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Defining the Future of Dermatology

Atopic Dermatitis

About

Atopic dermatitis is a common disease that affects roughly 15% of the population. It is hereditary and is usually seen in families where other family members have atopic dermatitis, allergies, hay fever or asthma. Atopic dermatitis is often called eczema, meaning to "ooze."

Causes

The exact cause is unknown, but it is now believed that people with atopic dermatitis have a defective skin barrier that leads to an imbalance in their immune system, making them overly sensitive to their surroundings.

Diagnosis

Atopic dermatitis is diagnosed by medical history and physical examination. There are no blood tests to make this diagnosis. The main features are a recurring or persistent, itchy rash involving typical body sites in a person with a family history of eczema, asthma or allergies. Patients with atopic dermatitis will often have positive tests for allergies, but most of the allergens noted as positive by testing have no effect on the eczema.

Treatment

How should you care for skin with atopic dermatitis?

Aggressive and complete treatment of flares (Clearance Phase) and prevention of new flare-ups (Maintenance Phase) are critical to managing atopic dermatitis. Both need equal attention and distinct management.

Clearance Phase
Clearance phase (“flares”) requires intensive therapy as the skin is itchy, red, swollen, oozing, and/or crusted and is interfering with daily function (e.g. school, sleep). The goal is to clear the skin and restore it to its normal appearance and function, as well as to decrease itch and discomfort. This nearly always requires the use of anti-inflammatory medications like topical steroids and/or topical calcineurin inhibitors, and the strict avoidance of all potential irritants and allergens that come into contact with the skin. Other treatments may include oral antihistamines, tar products, antibiotics for infection, and various anti-itch medications. This phase may last only a few days or several weeks. It is best to think of the clearance phase as throwing a large bucket of water on a fire to put the flames out, understanding the embers will remain behind and the flames will re-ignite in the future. When the fire is extinguished more completely this will result in decreased flames (better symptom control) and possibly a longer period of time until the flames shoot up again (subsequent flare).

Maintenance Phase
Maintenance phase is achieved after clearance. The skin is now restored to a more normal appearance (thick skin lines and darker or lighter color may persist) with decreased itch and/or discomfort. There is return to daily function (e.g. school, sleep). The use of anti-inflammatory medications like topical steroids or topical calcineurin inhibitors can be stopped or decreased significantly. During this phase the avoidance of all potential irritants and allergens that could come into contact with the skin should continue, especially when the patient has just completed the clearance phase. This phase should continue until the next flare when the clearance phase is restarted.

The skin care regimen for both phases is listed below:

  • 1. Bathing: as often as required to maintain hygiene and comfort.
    DO NOT bath excessively.
    DO NOT use excessively hot water.
    DO use tepid water.
    DO make baths and showers brief (~10 min)
    DO use dilute bleach in the bath water if recommended (1/2 cup bleach in full bath 1-2 times weekly)
  • 2. Body and facial soaps
    DO NOT use any soap-based cleansers during the flares (during the clearance phase) as all soaps will further irritate the already inflamed skin.
    DO USE soap-free cleansers such as:Cetaphil Gentle Skin Cleanser, Vanicream Cleansing Bar, Free & Clear Liquid Cleanser, Aquanil Cleanser, Olay Complete Body Wash with Shea Butter
    DO NOT use deodorant soaps (e.g. Dial, Zest, Irish Spring, Coast, Ivory) or soap that makes you feel "squeaky clean".
  • 3. Moisturizers
    Moisturizers should be used regularly and liberally whenever the skin is dry. Always apply moisturizer after bathing; pat skin dry after bathing so that residual water remains and then apply moisturizer within 3 minutes after bathing so that excess water is trapped by the moisturizer and hydrates the skin (SOAK and SMEAR).
    Recommended moisturizers include:
    Vanicream, Vaniply, Vaseline, Aquaphor ointment, Eucerin Cream, Moisturel Cream, Cetaphil Cream, CeraVe Cream, Theraplex Emollient. This should be applied at least daily or multiple times per day to protect the skin and maintain hydration (should not see flakiness or white scale). Look for products that are hypoallergenic, free of common chemical irritants, fragrance-free, preservative-free, paraben-free, and formaldehyde-free. There is also increasing sensitivity to lanolins so lanolin-free products may be needed.
    DO USE ointments as much as possible during flares and then you can transition to creams during maintenance phase
    DO NOT use lotions (they are watery and evaporate and are not as effective)
  • 4. Clothing and laundry detergents
    DO wear cotton or silk clothing
    DO NOT wear wool or polyester (prickly feeling) clothing
    DO NOT use harsh laundry detergents like Tide
    DO use mild detergents like All Free Clear Laundry detergent, Dreft, Purex baby.
    DO NOT use fabric softeners or dryer antistatic sheets (e.g. Bounce, Cling Free Sheets)
  • 5. Topical Corticosteroids or Topical Calcineurin Inhibitors (TCIs) often used to treat the flares during the clearance phase:
    All generally used 2x/day for 2 weeks then as needed
    Examples: Hydrocortisone ointment, Triamcinolone ointment, Mometasone ointment, Clobetasol ointment,
    Dermasmoothe FS oil, Tacrolimus (Protopic) ointment, 0.03% or 0.1%, Pimecrolimus (Elidel) 1.0% cream
    For severe flares, medications can also be applied with the SOAK and SMEAR technique at night
  • 6. Anti-itch medications (antihistamines) by mouth are occasionally needed for itching; all may be sedating
    Examples: Hydroxyzine (Atarax),Diphenhydramine (Benadryl), Cyproheptadine (Periactin), Cetirizine (Zyrtec), and Doxepin syrup (Sinequan)

