Clinical Aspects of Eczema
Assistant Professor of Pediatrics & Dermatology at Northwestern University’s Feinberg School of Medicine, and Attending Physician at Children’s Memorial Hospital in Chicago
I hope to shed some light on the clinical aspects of atopic dermatitis, or eczema. I’m going to talk about the treatment of inflammation including the use of topical steroids and the calcineurin inhibitors Elidel and Protopic. I’ll also talk about treating itch and sleep disruption and infection. I hope to help you make sense of all the medicines used to treat this disease.
As a prescribing physician, I try to keep a Sharpie pen in my pocket so I can write down for my patients the proper dose and where to apply each tube of medicine. Bring a Sharpie to your next doctor’s appointment and have your doctor write application instructions on all your tubes of medicine.
Treating inflammation is a primary goal of therapy. Despite all of the advances in medicine topical steroids are still the mainstay of treatment, and I really believe they’re safe if used correctly.
I use high- to mid-potency corticosteroids for flares, and I taper to lower-strength as the skin improves. I prefer ointments over creams because they better moisturize and heal the skin. I suggest twice daily application most of the time. For thick skin I use high-potency medications, and for thin skin I use low-potency ones. The thickest skin on the body is on the hands, feet, elbows, and knees.
Steroid side effects are pretty rare. Rare and reversible side effects include extra blood vessels on areas of thin skin, acne, rosacea on the face, and increased hair growth in areas where you’re using a potent cortisone under occlusion. Most often I’ll see that on the extremities. Only stretch marks are irreversible. When I see stretch marks on the inner thighs of teenage girls, I wonder whether the marks stem from using a mid-potency corticosteroid or from normal growth. As I said, stretch marks are the only irreversible side effect of steroids, and that’s why we’ll often use low-potency cortisones on thin-skinned areas. White spots on the skin are usually caused by inflammation or the eczema itself, not by steroids.
Patients often don’t know when to stop treatment with their prescription medications or when to start treatment. I like to teach them the touch rule: if you touch the skin and it’s rough, you can start treatment. Or you can start treatment when you experience intense itching in an area. Some patients seek alternative treatments, but “alternative” is not synonymous with safe. Oftentimes it’s synonymous with unregulated and unknown.
Parents are really concerned about growth problems when using this class of medicines on their children’s skin. Steroids can be absorbed systemically when potent cortisones are used over widespread areas for prolonged time periods, not when they are used now and then on thick-skinned areas. So I’m really not worried about growth delays or growth problems from using this class of medicines on the skin. Steroids remain a mainstay of treatment; we don’t have a substitute for them. We do have new treatments that can help with maintenance and mild flares but not with more severe flares.
Now I’m going to talk about Elidel (pimecrolimus) and Protopic (tacrolimus), our new nonsteroid alternatives. In 2001, tacrolimus, an ointment, was approved to treat mild to moderate eczema in adults and children over the age of two, and pimecrolimus, a cream, was approved the following year. Long-term monitoring of these treatments is underway, but some controversy has arisen in the past year, so I’m going to briefly review that as well.
I like this class of drugs because they’re a great choice to use right around the eyes and the face, as well as other thin-skinned areas. Unfortunately now lots of my patients are afraid of using this class of drugs just as they are afraid of using steroids. When these drugs are used as indicated, we’re not seeing systemic absorptions or systemic immune suppression. The disadvantages are transient stinging and burning. Some of these side effects are transient if you just wait them out, but it’s difficult to wait them out if your child cries when you apply the medications. Another option is apply the medicine and then put a cool washcloth over the area so the medicine feels cool. It confuses the nerve endings and they feel cool instead of itching, and that helps sometimes.
This class of drugs is less effective for severe flare. It’s more effective when a flare is getting better or at the first sign of a mild flare. If you use this on severely affected open skin, it will burn more and you’ll never use it again. I like to use this for a few days after a flare clears because there may be some inflammation in the skin that we don’t appreciate with our eyes or feel when we touch the skin, and maybe it will help to prevent the flare from restarting.
In 2005 the FDA convened a pediatric advisory committee on the safety of this class of medications because there were some concerns about increased risk of lymphoma with their use. One of the things that spurred this was a monkey study where one of these drugs was given orally, not applied topically. When you orally give monkeys 30 times the serum level of one of these drugs for prolonged periods of time — for 39 weeks — they sometimes get lymphoma. This was no surprise to the medical community because we use these drugs to suppress the immune system of transplant patients, and we know that transplant patients have a higher risk of skin malignancy and lymphoma because we’re suppressing their immune system for years at a time after a liver transplant or a kidney transplant. The news wasn’t new, but suddenly it hit the media, and we could not convince the FDA that there was no proof of problems.
