eczema
A Patient's Guide to Eczema
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Treatment Triangle

Treatment Triangle

Consider that treatment decisions made by physicians are not built solely on high quality evidence based medicine. There may not be sufficient clinical trial evidence to support the treatment or its use in combination therapy. Drugs that commonly find favor with doctors and patients have sometimes not been subjected to randomized double-blind studies. This does not prevent their use by the caring physician nor does it mean that they are ineffective medications.



About one-third of patients claim that their medication is ineffective. (Paller AS, et al. Perceptions of physicians and pediatric patients about atopic dermatitis, its impact, and its treatment. Clin Pediatr (Phila). 2002 Jun;41(5):323-32.) This may be in part related to inadequate exploration of treatment options, as well as poor adherence to the recommended therapy. Therefore, it is clear that physicians need to consider patients' preferences, lifestyles, and feedback in determining treatment strategies, in order to improve adherence to the prescribed regimen and improve therapeutic outcomes.

The Three Points of the Treatment Triangle:

1) Evidence Based Medicine In Eczema:

  • Topical corticosteroids
  • Topical immunomodulators
  • Interferon gamma
  • Cyclosporine
  • UVB
  • PUVA

2) Treatment Based On Evidence And Clinical Experience:

  • Moisturizers
  • Mild cleansers
  • Avoid irritants
  • Topical corticosteroids
  • Topical immunomodulators
  • Topical antibiotics
  • Oral antibiotics
  • Oral antihistamines

Resistant cases:

  • UVB
  • PUVA
  • Cyclosporine
  • Methotrexate
  • Oral or IM (intramuscular injected) steroids

3) Patient Preference:

Not all skin is created equal. There are multiple genetic and environmental variables contributing to eczema and it is this spectrum of factors that influences the emergence and scope of this skin disorder. Consequently, its diverse manifestation requires a treatment approach that is tailored to suit each individual patient's needs and preferences.

The lack of adherence to prescribed therapies can significantly and adversely interfere with the response to therapy. Rather than the doctor solely dictating specific brands and medication bases, factoring in patient preferences and lifestyle when selecting treatments can have a positive effect on outcomes. Treatments that are fast-acting, simple to use and require less frequent dosing are generally more likely to gain patient acceptance and achieve better rates of improvement.

Moisturizers and Cleansers:

Reproducible, scientific evidence has shown that emollient-based moisturizers and cleansers can yield therapeutic benefits. Most act by improving the skin's barrier function with lipids and oils rather than by introducing moisturizing ingredients into the skin. The effectiveness of moisturizers is mainly derived from their ability to temporarily seal the epidermis (outermost layer of skin) and break the dry skin cycle.

Moisturizers that have a thicker consistency are often the most effective for eczema, however, some individuals find the sticky/greasy feel difficult to tolerate and others may discover that certain brands can cause sensitivity reactions, such as itching, stinging or burning. If these side-effects occur, discontinue their use immediately. Silicone-based derivatives (e.g., dimethicone) are oil-free alternatives that tend to be noncomedogenic, nonirritating, nonsensitizing, and more cosmetically acceptable. Appropriate product recommendations may be obtained from your doctor or pharmacist.

The regular use of mild cleansers is an important part of the ongoing optimal management of eczema. Not only is cleansing an essential component of basic personal hygiene, as it removes dirt, sweat, bacteria, and exfoliated cells, but it also prepares the skin to receive topical medications and improves drug absorption. Cleansers that are suitable for eczematous skin are generally based on mild synthetic surfactants that cause minimal barrier disturbances. Emollients contained in cleansers can minimize barrier damage by emulsifying dirt and oil for easy removal, while at the same time replacing lipids that are lost during the washing process.

Corticosteroids:

Topical corticosteroids are considered to be the gold standard treatment for eczema. These agents are quick-acting and exert an anti-inflammatory effect. Their degree of potency ranges from mild to very potent and patients receiving the same strength of corticosteroid can exhibit variable responses in terms of efficacy and side-effects. Once active lesions heal, discontinue their use to limit side-effects.

Topical Steroid Phobia:

Some patients are apprehensive about using topical steroids. Generally, many of these individuals have not experienced the adverse side-effects personally, but rather their concerns are often based on incomplete or inaccurate information regarding thinning of the skin and systemic effects. Although these side-effects are possible, they generally develop as a result of inappropriate use of the medication - either the selected drug potency was too strong, used in the wrong location or simply too much used for too long.

Topical Immunomodulators or Calcineurin Inhibitors:

Topical immunomodulators (also referred to as topical calcineurin inhibitors) may be used when conventional treatment options, such as corticosteroids, are unsuitable or the response is inadequate. Topical calcineurin inhibitors (TCIs) are steroid-free and can be used on sensitive skin areas, such as the face and eyelids, where corticosteroids are avoided. TCIs interrupt the inflammation process, which is part of the body's immune reaction. By limiting the inflammatory response, these medicines relieve the associated itching and improve the rash. These medications are used short-term or intermittently long-term for mild to moderate eczema. Their cost may inhibit some potential users.

In 2006, the US FDA issued a Public Health Advisory over concerns that TCIs may potentially increase the risk of cancer. Rare cases of malignancy, including skin cancer and lymphoma, have been reported, but a causal relationship has not been established. Animal studies suggesting this link involve oral formulations that were administered at very high doses. However, safety for long-term continuous use has not been confirmed and should be avoided.

Antihistamines:

Antihistamines may be recommended by your doctor if your eczema causes severe itching. Although there is little scientific evidence supporting the role of antihistamines in effectively relieving itch and other symptoms relating to eczema, sedating antihistamines may help to improve sleep quality. Sleep disturbance from intense itching can be a major problem for many patients and their families, especially for both the child afflicted by eczema and their parents. Sustained sleep disturbance can adversely affect concentration and increase fatigue and irritability. A heightened sensitivity to sedation or performing jobs that require an early start may be considerations in prescribing the appropriate type and dose of antihistamines.

Antimicrobials:

Topical or oral antibiotics may be prescribed to treat infected lesions. Overuse or prolonged treatment can increase the risk of developing antibiotic resistance. Oral antivirals can be used for cases of eczema herpeticum (eczema infected with herpes virus).