Neurodermatitis (Atopic Eczema): Drug Therapy

Therapeutic target

Improvement of the symptomatology

Therapy recommendations

Avoidance of trigger factors (triggers):

  • House dust mites
  • Contact allergens
  • Pollen on the skin
  • Food allergy [only immediate-type food allergy or significant late reactions warrant abstinence measures (elimination diets/exclusion diet)].

Step therapy as described below:

  • Stage 1 (dry skin): basic therapy (several times a day and after each bath):
    • Skin care with refatting substances/hydration of the skin (basic therapeutics) and avoidance of skin irritation; urea (not indicated in infants or glycerol can be added to basic therapy; the use of basic therapeutics leads to the saving of topical glucocorticoids;
    • Avoidance or reduction of provocation factors.
  • Stage 2 (mild eczema): measures of stage 1 + plus.
    • Low-potency topical glucocorticoids and/or topical (“topically acting”) calcineurin inhibitors (inhibitors).
    • Possibly UV therapy (not in childhood).
    • Possibly additional application of antiprurigninösen (“itching quenching”) and antiseptic (“against the germs directed”) agents.
  • Stage 3 (moderate, temporarily severe eczema): measures of stage 1 + 2;
  • Stage 4 (persistent, severe eczema): 1 + 2 + 3 plus.
  • See also under “Further therapy“.

Further notes

  • During the acute phase, the ABC strategy has proven to be effective:
    • Anti-inflammatory (“A”) treatment of the skin with topical glucocorticoids or topical calcineurin inhibitors (inhibitors).
    • After symptoms subside, creams (lipids, especially ceramides) for the repair of the skin‘s protective barrier (“B”).
    • When the skin protective barrier is stabilized again, use of care creams (“C”), which support the skin in its function
  • Before moving from stage 3 to stage 4, determine whether trigger factors or other stressful factors requiring treatment, such as skin infection. Furthermore, the topical anti-inflammatory (anti-inflammatory) therapy should be optimized and intensified for up to four weeks, depending on patient age.
  • Adults with moderate to severe atopic dermatitis (AD) who are eligible for systemic therapy: Dupilumab (inhibition of overactive signaling pathways of interleukin (IL)-4 and IL-13) [In addition to ciclosporin A is approved for first-line systemic therapy].
  • Atopic eczema should only be treated with antibiotics if an infection is present!The skin of patients with atopic dermatitis is usually colonized with high numbers of Staphylococcus aureus. While this germ plays a role in inflammatory skin processes, oral antibiotic treatment does not reduce the symptoms or severity of atopic dermatitis. For antibiotic therapy:
    • Do not use topical antibiotics!
    • Use of systemic antibiotics and topical antiseptics in bacterial superinfection or superinfection.
  • No itch reduction by oral antihistamines! Efficient anti-inflammatory therapy is the most effective therapy for pruritus.
  • Antiviral system therapy (eg, aciclovir for eczema herpeticatum).
  • Azathioprine only in severely affected patients
  • Possible use of specific allergy immunotherapy (SIT) in selected sensitized patients.
  • The use of bath additives (emollients: water-in-oil or oil-in-water emulsions), which the guidelines advise as part of a basic therapy for atopic dermatitis (neurodermatitis), has been shown to be largely ineffective in a randomized trial.
  • Pimecrolism Note: The immunosuppressant is also used systemically to prevent organ transplant rejection. Side effects occurred such as skin cancer and lymphoma.Topical use for the treatment of atopic dermatitis showed in evaluations that no increased risk of cancer stands.Calcineur inhibitors (inhibitors) treated were compared with patients treated with topical corticosteroids or with untreated patients. The result showed that the use of topical calcineurin inhibitors was not associated with an increased risk of keratinocytic carcinoma (squamous cell carcinoma) compared to patients with topical corticosteroid use only or compared to patients without therapy.
  • Caution.
    • Do not use during pregnancy unless no suitable alternative treatment is available to prevent graft rejection.
    • Do not use in women of childbearing age who are not using a highly effective method of contraception.
    • To preclude unintended use during pregnancy, treatment with mycophenolate sodium should not be initiated in women of childbearing age without presentation of a pregnancy test result.
    • Should not be used by nursing mothers.
    • Physicians should ensure that women and men using mycophenolate sodium understand the risks of harm to the baby, the need for effective contraception, and the need to notify their physician immediately in the event of a possible pregnancy.

Monoclonal antibodies

Active substances Dosage Severity
Dupilumab 300 mg/every 2 weeks Moderate to severe atopic dermatitisNote: approximately one-third become symptom-free on monotherapy; the remainder should continue topical therapy with a glucocorticoid or calcineurin inhibitor, if necessary
  • Mode of action; specific inhibition of overactive signaling pathways of interleukin (IL)-4 and IL-13.
  • The maximum effect on efflorescences (skin changes) is usually achieved after one month, for pruritus it takes a little longer.
  • Indication: adults with moderate to severe atopic dermatitis (AD) eligible for systemic therapy.
  • May be administered as monotherapy or in combination with topical corticosteroids.
  • Dosage information: Administered in the form of a pre-filled syringe; is self-injectable subcutaneously by the patient every two weeks after an initial dose.
  • Side effects: Skin reactions at the injection site; conjunctivitis (then if necessary fluorometholone 0.1% eye drops).
  • Single case report: recurrence of Crohn’s disease after treatment of atopic dermatitis with Dupliumab.

Phytotherapeutics

A comprehensive evidence-based review is available on this topic. The following phytotherapeutics are supported with studies for adjuvant therapy of atopic dermatitis:

  • Tannins from the rhizome of bloodroot (Potentilla officinalis).
  • Evening primrose (Oenothera biennis; oil from the seeds of evening primrose).
  • St. John’s wort (Hypericum perforatum; hyperforin-rich extract of St. John’s wort); effects: antibacterial, anti-inflammatory and differentiation-promoting properties.
  • Licorice (Glycyrrhiza glabra; glycyrrhetinic acid standardized extract of licorice).

Supplements (dietary supplements; vital substances)

Suitable dietary supplements should contain the following vital substances: