[Doctor's Interview] Atopic Dermatitis - Current State of Treatment

​Self-care alongside treatment... What are some points to keep in mind?

Is moisturizing really the most important part of daily skincare?

If your skin is dry, moisturizing is a good idea. However, if you have inflammation such as redness or itching, moisturizing alone will not be enough, so it is essential to use a topical steroid cream. Ideally, you should use moisturizers and topical steroid creams depending on the symptoms, but if you use both, apply the moisturizer to the entire dry area first, and then apply the topical steroid cream only to the inflamed areas.

Furthermore, care is needed when washing your body. Alkaline cleansers can damage the skin's barrier function and worsen dryness, so choose a mildly acidic, gentle cleanser. Also, absolutely avoid scrubbing with nylon towels or sponges; instead, lather well and wash your skin gently with your hands. For those who find lathering troublesome, foaming body washes are a convenient option.

What kind of moisturizer would you recommend?

In dermatology, petrolatum, urea preparations, and heparinoid-containing preparations are commonly used. Each has different characteristics, so choose the one that suits you best.

Also, please be careful with oils. If the skin's barrier function is compromised, it can cause rashes. Some people have even found that using olive oil worsens their condition.
Furthermore, layering various products increases the likelihood of encountering ingredients that don't suit your skin, so it's not recommended. It's best to choose products that suit your skin condition and preferred texture, and keep moisturizing simple.

Are there any precautions I should take regarding shampoo and conditioner?

If you have scalp problems, choose a mildly acidic shampoo to protect the skin's barrier function. Some people apply shampoo directly to their scalp, but even if it's a bit of a hassle, make sure to lather it up thoroughly before use. Apply conditioner mainly to the ends of your hair.
When washing, be sure to use the pads of your fingers and avoid using your fingernails. Avoid using shampoo brushes, as they can be harsh on the scalp.

In terms of ingredients, it's best to avoid products containing menthol. You should also refrain from hair dyeing and perming when you have scalp inflammation. This will prevent irritation to your scalp and damage your hair.

Are there any dietary precautions I should take?

Eating a balanced diet is fundamental. When you have symptoms of atopic dermatitis, consuming spices or alcohol may increase blood flow and potentially cause itching, so it's best to be careful.

In addition to diet, it's also important to maintain a regular lifestyle and get enough quality sleep.

The approach using topical medications is the basis of treatment.

Is topical steroid medication the main treatment for atopic dermatitis?

While moisturizers can be used on dry areas, moisturizing alone is insufficient to soothe inflammation such as redness and itching. For such areas, applying a topical steroid cream is the standard treatment.

Topical steroids are classified into ranks from weak to strongest based on their potency. The appropriate medication is prescribed based on symptoms, age, and the affected area. Applying the correct amount is crucial for effective symptom relief.

A "finger tip unit" is a guideline for the amount squeezed from the tube from the tip of an adult's index finger to the first joint. This is approximately 0.5g, which is considered the optimal amount for an area the size of two adult palms.

If you're unsure how much to apply, try placing a tissue over the area you've applied it to. The ideal amount is one that adheres to the skin without falling off.

Besides steroids, what other topical medications are used?

For children aged 2 and older, tacrolimus ointment may be used in addition to steroids. It is particularly effective for symptoms on the face and neck, but some people may experience a burning or tingling sensation.

What is the role of antihistamines?

While oral antihistamines and anti-allergic drugs may be used, they cannot completely suppress the itching associated with atopic dermatitis. It's best to consider them as an adjunct to topical treatments.

Some antihistamines can cause side effects such as drowsiness and fatigue, so be careful when taking them before driving.

I've heard that they also offer treatment using traditional Chinese medicine. Do you have any recommendations for herbal remedies?

Since herbal medicines are prescribed according to an individual's constitution and symptoms, it's not possible to recommend a specific herbal medicine for atopic dermatitis without general guidance. Traditional Chinese medicine has its own unique methods for determining constitution, such as "sho" (pattern of disharmony), so it's recommended to consult a physician certified as a specialist in traditional Chinese medicine by the Japan Society for Oriental Medicine.

​The likelihood of symptoms appearing varies depending on the affected area.

I hear that facial symptoms are particularly noticeable among all symptoms affecting the body, and that many patients are troubled by them.

The face is a part of the body where symptoms are likely to appear. Because it is constantly exposed, people often scratch it, which can worsen the condition. The skin around the eyes, in particular, is thin, so symptoms are more likely to appear there.

