The prevalence of atopic eczema, (dermatitis) has been growing over the past two decades and now affects a disproportionate number of children. According to current estimates, roughly 15% to 20% of children in industrialized countries around the world develop atopic dermatitis in the first few years of life. In contrast, only an estimated 3 percent to 5 percent of adults have an active form of the condition.
Are we making any headway against it?
“There has been an abundance of new research looking at genetic abnormalities associated with atopic dermatitis, including those in the skin’s barrier function – or its protective outer layer,” says Dr. Lawrence Eichenfield, professor of pediatrics and dermatology at the University of California, San Diego “It appears that a subset of patients with atopic dermatitis and eczema is born with problems with the function of their outer layer of skin, which can cause the skin to be drier and more prone to the absorption of irritants, microbes and allergens that can penetrate the skin and cause adverse reactions. Fortunately, this new understanding is leading to new and better treatments for patients of all ages.”
A range of potential new therapies that target several aspects of atopic dermatitis could help patients find new relief from the pain, both physical and emotional, that comes with this complex condition. Here are a few of them.
New Topical Corticosteroids
Useful for reducing the skin’s inflammatory response, topical corticosteroids are a stronghold in atopic eczema treatment. Now, newer forms of topical corticosteroids, in foams, gels, and oils, have gone through safety and efficacy testing, and are approved for use in younger patients – even infants as young as three months of age.
The products that are approved by the U.S. Food and Drug Administration (FDA) for this age group to treat atopic dermatitis and eczema include fluocinolone acetonide, topical oil 0.01%, desonide gel 0.05% and desonide foam 0.05%.
Some patients have spoken of their worry about the cost of treatments. Because pharmacy chain stores are now promoting generic drug programs, they may find there is a more cost-effective therapy for managing chronic atopic dermatitis.
“The newer approved formulations may cost more compared to the generic medications, so it is important for patients to discuss generic options with their dermatologist,” said Dr. Eichenfield.
Topical Calcineurin Inhibitors
Another group of atopic eczema therapies used to stem inflammation of the skin is the topical calcineurin inhibitors. The FDA-approved Tacrolimus ointment and Pimecrolimus cream are two examples. New studies have looked at whether intermittent use of topical calcineurin inhibitors can manage atopic dermatitis effectively.
In fact, for patients whose atopic dermatitis was initially controlled with the application of topical corticosteroids or tacrolimus ointment, applying topical calcineurin inhibitors intermittently was quite effective in controlling flare-ups.
“Studies have shown that topical calcineurin inhibitors can be very helpful in a variety of atopic dermatitis treatment regimens,” said Dr. Eichenfield. “For instance, these recent studies demonstrate that applying topical tacrolimus ointment two to three times per week successfully controlled the condition for months, on average, before a significant flare of dermatitis. Other studies show that using tacrolimus ointment or pimecrolimus cream intermittently at the first signs and symptoms of a flare-up was quite successful. These products may be especially useful for patients who otherwise would have more persistent or frequent recurring eczema.”
Engineered Emollients and Barrier Creams
Barrier creams and engineered emollients are among the newer FDA-approved topical agents designed to improve the skin’s barrier function, which is degraded in atopic eczema. By adding agents such as lipids or ceramides, natural lipids that act as water regulators, they help to rebuild damaged skin.
These topical preparations include water-based emulsion with N-palmitoylethanolamide; MAS063ADP, with glycyrrhetinic acid; and ceramide-dominant products.
“Barrier creams and engineered emollients appear very helpful in decreasing symptoms and the need for stronger prescription products, but these medications are fairly new and dermatologists are in the process of assessing their optimal use in atopic dermatitis treatment regimens,” according to Dr. Eichenfield. “Initial assessments demonstrate that the damaged skin can be improved showing less dryness due to less water loss, less inflammation and less need for more potent anti-inflammatory agents.”
For a considerable subset of atopic dermatitis patients of all ages, systemic therapy is required to control their condition. While systemic therapies for atopic dermatitis pose safety concerns due to possible side effects, Dr. Eichenfield reports that a few of the newer immunosuppressive agents and newer biologic therapies are being used successfully, yes, even in children.
“Newer immunosuppressives such as mycophenolate mofetil can be very useful in providing relief for patients with more severe cases of atopic dermatitis and have been studied for use in the pediatric population,” said Dr. Eichenfield. “In addition, dosing of azathioprine is now based on an individual’s genetics and metabolic activity to process the medication, allowing it to be used with less chance of dangerous side effects. Newer studies of the latest biologic therapies, such as efalizumab, show some benefits, but in general more research needs to be done to confirm the safety profile of all systemic therapies for this condition.”
Dr. Eichenfield says that with the new understanding of how atopic dermatitis develops in relation to barrier dysfunction, there is interest in studying whether early intervention with a variety of topical therapies may impact the overall course and severity of atopic dermatitis and prevent or delay the development of other related allergies – such as food allergies and asthma that affect many patients with atopic dermatitis.
Note: Statistics on prevalence of atopic dermatitis are from “Management of atopic dermatitis in the pediatric population,” published in Pediatrics October 2008 issue. Image by Patrick Kennedy, Creative Commons Attribution License.