July 28, 2021
Topical corticosteroids should be applied just once daily to treat atopic dermatitis (AD), and prescribing oral antihistamines should be phased out, dermatologists recommend in a new review. The authors also encourage four other treatment practices for AD and dissuade use of well-known inventions that have shown no clinical benefit.
These recommendations give patients "safer and more effective approaches with a less cluttered cupboard of medications and complicated rituals," Hywel Williams, MBBS, DSc, PhD, co-director of the Center for Evidence-Based Dermatology at the University of Nottingham, in Nottingham, England, told Medscape Medical News in an email. Williams co-authored the review with Bayanne Olabi, MBChB, a dermatologist affiliated with Newcastle University in England.
In the review, the authors highlight five treatments that healthcare professionals should implement in their practice:
- Using topical corticosteroids once daily, rather than twice daily
- Prescribing systemic treatments for severe AD
- Using topical calcineurin inhibitors for sensitive areas (such as the face)
- Increasing patient education, including written action plans for AD breakouts and management
- Maintaining AD remission with topical treatment or a "get control, then keep control" approach
Communicating to patients that AD needs to be managed, just as any other chronic condition does, is key, the authors note. "Because patients can see that the skin is inflamed, the inclination may be to stop topical treatment once the redness has reduced," the authors write. "This contrasts with the treatment of asymptomatic 'invisible' illnesses such as hypertension, where medication adherence is unaffected by symptoms or visible indicators." Even after the redness and itchiness has gone away, there is still inflammation under the skin. Patients are advised to continue daily treatment until "the skin feels smooth again and not just looks less red," Williams said. This can range from 1 to 4 weeks, depending on the thickness of the untreated eczema and where it is on the body.
But getting control of AD is only part of the battle, Adriane Levin, MD, director of the Atopic Dermatitis Program at Brigham and Women's Hospital, in Boston, Massachusetts, told Medscape Medical News. Levin was not involved with the study. Patients also need a regimen to maintain control of eczema. Because it is not safe to use potent topical steroids daily in the long term, physicians now advise patients to apply medications over two consecutive days of the week, Williams noted, usually over the weekend, because it is easier to remember. But people with AD should tailor their maintenance routine to their needs, Levin added. "For example, if patients find that they're flaring every fourth day after stopping a course of topical steroids, then preventatively using something like a calcineurin inhibitor on day 3 can be helpful to prevent that flare on day 4," she said.
Advising healthcare professionals to prescribe topical corticosteroids for once-daily use is also an important take-away, said Aaron Drucker, MD, a dermatologist at the Women's College Hospital and the University of Toronto, in Toronto, Canada, who was not involved with the study. "[By] counseling our patients that once a day is enough for these topical medications, we potentially can mitigate adverse events that might occur with increased use," he told Medscape, and it may make AD treatment easier for patients.
The review, published in the August issue of Current Opinion in Allergy and Clinical Immunology, also listed interventions for AD that are not supported by clinical evidence and that should be demoted:
- Oral antihistamines
- Topical antistaphylococcal treatments
- Nonpharmacologic treatments, including silk clothing, water softeners, and bath emollients
- Emollient use in infants at high risk of developing eczema
Although oral antihistamines are commonly prescribed along with steroids, "eczema is not a histamine-driven process, and because of that, antihistamines are not typically helpful for the kind of itch that patients experience," said Levin. In a 2019 Cochrane review of 25 studies, researchers concluded that oral antihistamines as an add-on therapy for eczema were no more effective than placebo treatments. Nonpharmacologic interventions, such as ion-exchange water softeners, emollient bath additives, and specialized silk clothing, are also common treatments for AD, but "none have been shown to work when subject to rigorous randomized controlled trials," said Williams.
The review shows that "a lot of what we do for atopic dermatitis is not based on evidence," Drucker said. By focusing more on what works and moving away from therapies for which there is little evidence, "we can do better by our patients," he added.
Williams is chief investigator of the Barrier Enhancement for Eczema Prevention (BEEP) study funded by the UK National Institute for Health Research Health Technology Assessment Programme. Drucker and Levin have disclosed no relevant financial relationships.
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