Making Your Atopic Dermatitis Treatment Work for You

By Shawn G. Kwatra, MD, as told to Sarah Ludwig Rausch

When you have atopic dermatitis (AD), your skin barrier is altered, your immune system is revved up and causes inflammation, and during flares, you have what’s called microbial dysbiosis (an imbalance of bacteria, viruses, and fungi on your skin).

Even though there are many things involved in AD, such as the world around you and problems with your genes or your skin barrier, most therapies used today target the inflammation to ease symptoms.

Everybody has different triggers. I think it’s important for people to try to see what things tend to really irritate them, like different types of clothing, household irritants, or hot or cold weather. There are many things that people have to keep in mind that could irritate them. And it’s important to use gentle cleansing soaps, too.

There are definitely genetic factors in AD, so how severe the disease is varies. Some people have the atopic dermatitis triad, which is asthma, seasonal allergies, and AD.

Actually, I was born with asthma and was hospitalized when I was 2. Then I developed significant eczema and seasonal allergies. Now, I often have hives too, and I’m very itchy, which is why I choose to study dermatology. Having the AD triad tends to cause more severe disease that can sometimes be more difficult to treat.

Moisturizing is really important, especially right when you hop out of the shower, because you have a barrier of water in the outer layer of your skin that protects your nerves from being irritated. The greater water barrier you can have, the better for protecting your skin barrier.

Right when you get out of the shower, within 10 to 30 seconds, you want to barely pat down and then put in a thick, cream-based moisturizer to really lock in the moisture. That can help build that water barrier that then can help prevent the nerves from being super irritated.

Cream-based moisturizers tend to be the most nourishing, but the most important thing is that you find something you’ll use. There are also ointments that can be good. If you have contact allergies, it’s important to check the label of the product to make sure you’re not allergic to any of the ingredients.

Also, eczema is tied to widespread (or “systemic”) inflammation, so make sure that when it starts acting up, you try and nip it in the bud and don’t let it get worse. When it festers, that’s when you can really have bad disease flares.

As we’re learning with lots of diseases, the microbiome (a community made up of bacteria, fungi, parasites, and viruses) in the skin and in the gut affects the immune system. Eating a high-fiber diet helps promote a healthy microbiome because it carries food for good bacteria, which are linked with immune function. It really is all connected.

Smaller steps like these will give your treatments the best chance to do their job.

There are a few FDA-approved therapies for AD, but many more are in the pipeline.

Topicals. Topical steroids are often prescribed first, and they usually work pretty quickly. “Topical” means you put them directly on your skin. But with long-term use, they can cause skin atrophy (thinning), skin lightening, and telangiectasias (tiny, dilated blood vessels). That’s why you can’t use a topical steroid twice a day forever with no breaks.

Other topicals like calcineurin inhibitors can ease symptoms without those side effects. Another new type of topical is phosphodiesterase-4 inhibitors (PDE4). This is basically a way to target inflammation without weakening the immune system. Calcineurin inhibitors and PDE4 inhibitors are often used along with topical steroids.

Phototherapy. If your AD is more widespread or hasn’t responded well to topical treatments, we consider systemic treatments. Phototherapy is one treatment that’s been used for decades, and it’s usually two to three times a week. It uses different wavelengths of ultraviolet (UV) light to treat AD. There have been many studies showing how phototherapy can trigger an anti-inflammatory effect in the skin.

Oral antihistamines. The itch of atopic dermatitis is not from histamine. So antihistamines, especially ones that don’t make you sleepy, aren’t very helpful. But sedating antihistamines such as diphenhydramine (Benadryl) and doxylamine (Unisom) can help with itch, particularly at night, because they tend to make you drowsy.

Injectables and immunosuppressants. Dupilumab (Dupixent) is an FDA-approved treatment for moderate to severe atopic dermatitis. This medication has been found to rapidly improve symptoms of eczema and itch.

Many people who have Medicaid or Medicare can’t get approved to take dupilumab, so they have to use immunosuppressants like methotrexate or cyclosporin. These are medications that may reduce inflammation, but they need frequent lab tests for things like liver function, kidney function, and blood counts.

Sometimes, AD can be hard to treat if you have symptoms in thinner-skin areas — like the face, genitals, or eyelids — where you worry about using a high-potency topical steroid. But eczema is very heterogenous, which means it affects everyone differently. So some people are more likely to respond to therapy than others.

Each treatment has a different level of effectiveness. If the condition is only on a limited area of the body, then a combination of topical steroids and inhibitors tends to work pretty well. Even in most of my patients with severe disease, I see that they’re able to get significant improvement.

The fact that we have many agents in development is also very promising. So there are going to be even more options coming in.

The big problem with alternative therapies is that there’s limited smaller studies, so everything we advise is based on very limited data.

There are small studies to suggest that L-histidine, an over-the-counter supplement, can be helpful with AD, since problems with filaggrin (a protein that’s crucial to the skin barrier’s strength) are believed to raise your risk of atopic dermatitis. L-histidine is important in the natural moisturizing factor of your skin.

Manuka honey has been found to affect the cell division of Staphylococcus aureus, a bacteria found on most people with AD. Some small studies have shown it could be helpful.

It has even been found in some small studies that vitamin E could reduce immunoglobulin E (IgE), an antibody that’s often higher in people with AD. Vitamin E is naturally found in vegetables and nuts.

We’re at the tipping point of a revolution. The movement in atopic dermatitis is in many ways mirroring what happened in psoriasis, where so many treatments became available.

It’s really the golden age for atopic dermatitis, because many of these drugs are going to be available in the near future.