EDITORIAL BACKGROUND

ATOPIC DEMATITIS AND URITCARIA TREATMENT GUIDELINES; WHAT TO EXPECT FROM YOUR DOCTOR

Skin rashes are very common, yet the cause can be difficult to determine. There are hundreds of different kinds of rashes, and they can be triggered by everything from reaction to a medication to a food allergy or even occasionally, systemic illness. Sometimes, the cause is never determined.

Atopic dermatitis (allergic eczema) and urticaria (hives) are two of the most common skin rashes. Atopic dermatitis affects between 10 percent and 20 percent of children and 1 percent to 3 percent of adults, while an estimated 20 percent of Americans have hives at some point in their lives.

The conditions often occur as an allergic or non-allergic reaction to something, whether it’s eaten, breathed or touched. Sometimes stress can be a factor. Therefore, it’s helpful if you take notes of food eaten or things you’ve been exposed to prior to and during your skin rash outbreak and bring it with you to your doctor visit. With careful assessment, your doctor may be able to determine the cause of your rash and will be able provide appropriate therapy to ease the itch and discomfort. If your condition is allergy-related, becomes chronic, or does not respond to treatment, you may be referred to a specialist such as an allergist or dermatologist.

The American College of Allergy, Asthma and Immunology (ACAAI) suggests the following treatment guidelines for people who suffer from atopic dermatitis and urticaria. You should expect your doctor to do the following:

  1. Examine, question and potentially test. In diagnosing your skin problem, your doctor should:
    • Take a close look at the rash in question, and examine other parts of your body including your skin, lymph nodes, eyes, joints, throat, neck, ears, lungs, heart and abdomen.
    • Take a thorough medical history, which is the most important tool in helping determine what may be causing or exacerbating the skin rash. The history should include a review of your symptoms, where on the body and when and how often the rash occurs, things you have been exposed to at home and work, medications you’re taking, your family history, and the impact of the disease on your daily activities.
    • Possibly suggest a skin test or food challenge to help determine the cause or trigger of the condition. A skin test (also called a scratch test) exposes the skin to tiny amounts of potential allergens and gauges the reaction. Food challenges involve ingesting particular foods to determine whether any of them are causing an allergic reaction. Both skin tests and food challenges are done under controlled medical supervision. Other tests that may be recommended include blood or urine tests, and x-rays.
    1. Help you identify and control your triggers.
      2. The first step in treating both atopic dermatitis and urticaria is identifying and avoiding the trigger, if possible, as well as factors that may exacerbate the condition.
    • Common triggers for atopic dermatitis are foods, soaps, detergents, chemicals, air-borne allergens (such as pollen or dust mites), abrasive clothing (such as wool), temperature/humidity and stress.
    • Urticaria can be allergic or non-allergic:

    Allergic urticaria: Triggers include foods (especially eggs, nuts and shellfish), medication (particularly penicillin and sulfa drugs), infection, insect stings, blood transfusions and other substances.

    Non-allergic urticaria:Triggers include cold temperatures, food dyes and additives, medication, exercise, anxiety, constricting clothing (such as a belt or bra strap), the sun and stroking the skin with a firm object. In some cases triggers cannot be avoided, but steps can be taken to lessen exposure. For example, patients with solar urticaria should wear protective clothing and apply sunscreen when they go outdoors and patients with pressure urticaria can wear loose-fitting clothing.

    1. Explain your treatment options. In addition to avoidance of triggers, your physician may recommend other therapies to prevent outbreaks or provide relief from symptoms. Treatment options vary according to the diagnosis.

    Management of atopic dermatitis varies, depending on the severity of the condition or the particular outbreak:

    • Hydration and moisturization
      • consists of 20-minute lukewarm baths followed by application of moisturizer to prevent the skin from drying out and help control itching. Moisturizers should be non-irritating. Your physician can help determine the most appropriate moisturizer for you.
    • Topical corticosteroids
      • , which are the most common treatments prescribed, ease the itching by reducing the inflammation. Topical corticosteroids come in several strengths. Low-potency corticosteroids control symptoms over the long term. Intermediate-potency corticosteroids treat chronic atopic dermatitis on the trunk of the body, arms and legs and can be used for three weeks or longer. High-potency corticosteroids can be used to treat outbreaks of atopic dermatitis, but should be used for no longer than three weeks and never on the face or genitals.
    • Topical calcineurin inhibitors
      •  can provide fast relief from itching and discomfort, and may be appropriate as long-term maintenance therapy. The creams can be used as an alternative to corticosteroids.
    • Tar preparations
      •  also can ease itching, but should not be applied to acutely inflamed skin.
    • Oral antihistamines
      • taken in liquid or pill form can provide system-wide relief from itching. Topical antihistamines should not be used.

    Severe cases may require additional treatment, including oral medication, wet dressings, exposure to ultraviolet light, immunotherapy (allergy shots) or other therapies. In rare cases, hospitalization may be required.

    One episode of hives usually does not require medical attention, however patients should see a doctor if the urticaria recurs, is chronic or is complicated by swelling, difficulty breathing or other potentially serious problems. Therapy varies depending on the severity of the case.

    • Oral antihistamines
      •  can relieve the inflammation and discomfort of most cases of urticaria.
    • Epinephrine (adrenaline) injections may be necessary to treat severe attacks of urticaria and combat potentially serious health problems.
    • Oral cortisone may be necessary temporarily after a severe attack.
    • Other medications and therapy may be required for specific types of urticaria.
    1. Provide ongoing education and support.  You and your physician are partners in treating your skin condition, so a good relationship is essential to successful long-term management.  Your doctor can help you learn how to become more observant about possible triggers and help your devise strategies to avoid or lessen their effects.  You also should have your doctor thoroughly explain the therapies prescribed, including when to use them.  Remember to schedule regular visits with your doctor so that your progress can be monitored and treatment adjusted as needed.

    If these components are not part of the skin rash treatment plan your doctor provides, or if you feel your condition could be under better control, ask for a referral to a specialist. Allergists are physicians who specialize in allergies and asthma and provide tailored, comprehensive care to their patients every day.

    The ACAAI has more information that can help you get your allergies and asthma under control. Call its toll-free number 800-842-7777 or visit www.acaai.org.