Eczema treatment

Eczema or dermatitis, is a type of skin inflammation that affects the skin, and recognizes extremely various believed causes; however since they are not confirmed, treatments do not interfere with the etiology but tend to orient themselves upon alleviating symptoms and improving the quality of life in each patient. Just like in psoriasis, two main theories dominated the pathology of eczema. The first, assumed that the defect causing eczema was primarily located within the damaged organ that is in our case the skin; this supposed a very logical use of topical (local) agents in the attempt to either cure the disease of to alleviate symptoms. However research testing of substances that act on the immune system mainly, that were not specifically designed for psoriasis alone, proved that it is much more probable that eczemas are part of a wider group of immunological disbalances occurring in individuals, and that the skin is the place where these disbalances tend to be expressed although that place might not be the major lesion (the immunologists' cliche: the tip of the iceberg).

Mainly during clinical trials, and sometimes during clinical practice, the severity of psoriasis occurring in a certain individual needs to be assessed in order to decide upon the aggressiveness of a treatment that needs to be ensued. So as to be objective, a scale called PASI (psoriasis area severity index) has been created, thus giving researchers an instrument used to evaluate patients. The PASI scale includes variables such as a the extent of the lsions, the thickness of the skin, age, sex, responsiveness to previous therapies administered and others. The lowest PASI score is 0 (equals to no psoriatic activity detected) whereas the maximum score is 72 (equals to disease of maximum gravity present). PASI scores will divide patients into mild cases, moderate cases and severe cases, accounting in the general population for 65%, 25% and 10% respectively.

According to the severity class, a certain "ladder-approach" has been conceived in order to decide the best initial treatment of a patient firstly-reported with psoriasis. It is called a ladder-approach, because the more severe the disease gets, the more the physician escalates the ladder by introducing more aggressive chemicals or methods within the treatment plan. By aggressive we mean either methods that allow for serious side-effects, or chemicals that do not have a localized profile of action but a systemic one. Explicitly, a mild case starts on topical treatment (locally applied), a moderate case adds to, or replaces the topical treatment with phototherapy, a technique which will be subsequently discussed, and severe cases go directly into systemic therapy. All these will be detailed subsequently.

Two entities should be considered separately, and those are psoriatic arthritis and psoriatic erythroderma. Psoriatic arthritis can exist either by itself, consisting of a form of dry psoriasis, since there will not be any secretion visible; it is mostly a diagnosis based on excluding other causes of arthritis, since if it develops on its own the physician cannot benefit of the advantage of identifying classical psoriatic lesion in other parts of the body. But it can as well complicate classical forms of psoriasis, like for example the most common form, called psoriasis vulgaris (a plaque-form). Psoriatic erythroderma, represents a serious complication during psoriatic treatment usually, but can also be triggered by quantitatively highly present usual triggers in exacerbation of psoriasis: stress, alcohol comsumption, smoking, streptococcal infections and others. It refers to a brutal deterioration in the patient's health associated with wide spreading of the lesion to such cases in which they affect the whole skin of the body, secondary to abrupt termination of a therapy, for example corticosteroid (thus it constitutes a rebound syndrome); or as stated above, it can be secondary to a very large amount of triggers present.

During treatment, if doctors rely on one method for two long, especially if it is a chemical (drug therapy) one, the disease tend to gain resistance to it (phenomenon called tachyphilaxis), and thus the approach to this is to periodically switch to "new" therapies and let the disease "forget" about how the prior one worked. This procedure is called treatment rotation, and should be used by any physician in order not to deplete curative options throughout the life of the patient. In case of using corticosteroid therapy, and trying to temporarily interrupt the use, as part of rotation of treatment, it is very important to abort steroid therapy gradually and not on the spot, because of the possibility of psoriatic erythroderma ensuing, as a rebound phenomenon.

The same classes of chemicals can be used in the treatment of all eczemas, there are some particularities in psoriasis that we shall point out at that time.

