SUMMARY:

Eczema, or atopic dermatitis, is a chronic, relapsing, intermittent inflammatory skin condition characterized by pruritic skin lesions.  It affects 10% of the U.S. population, primarily in childhood and early adolescence.  Lifestyle modifications including frequent use of emollients is the mainstay of treatment, along with topical medications.  Phototherapy and systemic medications are useful in cases where optimized treatment has not completely controlled symptoms

KEY POINTS: 

Pathophysiology

• Combination of barrier dysfunction, immune dysregulation, epidermal gene mutations, and environmental factors
• Trans-epidermal water loss caused by disruptions of the epidermis lead to xerosis, pruritis, and a self-perpetuating itch-scratch cycle

Clinical Presentation

• Commonly begins in childhood but prevalence in older children and adults is increasing
• Stages of skin appearance
  • Acute phase: Vesicular, weeping, crusting eruption
  • Subacute phase: Dry, scaly, erythematous papules and plaques
  • Chronic phase: Lichenification (hyperpigmentation, skin thickening) from repeated scratch-itch cycles
• Most commonly involves
  • Flexural surfaces | Anterior and lateral neck | Eyelids | Forehead | Hands
• Comorbidities associated with eczema include
  • Allergies | Asthma | Allergic rhinitis | Ear infections | Strep pharyngitis | UTIs

NOTE: Redness may be hard to see in dark skin | Flare ups may look darker brown, purple or ashen grey | Skin swelling, warmth, dryness/scaling or itching and oozing may help diagnose | . Black Americans more commonly develop papular eczema

Risk Factors

• Family history of atopy
• FLG gene mutations leading to loss of function
• No association with diet, ethnicity, or socioeconomic background

Diagnosis

• Based solely on history and physical exam
• Diagnostic criteria exist but are not useful in the clinical setting
• No clinically useful biomarkers exist, although elevated serum IgE levels are common
• Allergy testing, food or environmental, is only recommended in patients without a history of allergies

Non-pharmacologic interventions

• Patient education is extremely important
• Moisturizers/emollients are the mainstay of treatment and prevention of flare-ups
  • Thick cream or ointment
  • Apply once or twice daily soon after bathing
  • Should be always used, even if the patient does not currently have a flare-up
• Bathing practices
  • No standard for frequency or duration of bathing
  • Limited use of non-soap cleansers is recommended
  • Use of tepid water rather than hot water is recommended as hot water increases pruritis and can perpetuate the itch-scratch cycle
  • No data supports addition of oils or other additives to bath water
• Dietary interventions
  • Not recommended except in children <5 years of age with persistent eczema despite optimized treatment or with a history of allergic reaction to certain foods
• Environmental modifications not supported by data include
  • Reduction of contact with house dust mites (unless proven allergic reaction)
  • Modification of laundering techniques
  • Use of certain clothing fibers and fabrics

Pharmacologic therapy

Topical medications

• Topical corticosteroids
  • First line treatment for flare-ups
  • Mild-potency for face, neck, axillae, groin, and flexor surfaces – can use moderate potency in these areas but only for <2 weeks at a time
  • Higher potency and longer treatment duration are needed if the patient has reached the point of lichenification
  • Ointment is more potent than cream which is more potent than lotion
  • No difference in outcomes between once-daily and twice-daily use
  • Major concerns are side effects of skin atrophy, hypopigmentation, striae, telangiectasias
• Topical calcineurin inhibitors
  • Immunomodulators pimecrolimus (Elidel) and tacrolimus (Protopic) can be used alongside topical corticosteroids as second-line treatment
  • Do not cause skin atrophy and so are useful in treatment on the face and other thin-skinned areas
  • The effectiveness of Protopic 0.1% is equivalent to moderate and high potency topical steroids
  • Protopic 0.03% is more effective than mild potency topical steroids and Elidel
  • Elidel 1% is similar in efficacy to mild potency topical steroids
  • Concern for connection to skin malignancies, lymphomas, and systemic immunosuppression, but studies have not demonstrated clear and consistent links
  • Given the potential long-term safety risks, the FDA recommends against continuous long-term use

Note: Protopic 0.1% is not indicated in children 15 years or less | Protopic 0.03% and Elidel 0.1% are not indicated for children less than 2 years old

• Topical phosphodiesterase inhibitors
  • Crisaborole (Eucrisa) is a topical phosphodiesterase 4 inhibitor used in treatment of mild to moderate eczema in children 2 years and older
  • Effective but highly cost prohibitive
• Topical antimicrobials and antiseptics
  • Anti-staphylococcal antibiotics improve eczema symptoms only in patients with signs of secondary bacterial infection
  • Bleach baths with nasal mupirocin (Bactroban) are as effective as systemic antibiotics
• Topical antihistamines are not recommended

Phototherapy

• UV treatment can be used as monotherapy or in addition to systemic medications
  • Low-risk profile and strong efficacy data
  • Not readily available and may be cost-prohibitive for many patients
  • May be difficult for children to comply with treatment protocols

Systemic medications

• Must consider previous therapy failures or contraindications, quality of life and disease severity
• Systemic steroids and systemic antibiotics should be avoided
• Short-term use of oral antihistamines
  • Can help with lack of sleep
  • Have not been shown to significantly decrease pruritis
• Dupilumab (Dupixent)
  • Subcutaneously injected systemic immunomodulator
  • Approved for treatment of moderate to severe eczema in adults
  • Effective but limited in its use due to contraindications and potential side effects, and highly cost prohibitive
• Off-label medications: Cyclosporine | Azathioprine | Methotrexate | Mycophenolate mofetil | Interferon gamma
• Treatments not supported by data include
  • Probiotics, fish oil, primrose oil, borage oil, multivitamins, zinc, vitamins D, E, B12, or B6, immunotherapy or sublingual immunotherapy

NOTE: Darker skinned patients experience higher rates of hyper and hypopigmentation following resolution | . Skin color can return to normal several months later once eczema controlled 

Indications for referral to dermatology

• Uncertain diagnosis
• Symptoms uncontrolled despite optimized management
• Eczema on the face that has not responded to treatment
• Children requiring high potency topical steroids for control
• Frequent flare-ups or severe disease
• Systemic treatment is required for flare-ups or maintenance
• Causing significant psychosocial problems
• Contact allergic dermatitis is suspected

Learn More – Primary Sources

American Academy of Dermatology: Atopic Dermatitis Guideline

Tips and Tricks for Controlling Eczema (Raveendran et al. Immunol Allergy Clin North Am, 2019)

American Family Physician: Atopic Dermatitis: Diagnosis and Treatment

Atopic Dermatitis: Pathophysiology

Topical tacrolimus for atopic dermatitis

“Protopic (tacrolimus) label” FDA Medication Guide

“Elidel (pimecrolimus) label” FDA Medication Guide

Management of atopic dermatitis: safety and efficacy of phototherapy

National Eczema Society: Eczema in Skin of Color