Topical corticosteroids should be used in conjunction with adequate skin care, such as avoiding triggers of inflammation and frequent application of emollients. Twice-daily application of corticosteroids is recommended. The goal is to limit the need for anti-inflammatory medications and thereby avoid potential for adverse effects. Local side effects such as skin atrophy, striae, acne, and hypopigmentation are related to corticosteroid potency, site of application, and duration of application. Systemic side effects of adrenal suppression or Cushing syndrome can result with application of a potent topical corticosteroid to large surface areas or occluded areas at risk of enhanced penetration.
Topical calcineurin inhibitors (also referred to as topicalimmune modulators) such as topical tacrolimus and pimecrolimus may be part of the treatment regimen for atopic dermatitis.These agents selectively inhibit T-cell proliferation by inhibitingcalcineurin and subsequent interleukin 2 production. There isno potential for skin atrophy; thus these agents are particularlyuseful for face or genital lesions. They are currently approvedfor intermittent therapy as second-line treatments for mild tomoderate atopic dermatitis. Long-term studies, combined withother modalities for treatment, are underway.
Sedating antihistamines (e.g., diphenhydramine, hydroxyzine)are useful adjunctive therapy, especially during flares. These may have only mild effect on pruritus but can improve the sleeplessness due to scratching during the night. A dose before bedtime is most effective, and additional daytime doses can be added on an individual basis when needed. Nonsedating antihistamines are of little benefit in controlling the pruritus of atopic dermatitis.
Short-term administration of systemic corticosteroids is rarely indicated for cases of severe disease and may be considered when adequate topical therapy failed or is being instituted.Systemic corticosteroid courses should be adequately taperedand used in conjunction with an appropriate atopic skin careregimen. Rebound flare of atopic dermatitis is common following withdrawal of corticosteroids and should be anticipated toavoid misinterpretation of the natural disease severity. Longterm and frequent repeated courses should be avoided to prevent adverse effects.
Ultraviolet light therapy (UVB, narrow band UVB, UVA, or UVA1) can be an option for moderate to severe cases in older children. Typically, light therapy is administered two to three times weekly until improvement is seen, and then is tapered or discontinued once the acute flare has resolved. More frequent use of light therapy in children is hindered by requirements for frequent office visits, ability to cooperate with standing in a light box while wearing protective goggles, and risk of long-term skin damage, including the potential for skin cancer development with excessive UV light exposure. Systemic cyclosporine (up to 5 mg/kg/day) can be effective therapy for atopic dermatitis in severe cases. It is used for periods of up to 1 year to gain control of severe disease and should be tapered once the atopic dermatitis is controlled.
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An increased tendency toward bacterial, viral, and fungal skin infections is due to an impaired skin barrier and decrease in innate immune proteins in the skin as well as maladaptive secondary immune responses.