Corticosteroid treatment

The usual approach is using these steroids for their anti-inflammatory and immunosuppressant activity topically, in ointments. The corticosteroid must be of a hydroxilated type, since being applied on the skin will shunt the portal circulation, thus not allowing for activation in the liver. Substances vary in their potency, and preferably lesser potent ones are to be used ahead of more potent ones so to limit the side-effects. Examples include: hydrocortisone, desonide, clobetasol propionate, fluocinonide or triamcinolone. Side effect include atrophying of the skin, with it becoming thinner and more fragile thus more prone to microlesions and infections; suppression of the corticosteroid axis in the body, with subsequent adrenal shrinking - in case of high dosage, glaucoma, hypertension due to salt and water retention osteoporosis, decreased resistance to microorganisms such as bacteria or fungus. The main recommendation is to use corticosteroid sparingly, this meaning both in time and in space. The use should be limited to acute episodes of eczema, and the application area should be limited to that of the affected spot. Usually, the side effects mentioned do not appear within topical treatment but during treatment reserved for severe cases which is administered orally or by injection.

Immunomodulators

These constitute a class that is very different from that of corticosteroids, at least chemically, although their final aim is quite similar. Immunomodulators were discovered more by chance, than by trying to find a compound with the same goal as corticosteroids but with lesser side-effects. The first drug created was sirolimus or rapamycin, so called after Rapa Nui (another name of Easter Island). Scientists discovered this substance in a fungus living in the soil and later concluded that is was actually produced by a bacteria that co-habited the soil named Streptomyces tsukubaensis. Later derivatives include pimercolimus and tacrolimus. All these products have proven an efficient immunosuppressive action, though the FDA introduced warning about their possible side-effects regarding pro-carcinogenic activity at least regarding skin-cancers, as they are used in topical application. The observation seems logical, since they suppress a normal immune system, thus allowing malignant clones that usually do occur throughout life but are killed by a competent immune system to escape. The counter-argument of this is that eczema itself, by local irritation and inflammation may actually consist a pre-cancerous condition when discussing skin-cancer; so large scale use might be soon promoted, since they do not have as many side-effects. However they do display some side-effects among which severe flushing, photosensitivity, and drug-interactions. The price of such compounds might also prove prohibitive on large scale use.

Antibiotic/antifungal treatment

Since except for a few cases like athlete's foot for example, eczema is not triggered as an infectious phenomenon, generalized prescription of antibiotics or antifungals should be avoided. Antifungals should be given in athlete's foot either topically or orally, since the increased humidity does account for fungal development in case of this eczema. In other types of eczema, antibiotics or antifungals can be taken into consideration however as long as breaches appear in the skins natural composition due to excessive thickening and crusting which makes sin friable.

Immunosuppressant drugs

This category of drugs revolutionized the fate of transplantation in the past decades. Starting with the development of cyclosporine in the 1960s a series of compounds started to be used in any kind of disease that implies an inflammatory pathogenic component. Thus cyclosporine, azathioprine and metothrexate are now sometimes used in treating severe cases of eczema that do not respond to lower steps of the ladder therapy, or in the treatment of psoriatic erythroderma, the acute aggravation of the disease usually following abrupt abortion of corticosteroid treatment.

Relieving the itch

Although doctors tend to focus on the essence of the disease, since they are familiar with the undergoing processes behind the clinical aspect, patients who are no experienced with this might not be mainly troubled by the presence of the eczema but by its symptoms. One of the most bothering, resource-consuming and disabling is itching. Usual drugs used to treat this comprise histamine type 1 receptor blockers, also called antihistamine drugs. They can prove to be of use in eczema.

