Eczema Part 2: Focusing on Treatment in Moderate to Severe Atopic Dermatitis
Atopic dermatitis (AD)
Also referred to as allergic eczema, AD can be difficult to treat but many people respond to measures that focus on avoiding triggers, moisturizing the skin and reducing inflammation/infection.
Previously, I discussed terminology, prevalence, diagnostic and basic treatment measures for AD. In this article, I will elaborate on current recommendations regarding treatment of more moderate to severe AD.
Avoidance or allergic and irritant triggers
Allergic food triggers are more common in young children (preschool age) than in older children and adults. Identifying the possible food triggers may be crucial to preventing flare-ups and reducing ongoing skin inflammation. Often there are only a few relevant foods that trigger AD, and ninety percent of the time they are in the category of the "Big 8". These include milk, egg, wheat, soybean, fin fish, shellfish, peanut, and tree nut. Restricting further contact or consumption of allergic food triggers may greatly reduce the need for medications. Unfortunately, food triggers are often not the only factor in disease progression.
Other potential triggers include irritants such as soaps, and detergents, shower gels, shampoos, laundry products, wool and certain other textiles. Almost any material or substance which contacts the skin may cause irritation and aggravate AD.
Soaps that are frangrance, dye and paraben free are also preferred over other types. Additionally, bar soaps are preferred over liquids and gels. All shampoos are heavily processed and have tons of chemicals in them. Avoid shampooing in the shower since the body tends to get over exposed to these chemicals at a time when the skin may be more vulnerable (skin pores are open from the warmth and moisture).
Soft cotton or silk clothing tend to be better tolerated and are not only associated with less skin irritation but also reduce the impact of rubbing and scratching by covering itchy areas.
Inflammation drives the reddening, swelling and oozing of eczematous skin. The itch-scratch cycle damages the skin and further amplifies the problem by causing more inflammation. Proper moisturizing and appropriate application of topical steroids may reduce inflammation and further flare-ups of eczema as discussed in the first article. But what can you do when you or your child fail to respond to these measures?
It is important to consult your doctor about additional treatment alternatives when medications fall short of controlling AD.
Believe it or not, rubbing in recommended topical steroid followed by putting on warm, water soaked pajamas, followed by dry clothing can help manage tough eczema flare-ups. I know it sounds horrible but after a period of getting used to, children often respond very well to this maneuver. One might think this is a set up for pneumonia, but that has not been the experience. The wet garments should be warm (not dripping wet) and the dry top clothing should help preserve warmth and heat under the covers. Some parents go further by taking the dry garments right from a warm dryer in order to create, early on, a "sauna effect" (as reported by Lio et al. in the reference below).
How does it work? The moist warm surroundings created by the wet dressings promote the pores of the skin to open and allow better penetration of the steroid cream into deeper layers of the skin. In addition, the multiple layers of clothing act as a barrier to scratching and rubbing which as stated, further worsens this condition.
What are the drawbacks? Many children aren't so keen on going to bed in damp clothing so it may be difficult early on. Furthermore, higher absorption of steroid through the skin can occur. For this reason, wet dressings should not be utilized for long periods of time and should always be done under the guidance of a physician.
AD may fail to respond to medications when infectious complications arise. Appropriate antibiotics (ones that can kill Staphylococcus or other possible culprits) will be required to gain control and reduce inflammation. Short courses of antibiotics are considered in these situations. In recent years some doctors have recommended a more long term approach to reducing some bacteria that reside in the skin of AD patients. Dilute bleach baths have emerged as a way to control AD and reduces the need for oral antibiotics in some people.
Although it may make you feel like you are treating your kid like laundry, dilute bleach baths can actually work. This practice may take some getting used to (as with the wet dressings) but the results may be very encouraging.
It's of no surprise that some people with AD have found that regular swimming in pools (which contain chlorine) has helped reduce severity and flare-ups.
Latest treatment options
Duplilumab (Dupixent). Approved for treatment in 2017, this is the first biologic medication approved by the FDA for adults with moderate to severe_ AD_. The biologic is taken bi-weekly by injection, and has been proven to reduce symptoms by 75 percent in more than half of clinical trial participants. Side effects can include conjunctivitis (pink eye), injection site infections, and cold sores on the lips and in the mouth.
Eucrisa (crisaborole). This topical treatment, approved in 2016, can not only be used on adults, but also in children aged two or older. Best used for mild to moderate AD, Eucrisa is applied topically two times a day and can clear skin in a matter of weeks.
Again, discussion with your health care provider before considering any of the above measures is very important.
The wrap up
AD is a complex inflammatory skin disorder which may require an individualized or customized approach when moderate to severe. Experts (particularly dermatologists) have several avenues of thought when it comes to considering additional treatments in this setting. Your job is to learn as much as you can, and partner up with your general doctor, specialists and staff to find the best recipe for success.
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