Advices for Life


October 23, 2016 23:01

Treatment of atopic dermatitis : a medicinal , physiotherapy and spa

Complex treatment of atopic dermatitis involves the following activities: a hypoallergenic diet (especially in children);medical treatment;physiotherapy and spa treatment;preventive measures.

hypoallergenic diet in atopic dermatitis include the following basic principles:

  • restriction or elimination of foods that have a high sensitizing activity (eggs, fish, nuts, eggs, honey, chocolate, coffee, cocoa, alcoholic beverages, canned, smoked, mustard, mayonnaise, spices, horseradish, radishes, radish, eggplant, mushrooms, berries, fruits, vegetables, with orange and red color: strawberry, strawberries, raspberries, peaches, apricots, citrus, pineapple, carrots, tomatoes);
  • prichinnozavisimyh complete elimination of food allergens;
  • ensure the patient's physiological needs for essential nutrients and energy through adequate replacement of excluded products;
  • for inclusion in the hypoallergenic diet are recommended: berries and fruit bright color, dairy products;cereals (rice, buckwheat, oats, barley);mea
    t (beef, lean pork and mutton, rabbit, turkey, horse meat);vegetable oil and melted butter;rye bread, wheat second class;sugar - fructose, xylitol.The food is steamed or boiled, potatoes and cereals are soaked in cold water for 12-18 hours, the meat twice digested.

Such a diet administered in the acute and subacute period of validity of the disease for 1.5-2 months, and then carried out its gradual expansion by introducing the previously eliminated products.In the absence of positive dynamics of the diet should be used to revise the diet for 10 days.

Considering the pathogenesis of atopic dermatitis, treatment should be aimed at achieving a rapid and persistent long-term remission, restore the structure and function of the skin, preventing the development of severe forms of the disease with minimal side effects from the drugs.Currently, there are many different methods and drugs for the treatment of atopic dermatitis.An important place is occupied by diet therapy.In connection with severe dysfunction of the gastrointestinal tract, in a timely and adequately appointed diet therapy in most cases, contribute to disease remission or even complete recovery.An elimination diet is based on the proven reliable sensitizing role of certain products in the development of exacerbations of atopic dermatitis and their exclusion.From the diet of patients suffering from atopic dermatitis exclude products containing food additives (colorants, preservatives, emulsifying agents), as well as strong broths, fried foods, spices, acute salted, smoked, canned foods, liver, fish, eggs, eggs, cheese, coffee, honey, chocolate, citrus fruits.The diet should include dairy products, cereals (oat, buckwheat, pearl barley), boiled vegetables and meat.Designed diet should be optimal content of proteins and vitamins, and are prepared in close cooperation allergist and a dietitian.

From pharmacological therapies distinguished general, pathogenic and topical therapy.General (conventional) treatment is carried out in mild and limited form of atopic dermatitis and is to appoint allergen (30% sodium thiosulfate), antihistamines (tavegil, fenistil, apalergin, diazolin, loratal, Claritin, and others.), Vitamins (A,C, group B, nicotinic acid), enzyme (festal, Hilak forte, mezim forte) drugs, bio-stimulators, immunomodulators (prior to treatment to determine the state of the immune system), antioxidants, Membrane (ketotifep, cromolyn sodium), medicines for correction relateddiseases and external agents (glucocorticoid creams, ointments or lotions).Efficacy antipruritic therapy enhanced by the combined use fenistil (morning - 1 capsule or drops, depending on age) and tavegila (tablet or evening -1 2 ml intramuscularly).For correction of autonomic dysfunction, and psychological disorders used weak neuroleptics in small doses or antidepressants (depressive, sanapaks, hlorproteksin, lyudiolil et al.).

Pathogenetic treatment

Assign this type of treatment, when indicated weak effect or no effect on the general care and in severe disease.At the same time with pathogenetic therapy it is advisable to carry out and generally accepted treatment.By pathogenic therapies include phototherapy (selective phototherapy, PUVA therapy), cyclosporin A (sandimmuppeoral) and glucocorticosteroids.It is impossible to imagine the treatment of atopic dermatitis without the use of external funds, and in some cases (for light or limited form) are of paramount importance.

