Atopic dermatitis has a substantial impact on sleep, appearance, psychological well-being, and other qualities of life. The visual appearance of lichenification, cheilitis, hyperpigmentation, ichthyosis, and erythema can be socially stigmatizing, and treatment of these symptoms is challenging. In managing pruritus in patients, practitioners should assess and document pruritus through questionnaires at each routine visit. Initially, practitioners should advise patients to employ non-pharmaceutical treatments such as emollients with wet wraps, elimination of triggers, changing scratching habits, and psychological interventions. If these methods of treatment are not successful or if the disease presentation is severe, pharmacological therapies should be employed. This chapter describes the therapeutic ladder for pruritus in atopic dermatitis and discusses each treatment modality in further detail for practitioners to advise their patients.
First-line topical pharmaceutical agents include topical glucocorticoids and topical calcineurin inhibitors. Second-line topical agents include coal tar, menthol, capsaicin, or doxepin. After the use of topical agents has been exhausted, primary systemic agents can be applied. These include sedating antihistamines, non-sedating antihistamines, oral glucocorticoids, or cyclosporine A. Finally, neuromodulating or immunomodulating agents can be attempted, including SSRI/SNRIs, TCAs, immunosuppressants, neural modulators, and opioid receptor modulators. Outside of pharmacological treatments, phototherapy has been shown to provide a dramatic improvement of pruritus in atopic dermatitis and can be used at any stage of treatment including as a first-line agent.
Johnson H, DeOreo G, Lascheid W, Mitchell F. Skin histamine levels in chronic atopic dermatitis**From the Division of Dermatology, Department of Medicine, Western Reserve University, School of Medicine, Cleveland, Ohio.(Aided by grant from Research and Development Division, Department of the Army, Contract #DA-49-007-MD-573). J Invest Dermatol. 1960;34(4):237–8. doi:10.1038/jid.1960.38.CrossRefPubMedGoogle Scholar
Darsow U, Scharein E, Simon D, Walter G, Bromm B, Ring J. New aspects of itch pathophysiology: component analysis of atopic itch using the ‘Eppendorf Itch Questionnaire’. Int Arch Allergy Immunol. 2012;124(1–3):326–31. doi:10.1159/000053748.CrossRefGoogle Scholar
Niordson A, Stahl D. Treatment of psoriasis with clinitar cream. A controlled clinical trial. Br J Clin Pract. 1985;39:67–8.PubMedGoogle Scholar
Roelofzen J, Aben K, Oldenhof U, Coenraads P, Alkemade H, van de Kerkhof P, et al. No increased risk of cancer after coal tar treatment in patients with psoriasis or eczema. J Investig Dermatol. 2010;130(4):953–61. doi:10.1038/jid.2009.389.CrossRefPubMedGoogle Scholar
Yosipovitch G, Szolar C, Hui X, Maibach H. Effect of topically applied menthol on thermal, pain and itch sensations and biophysical properties of the skin. Arch Dermatol Res. 1996;288(5–6):245–8. doi:10.1007/s004030050053.CrossRefPubMedGoogle Scholar
Bonnel R, La Grenade L, Karwoski C, Beitz J. Allergic contact dermatitis from topical doxepin: food and drug administration’s postmarketing surveillance experience. J Am Acad Dermatol. 2003;48(2):294–6. doi:10.1067/mjd.2003.46.CrossRefPubMedGoogle Scholar
Der-Petrossian M, Seeber A, Hönigsmann H, Tanew A. Half-side comparison study on the efficacy of 8-methoxypsoralen bath-PUVA versus narrow-band ultraviolet B phototherapy in patients with severe chronic atopic dermatitis. Br J Dermatol. 2000;142(1):39–43. doi:10.1046/j.1365-2133.2000.03239.x.CrossRefPubMedGoogle Scholar
Nisticò S, Saraceno R, Capriotti E, Felice C, Chimenti S. Efficacy of monochromatic excimer light (308 nm) in the treatment of atopic dermatitis in adults and children. Photomed Laser Surg. 2008;26(1):14–8. doi:10.1089/pho.2007.2116.CrossRefPubMedGoogle Scholar
La Rosa M, Musarra I, Ranno C, Maiello N, Negri L, del Giudice M, et al. A randomized, double-blind, placebo-controlled, crossover trial of systemic flunisolide in the treatment of children with severe atopic dermatitis. Curr Ther Res. 1995;56(7):720–6. doi:10.1016/0011-393x(95)85143-7.CrossRefGoogle Scholar
Blakely K, Gooderham M, Papp K. Dupilumab, a monoclonal antibody for atopic dermatitis: a review of current literature. Skin Therapy. 2016;21(2):1–5.Google Scholar
Brenninkmeijer E, Spuls P, Lindeboom R, Van Der Wal A, Bos J, Wolkerstorfer A. Excimer laser vs. clobetasol propionate 0·05% ointment in prurigo form of atopic dermatitis: a randomized controlled trial, a pilot. Br J Dermatol. 2010;163(4):823–31. doi:10.1111/j.1365-2133.2010.09858.x.CrossRefPubMedGoogle Scholar
Goeckerman W. The treatment of psoriasis. Northwest Med. 1925;24:229–31, 211.Google Scholar