Pruritus that is refractory to moisturizers and conservative measures can be treated with antihistamines or tricyclic antidepressants. Compared with the newer, nonsedating histamines, the older, sedating agents such as hydroxyzine (Atarax) and diphenhydramine (Benadryl) are more effective in controlling pruritus. 20 However, these agents can affect a child's ability to learn or an adult's ability to drive and work. 21 If drowsiness is a problem, a nonsedating antihistamine can be tried to see if it is effective. Tricyclic antidepressants such as doxepin (Sinequan) and amitriptyline (Elavil) also have an antihistaminic effect, induce sleep and reduce pruritus. 22
Fragrances are complex substances that contain hundreds of different chemicals. Some examples are Balsam of Peru, cinnamic aldehyde, cinnamyl alcohol, hydroxycitronellal, geraniol, isoeugenol, eugenol and oak moss. These chemicals make up the most common causes of ACD to cosmetics. They are also present in many topical preparations, soaps, perfumes, toothpastes and other personal care products. Sensitized patients must use "fragrance free" products. "Unscented" products are not suitable since they may still contain masking fragrances. It is important to note, however, that fragrance free products may contain large quantities of botanical extracts. These extracts are used to improve the odor of the product but can also be a source of sensitizers. It is necessary to perform patch testing with a sufficient number of chemicals to detect a delayed hypersensitivity to fragrances. Once a fragrance allergy is diagnosed, a treatment plan to avoid exposure to culprit fragrances in products should be established.
The doctor may suggest hospitalization simply because it may be necessary to break the cycle of chronic inflammation, or other problems that are exacerbating the illness. Frequently, five or six days of vigorous in-hospital treatment care can result in a dramatic clearing of the eczema. Food tests, allergy skin testing, and the development of an outpatient therapy plan can all be done during the hospitalization. Unfortunately, getting approval from insurers is often difficult. During an acute flare the number of 15-20 minute baths must be increased to three or four per day. Besides hydrating the skin, baths also increase the penetration of topical medication up to ten-fold if the medicine is applied immediately after the bath. Wet wraps after baths may also help hydration and medicinal penetration. Bedtime wet wraps are most practical, and can be done with elasticized gauze followed by ace bandages or double pajamas. (The first pair of pajamas is worn damp but not soaking wet, and a second pair of dry pajamas is worn over them. For a tighter fit, sometimes a plastic sauna suit is used instead of the dry pajamas.) For feet and hands, socks can be used. Additional blankets or increased room heat may be necessary during this three to seven days to prevent chilling.