Abstract
The author gives an overview of treatment options for atopic dermatitis, based on experience from the USA. In particular, the classification of corticosteroids is different in Europe.
In the Czech dermatological literature we use the terms atopic dermatitis - atopic eczema as synonyms. In contrast to the term "eczema", which can be characterized by a typical clinical picture, ie the sowing of a cluster of red papules, vehicles and papulovesicles, the term "dermatitis" has a histopathological basis (superficial dermatitis with spongiosis and infiltrate in the corium).
The treatment of atopic dermatitis / eczema is based on emollients, which is a characteristic feature of atopic skin and its dryness. The goal is how much it should be used with the use of "violent" emotions, but in any case it is a repeated application of the emollient that best suits a particular patient and which is applied several times a day (often not enough at all twice a day).
Another significant symptom of patients with atopic dermatitis is itching, which is the cause of subsequent complications and accompanying complaints (sleep disorders, concentration, irritability, etc.). The authors rightly mention that the use of non-sedating antihistamines does not make sense in atopics, and also confirm the assumption that the preventive use of antihistamines will lead to a reduction in the incidence of asthma in later life.
The most important method of reducing skin dryness and itching is therefore the correct application of emotions together with other principles of atopic skin care: short showering, use of oil additives to wash the skin, application by emolition after showering, but also early showering after skin sweating. Atopics, in addition to all the above, irritates their own sweat (typically we see this in school children, who after a physical education class have to endure in clothing without prior showering until the end of the class).
As a very example, I consider the important mention that alternative methods of treating atopic dermatitis, so popular in our patients, are not demonstrably effective. (It is even done that Table 2 since should not be missing in the offices of general practitioners and pediatricians!) The differential drugs used in the treatment of atopic dermatitis include topical corticosteroids and topical immunomodulators. Corticosteroids used in Europe are classified into only four classes according to efficacy, if, in addition, a low-potency corticosteroid is designated as class 1, a high-performance corticosteroid as class 4 (the exact opposite is the American scale).
As some corticosteroids are not registered in the Czech Republic or are in another pharmaceutical form or quantity or are known under a different name, the editors have taken over the European table of topical corticosteroids. However, it is possible to agree with the general principles of treatment, especially that any corticosteroid should be administered only for the time strictly necessary and a maximum of twice a day (recommended for their patients to take corticosteroids only once a day, before bedtime).
Corticosteroid treatment strategies are in the hands of dermatovenerologists, who would perform treatment and delegate to a general practitioner, especially in the case of highly effective corticosteroids (Classes 3 and 4). The reason is the fact that to this day we see in the offices of dermatovenerologists patients treated for many years with topical corticosteroids without the use of emotions and without education of the patient regarding, for example, skin cleansing.
Second-line drugs - topical immunomodulants, represent a new, modern way in the treatment of chronic skin diseases, including atopic dermatitis. Especially atopics, it is often necessary to treat the same area of skin for a long time, including the face, where the use of corticosteroids is dangerous due to skin atrophy.
An alternative that is only slowly finding its place in therapeutic regimens is pimecrolimus and tacrolimus. Both preparations have their place in the treatment of atopic dermatitis - pimecrolimus is a cream intended for the treatment of mild and moderate eczema in children older than two years, tacrolimus in 1% concentration in ointment is indicated in the treatment of moderate and severe atopic dermatitis in children over 16 years and adults.
Ie. that these preparations do not compete with each other, but complement each other (this situation is due to the fact that tacrolimus is not available in the Czech Republic in a concentration of 0.3% for children from two years of age). When treating atopic eczema, emollients and corticosteroids are the first choice.
In case of insufficient effect or intolerance, and especially in the treatment of thin skin (face, neck), the drug of second choice is either pimecrolimus (children 2-18 years) for mild eczema or tacrolimus (children 16 years and adults) for severe eczema. Similarly, if a patient does not respond well to pimecrolimus treatment, I switch to tacrolimus treatment.
Topical immunomodulators can often also substitute for the systemic administration of immunosuppressants. Unlike the author of the article, we use not only corticosteroids in general (those only very rarely), but we have good experience with cysklosporin (Sandimun Neoral, Consupren), not only in adults but also in children.
The treatment of atopic eczema is not only mentioned by the mentioned methods of phototherapy - UVB is rarely used today, it is gradually replaced by so-called narrowband UVB radiation (311 nm), PUVA chemophototherapy has more side effects, so it recedes, on the contrary, so-called UVA1 phototherapy has its place. (note: in the Czech Republic, I think this radiator is not available yet).