Managing Atopic Dermatitis: A Practice Guide for...
2
Managing Atopic Dermas: A Pracce Guide for Clinicians Most paents who are diagnosed with atopic dermas (AD) have mild-to-moderate disease and can be managed effecvely in a primary care seng. Treatment recommendaons that emphasize what to avoid are as important as what to use. In pracce, paents’ AD flare ups are commonly treated with systemic anbiocs, anhistamines, predni- sone, and a variety of over-the-counter (OTC) and prescripon topical products, which yield short-term relief, but not long-term control. A changing treatment paradigm recognizes the negave long-term impact of this approach and emphasizes the use of basic skin care (described below) as the safest, most convenient, and readily available approach (albeit requiring more me and effort to understand), to minimize inflammaon, support restoraon of healthy skin barrier funcon, and achieve AD control. AD: AVOID Staphylococcus aureus (S aureus) chronically colonizes the skin in the great majority of children with AD and is associated with inflammaon and pruritus. True infecon is marked by localized, tender lesions and puru- lent drainage. Posive skin surface cultures are oſten misinterpreted as infecon and treated with short- course oral anbiocs, but this approach yields only short-term AD improvement and may contribute to long-term colonizaon with resistant strains, including methicillin-resistant S aureus (MRSA). S aureus colonizaon can be controlled with bleach baths and interval applicaon of a topical anbioc applied to nares and skin folds. Many types of oral anhistamines are generally perceived as safe, are readily available, and are oſten used by and prescribed to children with AD to treat itch. Many perceive benefit from this treatment, because some children with AD also have under-recognized urcaria, and in others, the short-acng anhistamines like diphenhydramine and hydroxyzine provide a soporific effect. But, the itch of AD is not histamine-mediated, and sedang anhistamines have under-appreciated adverse effects that can create more problems than they solve, including idiosyncrac agitaon and neurocognive sequelae, detrimental to school performance. Daily use of nonsedang anhistamines is most effecve for paents with coexisng hives. To help with sleep, in general, it is most important to implement daily skin care. Melatonin is a safe alternave to help with sleep. “Complex topicals” refers to OTC products with hidden allergens that can complicate AD by causing secondary irritant and allergic contact dermas, an important, under-recognized factor that contributes to treatment failure in children with AD. A myriad of OTC cleansers and moisturizers are rife with meaningless markeng terms. These products are oſten expensive and foster lost opportunies for using more effecve treatments. Complex topical prescripon regimens (eg, concomitant use of topical corcosteroids [TCSs] of different potencies for different areas of the body) contribute to confusion, poor adherence, and treatment failure. Safe and effecve use of prescripon TCSs requires guidance. Using too lile medicaon will not be effecve, but using too much increases the risk of side effects.
Transcript of Managing Atopic Dermatitis: A Practice Guide for...
Managing Atopic Dermatitis: A Practice Guide for Clinicians
Most patients who are diagnosed with atopic dermatitis (AD) have mild-to-moderate disease and can be managed effectively in a primary care setting. Treatment recommendations that emphasize what to avoid are as important as what to use.
In practice, patients’ AD flare ups are commonly treated with systemic antibiotics, antihistamines, predni-sone, and a variety of over-the-counter (OTC) and prescription topical products, which yield short-term relief, but not long-term control. A changing treatment paradigm recognizes the negative long-term impact of this approach and emphasizes the use of basic skin care (described below) as the safest, most convenient, and readily available approach (albeit requiring more time and effort to understand), to minimize inflammation, support restoration of healthy skin barrier function, and achieve AD control.
AD: AVOIDStaphylococcus aureus (S aureus) chronically colonizes the skin in the great majority of children with AD and is associated with inflammation and pruritus. True infection is marked by localized, tender lesions and puru-lent drainage. Positive skin surface cultures are often misinterpreted as infection and treated with short-course oral antibiotics, but this approach yields only short-term AD improvement and may contribute to long-term colonization with resistant strains, including methicillin-resistant S aureus (MRSA). S aureus colonization can be controlled with bleach baths and interval application of a topical antibiotic applied to nares and skin folds.
Many types of oral antihistamines are generally perceived as safe, are readily available, and are often used by and prescribed to children with AD to treat itch. Many perceive benefit from this treatment, because some children with AD also have under-recognized urticaria, and in others, the short-acting antihistamines like diphenhydramine and hydroxyzine provide a soporific effect. But, the itch of AD is not histamine-mediated, and sedating antihistamines have under-appreciated adverse effects that can create more problems than they solve, including idiosyncratic agitation and neurocognitive sequelae, detrimental to school performance.
Daily use of nonsedating antihistamines is most effective for patients with coexisting hives. To help with sleep, in general, it is most important to implement daily skin care. Melatonin is a safe alternative to help with sleep.
“Complex topicals” refers to OTC products with hidden allergens that can complicate AD by causing secondary irritant and allergic contact dermatitis, an important, under-recognized factor that contributes to treatment failure in children with AD. A myriad of OTC cleansers and moisturizers are rife with meaningless marketing terms. These products are often expensive and foster lost opportunities for using more effective treatments. Complex topical prescription regimens (eg, concomitant use of topical corticosteroids [TCSs] of different potencies for different areas of the body) contribute to confusion, poor adherence, and treatment failure.
Safe and effective use of prescription TCSs requires guidance. Using too little medication will not be effective, but using too much increases the risk of side effects.
Tenets of Basic Skin Care for AD• Daily bathing• Choosing appropriate over-the-counter products• Daily emollients applied after bathing• Correct topical medication quantity and frequency • Having an office expert
AD: USEThe best flare management is to use basic bland skin care:
BathingBleach baths are the mainstay (~1/4 cup per child’s bath, 1 Tbsp per infant bath) of basic skin care. When prescribing bleach baths, inform parents who are concerned about using bleach that this bath is like bathing in a swimming pool. Other possible additives (with less evidence to support) include vinegar and lemon juice. The goal is to restore acidification to the skin surface.
Such baths should aim to be about 10–15 minutes long, if possible, 2–3 times per week.
After the bath, pat the skin dry to reduce friction.
These are guidelines. The family needs to do what works for them; something is better than nothing.
Soaps and LotionsTeach your patients how to navigate the confusing “Cosmeceutical-Industrial Complex” – the unsupported marketing claims on skin care products. Patients/families should be taught how to carefully read labels of OTC products. Emphasize reading the ingredient list on the back of the package more than the front, includ-ing the inactive ingredients. Marketing terms such as “Natural,” “Hypoallergenic,” “For Sensitive Skin,” or even “Fragrance Free” are not guided by FDA definitions. Look for products that have fewer ingredients. Liquid cleansers have more allergens than gentle bar soaps.
Emollients Use emollients liberally, preferably petroleum jelly, or mineral/coconut oil. Optimal application frequency is 4 times a day, but applyingtwice a day is still useful. Work with the school nurse to keep a supply of petroleum jelly at school.
Topical Medication Dosing For short-term flare control: Apply daily for 3–7 days until clear, then switch to a maintenance regimen. It is more important for the patient to use a defined quantity of medication over time (eg, <45 g per month) than a specific amount per application. Start with more liberal amounts, then taper. TCSs need not be applied more than once a day. Intermittent dosing is safest (eg, every other day, or 15 days per month).
Create an Office ExpertThe office expert is essential for taking the time to convey the key patient education points at an appropriate health literacy level and to provide a consistent message. The office expert can be an LPN or office assistant.