SOAK and SMEAR

Many dermatologic conditions are manifested by dry, irritated, and itchy skin. Patients with skin disease tend to have more sensitive skin than normal skin.

Three types of glands found on the skin:

  • Sebaceous gland: produces an oily substance, called sebum (body’s natural moisturizer). Found over most of the bodywith the highest amount on the face and upper trunk and the fewest on the arms and the legs, which tend to dry the earliest.
  • Eccrine Sweat Gland: produces sweat during over-heating. Sweat has the same consistency as water, so it will be removed from your skin when water (without soap) runs over your skin in the shower.
  • Apocrine Gland: found only in the armpits and groin and thus, limit the use of soap in your armpits and groin to avoid drying and irritation.

'Soaking and Smearing' involves ‘soaking’ the affected body part or whole body bathing in water (withoutadditives) for 20 minutes and immediately following by ‘smearing’ an ointment over the affected area withoutdrying the skin.

'Soaking and Smearing' complement each other and work to restore and maintain normal skin barrier functions. 'Soaking’ serves the important purpose of removing crust and scale, while ‘smearing’ causeshydration to the damaged layers of your skin.

Strategies to limit drying of the skin:
Limit the use of soap to armpits and groin (apocrine-containing sites) and add moisturizers afterany washing.
Soaking in pools or hot tubs does not work and often induces irritation.

Procedure for Soaking and Smearing:
Usually soaking and smearing is done at night for 4 nights to 2 weeks. Treatment is done at night forcomplete moisturization to take place for several hours during sleeping. After the skin is under control,the soaking should stop, but the night ‘smears’ with an ointment or moisturizer should continue.

Soak in a bath (not a simple shower) in water (no additives) for 20 minutes at night. Following the 20 minute ‘soak’, ‘smear’ the topical steroid ointment (prescribed by your doctor). After your skin has improved, your physician mayrecommend that you continue the ‘soak and smear’ technique with over the counter ointments to keepthe skin irritation form returning.

‘Soaking’ traps water in the skin (since water cannot move through oil) and thus, effectively moisturizes the superficial skin layers.The anti-inflammatory ingredients in the ointment are able to seep deep into the skin.

Recommended Moisturizers after Prescription Ointment Applications:
(From less greasy to heavy Vaseline type)
Cetaphil Cream, Eucerin Plus, CeraVe, Vanicream, Aveeno for extra dry skin, Vaniply, Aquaphor, Vaseline Ointment

After the skin has regained control, the ‘soak’ can be eliminated, but continue to apply the ointment asrecommended.

To amplify the moisturizing effect, your doctor may recommend that you wear a sauna suit. The sauna suit has two roles: it traps in moisture and will limit the mess from the topical ointments. Example of sauna suit: (http://www.big5sportinggoods.com/searchx/0/0/1/1/?s=sauna+suit)

Follow the same instructions and after ‘smearing,’ wear the sauna suit. If you find the sauna suit uncomfortable, you may take if off after an hour or two. Gradually, you will be able to tolerate the suit for longer periods with time. You can also use ‘wet todry’ pajamas instead of the sauna suit (a pair of damp pajamas covered by a pair of dry pajamas).