Since then, long-term monitoring of patients that have used this drug, tacrolimus, topically have shown that we’re not seeing the types of lymphoma that we would see from systemic immune suppression. One study has 25,000 patients and there are no reports of the types of lymphomas we would see with systemic immune suppression. The same holds true in another big study with spontaneous reports from more than 6 million patients. Similarly, oncology or cancer experts did not find any sort of causal relationship between Elidel cream and cancer. That’s because the types of cancers we see when your immune system is suppressed are B cell lymphomas and Epstein Bar virus–related lymphomas. These can be easily identified with the right studies. Another study has followed 7,000 patients who have taken Elidel and there is no evidence of that type of cancer. So, overall, medical professionals are reassured that these drugs are safe to use.
Some pediatricians who heard about the FDA report have stopped using these drugs on infants, and I think that there’s a balance. Maybe they shouldn’t be used on children under the age of 2 until we have information on decades of use, but for now I think that using them appropriately on people over the age of 2 is absolutely fine.
There is a myth that antihistamines don’t really help individuals with eczema, but sedating antihistamines really do help to stop the itch/scratch cycle. They don’t help much with itch relief, but they can be used at night to help with sleep. Children and adults will still scratch in their sleep, but they might have an easier time falling asleep and staying asleep. Even though we use these drugs widely, they have never really been studied in the pediatric or adult population, and that needs to be done.
The itch-scratch cycle is habit forming, and it’s really hard to break that cycle, so I treat itch with sedating antihistamines even beyond the flare to help break some of those learned habits. I don’t think there is evidence that nonsedating antihistamines help with atopic dermatitis. There is evidence they help with allergies, so if you have allergies and atopic dermatitis, use them in conjunction, but using nonsedating antihistamines for the itch of eczema is not usually very effective.
There is no good way to keep kids from itching. Some parents sew socks to the ends of long-sleeved clothing. Some parents stay awake all night and hold their child in bed between them so the child sleeps but they don’t sleep. I’d love more ideas on how to keep kids from scratching.
Benadryl (diphenhydramine) may cause paradoxical excitation, hyperactivity, so don’t try it on a night when you really need sleep. Hydroxyzine at a high dose is most effective. Doxepin works really great if you’re not sedated from it. It also has side effects of dry mouth and constipation. None of these drugs are tolerated by everyone, so you just have to keep switching around.
What works today might not work tomorrow, so rotate things. Don’t give up on a treatment that worked for a while and then stopped working. It might have stopped working because the skin was infected. If you switch to something else and then go back to the medicine, it might start working again.
Another myth is that skin bacteria are innocent bystanders. Sometimes infected skin is really crusted over and sometimes it is just thickened with lots of erosions in it. Oftentimes you won’t see a lot of crusted infection, but you will see just some folliculitis or little pus bumps; that is often a sign of infection. And until you treat that infection your skin will not get better. Treating eczema is a bit like juggling. If you don’t treat the infection, the inflammation, and the itch, if it you don’t moisturize and do everything right at the right time, sometimes the problem won’t get better. You can get an herpesvirus infection of the skin, and if it’s severe, it can require hospitalization. And we are seeing more and more infection from methacyclin-resistant staph aureus in the atopic population. Staph alone is incredibly common. And sometimes just having the bacteria on the skin can cause a flare to keep flaring. Seven to ten days of treatment can lead to improvement, but some patients need prolonged therapy and bleach baths.
You must balance risks with benefits, and as I said, we’re seeing more methacylin-resistant staph aureus in the general community and in the community with atopic dermatitis. Erythromycin is now the treatment of choice, but we’re seeing erythromycin resistance, too. As a dermatologist I don’t like to use a lot of Bactrim, but we’re using more and more Bactrim for treatment of skin infection. We’re also seeing more drug reactions with Bactrim. So, again, it is important to balance the risks with the benefits.
Corticosteroids can be used to treat most mild infections. You don’t always need antibiotics, but do think about them if the infection is not getting better. Here’s a list of some antibiotic choices: I think Ceflex works for almost everybody until they have a resistant infection. Amoxicillin is not effective. If you go to a general practitioner instead of a dermatologist and they give you Amoxicillin, tell them that’s not going to work for your skin infection; it does not work for staph aureus on the skin.
Narrow-band UVB treatment, cyclosporin, mycophenolate, and other treatments are also used.
One thing I always say is atopic dermatitis is not a one-size-fits-all disease. We have to change treatments and rotate treatments. If something hasn’t worked in the past, don’t assume it won’t work in the future. Don’t throw it away. It might work a few months later.
Treatment is like juggling. Just be sure your doctor provides you with written instructions.