on Atopic Dermatitis/EADV Eczema Task Force. ETFAD/EADV eczema task force 2009 position paper on diagnosis and treatment of atopic dermatitis. J Eur Acad Dermatol Venereol. 2010;24(3):317-328. doi: 10.1111/j.1468-3083.2009.03415.x.
• Eichenfield LF, Wynnis LT, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014;71(1):116-132. doi: 10.1016/j.jaad.2014.03.023.
• Charman CR, Morris AD, Williams HC. Topical corticosteroid phobia in patients with atopic eczema. Br J Dermatol. 2000;142(5): 931-936.
• Rathi SK, D’Souza P. Rational and ethical use of topical corticosteroids based on safety and efficacy. Indian J Dermatol. 2012;57(4):251-259. doi:10.4103/0019-5154.97655.
• Nieman LK. Consequences of systemic absorption of topical glucocorticoids. J Am Acad Dermatol. 2011;65(1):250-252. doi:10.1016/j.jaad.2010.12.037.
• Jacob SE, Steele T. Corticosteroid classes: A quick reference guide including patch test substances and cross-reactivity. J Am Acad Dermatol. 2006;54(4):723-727.
• Protopic [package insert]. Deerfield, IL: Astellas Pharma US, Inc; 2011.
• Elidel [package insert]. Bridgewater, NJ: Valeant Pharmaceuticals North America LLC; 2014.
• Isolauri E, Arvola T, Sütas Y, Moilanan E, Salminen S. Probiotics in the management of atopic eczema. Clin Exp Allergy. 2000;30(11):1604-1610.
• Abrahamsson TR, Jakobsson T, Böttcher MF, et al. Probiotics in prevention of IgE-associated eczema: a double-blind, randomized, placebo-controlled trial. J Allergy Clin Immunol. 2007;119(5):1174-1180.
• Drugs@FDA: FDA approved drug products. FDA website. www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm. Accessed March 15, 2015.