Atopic Dermatitis: Moisturize, Moisturize, Moisturize!

Atopic dermatitis is an umbrella term encompassing several inflammatory skin conditions. The word “atopy” is derived from the Greek word “ATO POS” meaning “out of place,” and in fact the patchy skin that patients with atopic dermatitis develop looks very out of place. In the past, we called atopic dermatitis “eczema”—a term term that many people continue to use.

Usually, atopic dermatitis develops in the childhood years with its greatest prevalence in children aged 5 or younger. Often, affected individuals (or their parents) report a familial history.

Although more than half of atopic dermatitis resolves by the time the affected individual turns 15, some children continue to experience symptoms throughout life. The earlier that atopic dermatitis develops, the more likely it is to be a severe and very uncomfortable dermatological condition.

A hallmark of atopic dermatitis is chronic pruritic, dry, red patches. The most common locations for atopic dermatitis are the elbows and knees hands neck and genitalia. Most patients will report patient specific triggers that seem to worsen the condition. When individuals have atopic dermatitis, they usually have inappropriate immunoglobon E production in response to common environmental proteins. These may include but are not limited to dust mites, grass, pollen, and foods.

Retail health care providers will see certain hallmark signs when patients appear with atopic dermatitis. They scratch compulsively, leaving redness, rash, and lichenification (thickening of the scan and leathery, bark-like appearance) on the skin. Sometimes, they develop vesicles or oozing blisters. An important point to note for differential diagnosis is that patients with atopic dermatitis never have scalp or nail involvement; consider a diagnosis of psoriasis or seborrhea if scan in these areas is involved.

Treatment for atopic dermatitis is generally prescribed in a stepwise fashion. The first, and possibly most important, point is moisturization. These patients need to moisturize constantly and keep skin supple. Often moisturization alone can resolve mild atopic dermatitis.

A general rule is that the thicker and more inclusive the moisturizer, the faster the skin will respond. Patient preference, however, is important to consider. Many patients dislike the feel of ointments and very thick lotions because they feel greasy. Advise patients or their parents to select the thickest unscented, hypoallergenic product that feels comfortable; limit bathing to short baths in tepid water; apply moisturizer within 3 minutes of bathing; and return to the clinic if they don’t see improvement within 7 days.

Next, retail health care providers can prescribe low- to medium-strength topical steroids if patients experience flares. For flares, ointments are preferred. The FDA recently approved crisaborole for maintenance therapy of mild to moderate atopic dermatitis in patients 2 years or older. It appears to have anti-inflammatory activity that suits the skin.

In more severe cases, patients may need topical calcineurin inhibitors (pimecrolimus or tacrolimus) and possibly intermittent corticosteroids. In the most resistant of cases, patients may need to schedule sessions of phototherapy, or use cyclosporine, oral or potent topical corticosteroids, methotrexate, or azathioprine. These therapies are usually provided or prescribed by a dermatologist.

Some data indicate that probiotics can significantly improve atopic dermatitis. In fact, in January 2015, the World Allergy Organization recommended that all pregnant and lactating women and their breast-feeding infants take probiotics to prevent the development of atopic dermatitis. This recommendation, based on meta-analysis, reflects the finding that the incidence of eczema is considerably lower (9% to 16%) in offspring of women who supplemented with probiotics during pregnancy or breast-feeding. The strains that seem to confer the most benefit areLactobacillusandBifidobacterium

Patients may also find bleach baths helpful, especially if they have clinically apparent secondary bacterial infection. Research has confirmed that diluted bleach baths—that is, baths containing 0.005% sodium hypochlorite—seem to reduce the severity of atopic dermatitis. Advise patients to mix 1/2 cup of regular bleach into a bathtub that is one-quarter filled with lukewarm water. The affected individual should bathe for about 1 minutes. Usually, dermatologists recommend diluted bleach baths twice weekly.

Prescribers should avoid the use of antihistamines and reserve them only for times when patients are losing sleep because of itching. In addition, prescribers should be very careful to use oral antibiotics only if the patient has clinically apparent infection.

Recommended Reading

Eichenfield LF, Tom WL, Chamlin SL, et al. Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis.J Am Acad Dermatol.2014;70(2):338-351. doi: 10.1016/j.jaad.2013.10.010.

Paller AS, Tom WL, Lebwohl MG, et al. Efficacy and safety of crisaborole ointment, a novel, nonsteroidal phosphodiesterase 4 (PDE4) inhibitor for the topical treatment of atopic dermatitis (AD) in children and adults.J Am Acad Dermatol.2016;75(3):494-503.e4. doi: 10.1016/j.jaad.2016.05.046.

Howell MD, Parker ML, Mustelin T, Ranade K. Past, present, and future for biologic intervention in atopic dermatitis.Allergy.2015;70(8):887-896. doi: 10.1111/all.12632.