Maintenance Treatment: Prevent Future Drying/Irritation
Repeated wetting (i.e., baths, showers, swimming) without application of moisturizer will continue to dryout the skin.Anytime you are submerged in water, apply moisturizer following the ‘soaking’.Lighter moisturizers can be used during the day, including Vanicream, Eucerin,Aveeno or Cetaphil cream.
For nighttime, ointments are preferred, including Vaniply, Vaseline, or Aquaphor


FAQs

What is atopic skin like?

People with atopic dermatitis have sensitive skin. Atopic skin tends to dry out easily, and is quickly irritated by soaps, excessive washing, extremes of temperature, and other irritating conditions, which will require attention to protect the skin. Fortunately, the severity seen mostly in infants and small children tends to decrease with age. Even when the skin apparently looks "clear," the tendency to "become irritated" persists.

SOAK and SMEAR

Many dermatologic conditions are manifested by dry, irritated, and itchy skin. Patients with skin disease tend to have more sensitive skin than normal skin.

Three types of glands found on the skin:

  • Sebaceous gland: produces an oily substance, called sebum (body’s natural moisturizer). Found over most of the bodywith the highest amount on the face and upper trunk and the fewest on the arms and the legs, which tend to dry the earliest.
  • Eccrine Sweat Gland: produces sweat during over-heating. Sweat has the same consistency as water, so it will be removed from your skin when water (without soap) runs over your skin in the shower.
  • Apocrine Gland: found only in the armpits and groin and thus, limit the use of soap in your armpits and groin to avoid drying and irritation.

'Soaking and Smearing' involves ‘soaking’ the affected body part or whole body bathing in water (withoutadditives) for 20 minutes and immediately following by ‘smearing’ an ointment over the affected area withoutdrying the skin.

'Soaking and Smearing' complement each other and work to restore and maintain normal skin barrier functions. 'Soaking’ serves the important purpose of removing crust and scale, while ‘smearing’ causeshydration to the damaged layers of your skin.

Strategies to limit drying of the skin:
Limit the use of soap to armpits and groin (apocrine-containing sites) and add moisturizers afterany washing.
Soaking in pools or hot tubs does not work and often induces irritation.

Procedure for Soaking and Smearing:
Usually soaking and smearing is done at night for 4 nights to 2 weeks. Treatment is done at night forcomplete moisturization to take place for several hours during sleeping. After the skin is under control,the soaking should stop, but the night ‘smears’ with an ointment or moisturizer should continue.

Soak in a bath (not a simple shower) in water (no additives) for 20 minutes at night. Following the 20 minute ‘soak’, ‘smear’ the topical steroid ointment (prescribed by your doctor). After your skin has improved, your physician mayrecommend that you continue the ‘soak and smear’ technique with over the counter ointments to keepthe skin irritation form returning.

‘Soaking’ traps water in the skin (since water cannot move through oil) and thus, effectively moisturizes the superficial skin layers.The anti-inflammatory ingredients in the ointment are able to seep deep into the skin.

Recommended Moisturizers after Prescription Ointment Applications:
(From less greasy to heavy Vaseline type)
Cetaphil Cream, Eucerin Plus, CeraVe, Vanicream, Aveeno for extra dry skin, Vaniply, Aquaphor, Vaseline Ointment

After the skin has regained control, the ‘soak’ can be eliminated, but continue to apply the ointment asrecommended.

To amplify the moisturizing effect, your doctor may recommend that you wear a sauna suit. The sauna suit has two roles: it traps in moisture and will limit the mess from the topical ointments. Example of sauna suit: (http://www.big5sportinggoods.com/searchx/0/0/1/1/?s=sauna+suit)

Follow the same instructions and after ‘smearing,’ wear the sauna suit. If you find the sauna suit uncomfortable, you may take if off after an hour or two. Gradually, you will be able to tolerate the suit for longer periods with time. You can also use ‘wet todry’ pajamas instead of the sauna suit (a pair of damp pajamas covered by a pair of dry pajamas).

Maintenance Treatment: Prevent Future Drying/Irritation
Repeated wetting (i.e., baths, showers, swimming) without application of moisturizer will continue to dryout the skin.Anytime you are submerged in water, apply moisturizer following the ‘soaking’.Lighter moisturizers can be used during the day, including Vanicream, Eucerin,Aveeno or Cetaphil cream.
For nighttime, ointments are preferred, including Vaniply, Vaseline, or Aquaphor

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