The treatment of atopic dermatitis is currently complicated and confusing, with various methods, but we still advocate standardized treatment.
I. Treatment of atopic dermatitis: a combination of systematization and individualization
The principle of treatment for atopic dermatitis is to restore the normal barrier function of the skin, find and remove the triggering and aggravating factors, and reduce or alleviate the symptoms as the main purpose. Since patients with atopic dermatitis have both common and different characteristics, a combination of systemic and individualized treatment options is needed to develop a scientific and standardized long-term management plan for patients with atopic dermatitis.
Depending on the condition, a stepwise treatment model can be used
Depending on the severity of atopic dermatitis symptoms, a stepped treatment model is appropriate to guide the clinical treatment of atopic dermatitis in the following ways.
1, Topical moisturizing emollients are the basis of treatment for atopic dermatitis throughout its treatment.
2. When atopic dermatitis patients have only dry skin, topical emollients need to be used along with avoidance of irritation and triggering factors.
3.Patients with mild-moderate atopic dermatitis need to choose weak or moderate glucocorticoids or calcium phosphatase inhibitors (>2 years old) reasonably according to the severity of skin lesions.
4.For patients with moderate-to-severe atopic dermatitis, medium- or strong-acting glucocorticoids or calcium phosphatase inhibitors (>2 years old) are indicated.
5.For patients with recalcitrant and severe atopic dermatitis, immunosuppressants or phototherapy can be systematically applied when the effect of topical medium- or strong-acting glucocorticosteroids is not effective.
Second, non-pharmacological treatment measures
1.Health education: correct understanding is the prerequisite for standardized treatment
Although the incidence of atopic dermatitis has been increasing year by year in the past 30 years, parents of children with atopic dermatitis have a relative lack of knowledge about atopic dermatitis. Doctors need to provide detailed information to children and their family members about the pathogenesis of atopic dermatitis, irritants, and how to choose the correct and standardized treatment while treating the disease itself; inform parents that atopic dermatitis is a chronic, recurrent disease that requires long-term standardized treatment and management under the guidance of a doctor to achieve clinical remission, and that doctor-patient cooperation is very important to achieve good results; the goal of atopic dermatitis treatment The goal of atopic dermatitis treatment is to control the disease and improve the quality of life rather than to “cure” it.
2. Finding and removing the causative factors: an important factor in preventing relapse
The triggering and exacerbating factors of atopic dermatitis in children and adults are different. In children, the predominance of ingestive and inhalant allergens is observed, whereas in adults the role of allergens is significantly reduced and the predominance of microorganisms, physical stimuli and mental stress is observed. Analysis of possible triggers and aggravating factors in patients with atopic dermatitis, and guidance to avoid them in life, is an important measure to prevent recurrence of atopic dermatitis.
3. Application of emollients: help restore skin barrier function
The existence of skin barrier dysfunction in children with atopic dermatitis is the basis for the development of atopic dermatitis. Research has confirmed that children with atopic dermatitis have reduced sebum content in the skin, reduced natural moisturizing factors, reduced hydration capacity, and increased transepidermal water loss. The application of emollients (humectants) can reduce transepidermal water loss, increase the sebum content of the skin, and help repair the skin barrier function. Existing research shows that long-term application of emollients can reduce the dosage of topical glucocorticoid preparations by about 50%, which is the basis of atopic dermatitis treatment.
Three, drug treatment formula
1.Topical medication
(1) Topical glucocorticoids: the first line of treatment for atopic dermatitis
At present, hormone abuse and hormone phobia coexist, and reasonable application is important.
1. Choose the appropriate type and intensity and master the time of medication: Different types and intensities of glucocorticoids should be chosen according to the age of the child, the site of the lesion and the severity of the disease. In the acute or subacute stage, choose strong enough hormones 1 – 2 times/day, and apply them continuously for at least 2 weeks and at most 6 weeks according to the recovery of skin lesions; then further adjust the intensity, concentration and dosage of hormones according to the improvement of skin lesions. Usually, the frequency of hormone administration is adjusted to 2 days per week for maintenance treatment, and the maximum duration of treatment is 16 weeks. During maintenance, if the disease recurs, daily dosing may be reverted. Local application of glucocorticosteroids should be selected according to the severity of skin lesions with different types and strengths of glucocorticosteroids.