Local therapy

topical corticosteroids are the mainstay of therapy of atopic dermatitis, as they have anti-inflammatory, immunosuppressive and aptiproliferativnymi properties.Action local kortikostreroidov can be explained by the following mechanisms: inhibition of phospholipase A activity, which leads to a decrease in the production of prostaglandins, leukotrienes;decrease the release of biologically active substances (gistamip et al.), and interleukins;inhibition of DNA synthesis in the Langerhans cells, macrophages and keratinocytes;inhibition of the synthesis of connective tissue components (collagen, elastin etc.);suppressing activity of lysosomal proteolytic enzymes.They quickly relieve inflammation and cause quite a good clinical effect.We must bear in mind that long-term use of corticosteroids occur most often viral, bacterial and fungal infections, atrophy, telangiectasia skin, hypertrichosis, hyperpigmentation, acne, rashes roseolous.As zudoutolyayuschego means good effect has fenistil gel.With long-term course of atopic dermatitis, it is advisable from time to time to replace corticosteroids fenistil gel, thus avoiding the side effects of corticosteroids.Multiplicity of reception - 2-4 times a day.

For the majority of patients with atopic dermatitis, topical therapy is the main method of treatment.Its successful outcome depends on many factors - the patient's motivation, the degree of understanding of the method of treatment and its limits, pragmatic approach with a doctor's point of view, his confidence in the acceptability for the patient and the therapeutic efficacy of the treatment assigned to them.However, for many patients treatment of the disease is still unsatisfactory because the effective control of the disease requires the repeated use of different drugs in different areas of the body for long periods of time.Recent developments topically active non-steroidal immunomodulators such as pimecrolimus and tacrolimus, are potentially a real advance for these patients.

Corticosteroids 50 years ago revolutionized the treatment of atopic dermatitis and for the majority of patients they are the main means of treatment.Local side effects such as skin atrophy and the risk of systemic toxicity, as optimal exclude corticosteroids drugs for the treatment of severe forms of the disease, especially with sensitive skin and children.However, the biggest barrier to effective treatment is the fear of side effects by the patients themselves.

new generation Corticosteroids, such as non-halogenated ethers (eg, prednicarbate, atseponat methylprednisolone, mometasone fumarate) have a high anti-inflammatory activity with a lower risk of systemic toxicity.After remission patients should abstain instructed to go to a weaker drug or to gradually reduce the frequency of administration of the drug.

main purpose of pimecrolimus (Elidel) is a long-term maintenance of remission without periodic external use corticosteroids.The drug is used in the form of 1% cream and approved for use in children from 3 months of age.Indications for Elidel is moderate and mild atopic dermatitis.A necessary condition for effective treatment cream "Elidel" is its combined use with moisturizers and emollients.Cream "Elidel" can be applied to all affected areas of skin, including the face, neck, genitals, even in young children, provided the intact surface of the skin.The effect of therapy with notes from the end of the first week of treatment and stored for one year.Cream "Elidel" is not applicable for the treatment of patients with severe atopic dermatitis and in severe exacerbation.

with atopic dermatitis have been identified numerous mediators of inflammation, so the substance capable of blocking any one of the mediators, hardly bring clinical benefit.However, some of the antagonists are of value in atopic inflammation (including asthma), which suggests a dominant role of certain neurotransmitter mechanisms.

Doxepin, a tricyclic antidepressant with a strong ability to block receptors H1, H2 and muscarinic receptor, has recently been licensed as a means of local therapy for control of pruritus associated with atopic dermatitis.

Macrolide immunosuppressants have makrolidopodobnuyu structure and exhibit a potent immunomodulatory activity in vivo, and in vitro.Cyclosporine is perhaps the best known of this group of substances, and is extremely active when administered systemically.However, some new drugs belonging to this class show topical activity and are the subject of intense interest isledovatelskogo.The most advanced stage in terms of development for clinical application have reached the cream "Elidel" (pimecrolimus) and ointment "Protopic" (tacrolimus).

Pimecrolimus (cream "Elidel") specifically designed for use as an antiinflammatory external preparation for the treatment of patients with atopic dermatitis.Pimecrolimus makrolaktamnyh refers to a group of antibiotics and is a derivative of the ascomycin.The preparation has high lipophilicity, whereby it is distributed mainly in the skin and does not penetrate therethrough into the systemic circulation.The drug selectively blocks the synthesis and release of inflammatory cytokines, whereby there is no activation of T-cells and mast cells needed to "launch" and maintenance of inflammation.Due to the selective effect on the synthesis of pimecrolimus provospa-inflammatory cytokines by T-lymphocytes and mast cells release mediators of inflammation, without inhibition of synthesis of collagen and elastic fibers, its use eliminates atrophy, telangiectasia, skin, hypertrichosis.Based on these characteristics of the drug, it can be used continuously without any risk of local side effects.

