Topical Therapies (in alphabetical order):
AntifungalsSuperficial mycoses usually respond to topical therapy. In the setting of eczema, topical antifungal agents such as ketoconazole are used to reduce the fungal infection (Pityrosporum ovale = Malassezia furfur) that plays one pathogenetic role in seborrhoeic dermatitis. Systemic antifungal treatment may be necessary in extensive skin involvement and in immuno-compromised patients. Ketoconazole is available as shampoo or cream (1% or 2%). Side effects include irritation, burning, pruritus and oedema.
Antiseptics and antimicrobialsThese substances are important for those forms of eczema that are accompanied by superficial bacterial infections. They range from bacteriostatic drugs such as metronidazole, clindamycin, erythromycin to bactericidal drugs such as bacitracin. Side effects are burning, stinging, pruritus, erythema, irritant and allergic contact dermatitis. Topical clindamycin is contraindicated in patients with a history of ulcerative colitis or antibiotic-associated colitis. As in case of all topical medications, a history of hypersensitivity to any ingredient of the formulations is a contraindication.
Cooling lotions, menthol, camphorCooling agents such as cold compresses are antipruritic and provide temporary relief but dry out the skin in the long run. Besides, they are not a causal therapy of eczema. There are a number of lotions available containing menthol, camphor and/or phenol that have the same properties. They may lead to burning when applied in excoriated skin. Shake lotions mainly work by cooling the skin, provide temporary relief but may lead to drying of the skin when applied over a longer period of time resulting in xerosis and asteatotic eczema.
CorticosteroidsThere are large numbers of topical corticosteroids available in a wide range of potency. Seven classes ranking from class 1 (superpotent) to class 7 (low potency) are obtainable according to a new US-American potency ranking. In Europe, a classification into 4 classes (low potency to very strong potency) is more usual.
Topical corticosteroids are frequently the first line treatment for moderate and severe forms of eczema. Less potent corticosteroids such as e.g. hydrocortisone or desonide should be used for treatment of the face, intertrigineous areas (groin, axillary) and under diapers. More potent corticosteroids (e.g. mometasone furoate, methylprednisolone aceponate, prednicarbate, triamcinolone acetonide) may be applied on other parts of the body. For lichenified plaques and regions such as the palms and soles very potent substances (e.g. fluocinonide, desoximetasone, bethasone valerate) may be required. Long-term use of potent topical corticosteroids bears the risk of side effects such as cutaneous atrophy, telangiectasias, striae distensae, hypertrichosis, acne-like skin lesions and tachyphylaxis. Short term use can be accompanied by rebound upon discontinuation. With newer fourth-generation corticosteroids such as methylprednisolone aceponate and mometasone furoate, the risk for cutaneous atrophy is diminished. In severe eczema, the use of potent and very potent topical corticosteroid may be required to control the skin lesions. Topical corticosteroids are not indicated for use in virus infections such as herpes simplex, herpes zoster or varicella, skin diseases such as rosacea and perioral dermatitis and open wounds.
Doxepin This is a tricyclic antidepressant compound with antihistaminic, antimuscarinic and antiserotoninergic action. It is topically applied as doxepin hydrochloride cream (5%). Several reports suggest its use in eczematous dermatitis such as AD, nummular eczema, contact dermatitis and especially for symptomatic treatment of pruritus. Doxepin has proved to be a potent contact sensitiser when applied on inflamed skin. According to a systematic review of treatments for atopic dermatitis, no sufficient evidence for doxepin treatment was found for this type of eczema.
ImmunomodulatorsTopical macrolide immunomodulators (calcineurin inhibitors) are approved for the treatment of atopic dermatitis. Tacrolimus (FK 506) is currently available as an ointment with a concentration of 0.03% and 0.1% and pimecrolimus (ASM 981) is available as a 1% cream. Itching, burning and irritation at the application site skin may be observed within the first days of treatment. Patients are asked to minimise/ avoid natural or artificial sunlight exposure during topical treatment. Topical immunomodulators are not indicated for use in the presence of virus infections such as herpes simplex, herpes zoster, eczema herpeticatum or varicella. So far, they do not cause the associated cutaneous atrophy seen with longterm application of topical corticosteroids. Besides, rebound and tachyphylaxis are reduced compared to those associated with topical corticosteroids. One has to bear in mind that there are not enough long-term data of these agents to definitely rule out long-term side-effetcs of topical immunomodulator therapy.
