The Itch That Rashes

Myths, Misconceptions, and Education in Eczema Management

Jeanne Findlay, CPNP, CCRP, DNP; Bernard A. Cohen, MD


February 02, 2011

Pharmacologic Management

Oral antihistamines are commonly recommended in the management of pruritus, although they are not routinely used for children whose AD is not caused or worsened by immunoglobulin (Ig)E-mediated food allergies. In a recent Danish study of 112 children younger than 6 years of age with AD, only 18 were found to have skin prick-positive food allergies.[5] Nonsedating antihistamines (cetirizine, loratadine, fexofenadine) can be helpful to reduce daytime pruritus if there are known IgE-mediated allergies to foods or pollen. Judicious use of sedating antihistamines (diphenhydramine, hydroxyzine) can help with nocturnal pruritus, primarily to sedate the child at night to facilitate skin repair. Education is key in helping parents understand when and how to give these medications so that they can be active members in helping to effectively reduce the persistent and miserable itch-scratch cycle.

Topical steroids are the current mainstay for management of concomitant skin inflammation. Side effects of long-term use of topical steroids include thinning and depigmentation of the skin, striae, systemic absorption with immunosuppression, and tachyphylaxis (loss or reduced efficacy due to prolonged application). Although previous research indicated a potential for bone demineralization, a recent study of 60 children between 5 and 16 years of age with moderate-to-severe AD treated with low-potency topical steroids found no evidence of bone mineral decrease when compared with the general pediatrics population.[6] Although this information is important in educating parents, clinicians should be careful not to create "steroid phobia."

The importance of stepped therapy incorporating the appropriate class or strength of topical steroid for the shortest period of time possible and only to the areas of inflamed skin is another necessary teaching point. Although it is advisable to use a low-potency steroid formulation, a randomized controlled trial of 207 children between 1 and 15 years of age concluded that 3 days' application of a potent topical corticosteroid was as efficacious as 7 days' application of a milder topical steroid in controlling mild or moderate eczema, reducing the severity of symptoms (such as pruritus) and improving quality of life.[7]

Prescribing oral steroids to manage the chronic skin flares of AD is contraindicated, both because of the short-term rebound that occurs upon discontinuation and the long-term and well-documented adverse effects of bone demineralization and reduced cortisol production.

Nonsteroidal topical medications, such as the calcineurin inhibitors (tacrolimus, pimecrolimus), are immunomodulators that work by suppressing the body's immune response to inflammation. They are not absorbed in the bloodstream like topical steroids, nor do they cause pigment changes or thinning of the skin. This benefit allows for use on the neck, face, and scalp. The US Food and Drug Administration (FDA) mandated a "black box" warning for these products in 2005 due to concerns about a potential risk for cancer with their use. However, scientific evidence has demonstrated no increase in tumor formation or lymphoma. Unlike topical steroids, topical calcineurin inhibitors should not be used as first-line medications. Like topical steroids, they should be applied sparingly and only to the eczematous areas of skin involvement.

Topical lipid or ceramide formulations have shown efficacy in improving the skin barrier defect inherent in the management of AD.[8] These include proprietary products, such as EpiCeram® Skin Barrier Emulsion (Promius™ Pharma, LLC; Bridgewater, New Jersey), Neosalus™ (Quinnova Pharmaceuticals, Inc.; Newton, Pennsylvania), MimyX™ Cream (Stiefel Laboratories, Inc.; Research Triangle Park, North Carolina), and Atopiclair® (Graceway Pharmaceuticals, LLC; Bristol, Tennessee). The FDA has approved these products as medical devices rather than pharmaceutical products. This is an important distinction as FDA-approved pharmaceuticals undergo human clinical trials, whereas medical devices have a less rigorous and more rapid development cycle. Most insurance companies do not cover these newer formulations, adding to the expense that families must bear for managing this chronic skin disease.


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