Review
Topical therapy of atopic dermatitis: Controversies from Hippocrates to topical immunomodulators

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Although atopic dermatitis can be treated efficiently, there is still much controversy about the risk/benefit ratio of both topical corticosteroids and topical immunomodulators. Conflicting data may be found about the usefulness of bathing, diet regulation, and other therapeutic interventions. These controversies result in part from the persistence of Hippocratic doctrines in modern medical thinking. Humoralist and diathetic doctrines, as they pertain to eczema, are reviewed. The paradoxical worsening of oozing and the deadly hazards of hospitalization before the era of antibiotics are brought to mind. We hope that this historical review will improve the understanding of current controversies and help dermatologists to manage patients with atopic dermatitis and other chronic skin diseases.

Section snippets

Humoralism and diathesis: the conceptual basis for non-topical therapy

AD is a great model to illustrate the conceptual representations linking skin disorders and internal medicine. In particular, the visible oozing of eczema and alternating phases of AD and wheezing gave credit to the role assigned to cutaneous symptoms by the Hippocratic school. For the physicians favoring such a conception, eczema has been considered as a “noli me tangere” (don't touch me) and the nontopical treatment of AD is more beneficial than the topical therapy. Those physicians who

“Saignée séreuse” and rapid death: puzzling paradoxes of the hazards of active treatment

Until recently, the beneficial importance of oozing was regarded as evidence of the role played by the skin in the clearance of the vicious humors. Oozing had to be preserved or restored, even to be worsened or replaced by alternative ways of elimination of toxic humors. In the case of exceedingly rapid drying of the oozing, many authors recommended its replacement with bloodlettings (Alibert,7 Cazenave,9 Devergie,29 and Gibert33), leeches (Rayer regarded leeches as the only method that could

The influence of the Vienna school on topical therapy of chronic eczemas

In the 19th century, German dermatology has epitomized the opposite side of the controversy. According to Hebra, “hypothesising that cutaneous diseases and particularly those with oozing phenomena had to be considered as salutary, physicians exhorted their patients to endure eczema.”48 Hebra promoted the therapeutic value of bathing and showering, emollients, tar, and sulfur. A few years later, his successor in Vienna, Kaposi, also a strong advocate of the autonomy of skin disorders, was

Bathing and showering: hygienic measures still controversial

The use of water and its value in topical treatment of children with AD have been frequently debated. Strongly influenced by medical doctrines, some authors considered water as a curative agent, while some others denied its therapeutic value, regarding it as an irritating factor. Early in the 19th century, Alibert, as a proponent of the humoralist concepts, recommended that the eczema be allowed to ooze and promoted baths and showers as the most powerful methods for the treatment of cutaneous

From topical corticosteroid phobia to TIM phobia: a survival of Hippocratic medicine?

In 1952, Sulzberger and Witten70 published a preliminary report: “very short, consisting on but 34 lines, one table, a bibliography citing one pertinent paper and the formula for a simple prescription.” They actually promoted the use of a new topical drug in dermatology,5 17 hydroxycortisone–21 acetate (named compound F) 2.5% in a mixture of lanolin-petrolatum in treating 19 patients, aged 2 to 56, 8 of them having AD. Improvement was judged after 1 week based on clinical criteria, namely

Conclusions

The paradox of the still active reminiscence of unconscious humoralism in the approach to treatment of AD, which considers the skin at best as the target of some internal immune diathesis, or merely as a safety valve that is dangerous to close, is the mounting consensus of the central role of skin itself in the pathophysiology of the disease.74 The link of AD and asthma to a genetically proven barrier defect in the stratum corneum,75 which was hypothesised earlier, reinforces the importance of

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