What are the treatment options for atopy?

Treatment Options for Atopy

First-line treatment for atopic conditions depends on the specific manifestation: for atopic dermatitis (eczema), use liberal emollients with mild-potency topical corticosteroids (1% hydrocortisone in children, moderately potent steroids in adults); for allergic rhinitis, use intranasal corticosteroids (fluticasone, mometasone, budesonide) for moderate-to-severe disease or second-generation antihistamines (cetirizine, loratadine, fexofenadine) for mild disease. 1, 2, 3

Atopic Dermatitis (Eczema) Management

Basic Maintenance Therapy

• Apply emollients liberally and frequently to maintain skin hydration and improve barrier function 1, 3
• Apply emollients immediately after bathing to lock in moisture and prevent dryness 1
• Replace regular soaps with soap substitutes (dispersable creams) to prevent removal of natural skin lipids 1
• Daily bathing with soap-free cleansers is recommended as part of maintenance therapy 3

Topical Corticosteroids for Flare-Ups

• Use mildly potent topical corticosteroids (1% hydrocortisone) for infants and children 1
• Use moderately potent topical corticosteroids for adults 4, 1
• Apply for limited periods until the flare resolves, then discontinue 1
• Use the least potent preparation required to maintain control 1
• Infants are particularly susceptible to side effects due to high body surface area to volume ratio 5

Topical Calcineurin Inhibitors

• Pimecrolimus and tacrolimus can be used in conjunction with topical corticosteroids as first-line treatment 3
• These agents are effective alternatives when corticosteroid side effects are a concern 6

Managing Pruritus

• Antihistamines may be useful as a short-term adjuvant during severe flares with significant itching 1
• The therapeutic value is primarily due to sedative properties, not antipruritic effects 1
• Non-sedating antihistamines have little to no value in atopic eczema 1
• Oral antihistamines are not recommended as they do not reduce pruritus effectively 3

Secondary Bacterial Infections

• Monitor for signs of secondary bacterial infection: crusting, weeping, punched-out erosions 1
• Flucloxacillin is the most appropriate antibiotic for treating Staphylococcus aureus, the most common pathogen 1
• Antistaphylococcal antibiotics are effective in treating secondary skin infections 3

Viral Infections

• Eczema herpeticum (herpes simplex infection) requires prompt treatment with acyclovir 1

Allergic Rhinitis Management

Mild Intermittent or Mild Persistent Disease

• Second-generation H1 antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) as first-line therapy 2
• Intranasal antihistamines (azelastine, olopatadine) are alternative first-line options 2

Moderate-to-Severe Persistent Disease

• Intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) should be used initially 2
• Can be used alone or in combination with intranasal antihistamines 2
• Maximum benefit may not be reached for several days after initiation 5
• Some patients experience symptom improvement within 12 hours of initial treatment 5

Allergen Avoidance

• Patients should avoid inciting allergens when possible 2
• Evidence for house dust mite eradication benefits is not strong, and complete eradication is not currently achievable 4

Second-Line and Advanced Therapies

When to Refer to Specialist

• Failure to respond to maintenance treatment with mildly potent steroids in children or moderately potent steroids in adults 4, 1
• Diagnostic uncertainty 4, 1
• When second-line treatment is required 4, 1
• When dietary manipulation is being considered 4

Phototherapy Options

• Ultraviolet phototherapy is safe and effective for moderate-to-severe atopic dermatitis when first-line treatments are inadequate 3
• Narrow band ultraviolet B (312 nm) therapy may be beneficial 7
• PUVA (psoralen plus ultraviolet A) therapy can be considered, though long-term risks must be weighed 7

Systemic Therapies for Refractory Cases

• Azathioprine has shown efficacy in steroid-resistant cases 4, 7
• Cyclosporin may be effective when other treatments fail 4, 7
• Dupilumab (biological drug) may be considered in patients with moderate-to-severe disease with no improvement from other systemic treatments 3, 6
• Crisaborole (topical phosphodiesterase 4 inhibitor) can be used twice daily in patients over three months old 3, 6

Dietary Manipulation

• Consider dietary manipulation when patient history strongly suggests specific food allergy 4, 7
• Also consider when widespread active eczema is not responding to first-line treatment 4
• Access to a dietitian is recommended for comprehensive evaluation 4

Experimental and Unproven Therapies

• Evening primrose oil has conflicting evidence: two large trials showed no benefit, but other studies reported benefit for moderate-to-severe eczema 4
• If tried, use adequate doses: 160-320 mg daily in children aged 1-12 years and 320-480 mg in adults for three months 4
• Discontinue if no benefit after three months 4
• Chinese herbal medicines have been reported effective but carry risk of hepatotoxicity; regular liver function tests are required 4, 7
• Scientific evidence for homeopathic remedies is lacking 4

Critical Pitfalls to Avoid

• Do not continue ineffective treatments indefinitely; pursue alternative approaches if no response after reasonable trial 7
• Do not use first-generation sedating antihistamines expecting antipruritic effects in eczema—their value is only sedation 1
• Do not delay specialist referral when first-line treatments fail, as this can worsen morbidity 4, 1
• Monitor growth velocity in pediatric patients receiving intranasal corticosteroids, as growth suppression can occur even without HPA axis suppression 5
• Be aware that some patients may require multiple therapeutic approaches simultaneously for adequate control 7