Simple Solutions Treat Tough Atopic Dermatitis
If that doesn't work, try compounded triamcinolone and salicylic acid in mineral oil, “but be aware of the potential risks of increased absorption.”
Dr. Paller called hands and feet “the toughest areas that we tend to see.” They typically require an increased potency of any agents used.
When these basic approaches fail or are not tolerated, consider the following: hospitalization to “cool down” the patient; systemic immunosuppressants; ultraviolet light, including narrow-band UVB; and balneotherapy.
“UVB treatment in pediatric patients is very difficult, often because of time constraints, and concern about UV exposure, compliance, and tolerance,” she said.
As for systemic corticosteroids, “we try to avoid long-term use in children because of the many potential side effects including growth failure,” she said. “When you stop someone on systemic corticosteroids, there tends to be a rebound effect.”
The systemic immunosuppressant she uses most often is cyclosporin A. She usually starts with a dose of 5 mg/kg per day (3 mg/kg per day if it's the microemulsion form). “In many cases there's a response within a few weeks,” Dr. Paller said. “In other cases it can take longer, so I will tend to go for a 3-month trial and see how that patient is doing. I always try to taper about 1 mg/kg per day each month as tolerated. I find that many patients cannot get off the medication, but they can be tapered down to a lower level.”
Although use of cyclosporin A requires monitoring of blood pressure and renal and liver function, “I have not had one patient who's had a side effect that's significant from the use of cyclosporine, so I don't hesitate to use it, even in young children if that's necessary.”
If the patient is still not responding, consider the possibility of an alternative diagnosis. Atopic dermatitis impostors can include contact dermatitis, scabies, Wiskott-Aldrich syndrome, hyperimmunoglobulinemia E, and Netherton's syndrome.
“Sometimes we need to step back and ask, 'Do we have the right diagnosis?'” Dr. Paller said.