Tacrolimus ( "Protopic" ointment) is a macrolide compound 822-Da, originally derived from the fermentation broth Streptomyces tsukubaensis.Last extracted from the soil sample in Tsukuba (Japan), hence the acronym T title product, "acrolith" the term "macrolide" and "Imus" from "immunosuppressant" term.Tacrolimus produces a range of actions on different types of cells, which are potentially important for its therapeutic efficacy in atopic dermatitis.

menthol essential oils (peppermint leaves) and camphor (camphor) exert their antipruritic effect by stimulating cutaneous sensory receptors.Many patients report a pleasant cooling effect.Menthol (0.1-1.0%) and camphor (0.1-3.0%) for local therapy are produced synthetically.For children treated with these drugs is not shown because of possible irritant and toxic.

Capsaicin - a substance derived from peppers, used for local therapy (0,025-0,075%) painful and pruritic dermatoses.Initially, it causes a burning sensation in the resulting release of neuropeptides from peripheral C-slow conducting fibers.With continued application comes depletion of neuropeptides, which explains antipruritic and analgesic effects.

Basic research in immunology have allowed a better understanding of immunopathogenesis of atopic dermatitis, with the result that in addition to drugs that provide a systemic effect, there were drugs (Elidel and Protopic) having a local immunomodulating properties.Elidel - a non-steroidal drug is an inhibitor kaltsipeurina and has a selective effect on T-lymphocytes.As a result, it inhibits the secretion of interleukins and other cytokines provospolitelnyh.Tactics use of Elidel 1% cream is applied to applications for children with atopic dermatitis mild to moderate severity and with corticosteroids - with severe 2 times a day.

Systemic treatment of atopic dermatitis

course, torpid diseases, especially common dermatitis, systemic therapy is the most appropriate.The main problem of the therapeutic dilemma - lack of effectiveness of safe drugs and a large number of side effects have effective drugs used in the systemic treatment of atopic dermatitis.It remains to choose between the benefits and potential risks.

Cyclosporine (Sandimmune, Neoral) is the most studied of the drugs used for systemic treatment of severe atopic dermatitis.The usual starting dose is 5 / mg / kg / day.The first therapeutic results are visible for a period of several days to weeks.After two weeks, you can start reducing the dose of 100 mg every other week.Switch to alternate-day dosing may be, if the initial daily dose is 300 mg / kg / day;the desired goal - the end of the treatment after 3-6 months.By reducing the dose of cyclosporine should start to conduct a stabilizing treatment by combining the use of ultraviolet radiation A and B. This provides a return to the local therapy as well as prevention of possible aggravation of skin inflammation.The primary side effects of cyclosporine - nephrotoxicity and hypertension, so the control of these parameters should be performed prior to treatment, 2 weeks, a month, and then every month during treatment.Long-term studies have shown that with careful patient selection and monitoring of tacrolimus is a safe and effective systemic therapy in the case of heavy torpid atopic dermatitis.Since starting treatment dose can be selected, preferably begin with an effective dosage in the hope of reducing the overall duration of the treatment.Some clinicians suggest lower initial dose of 2-3 mg / kg / day, especially in pediatrics, there are cases where nausea at higher doses.In the adult, by contrast, to obtain a remission, a higher dose of 7 mg / kg / day, especially in severe cases.

System tacrolimus formulation for oral administration proved to be effective in psoriasis, but its use in atopic dermatitis is not enough formally investigated.At doses of 1-4 mg / day of the drug has a second safety profile of side effects similar to those of cyclosporin, which can be interchanged.This should be taken into account especially for patients who inadequately respond to cyclosporine.

now developed a new drug for systemic use in atopic dermatitis - pimecrolimus.Hitherto studied local dosage form of the drug, but a recent study in psoriasis showed that the drug may be effective when administered orally to a safer profile of side effects than cyclosporine and tacrolimus.That this form of the drug and is expected to be effective for atopic dermatitis.

Azathioprine is often used for severe dermatologic diseases as an immunosuppressive agent.The therapeutic dose in atopic dermatitis is considered to 2-2.5 mg / kg / day, and patients should be aware that it may take 6 weeks before the start of the drug.Azathioprine is well tolerated, only occasionally reported nausea and vomiting.Regular laboratory monitoring is carried out in the first month of treatment every two weeks and then every month for the duration of therapy.