Treatments for Atopic Dermatitis

Skincare

How you wash during your daily bath also affects the symptoms. As with the treatment of asteatotic eczema, it is important not to strip away too much sebum and not to rub. Also, because the skin barrier is weakened in atopic dermatitis, facial cleansers and cosmetics often cause irritation on the face. It is necessary to review whether your skincare suits your skin.

Topical therapy

Moisturizers

Using a moisturizer reinforces the skin’s moisture-retention function and enhances its barrier function. Moisturizers include heparinoids and petrolatum. If a prescription product does not suit your skin, or if you can control things sufficiently with an over-the-counter product, a commercial body cream is fine, but we do not particularly recommend organic types, as they can be a source of contact irritation. As for when to apply it after bathing, we believe it is important to apply it immediately, before the skin dries out. Also, because stopping the moisturizer once the eczema improves makes the next bout of eczema more likely, it is important to keep using the moisturizer even when you take a break from steroids. In other words, moisturizers not only ease symptoms but also help prevent flare-ups.

Topical steroids

Topical steroids are drugs that effectively suppress skin inflammation and are widely used from children to adults.

There are many topical steroid drugs, ranked by the strength of their effect. Because stronger effects tend to mean stronger side effects, we choose the rank according to age, body area, and severity of symptoms. Side effects of steroids include thinning of the skin, a tendency to bruise, a tendency toward secondary infection, and dilation of capillaries. Generally, they are most often applied twice a day. There is also a method, called proactive therapy, of continuing topical steroids about twice a week even after symptoms improve, in order to prevent recurrence.

The side effects of steroids have been exaggerated by the so-called “atopy business,” and steroids are still sometimes cast as the “villain,” but if you understand the side effects and use them appropriately under a doctor’s guidance, the risks can be kept in check.

Tacrolimus ointment

Protopic® (tacrolimus) ointment is a topical drug with an immunosuppressive action that emerged as an alternative to steroids. Tacrolimus suppresses the activity of T lymphocytes, cells involved in inflammation, and suppresses the release of itch-causing substances. In terms of strength, it corresponds to about the middle rank of steroids. Because of its few side effects, it is often used especially on areas of thin skin such as the face and neck, but it can also be used on other parts of the body.

This medication is applied once or twice a day, up to 5 g per application. As with steroids, proactive therapy, in which application is continued about twice a week after the inflammation has settled, is also effective in preventing flare-ups. There are two concentrations: 0.1% is basically for adults and 0.03% is for children.

Side effects include a stinging sensation on application, herpes simplex, and acne. Unlike steroids, it does not have the side effect of thinning the skin. As a rule, it cannot be used in children under two years of age. Pregnant and breastfeeding women use it with attention to the amount.

Delgocitinib ointment

Corectim® (delgocitinib) ointment is a topical drug of the JAK-inhibitor class, developed in Japan, that suppresses the action of the cytokines that cause inflammation and itching. It seems to cause less of a stinging sensation than Protopic and can be used on the face. It does not have the sharp effect of steroids, but because side effects are unlikely it is considered suited to long-term application, and one approach is to improve the skin somewhat with steroids first and then transition to it.

This medication is applied twice a day, up to 5 g per application. There are two concentrations: 0.5% is for adults and 0.25% is for children.

Side effects include herpes, acne, and irritation. As a rule, it cannot be used by pregnant women, breastfeeding women, or infants under six months of age.

Difamilast ointment

Moizerto® (difamilast) ointment, called a PDE4 inhibitor, inhibits the action of PDE4, an enzyme that breaks down the cyclic AMP (cAMP) signal that suppresses inflammation, thereby raising the cAMP concentration. It does not have the sharp effect of steroids, but for an ointment it spreads well and is easy to apply, and like a moisturizer it can be used preventively on areas prone to redness even when there is little redness.

This medication is applied twice a day. There are two concentrations: 1% is basically for adults and 0.3% is for children.

Side effects include irritation and acne. As a rule, it cannot be used by pregnant women, breastfeeding women, or infants under three months of age.

Tapinarof cream

Vtama® (tapinarof) cream is a drug of the AhR-modulator class that can be used for both atopic dermatitis and psoriasis vulgaris. By activating a molecule inside cells called the aryl hydrocarbon receptor (AhR), it reduces substances involved in inflammation and increases antioxidant molecules, suppressing skin inflammation while improving the skin barrier function.

This medication is applied once a day.

As a side effect, surprisingly for a topical medication, there is headache. Others include irritation and acne. As a rule, it cannot be used by pregnant women, breastfeeding women, or children under 12.

