Atopic Dermatitis (cont.)
Gary W. Cole, MD, FAAD
Gary W. Cole, MD, FAAD
Dr. Cole is board certified in dermatology. He obtained his BA degree in bacteriology, his MA degree in microbiology, and his MD at the University of California, Los Angeles. He trained in dermatology at the University of Oregon, where he completed his residency.
William C. Shiel Jr., MD, FACP, FACR
William C. Shiel Jr., MD, FACP, FACR
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
In this Article
What are aeroallergens?
Some allergens are called aeroallergens because they are present in the air. They may also play a role
in atopic dermatitis. Common aeroallergens are dust mites, pollens,
molds, and dander from animal hair or skin. These aeroallergens,
particularly the house dust mite, may worsen the symptoms of atopic dermatitis
in some people. Although some researchers think that aeroallergens are
an important contributing factor to atopic dermatitis, others
believe that they are insignificant. Scientists also don't understand
the way in which aeroallergens affect the
No reliable test is available that determines whether a specific aeroallergen is an exacerbating factor in any given individual. If the doctor suspects that an aeroallergen is contributing to a patient's symptoms, the doctor may recommend ways to reduce exposure to the offending agents. For example, the presence of the house dust mite can be limited by encasing mattresses and pillows in special dust-proof covers, frequently washing bedding in hot water, and removing carpeting. However, there is no way to completely rid the environment of aeroallergens.
What is the treatment for atopic dermatitis?
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Treatment involves a partnership between the doctor and the patient and family members. The doctor will suggest a treatment plan based on the patient's age, symptoms, and general health. The patient and family members play a large role in the success of the treatment plan by carefully following the doctor's instructions. Some of the primary components of treatment programs are described below. Most patients can be successfully managed with proper skin care and lifestyle changes and do not require the more intensive treatments discussed. Much of the improvement comes from homework, including lubricating generously especially right after showers or baths.
The doctor has three main goals in treating atopic dermatitis: healing the skin and keeping it healthy; preventing flares; and treating symptoms when they do occur. Much of caring for the skin involves developing skin-care routines, identifying exacerbating factors, and avoiding circumstances that stimulate the skin's immune system and the itch-scratch cycle. It is important for the patient and family members to note any changes in skin condition in response to treatment and to be persistent in identifying the most effective treatment strategy.
Skin care: A simple and basic regimen is key. Staying with one recommended soap and one moisturizer is very important. Using multiple soaps, lotions, fragrances, and mixes of products may cause further issues and skin sensitivity.
Healing the skin and keeping it healthy are of primary importance both in preventing further damage and enhancing the patient's quality of life. Developing and following a daily skin-care routine is critical to preventing recurrent episodes of symptoms. The key factor is proper bathing and the application of an emollient to the wet skin without towel drying. Generally, an effective emollient is a reasonably stiff ointment or cream (one that does not move out of an opened inverted jar). People with atopic dermatitis should avoid hot baths and showers. A lukewarm bath with a capful of chlorine bleach (Clorox) helps to cleanse, disinfect, and moisturize the skin without drying it excessively. The doctor may recommend limited use of a mild bar soap or non-soap cleanser because soaps can be drying to the skin. Bath oils are not usually helpful.
Once the bathing is finished, apply an emollient immediately without towel drying. This restores the skin's moisture and inhibits the evaporation of water, increasing the rate of healing, and establishing a barrier against further drying and irritation. Lotions generally are discouraged because they have a high water or alcohol content and evaporate quickly. Creams and ointments work better at healing the skin. Tar preparations can be very helpful in healing very dry, lichenified areas. Whatever preparation is chosen, it should be as free of fragrances and chemicals as possible.
Another key to protecting and restoring the skin is taking steps to avoid repeated skin infections. Although it may not be possible to avoid infections altogether, the effects of an infection may be minimized if they are identified and treated early. Patients and their families should learn to recognize the signs of skin infections, including tiny pustules (pus-filled bumps) on the arms and legs, appearance of oozing areas, or crusty yellow blisters. If symptoms of a skin infection develop, the doctor should be consulted to begin treatment as soon as possible.
Treating atopic dermatitis in infants and children
Medications and phototherapy: If a recurrence of atopic dermatitis occurs, several methods can be used to treat the symptoms. With proper treatment, most symptoms can be brought under control within three weeks. If symptoms fail to respond, this may be due to a flare that is stronger than the medication can handle, a treatment program that is not fully effective for a particular individual, or the presence of trigger factors that were not addressed in the initial treatment program. These factors can include a reaction to a medication, infection, or emotional stress. Continued symptoms may also occur because the patient is not following the treatment-program instructions.
Corticosteroid creams and ointments are the most frequently used treatment. Sometimes, over-the-counter preparations are used, but in many cases, the doctor will prescribe a stronger corticosteroid cream or ointment. Occasionally, the base used in certain brands of corticosteroid creams and ointments is irritating for a particular patient and a different brand is required. Side effects of repeated or long-term use of topical corticosteroids can include thinning of the skin, infections, growth suppression (in children), and stretch marks on the skin.