2.Choose the appropriate dosage form: ointment with strong sealing effect and good moisturizing property is suitable for hypertrophic desquamative lesions, especially palmoplantar area; cream is used for chronic and subacute lesions; lotion and solution with the property of making lesions dry can be used for acute exudative lesions.
3.Hint: At present, many parents of children have misconceptions about the use of glucocorticoids: first of all, they think that hormones have dependence and do not apply them to their children as much as possible. Therefore, it should be emphasized to the parents of children that glucocorticoid therapy is the first-line treatment for atopic dermatitis. Second, when the skin inflammation is controlled, parents often choose to discontinue glucocorticoids immediately, which is actually a mistake because the histology of the seemingly normal-looking skin is actually in a subclinical inflammatory state, and stopping the drug too soon often makes the condition recur. Therefore, it is recommended that after continuous application of hormones to control inflammation, topical hormone maintenance treatment should be continued twice a week, and emollients should be used to restore the skin barrier so that the lesions will be in long-term remission before discontinuing.
(2) Calcium phosphatase inhibitors: second-line drugs for atopic dermatitis
These drugs are non-hormonal drugs with good anti-inflammatory effects and do not cause skin atrophy and other adverse reactions to hormone therapy, the most common adverse reactions are mainly local temporary burning and irritation after use. It can be applied to the face and neck and skin folds for a long time, and is a second-line drug for the local clinical treatment of atopic dermatitis. Currently, 0.03% tacrolimus ointment and 0.1% pimecrolimus cream are approved for use in children >2 years of age, and 0.1% tacrolimus ointment is recommended for adolescents >12 years of age and adults. Tacrolimus is indicated for moderate to severe atopic dermatitis and pimecrolimus is indicated for mild to moderate atopic dermatitis.
Tips: Patients with atopic dermatitis <2 years of age should use topical glucocorticoid preparations in both the acute phase of atopic dermatitis and its maintenance treatment; patients with atopic dermatitis >2 years of age are usually treated with topical glucocorticoids in the acute phase for symptom control followed by calcium-regulated phosphatase inhibitor drugs in the remission phase for maintenance treatment; children with atopic dermatitis >2 years of age with subacute phase or chronic lesions on the face and neck can Direct application of calcium phosphatase inhibitor drug treatment.
(3) Other: depending on the condition and lesion performance, appropriate use of cold compresses, astringent preparations, etc. Phototherapy is also one of the means of treatment for atopic dermatitis.
2.Orally administered drugs
(1) antihistamines: “itching – scratching – itching” cycle is one of the triggering and aggravating aspects of atopic dermatitis, antihistamines are the most commonly used drugs to break the vicious cycle and reduce itching, because the first generation of antihistamines have a hypnotic effect, so in the Because the first generation antihistamines have a hypnotic effect, they have an advantage over the second generation antihistamines in controlling pruritus at night.
(2) Anti-infective drugs: Patients with atopic dermatitis have impaired skin barrier function, along with abnormal immune function, and are prone to secondary bacterial infections. If there is clinical evidence of skin infection, systemic or topical antibiotics are required to control the infection. Children with atopic dermatitis are also prone to secondary viral infections (e.g., infectious molluscum contagiosum, Kaposi chickenpox-like rash) and fungal infections, and need to be given appropriate antiviral and antifungal treatment, and further consultation at a specialist hospital if necessary.
(3) Application of desensitizers: One third of patients with atopic dermatitis are allergic to dust mites, and for patients with clear allergens, the application of dust mite desensitizers can have a very good clinical effect, but the desensitization time is relatively long, usually taking about 2 years.
(4) Others: Glucocorticoids, cyclosporine and other immunosuppressants can be applied orally or by injection systematically, but they need to be applied for a short period of time under the guidance of a specialist;
3, Chinese herbal medicine treatment, according to the rash, disease duration, tongue and pulse, the correct identification and typing, diagnosis and treatment.
Chinese medicine classifies atopic dermatitis into damp-heat type, yin-deficiency type, and qi-deficiency type. According to the different types of symptoms dialectical treatment. The damp-heat type can be reduced by Huo Xiang Zheng Qi San, the yin-deficiency type can be reduced by Liu Wei Di Huang Wan, and the qi-deficiency type can be reduced by Shen Ling Bai Zhu San.