Salicylic AcidSalicylic acid has keratolytic, bacteriostatic, fungicidal and photoprotective propertities enabling its use in keratotic forms of eczema. The commonly used concentrations of salicylic acid in topicals vary from 5 to 40%. Extensive application of salicylic acid in eroded skin, newborns and infants may lead to increased absorption and systemic intoxication with neurologic and gastrointestinal toxicity.
Tanning agentsThey are not available and established in every country but are part of eczema treatment in countries such as e.g. Germany. They may be applied as gel, lotion, cream, fatty ointment, solution and powder. The latter two can also be used for bathing affected body parts. Tanning agents have antiinflammatory and desiccative properties and are in particular applicable in dyshidrotic forms of eczema.
TarsThere are mainly three types used in dermatology: wood tars, coal tars amd bituminous tars. Tar preparations are available in shampoos, creams and ointments. They are very effective in the treatment of nummular eczema, hyperkeratotic forms of eczema, chronic eczema and atopic dermatitis (AD). Side effects comprise folliculitis, acne-like eruptions and photosensitivity. They should not be used in the genital area and groins because of the increased risk of inducing skin cancer.
Systemic Therapies (in alphabetical order):
AntihistaminesThere are currently three classes of antihistamines (H1, H2, H3). Antihistamines of the H1 type are used for treating urticaria and some types of allergic diseases (e.g. hay fever). H1 antihistamines fall into three categories including first-generation (classic, marked additional sedative and anticholinergic actions), second-generation (low sedation) and third-generation (minimal or none sedation) antihistamines. Sedating antihistamines (e.g. hydroxycine, diphenhydramine) are helpful in breaking the itch-scratch cycle and should be preferably given at bedtime. They are helpful in patients in whom itching prevents sleep or in those who scratch during the night as for example in Atopic Dermatitis (AD). The value of H1 antihistamines in the treatment of AD is controversary in clinical studies and evidence is still lacking.
CyclosporineTwo forms are available, the original preparation (Sandimmune®) and a microemulsion (Neoral®). The use of cyclosporin in Atopic Dermatitis has been fairly well studied and a high percentage of patients improve with therapy. Relapses may occur after therapy cessation. It is best used on a short-term basis (< 6-12 months) in a dosage of 2.5-5.0 mg/kg body weight/day. Side effects include hypertension, hypertrichosis and gingival hyperplasia. When applied less than two years in dermatological patients, there is no increased risk of malignancy. Cyclosporine is not teratogenic but the use of this drug during pregnancy should only be considered in severe cases for whom the potential benefits of therapy outweigh the risk. Contraindications are liver function impairement, renal dysfunction, uncontrollable hypertension and gout / increased uric acid.
CorticosteroidsSystemic corticosteroids are strong antiinflammatory drugs that are used to treat acute forms of contact dermatitis, phototoxic/photoallergic dermatitis and atopic dermatitis (AD). For eczema treatment, they are applied for a short-term period (< 4 weeks). An oral agent with an intermediate duration of action such as prednisone is given in a single dose. In severe dermatoses, the dose can be divided in two to four doses per day for better initial control. The daily dose depends on the severity of the disease and the body weight of the patient and may be initially 40-60 mg for prednisone. If there is a need to reduce mineralcorticoid effects, methylprednisolone may be preferred. Intramuscular and intravenous application of corticosteroids are also possible in very severe forms of eczema. Long-acting intramuscular agents such as triamcinolone acetonide should not be applied more often than about 4-6 times a year. Intravenous administration is usually not necessary in eczema patients and its use is limited for very severe forms only. Most commonly, oral administration of corticosteroids is continued on a maintenance basis after intravenous application. Side effects are usually not common in short-term therapy. When they occur, they may appear as gastrointestinal intolerance, weakness, muscle effects, increased appetite, weight gain, mood changes, nervousness, acneiform eruptions, increased infections, derailed diabetes and impaired wound healing. Systemic corticosteroid use is contraindicated in active peptic ulcers, active tuberculosis, severe depression or psychosis and known hypersensitivity to an ingredient.