Tacrolimus (Protopic) and pimecrolimus (Elidel) ointments are powerful and expensive topical medicated creams (drugs that are applied to the skin) that are used for the treatment of atopic dermatitis. They are not particularly effective in patients with severe disease and are best used on the faces of children. These new drugs are referred to as "immune modulators." They were first and are still commonly used internally (oral form) to help patients with kidney and liver transplants avoid rejecting the organs they received. They work by suppressing the immune system. When these drugs are used in limited and small quantities on intact skin to externally to treat the skin, they are not thought to significantly weaken or change the body's immune system. Also, unlike topical steroids (cortisone creams), these new medications don't cause thinning of the skin and breaking of superficial blood vessels (atrophy). However, over the recent few years, there has been concern and a positional change by the Food and Drug Administration (FDA). A special warning has been placed on these two immune modulator drugs with potential caution regarding cancers and other immune-system suppression issues. While dermatologists and other physicians have continued to safely prescribe many of these drugs for children and adults, it is important to discuss these possible concerns and precautions with your physician when beginning a treatment regimen.
A newer class of drugs for improving barrier function in both pediatrics and adults includes Atopiclair and MimyX. These creams may be used in combination with topical steroids and other emollients to help repair the overall dryness and broken skin function.
Additional available treatments may help to reduce specific symptoms of the disease. Antibiotics to treat skin infections may be applied directly to the skin in an ointment but are usually more effective when taken by mouth in pill form. Certain antihistamines that cause drowsiness can reduce nighttime scratching and allow more restful sleep when taken at bedtime. This effect can be particularly helpful for patients whose nighttime scratching aggravates the disease. If viral or fungal infections are present, the doctor may also prescribe medications to treat those infections.
Phototherapy is treatment with light that uses ultraviolet A or B light waves or a combination of both. This treatment can be an effective treatment for mild to moderate dermatitis in older children (over 12 years old) and adults. Photochemotherapy, a combination of ultraviolet light therapy and a drug called psoralen, can also be used in cases that are resistant to phototherapy alone. Possible long-term side effects of this treatment include premature skin aging and skin cancer. If the doctor thinks that phototherapy may be useful in treating the symptoms of atopic dermatitis, he or she will use the minimum exposure necessary and monitor the skin carefully.
When other treatments are not effective, the doctor may prescribe systemic corticosteroids, drugs that are taken by mouth or injected into muscle instead of being applied directly to the skin. An example of a commonly prescribed corticosteroid is prednisone. Typically, these medications are used only in resistant cases and are only given for short periods of time. The side effects of systemic corticosteroids can include skin damage, thinned or weakened bones, high blood pressure, high blood sugar, infections, and cataracts. It can be dangerous to suddenly stop taking corticosteroids, so it is very important that the doctor and patient work together in changing the corticosteroid dose.
In adults, immunosuppressive drugs, such as cyclosporine, are also used to treat severe cases of atopic dermatitis that have failed to respond to any other forms of therapy. Immunosuppressive drugs restrain the overactive immune system by blocking the production of some immune cells and curbing the action of others. The side effects of cyclosporine can include high blood pressure, nausea, vomiting, kidney problems, headaches, tingling or numbness, and a possible increased risk of cancer and infections. There is also a risk of relapse after the drug is discontinued. Because of their toxic side effects, systemic corticosteroids and immunosuppressive drugs are used only in severe cases and then for as short a period of time as possible. Patients requiring systemic corticosteroids or immunosuppressive drugs should be referred to a dermatologist or an allergist specializing in the care of atopic dermatitis to help identify trigger factors and alternative therapies.
In extremely rare cases, when no other treatments have been successful, the patient may have to be hospitalized. A five- to seven-day hospital stay allows intensive skin-care treatment and reduces the patient's exposure to irritants, allergens, and the stresses of day-to-day life. Under these conditions, the symptoms usually clear quickly if environmental factors play a role or if the patient is not able to carry out an adequate skin-care program at home.
Tips for working with your doctor
Atopic dermatitis and quality of life
Despite the symptoms caused by atopic dermatitis, it is possible for people with the disorder to maintain a high quality of life. The keys to an improved quality of life are education, awareness, and developing a partnership among the patient, family, and doctor. Good communication is essential for all involved. It is important that the doctor provides understandable information about the disease and its symptoms to the patient and family and demonstrate any treatment measures recommended to ensure that they will be properly carried out.
When a child has atopic dermatitis, the entire family situation may be affected. It is important that families have additional support to help them cope with the stress and frustration associated with the disease. The child may be fussy and difficult and often is unable to keep from scratching and rubbing the skin. Distracting the child and providing as many activities that keep the hands busy are key but require effort and work on the part of the parents or caregivers. Another issue families face is the social and emotional stress associated with disfigurement caused by atopic dermatitis. The child may face difficulty in school or other social relationships and may need additional support and encouragement from family members.
Adults with atopic dermatitis can enhance their quality of life by caring regularly for their skin and being mindful of other effects of the disease and how to treat them. Adults should develop a skin-care regimen as part of their daily routine, which can be adapted as circumstances and skin conditions change. Stress management and relaxation techniques may help decrease the likelihood of flares due to emotional stress. Developing a network of support that includes family, friends, health professionals, and support groups or organizations can be beneficial. Chronic anxiety and depression may be relieved by short-term psychological therapy.
Recognizing the situations when scratching is most likely to occur may also help. For example, many patients find that they scratch more when they are idle. Structured activity that keeps their hands occupied may prevent further damage to the skin. Occupational counseling also may be helpful to identify or change career goals if a job involves contact with irritants or involves frequent hand washing, such as kitchen work or auto mechanics.
Controlling atopic dermatitis
Reviewed by William C. Shiel Jr., MD, FACP, FACR on 8/3/2012
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