If your atopic dermatitis (AD) treatment doesn’t do the trick at first, don’t worry. Your health care provider may be just getting started.
First-line treatments are the standard approaches your provider might take to improve your AD. It doesn’t always mean it's the best overall treatment for you, though. In many cases, it’s just the first step in a process as your doctor learns more about your personal symptoms and triggers, possible allergies, genetic background, personal habits, and even your workplace conditions.
The First Line Is a Starting Point
“Generally there’s a laddered approach to treatment,” says Bruce Brod, MD, MHCI, FAAD. He’s director of the Contact Dermatitis Clinic and a clinical professor of dermatology at the University of Pennsylvania Perelman School of Medicine. “You establish the diagnosis. It doesn’t [always] fit into a neat category, though sometimes it does.”
Brod’s goal with first-line treatment for AD is to reduce inflammation and improve your skin’s moisture barrier, which protects your body from water loss and retains moisture. Along with prescribing a cream or ointment to apply to your skin to help it heal and soothe your symptoms, he’ll likely ask you to try a combo of changes in your daily routine. This can help ID things that might trigger your AD or make it worse.
When Front-Line Treatment Doesn’t Work
Not everybody responds to first-line therapy, Brod says. This can happen for a number of reasons, including:
Allergic contact dermatitis makes things worse. You might be allergic to certain ingredients in the products you use or substances you come into contact with, including in your workplace, Brod says. Doctors can zero in on the allergen using patch testing.
In a patch test, your provider puts chemicals that might be the source of your allergies onto a chamber held in place by a piece of tape. It’s placed on your skin, usually your back. The test is positive if the patched area reacts, such as getting red or itchy. Reactions happen with about 20% to 30% of people with AD.
“If that’s the case, you can identify ingredients such as fragrances or preservatives in shampoos, cleansers, makeup, or other products” you use, Brod says, and try to nix the allergy part of your AD.
Your provider can then counsel you on how to avoid the allergens and suggest other products you can try. Some of the common allergens in cleansers include some of the foaming agents, preservatives, and botanicals. Synthetic cleansers rather than soap-based cleansers are gentler on the skin, Brod says. Ingredients in cleansers and body washes that are most helpful include moisturizers like petrolatum and ceramides, which are lipids that can keep skin moist.
You might not be sticking with your treatment plan. Much of the treatment approach includes setting expectations for you to follow through on, Brod says. If applying the recommended lifestyle changes along with topical cream for a week or two doesn’t help, your provider might need to press a little more to make sure you’re ticking all the boxes. “They need a constant routine, and be using it correctly,” he says.
An issue with how well your body receives and retains moisture during treatment.
“Among patients with AD, many of them have a genetic glitch that causes their skin to not retain moisture so well,” says Brod, noting this can make skin easily aggravated. “It’s important to talk to them about the use of moisturizer on the skin.”
A strong moisturizer plays a key part in effective treatment. Brod favors thicker, cream-based products that contain petrolatum to help cut down the loss of moisture and water from your skin. Petrolatum, also known as petroleum jelly, can help heal burns and scrapes, but it also hydrates skin. It’s often used as a base for ointments. “That often helps reduce the symptoms and the inflammation of the AD,” Brod says.
Relapses and flare-ups keep happening. When someone isn’t responding to treatment, or quickly relapsing and flaring, it’s time to think about other approaches, Brod says. Some choices might be among newer prescription topical medications that don’t have steroids in them. “They’re often helpful to use … to help keep the AD from flaring, for maintenance,” he says. “They’re also good tools in the chest in areas where you don’t particularly want to use topical steroids, like the face and body fold areas.” These areas include your armpits, groin, and other places where your skin folds over tender parts of your body.
Things in the environment
Your workplace. If you work in a profession that exposes you to potential allergens, such as the food and beverage or manufacturing industry, you might need to be hyper aware of things that might rile up your AD. “That can come into play, for instance, for someone who works as a food handler or a bartender or server, or someone who works in an assembly line where there are pooling oils and fluids,” Brod says. “Hair stylists have their hands in water and shampoo. … Those are irritating things that can certainly make (AD) worse for sure.” People who’ve seen their AD improve over time might see their symptoms return when they come into contact with a certain substance later in life. Patch testing can help isolate what you might be allergic to. “Sometimes it’s hard to change the environment. We don’t always have a choice as to where we work.”
Seasonal changes. “There’s a subset of patients who flare with the change of seasons,” Brod says. Some people do worse in the cold or dry winter, while others are affected more by heat and sweating. “There are all sorts of variants, and it's important to try to assess what makes their condition worse,” Brod says.
Second-Line Treatments
Phototherapy
Another form of treatment your doctor might prescribe for moderate to severe AD is phototherapy, also known as light therapy. It’s a common, safe treatment that uses ultraviolet (UV) lights to help control skin conditions including AD.
Phototherapy mainly targets inflammation. “We use something called a narrowband UVB,” Brod says.“ The barrier to that is patients, when they get started, typically come to the office two to three times a week,” a firm commitment period for frequent treatments.
While there’s a home device that can be helpful, it’s best to start under your health provider’s care to learn how it works.
Biologic drugs
“We have many more choices today than we did 20 years ago,” Brod says. “Many of the drugs are very effective and safe as well.” An important new field is biotechnology, which has come up with biologic meds that come from living proteins and genetic materials. “Before biologics … entered the market to treat AD, doctors had to rely on various immune-suppressing drugs” that came with too many side effects for AD treatment, he says.
More new meds on the market
Your doctor might reserve certain oral meds – meaning they’re taken by mouth – when first-line therapy doesn’t work or isn’t practical. Also new to the market are a class of meds called JAK inhibitors. They shut down an overactive chemical signal pathway called the JAK-STAT (which stands for Janus kinase-signal transducer and activators of transcription) pathway in your cells. “These have more of an impact on the immune system over the biologics, which provides a range of choices for patients with harder to treat AD,” Brod says.
The influx of new treatments for AD offers more second-line options to try than ever, he says. “We’ve really seen an explosion over the past five to 10 years.”
Show Sources
Photo Credit: iStock/Getty Images
SOURCES:
Bruce Brod, MD, MHCI, FAAD, director, Contact Dermatitis Clinic, and clinical professor of dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia.
National Cancer Institute: “First-line Therapy,” “Petrolatum.”
DermNet NZ: “Barrier Function in Atopic Dermatitis.”
Penn Medicine: “Patch Testing.”
Cleveland Clinic: “The Best Moisturizer for Your Dry Skin? Here’s What To Look For and How To Use It,” “Phototherapy (Light Therapy),” “Biologics (Biologic Medicine).”
National Eczema Association: “JAK Inhibitors Are Coming and They Are the Biggest Eczema Development in Years.”
