Neurodermatitis - Basic And Special Therapy

Neurodermatitis: Therapy

The basis of every neurodermatitis treatment is the so-called basic therapy, which should not only be carried out during episodes of neurodermatitis, but also in symptom-free phases. Depending on the current skin condition, special medication for local or oral use is also prescribed according to a four-stage scheme. It is also decisive whether the skin changes have been present recently (acute inflammatory state) or have been present for several weeks or even months (chronic inflammatory state). The age and level of suffering of those affected as well as the course and location of the skin changes are also taken into account.

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Individually adapted step therapy

Depending on the skin condition, a distinction is made between four therapy levels with the following recommendations:

• Stage 1: Dry skin - topical basic therapy, avoidance or reduction of trigger factors.
• Level 2: Mild eczema - Level 1 measures plus weak to moderately effective local (= topical) glucocorticoids and / or topical calcineurin inhibitors.
• Stage 3: Moderate Eczema - Measures of Stage 1 and 2 plus strong to very strong topical glucocorticosteroids and / or topical calcineurin inhibitors.
• Level 4: Persistent, severe eczema - Level 1-3 measures plus systemic immunomodulatory therapy (e.g. ciclosporin A).

Reduce & avoid provocation factors

If provocation factors are known to trigger or intensify the disease, they should - if possible - be consistently avoided (see also chapter Prevention). These are determined in the course of the initial anamnesis or by an allergy test.

The main aim of the basic therapy is to reduce the dryness of the skin and the symptoms associated with it (especially itching). If necessary, an anti-inflammatory and antipruritic therapy is added depending on the severity of the disease. Antiseptic and antibiotic drugs as well as substances that influence the body's own immune system (immunomodulators) are used in severe forms.

How is the basic therapy for neurodermatitis carried out?

The basic therapy of atopic dermatitis consists in particular in the reduction of provocation factors and in a stage-dependent treatment of the skin with basic therapeutic agents. These are adapted to the condition of the skin and must also be used when there are no signs of inflammation - even in symptom-free phases. The main goal is to treat dry skin:

• Greasy ointment bases are used for very dry skin.
• For less dry skin, hydrated oil-in-water emulsions.
• Special means for skin cleansing are also part of the basic therapy.
• In addition to ointments, creams, lotions, etc., there are also moisturizing bath additives.
• By using so-called emollients directly after a bath, the water is to be retained in the still damp skin.
• The moisture of the skin can also be improved by using moist compresses.

The reduction of provocation factors includes, for example, avoiding allergens and reducing skin irritation. For example, wearing special overalls in childhood is suitable. These are designed to protect the affected child's skin from scratching damage while playing and especially at night in bed, when the itching is often strongest. There are also special neurodermatitis gloves. Avoiding occupational skin irritants is particularly important in adulthood. This includes working in a moist environment, heavy skin soiling, frequent hand washing and frequent handling of skin-irritating substances.

Another important basic therapy principle is the use of special oil baths (balneotherapy), especially for young children. Children should not be washed too often. Products specially developed for neurodermatitis patients should be used with preference. Ordinary cosmetic moisturizers usually do not have the desired effect due to the high water content.

Which special therapies are used?

If the use of basic therapeutic agents is not sufficient to bring the symptoms of atopic dermatitis to subside, special drug therapies are also used depending on the severity of the atopic dermatitis in different strengths. These are preferably applied locally (topically). If necessary - i.e. when local therapeutic agents do not work sufficiently or the neurodermatitis is very pronounced - systemic drugs (e.g. tablets) can also be used for a short time.

Glucocorticoids

• External (topical) glucocorticoids:Topical glucocorticosteroids ("cortisone") have been used to treat eczematous areas for half a century. Among other things, they have an anti-inflammatory effect and are divided into four classes (from weak to very strong) in terms of their effectiveness. Topical glucocorticosteroids are usually used for a limited period or as interval therapy. There are no fixed, generally recognized schemes. Continuous treatment should be refused, however, because it increases the risk of unpleasant side effects such as skin thinning. As a rule, topical glucocorticosteroids of class 1 to 2 are sufficient for neurodermatitis. Only in the case of very pronounced skin changes can strong and very strong glucocorticosteroids (classes 3–4) be used at short notice.
• Oral (systemic) glucocorticoids: To interrupt an acute attack, a short-term therapy with oral glucocorticoids can be used, especially in adults with severe forms of neurodermatitis.