Applying thick layers of foundation to conceal symptoms is not recommended. The ingredients may irritate the skin, and removing the makeup may require a strong cleanser, potentially worsening the condition. False eyelashes should be avoided as the adhesive can cause skin irritation.

Are the treatment methods different for the face and body?

The active ingredients in topical medications used for treatment are absorbed through the sebaceous glands, and the face has a high concentration of these glands. Applying strong steroid topical medications to the face can sometimes cause side effects. It's essential to use different medications for the face and body.

Are there any other areas besides the face where symptoms tend to appear?

Many patients suffer from neck symptoms. Symptoms can easily be triggered by irritation from things like hair or turtlenecks touching the skin. In some cases, symptoms can worsen due to functional innerwear, so it's best to avoid synthetic fibers in your underwear and choose cotton or silk instead. If you need to cover your neck, a silk scarf is a good option.

Post-inflammatory hyperpigmentation can occur not only on the neck but also on the face. In particular, on the neck, it can manifest as a "dirty neck," a wave-like darkening of the skin, which is a concern for many patients.

Some people believe that topical steroids are causing their skin to darken, but this is incorrect. The darkening is not due to the application of topical steroids, but rather to increased melanin synthesis caused by inflammation from atopic dermatitis, leading to hyperpigmentation.

Just like how skin darkens after burns or insect bites, this is inflammatory hyperpigmentation, so as the inflammation subsides, the pigmentation will gradually fade due to skin cell turnover. It would be best to use topical steroids appropriately to quickly reduce the inflammation.

What you should know about the latest treatments for atopic dermatitis

Please tell me about the latest treatment methods that are currently attracting attention.

Speaking of the latest treatments, there are "biological agents." These are highly effective treatments that are already available in the United States and are scheduled to be approved in Japan in 2018. In addition, "Janus kinase (JAK) inhibitors" are also attracting attention as a new treatment method, and research is underway.

What are some of the latest treatments already being used in Japan?

Positioned between steroids and biological agents, "narrowband UVB irradiation therapy," a treatment using ultraviolet light, is covered by insurance. It involves controlling symptoms with treatments once every 1 to 3 weeks.

Recently, some doctors have also been advocating for "proactive therapy." Topical treatments for atopic dermatitis include "reactive therapy," which addresses symptoms after they appear, and "proactive therapy," which works before symptoms appear.

In atopic dermatitis, symptoms tend to fluctuate between periods of improvement and worsening. Proactive therapy is an approach that aims to prevent relapses even when symptoms appear to have improved. This involves applying topical medication about twice a week after inflammation has subsided, and maintaining the condition with moisturizers at other times to suppress the recurrence of inflammatory symptoms.

Are there any objective indicators or measures to determine the severity of symptoms?

Recently, the "TARC value" is used to assess the severity of symptoms. This indicates the current stage of atopic dermatitis symptoms and is measured by a blood test. The normal range for adults is 450 pg/ml, while it is 743 pg/ml for children aged 2 years and older, and even higher for children under 2 years old.

Aside from the latest treatments such as biological agents and JAK inhibitors, are there any other differences between Western countries and Japan?

Compared to Europe and the United States, treatment in Japan is said to be more conservative. For example, this is evident even in the size of the steroid tubes. In Japan, tubes of topical steroids are mainly around 5g, but in Europe and the United States, they seem to range from 30g to 100g. There are differences in body size, but the size of the tubes themselves is different, so the amount dispensed at one time will also differ.

In terms of treatment as a whole, while university hospitals and similar institutions require a referral letter, I believe that in Japan, almost anyone can choose from a range of standard treatments.

Since treatment for atopic dermatitis can be long-term, it's desirable to have a doctor you can easily consult about any anxieties or questions you may have, and who will answer them thoroughly.

Furthermore, even if the goal is the same, the way doctors prescribe medication can differ. If patients themselves read the guidelines and have some knowledge about their treatment, it may lead to smoother treatment.

Finally, do you have any advice for patients and their families on how to cope with the treatment of atopic dermatitis?

Atopic dermatitis is a chronic disease. Symptoms vary greatly in severity, and often worsen and improve repeatedly. Rather than aiming for a complete cure, it's important to treat the symptoms appropriately according to their stage and effectively control them.

The goal of treating atopic dermatitis is to maintain a state where symptoms are absent, or if present, they do not significantly interfere with daily life, and where medication is not frequently needed. I hope you will approach treatment with a positive attitude and patience, knowing that it will eventually heal.