Light therapy, tablets and injections

Light therapy, also known as phototherapy, involves exposing the affected areas of skin to ultraviolet light (UV light). UV light inhibits the inflammation in the skin, and also influences cell division. The treatment takes place in special cabins with fluorescent lamps that shine light of a certain wavelength. There are also lamps that can be used to treat individual parts of your body, such as your head, hands or feet. Tanning beds can't be used for this purpose.

Light therapy usually involves two to six sessions per week in a specialized dermatological practice or hospital. The treatment lasts between four weeks and three months. In order to allow the skin to gradually get used to the radiation, the dose is adjusted to the patient's skin type and slowly increased. Light therapy sessions typically take less than a minute at first, and up to several minutes toward the end of the treatment.

UV light therapy involves quite a lot of effort because several sessions are needed per week. Although the sessions are quite short, the treatment takes up a lot of time overall because you have to drive there, wait in the waiting room, and then moisturizing skin care products have to be applied afterwards. Because of this, many people find it difficult to fit this treatment into their work and family life.

There are different kinds of light with different wavelengths, known as UVA rays and UVB rays. The type of light therapy that is most commonly used to treat eczema nowadays is known as narrowband UVB phototherapy. Here the skin is only exposed to UVB rays with a wavelength of 311 to 313 nanometers. Limiting the light spectrum in this way reduces the risk of side effects.

There is also another option called “psoralen plus ultraviolet A” (PUVA) therapy. This involves taking the medication psoralen first, in order to make your skin more sensitive to light. Then, about two hours later, the skin is exposed to UVA rays. Alternatively, a psoralen cream or gel can be applied to the affected areas of skin first.

As well as using the right wavelength of light, the right dose and duration of light therapy has to be determined too. Many different factors play a role here, including what kind of skin you have, the type and number of previous treatments, whether you have had other medical conditions such as skin cancer, and whether you are taking medication that makes your skin more sensitive to light, like NSAIDs or antibiotics. So it's a good idea to find a doctor who has a lot of experience with light therapy.

Light therapy can also be combined with bathing. This is known as balneo-phototherapy. You can either be exposed to the UV light while bathing or after bathing.

Another type of light therapy is known as UVA1 phototherapy. The costs of this treatment generally aren't covered by statutory health insurers in Germany when used for the outpatient treatment of eczema.

Research has shown that light therapy can effectively reduce the inflammation and relieve symptoms such as itching. This allows the skin to heal for a while. But it can't make eczema go away in the long term. According to current research findings, having light therapy at the same time as bathing is somewhat more effective than light therapy alone.

Light therapy can have various side effects. For instance, the UV rays can dry out your skin. So it's important to apply enough moisturizing cream afterwards. Sunburn-like skin irritations may occur too. This is particularly likely in people who tend to get cold sores on their lips. To try to prevent this from happening, you can put sunscreen on your lips before having the treatment.

Other, less common, side effects include hair follicle infections and raised red patches of skin. But these go away again. Frequent exposure to UV radiation can also lead to premature aging of the skin. Taking psoralen for PUVA therapy can cause nausea and vomiting.

In order to prevent side effects, it's important to avoid sunlight on the day of treatment, or protect yourself from natural UV light by wearing appropriate clothing, sunglasses and sunscreen. This is particularly important for people who have taken psoralen. They should avoid exposure to natural sunlight for the rest of the day.

Regular exposure to UV light increases the risk of skin cancer. So it's a good idea to keep a UV diary to help you keep track of the UV treatments you have had. Information about the number of sessions and the radiation doses can be entered into it.

Medical societies have issued recommendations on when to use treatment with systemic medication (tablets or injections). According to these recommendations, it should only be considered if

• locally applied treatments and light therapy haven't led to a big enough improvement,
• the eczema is particularly bad – for instance, if you have severe symptoms, a large area of skin is affected, or if you have very frequent flare-ups, and
• the eczema greatly affects your life – for example, due to sleep problems, strong itching or considerable limitations in your daily activities, work or free time.

Age plays a role in the decision too: For instance, some medications haven't been approved for use in children.

When eczema is treated systemically, ciclosporin or dupilumab are generally used. Because these medications are either swallowed or injected, they can have more side effects than ointments or creams can – especially if they are used over a long period of time. But serious side effects are rare.

Ciclosporin suppresses the immune system and has long been approved in Germany for the treatment of eczema. A number of studies have shown that it can effectively relieve rashes and itching.

Ciclosporin is taken in the morning and/or evening, at the same time every day if possible. It's important to know that ciclosporin shouldn't be taken together with grapefruit or grapefruit juice. The dose is determined based on your body weight, and is reduced as soon as the eczema starts to improve. The duration of treatment will depend on how well the medication works. It usually takes between two and six months.

The possible side effects of ciclosporin include swollen gums, gastrointestinal (stomach and bowel) problems and tingling or pins and needles, particularly in the hands and feet. Ciclosporin suppresses the immune system, so it may increase the likelihood of getting infections such as acute bronchitis.

Ciclosporin may also put a strain on your kidneys and increase your blood pressure, so your kidney function and blood pressure have to be checked regularly during treatment with this drug. If anything abnormal is found, the dose can be reduced or you can stop taking it. Your kidney function and blood pressure will usually return to normal then. But the risk of permanent kidney damage increases if ciclosporin is used for longer than six months.

Ciclosporin shouldn't be combined with light therapy because this can increase the risk of non-melanoma skin cancer. It also shouldn't be used by people who have already had many years of light therapy.

Because ciclosporin can interact with other drugs, it's important to let your doctor know about any other medication you are using before you start taking ciclosporin. This is also true for herbal products. For instance, St. John's wort can weaken the effect of ciclosporin.

Dupilumab is injected once every two weeks. It blocks certain inflammation-promoting chemical messengers (cytokines) and has been proven to reduce eczema symptoms such as itching and rashes. It has been approved for the treatment of eczema in adults and young people aged 12 and over.

The possible side effects of dupilumab include irritated skin at the injection site, conjunctivitis (pink eye) and an inflammation at the edge of an eyelid. The eye conditions can be treated with eye drops.

If someone can't have treatment with ciclosporin or dupilumab, or if it doesn't work, other medications can be considered. These include azathioprine, mycophenolate and methotrexate. These medications haven't yet been approved in Germany for the treatment of eczema. So they can only be prescribed for this purpose in certain cases, and this "off-label use" has to be justified.

Some family doctors often still prescribe oral steroids (steroid tablets), particularly for adults with severe eczema. But they are rarely recommended for the treatment of eczema nowadays, and should only be used for a short time in exceptional cases during severe flare-ups.

There are various reasons for hesitating to use steroid tablets: On the one hand, they can have serious side effects when taken for a longer period of time. On the other, the eczema often returns when you stop taking the tablets – and then tends to be even worse than before ("rebound effect"). To try to prevent that from happening, people are advised to have treatment with a different medication once they have come off the steroid tablets.

Sometimes eczema is treated with allergy medications known as antihistamines. Antihistamines inhibit the effect of histamine. Histamine is a chemical produced by the immune system when foreign substances enter the body. It dilates (widens) the blood vessels and causes more blood to flow through the tissue. It also irritates the nerves, causing itching.

Antihistamines are used to try to relieve itching in eczema. But research has found that they don't have this effect. Some antihistamines make you feel tired so they might help reduce sleep problems that are caused by itching. Because they don't relieve the symptoms of eczema, they aren't usually recommended as a treatment. It might make sense to use antihistamines if you have eczema and allergies such as hay fever too, though.