A more recent drug, capsaicine, a chili pepper extract with irritating properties proves to be extremely valuable in relieving itches by a complex mechanism. Since itch impulses travel into the nervous system using exactly the same fibers as pain stimuli do, it was implied that the gate control theory of Melzack might be applicable to itch as well as it is to pain. Explicitly, the gate theory states that in case an individual has neurons firing proprioceptive impulses along their fibers, these tend to inhibit transmission up the pain fibers (that is the reason for which we tend to rub a hurt area whenever we have minor trauma on in). If so, and the same fibers are used for itch impulses, it means that the mechanism can be applied to relieve itching sensation by stimulation of proprioceptive fibers. This is achieved by the substance capsaicine, locally applied, that acts as a local irritant, sending impulses up through proprioceptive fibers, and thus relieving the itch by inhibition of other fibers. It is still evaluated since eczema itself represent an irritation and capsaicine might do further damage.

Itch can also be managed by decreasing nerve transmission along pain fibers that as we previously stated also conduct itch impulses; this can be done by applying minty oils (containing menthol that interferes with nerve transmission).

Skin moisture

Dry skin favors complication of the eczema, by further reducing the capacity of the skin to act as a natural barrier in the way of pathogens.

As a general rule, people suffering from eczema should avoid contact with detergents and some soaps (but not all of them), especially if they have contact dermatitis, mostly triggered by detergents (sodium lauryl sulfate - the most common of them). Since these detergents are widely spread nowadays, "safe" soaps are usually required in order to scrub the skin clear of such irritants. Apart from this, recommendations are to avoid any other skin cleansers or scrubs, as they can further irritate the damaged areas. The term "safe" soap is not clearly defined, and campaigns sponsored by different companies to promote different formulas, always yield as best result their own product. At the same time terms like "skin friendly", "hypoallergenic" and "doctor tested" are not standards since they are quite subjective. Therefore a few common sense rules are to use as little soap as possible, not to scrub, to choose a fat-based soap that is also unscented and to patch-test it before spread use (test the soap on a skin area not that exposed). Replacement of soap with plain yoghurt has also been proposed. After soaping, you should rinse with plenty of water, never use sponges or other scrubbing material, only tap-dry, not rub-dry and afterwards use oil-based lotions before drying up in order to trap moisture underneath it so as to favor hydration of the skin for a longer time.

Modified environment

It proves effective as long as the major cause is within the environment, and not usually at our will. For example people bearing eczemas caused by house dust mites might use improved vacuum cleaning, might give up carpets over tiles for example, might change mattresses more often, aerate the bed sheets thoroughly since dust mites live on moisture from night perspiration and others.

PUVA therapy

The use of light therapy has been long known to be of some effect at least in psoriatic eczema, not necessarily in other types of eczema. Light therapy supposes the usage of UV lighting, directly applied on the skin. The wavelengths used differ on condition of using Wideband UVB (290-320 nm) or Narrowband UVB (311-312 nm). Advantage of Wideband UVB consists of higher efficacy and lesser exposure required, whereas Narrowband UVB has a wavelength high above 300 nm, the ones less than 300 nm being surely pro-carcinogenic at a certain dose. PUVA is not the same thing with phototherapy alone. PUVA means psoralens and UVA rays. Basically psoralens are plant compounds that can be given orally, and seriously photosensitize the skin, thus allowing for usage of UVA instead of UVB. Since UVA have longer wavelengths (380-315 nm) they are considered much more harmless than UVB radiation.

Nutritional indications

In the past few decades, food allergies have been described. This term comprises a series autoimmune condition arising secondary to sensitizing the organism with an antigen within foods that is molecularly similar to the one found in different common products. Just as an example: you eat something called A, that has an antigens similar with the ones found on object B, then you use object B, and you get a contact dermatitis. Or, for example, the antigens within the food are molecularly similar with the ones in the skin, and directly trigger an immune-mediated inflammation of the skin - eczema. Diets recognized to have this kind of effect include: dairy, coffee, soybean, eggs, nuts, wheat and sweet corn. German scientist observed that Omega-3 fatty acid rich diets tend to alleviate this process.