RetinoidsThey are structural and functional analogues of vitamin A with multiple effects on cellular differentiation and proliferation. Concerning eczema treatment, they are effective (non-approved indication) in those types with disorders of cornification such as hyperkeratotic eczema of the hands and feet and severe ichthyosis. Discontinuation may lead to a relapse of the skin disease. Standard dosage depends on the body weight and ranges between 25 and 50 mg/day. Side effects include dose-dependent mucocutaneous symptoms such as dry lips, cheilitis, dryness of nasal mucosa and mouth, xerophtalmia, blepharoconjunctivitis, corneal ulceration, xerosis of the skin, diffuse or localised hair loss and dyslipidemia. Retinoids are contraindicated during pregnancy, with renal insufficiency, liver function impairement and lipometabolic disorders. In fertile women sufficient contraception must be performed.
PhototherapySome patients may benefit from natural sunlight (atopic dermatitis, nummular eczema, dyshidrotic eczema, hyperkeratotic fissured eczema) whereas others may deteriorate (e.g. seborrhoeic eczema, acute contact dermatitis). Available phototherapy comprise UVB, UVA, combined UVA/UVB, long-wavelength UVA1, narrow-band UVB and photochemotherapy with psoralens (PUVA) applicable systemically, topically or as a bath. Phototherapy is clearly beneficial in appropriate patients under professional supervision in addition to topical treatment. Therapeutic success depends upon proper selection of the phototherapy for adequate indications. The choice of an appropriate phototherapy regimen is to be made by a dermatologist considering the patient’s individual constitution and needs. Some patients cannot tolerate the heat generated by the equipment. Side effects depend on the type of UV light, the patient’s UV sensitivity (skin type), the duration of therapy and the number of administered exposures. Short-term side effects of phototherapy are sunburn, erythema, xerosis and increased frequency of herpes simplex infections. Long-term side effects are photoaging and carcinogenesis such as induction of cutaneous malignancies.
Tap water iontophoresisLocal tap water iontophoresis is a physical procedure for all forms of eczema associated with hyperhidrosis and dyshidrosis (recurrent occurrence of vesicles). Initially, it is performed daily for 10 to 15 minutes, then slowly reduced to 2 to 3 times a week if symptoms permit. For maintaining good results, it is advisable to continue local iontophoresis once a week, even if dyshidrosis/hyperhidrosis is cured. Side effects are sensations during therapy such as prickling, stinging or burning. The use of local tap water iontophoresis is contraindicated in the following situations: open lesions and wounds of the hands, cardiac arrhythmia, cardiac pacemaker, metal implants in the hands and pregnancy.
Various:Acupuncture has been reported as successful in the treatment of allergic contact dermatitis and intractable pruritus but controlled clinical trials are lacking.
Topical capsaicin: Capsaicin, the pungent agent of red pepper, has been shown to be an effective topical treatment in some pruritic dermatoses such as eczema (lichen simplex, nummular eczema, prurigo forms of eczema). This is an off-label use. Repeated application 3 to 5 times a day is necessary for sufficient effectiveness. The concentration of capsaicin ranges from 0.025% up to 0.1%. It is advisable to start with a low concentration and then increase it every 3 to 5 days. The face and the genital area should not be treated because of increased rates of irritation. Side effects are usually limited to the first 3 to 5 days including redness, burning, stinging and an increase of itch. These symptoms may be more pronounced when sweating and showering with hot water. Topical application in open wounds and on mucous membranes is contraindicated.
Chinese herbal medicine has been studied in controlled clinical trials in Atopic Dermatitis (AD) with variable results but according to a systematic review of treatments for atopic eczema, insufficient evidence for Chinese herbs was found. Chinese herbs have non-steroidal anti-inflammatory activities, some of them additionally have antihistamine and immunosuppressive properties. Consequently, they seem to target the inflammatory character of AD. Side-effects include hepatotoxicity and the necessity of constant quality of supplement and availability. In some Chinese herbal preparations, though, cortisone has been detected, which may account for their efficacy.
Dietary lipid supplementation such as primrose oil (linoleic and alpha-linoleic acids) and fish oil (eicosapentaenoic acid) failed to show any advantage in the treatment of AD in double-blind, placebo-controlled trials and in a systematic review of treatment for AD.
Psychological approaches: It has become increasingly clear that psychological factors can affect the course of any physical disease process. Studies have shown that group psychotherapy, support groups and biofeedback help to improve quality of life in different forms of skin diseases such as AD and pruritus.