A small study suggests that an emollient applied alone without bathing may have a longer duration as measured by capacitance. Propylene glycol is easily irritating in young children aged less than two years and should not be used for toxicity reasons in these young children.
There is concern that the large preventive use of emollients containing intact proteins such as peanut allergens 57 or colloidal oat meal 58 may increase the risk of skin sensitization and allergy. Certain moisturizers could improve skin barrier function in AE and reduce skin susceptibility to irritants. Maintenance of stable disease can be obtained with emollients used twice weekly or more frequently in a subset of patients, after an induction of remission with topical corticosteroids. Several studies showed comparable results for intermittent emollient therapy and time to relapse, using comparable study designs in adults and children.
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Emollient bath oils and soap substitutes should also be used. Emollients with a higher lipid content are preferable in wintertime 3b,C. An induction of remission with topical corticosteroids or topical calcineurin inhibitors is required first 2a,B. Three different clinical reaction patterns in patients with AE have been described, depending on the type of symptoms and their time of onset. In vitro tests are valuable when skin prick tests SPT cannot be applied e.
So far, APTs have demonstrated to improve the accuracy of skin testing in the diagnosis of allergy to cow's milk, eggs, cereals and peanuts in patients with AE. Practically, OFC should be performed according to standardized protocols considering variables associated with food matrix, doses and time intervals. Unfortunately, the effects of dietary interventions on the course of AE have been studied only in a few controlled studies.
In a systematic review, 11 eight randomized controlled studies examining the effect of an elimination diet on existing AE were identified and summarized in the following way: a elimination diets are difficult to carry out even in a motivating atmosphere during a clinical study. A Cochrane systematic review based on nine randomized controlled trials concluded that eliminating egg from the diet in those who had positive specific IgE to eggs proved beneficial.
Although progress has been considerable, there are no simple strategies to prevent the development of AE and food allergy in infants. The recent publication of randomized trials, such as the Learning Early About Peanut Allergy LEAP 93 and Enquiring About Tolerance EAT 94 studies, has given some support to the notion that early oral ingestion of food may protect from sensitization and allergy later in life.
Probiotics such as lactobacillus mixtures have been studied in AE and have been shown to induce improvement. Previous systematic reviews on probiotics for the treatment of AE have consistently concluded a lack of effect in children.
Food elimination diets represent a major impairment in quality of life and are not easy to perform. There is evidence that elimination of basic foods in food allergic children can improve the AE. There is conflicting data on prevention or improvement of AE during uptake of probiotics such as lactobacillus preparations. Effective topical therapy depends on three fundamental principles: sufficient strength, sufficient dosage and correct application. Topical treatment should always be applied on hydrated skin, especially when using ointments. Simple or occlusive medications in less sensitive skin areas and for brief time periods may also increase efficacy and speed up lesion resolution.
This traditional, reactive approach has now an alternative, which is the proactive treatment concept. Clinical trial data are available for a number of steroid products as well as for tacrolimus ointment, but topical steroids are usually approved only for a very limited period of time such as a few weeks. The duration of the proactive management is usually adapted to the severity and persistence of the disease.
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Numerous substances are available in a variety of formulations. Such monthly amounts of even potent topical steroids usually do not have adverse systemic or local effects. Several factors should be considered when choosing a topical corticosteroid, including potency, galenic formulation, patient age and body area to which the medication will be applied. The potency of topical corticosteroids is grouped by potency according to Niedner from mild group I to superpotent group IV.
In France, this classification is even different. Children should be treated with less potent TCS than adults. Itch is the key symptom for evaluation of response to treatment, and tapering should not be initiated before the itch has largely improved. Tapering strategies consist of switching to a less potent corticosteroid, or keeping a more potent one while reducing the frequency of application intermittent regimen. In infants, inappropriate use of TCS in the diaper area can lead to granuloma gluteale infantum or even iatrogenic Cushing's disease.
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The risk of ocular complications by topical corticosteroids seems to be low. Development of glaucoma or cataract has been described after systemic glucocorticosteroid application. The use of potent topical corticosteroids in sensitive skin areas face, neck, folds should be limited in time to avoid skin atrophy. The special aspects and potential adverse effects of topical corticosteroids in pregnancy have been recently reviewed.
The simultaneous combination of topical corticosteroids with topical calcineurin inhibitors at the same site does not seem to be useful. Initial treatment with topical corticosteroids may be considered in patients with acute flare to minimize topical calcineurin inhibitor site reactions. Topical corticosteroids have a significant effect improving skin lesions compared to vehicle.
The efficacy of topical glucocorticosteroids can be increased using wet wraps. Two topical calcineurin inhibitors TCI , tacrolimus ointment and pimecrolimus cream, are licensed for AE treatment. Both topical tacrolimus and corticosteroids decrease skin recall activity and decrease serum IgE in patients with treatment response. Safety data of both topical calcineurin inhibitors have been reported in many clinical trials and registries, demonstrating the safety of these drugs in daily routine use.
In some patients, they are severe enough to induce prompt treatment discontinuation. Initial treatment with topical corticosteroids should thus be considered in patients with acute flare to minimize these site reactions. Generalized viral infections such as eczema herpeticum or eczema molluscatum have been observed during topical calcineurin inhibitor treatment, , but a high number of clinical trials failed to demonstrate an increased frequency or showed only a transient increase reviewed in - In contrast to corticosteroids, none of the topical calcineurin inhibitors induces skin atrophy.
Clinical and preclinical data do not indicate an increased risk of lymphoma.
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Tacrolimus ointment and to lesser extent pimecrolimus cream may cause burning sensation and transiently worsen AE especially when given on acutely inflamed skin. Topical calcineurin inhibitors do not cause skin atrophy, glaucoma or cataract. From the published data of the global scores and the individual items of an eczema score, a relatively low efficacy of crisaborole is probable. Crisaborole ointment is currently not licensed in Europe. First promising phase II clinical trial data with the topical JAK inhibitor tofacitinib have been published, but the topical development programme was halted.
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Further similar compounds are in the pipeline for topical as well as for systemic therapy, but none is currently licensed in Europe. As most patients affected by AE improve during the sunny summer season, artificial UV radiation is frequently employed in the treatment of AE. On the contrary, a small group of patients will exacerbate following UV radiation.
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The known mechanisms of action target immunomodulation through apoptosis of inflammatory cells, inhibition of Langerhans cells and alteration of cytokine production. Davos with predominantly UVB. Other light therapies have been introduced. Photopheresis is used in some centres for the treatment of selected cases. Positive effects in patients with severe refractory AE have been described. In practice, the choice of a certain UV treatment is limited by the availability of the phototherapy equipment: e. In addition, UV light does not effectively treat hairy areas as scalp and skin folds.
As a rule, phototherapy is not indicated in the acute stage of AE except UVA1, which is also effective in managing AE flares , but is more apt to treat chronic, pruritic, lichenified forms and should not be prescribed in those patients who experience a worsening of AE during sun exposure. UV therapy has to comply with special requirements with regard to personnel, documentation, UV protection especially of the eyes, contraindications and technical aspects.
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