Oral therapy

Antihistamines

Antihistamines are used to reduce itching by suppressing the action of histamine, a contributor to allergic reactions.

However, in the skin of people with atopic dermatitis, many itch-causing substances other than histamine are also at work, so it is often difficult to fully suppress itching with antihistamines alone. There is little point in continuing to take them if you have no other allergic condition such as allergic rhinitis and the itching does not change at all, but if taking them reduces the itching so that you avoid scratching, taking them is advisable, because eczema worsens with scratching. Since little effect on the skin inflammation itself can be expected, topical treatment plays the leading role and oral antiallergic medication is in a supporting position.

There are many types, and side effects vary by drug, but they include drowsiness, dry mouth, impaired liver function, and impaired kidney function.

Cyclosporine

Neoral® (cyclosporine) capsules are a drug of the calcineurin-inhibitor class that suppresses immune activity. Because of its many side effects, it is used only for treatment-resistant atopic dermatitis, as a short-term intensive treatment. (With the recent advent of injectable drugs, its frequency of use has decreased over the past few decades.)

The dose is adjusted according to body weight and symptoms, and it is taken twice a day before meals. It is ended at 8 to 12 weeks, but if longer use is necessary, a drug-free interval is set.

Reported side effects include high blood pressure, diabetes, high blood lipids, impaired liver function, impaired kidney function, various infections, numbness, and gum overgrowth. To use it safely, we perform regular blood pressure measurements and blood tests. As a rule, it cannot be used by pregnant or breastfeeding women. Note that you cannot receive live vaccines while taking cyclosporine. Also, because ultraviolet phototherapy raises the risk of developing skin cancer, it is best not to use the two together.

Injection therapy (biologic drugs)

Dupilumab

Dupixent® (dupilumab) subcutaneous injection is an injectable drug that suppresses two cytokines, IL-4 and IL-13, reducing skin inflammation and itching. It is used for moderate-to-severe patients who do not improve sufficiently with topical therapy.

For administration, only the first time you receive two subcutaneous injections, and thereafter one injection once every two weeks. Under a doctor’s guidance, you can self-inject, taking the drug home and injecting it yourself.

Side effects include herpes, conjunctivitis, keratitis, and rarely anaphylaxis. Because atopic dermatitis is inherently prone to eye diseases such as cataract, retinal detachment, and glaucoma (the latter from the side effects of topical steroids), it is important to be examined regularly by an ophthalmologist, and particular attention to eye symptoms is needed while on this drug as well. For pregnant and breastfeeding women, we carefully consider whether to administer it. It cannot be administered to infants under six months of age. Also, you cannot receive live vaccines while on this drug.

Nemolizumab

Mitchga® (nemolizumab) subcutaneous injection is an injectable drug that suppresses IL-31, a cytokine that causes itching. It is used for patients whose itching is hard to relieve despite various treatments.

It is usually injected subcutaneously once every four weeks. You can self-inject, taking the drug home and injecting it yourself, but it gives the impression of being harder to handle than other drugs.

Reported side effects include herpes, conjunctivitis, headache, and rarely anaphylaxis. For pregnant and breastfeeding women, we carefully consider whether to administer it. It cannot be administered to children under 13. We also carefully consider whether to receive live vaccines while on this drug.

Lebrikizumab

Ebglyss® (lebrikizumab) subcutaneous injection is an injectable drug that targets IL-13, a cytokine involved in the skin inflammation of atopic dermatitis. It is used for moderate-to-severe patients who do not improve sufficiently with topical therapy.

Two doses are given at the first visit and two weeks later, and from the third dose at four weeks onward, one dose at a time. From four weeks onward, depending on the condition, it can also be given every four weeks instead of every two weeks.

Reported side effects include injection-site reactions, herpes, conjunctivitis, headache, and rarely anaphylaxis. For children, it can be administered to those aged 12 and older who weigh at least 40 kg. For pregnant and breastfeeding women, we carefully consider whether to administer it. Also, you cannot receive live vaccines while on this drug.

Ultraviolet phototherapy

There is no established protocol or guideline for ultraviolet phototherapy for atopic dermatitis, but it is used empirically at many hospitals. It is worth considering mainly for those who do not improve well with topical therapy. Our clinic offers two types, narrow-band UVB (NB-UVB) and excimer light, but narrow-band UVB is usually used. For atopic dermatitis, as with psoriasis vulgaris, ultraviolet phototherapy is considered a treatment that is not recommended for children under ten, given the risk of skin cancer and so on.