Atopic dermatitis/eczema is a chronic disease and flare-ups are distressing. I often remind patients that “eczema skin is very delicate, the slightest movement of wind will eczema recurrence”, so what can be done to prevent recurrence? The first is to insist on long-term proper skin care; the second is to look for causes that trigger eczema flare-ups and avoid them as much as possible; and the third is to maintain active treatment during the remission period. Today we will talk about active maintenance therapy. 1. What is active maintenance therapy? Atopic dermatitis/eczema is a chronic disease, and usually the rash recurs in this way. The traditional treatment plan is like this That is, when the eczema is visible to the naked eye, start topical anti-inflammatory cream treatment, and when the eczema visible to the naked eye has completely subsided, stop the medication. When the eczema comes back after stopping the medication, the cream is used again, and when the eczema subsides, the cream is stopped again. This is a reactive treatment. Active maintenance treatment is different from the traditional treatment plan, it is like this – that is, when the visible eczema has subsided, still need to maintain the topical creams for a period of time, then the number of times and dosage of medication will be reduced, this treatment is the active treatment. 2. Why active maintenance treatment? Research has confirmed that atopic dermatitis / eczema patients with the appearance of normal skin or after treatment rash receding skin and normal human skin is not the same. Skin biopsies taken from normal looking skin or treated skin where the rash has subsided in patients with atopic dermatitis can be viewed under a microscope and reveal that there are still a number of inflammatory cells in the skin. These inflammatory cells are usually in a state of low activity (subclinical inflammatory state) and when the skin is slightly irritated, they are activated as quickly as a small spark that causes a forest fire to reignite, resulting in a recurrence of eczema. By testing the water content of the skin, skin pH and sebum content, it was found that atopic dermatitis patients with normal-looking skin or treated rash receding at the site of skin stratum corneum structure incomplete, water loss significantly increased, when the external environment of various irritants, allergens and microorganisms are more likely to enter the skin. This is like a forest fire that has just been extinguished and the remaining fire has not yet been cleared, when a strong wind can easily ignite the remaining fire. This is why the persistent impairment of skin barrier function and subclinical inflammation of eczema skin is the cause of recurrent eczema. The goal of active maintenance therapy is to reduce the recurrence of eczema by continuing to reduce the use of anti-inflammatory drugs to suppress the inflammatory cells still present in the skin after the eczema has subsided. This is just like putting out a fire not only to extinguish open flames and large fires, but also to carefully inspect and extinguish the remaining fires and small sparks that may cause rekindling. 3, active maintenance treatment methods Control the acute flare-up phase When eczema flares up, we have to regularly apply topical anti-inflammatory medications, such as topical hormone cream, tacrolimus ointment or pimecrolimus cream twice daily. In most cases with continuous use for 2-6 weeks, the eczema gradually improves or subsides. Transition phase When eczema is relieved after regular treatment, it is still necessary to continue topical anti-inflammatory creams on the eczema-prone areas. Topical hormones can gradually reduce the strength of hormones, such as from medium to strong hormones to weak hormones; can also reduce the number of topical drugs used, from two times a day to once a day. This will gradually transition into the maintenance treatment phase. Active maintenance treatment phase At this time, in addition to the daily insistence on the use of emollients, you need to use creams on the eczema-prone areas 2-3 times a week: either once on the weekend, once during the weekday (e.g. Wednesday) or two days in a row on Saturday and Sunday, with only emollients used during the weekday. Duration of maintenance treatment For patients with mild pre-treatment eczema, the recommended duration of active maintenance treatment is 2-3 months; for patients with more severe pre-treatment eczema, the recommended duration of active maintenance treatment is 6-9 months or more. Management of acute eczema flare-ups during active maintenance therapy During maintenance therapy, there is a risk of eczema exacerbation for unknown or unavoidable reasons, when the frequency of topical anti-inflammatory medication should be increased as soon as possible, for example, from twice a week to twice a day; or stronger medications should be used under the guidance of a physician. If handled properly and in a timely manner, most patients will have their rash under control and in remission within 2 weeks, after which they can gradually transition to maintenance therapy again. 4. What are the risks of active maintenance therapy? When I suggest active maintenance therapy to patients, one of the most common concerns is “if I continue to use the medication even after the eczema has cleared up, won’t I end up using a lot of medication”. The results of current domestic and international studies on active maintenance treatment with topical anti-inflammatory drugs show that the total amount of medication used in the same period of time does not increase when compared to conventional treatment regimens. In addition, the adverse effects of long-term drug use are also a concern. Most of the medications generally used for active maintenance therapy are soft hormones or tacrolimus ointment or pimecrolimus cream. Studies have confirmed that there is no significant increase in the incidence of localized skin adverse reactions or adverse reactions due to systemic absorption of the drug with long-term intermittent use of these topical medications.