Calcineurin antagonists

Topical calcineurin antagonists also have an anti-inflammatory effect and are sometimes better tolerated than glucocorticoids. They are mainly used when local glucocorticosteroids cannot be used or the duration of treatment can lead to local irreversible side effects. In particular, use on the face, on intertriginous skin areas (these are areas in which closely adjacent, sometimes directly opposite skin surfaces are constantly in contact, e.g. armpit, groin, hollow of the knee, gluteal folds, genital area, below the female breast, between the fingers and toes) as well as on the hairy scalp of small children appears to be advantageous over topical corticosteroids. Effective sun protection is important when using these drugs.

Antimicrobial and Antiseptic Therapies

Antimicrobial and antiseptic therapies Moderately to moderately pronounced eczema in atopic dermatitis, which respond well to anti-inflammatory therapy with topical glucocorticosteroids or calcineurin inhibitors, generally do not require any additional antimicrobial therapy. Moderate to moderately pronounced eczema with topical eczema, which is good for atopic dermatitis Corticosteroids or calcineurin inhibitors respond, usually do not require additional antimicrobial therapy. On the other hand, chronically recurring or

Moderate to moderately pronounced eczema in atopic dermatitis that respond well to anti-inflammatory therapy with topical glucocorticosteroids or calcineurin antagonists usually do not require any additional antimicrobial therapy. On the other hand, chronically recurring or chronic eczema should also receive topical antiseptic treatment. The long-term use of topical antibiotics is not recommended because of the risk of resistance and sensitization. In the case of eczema with clear signs of a subsequent bacterial infection, the antibiotics should be taken orally, as should the antivirals in the case of a superinfection with herpes viruses.

In the case of chronic neurodermatitis, the wearing of antimicrobial underwear can be considered. It is coated with silver nitrate or an ammonium compound and has a moderate effect.

Antihistamines

Oral antihistamines with an H1 receptor-blocking effect can be used in oral form to support the therapy of neurodermatitis, primarily to alleviate itching.

Other systemic therapies

The immunosuppressive agent ciclosporin can be used for severe neurodermatitis in adulthood. The monoclonal antibody dupilumab has been approved for the treatment of moderate to severe atopic dermatitis in adult patients since the end of 2017. Other systemic active ingredients for the treatment of neurodermatitis are mycophenolate mofetil (MMF), azathioprine and methotrexate (MTX).

Procedure with no proven effectiveness

Sufficient scientific evidence for the effectiveness (evidence) has not yet been provided for the following procedures. These include food supplements or drugs with the following ingredients:

Externally applicable substances:

• Cipamphylline,
• Lithium succinate,
• St. John's wort extract,
• Black cumin extract,
• Sea buckthorn extract.

Internally applicable preparations:

• Immunoglobulins,
• Anti-IL-5 antibodies,
• Leukotriene antagonist montelukast,
• Levamisole hydrochloride,
• essential fatty acids: e.g. evening primrose oil, borage oil, fish oils,
• Vitamin B6 (pyroxidine), vitamin E.
• Zinc,
• Lactobacilli (probiotics).

The effectiveness of complementary approaches such as autologous blood therapy, massage therapy, homeopathy, bioresonance therapy and the local or oral use of Chinese herbs for the treatment of neurodermatitis has not yet been proven in scientific studies.

Whom can I ask?

If you have any complaints, please contact your family doctor. Depending on the symptoms, a referral to a specialist in skin and venereal diseases or in paediatrics and adolescent medicine may be necessary to carry out a differentiated diagnosis and therapy. It makes sense to bring relevant previous findings and a list of the drugs used to the examination. You can find doctors in your area under Search for a doctor.

How are the costs covered?

Immunomodulators Chronic, severe neurodermatitis in adulthood can also be alleviated by oral administration of the immunomodulator ciclosporin A. However, the substance can cause considerable side effects. How are the costs going to be covered?

All necessary and appropriate diagnostic and therapeutic measures are taken over by the health insurance carriers. Your resident doctor or outpatient clinic will generally settle accounts directly with your health insurance provider. With certain health insurance providers, however, you may have to pay a deductible (treatment contribution) (BVAEB, SVS, SVS, BVAEB). You can also use a doctor of your choice (ie doctor without a health insurance contract). For more information, see Visit a Doctor: Costs and Deductibles.

For information on the respective provisions, please contact your health insurance provider, which you can find on the social security website.