|Year : 2017 | Volume
| Issue : 3 | Page : 166-173
Nonpharmacological management of atopic dermatitis
Sebastian Criton, Geethu Gangadharan
Department of Dermatology, Amala Institute of Medical Sciences, Thrisssur, Kerala, India
|Date of Web Publication||7-Jun-2017|
Department of Dermatology, Amala Institute of Medical Sciences, Amala Nagar, Thrisssur - 680 555, Kerala
Source of Support: None, Conflict of Interest: None
Atopic dermatitis is an immunologically mediated chronic inflammatory disease which cannot be controlled always with topical agents. Systemic drugs play important role in these difficult to manage cases. Systemic agents are also important in controlling the acute flare. Unfortunately these agents are very limited in number. Moreover none of them starting from corticosteroid to azathioprine can provide complete cure. Continuous research is unfolding different aspects of AD pathogenesis which was not known previously. Scientists are engaged in developing newer molecules targeting those novel pathological pathways thus adding in the armamentarium of existing drugs. This article is dedicated to current systemic treatment options available with their individual merit and demerit along with recent advances in this field.
Keywords: Atopic dermatitis, azathioprine, cyclosporine, methotrexate, steroid, systemic therapy
|How to cite this article:|
Criton S, Gangadharan G. Nonpharmacological management of atopic dermatitis. Indian J Paediatr Dermatol 2017;18:166-73
|How to cite this URL:|
Criton S, Gangadharan G. Nonpharmacological management of atopic dermatitis. Indian J Paediatr Dermatol [serial online] 2017 [cited 2017 Oct 22];18:166-73. Available from: http://www.ijpd.in/text.asp?2017/18/3/166/207605
| Introduction|| |
A topic dermatitis is a chronic inflammatory dermatosis affecting 7%–29% of the pediatric population across the world., The recent trend of an increase in the prevalence of atopic dermatitis is attributed to the changing gene–environment interactions. This has resulted in an upsurge of research into the pathogenesis, treatment, and prevention of atopic dermatitis. Even with the development of newer drugs and treatment modalities, nonpharmacological intervention remains an integral part of the management of atopic dermatitis. The success of management lies in a combined approach where drug therapy is combined with a set of interventions, apart from drugs, aimed at altering the factors involved in initiation and progression of the pathogenic cascade of atopic dermatitis in an individual patient.
| Nonpharmacological Management – The Rationale|| |
Atopic dermatitis is a chronic inflammatory disease which is to a greater extent influenced by genetically determined epidermal and immune defects and modified by environmental factors. The avenues for tackling it from outside should be fully understood and harnessed. In atopic dermatitis, defects in epidermal barrier lead to percutaneous penetration of allergens, causing elaboration of thymic stromal lymphopoietin by keratinocytes and activation of Th2 and Th22 cells, leading to liberation of cytokines, hence perpetuating the cascade., Various factors which contribute to this epidermal barrier defect include filaggrin gene mutation, lipid defects, proteases, irritants, pH changes, and influx of bacteria and other pathogens [Figure 1]. This intricacy of interaction between genetic defects, immune system, and environment, resulting in dysfunction of epidermal barrier integrity and elaboration of immune dysfunction,, emphasizes that no single drug or combination is effective in successful management of atopic dermatitis. Hence, a meaningful approach to the management of atopic dermatitis should be an all-encompassing one with both drug therapy and nonpharmacological intervention, each given its due importance.
|Figure 1: Pathogenesis of atopic dermatitis (adapted from essential updates in atopic dermatitis: Pathophysiology, Prevalence, and Clinical Manifestations, Anthony J Mancini, Medscape, August 2016)|
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Nonpharmacological management includes the treatment of atopic dermatitis using modalities other than drugs for control of flare and maintenance of remission of disease. It entails treatment modalities which complement the pharmacological therapy but not a substitute for drug therapy. The goals of nonpharmacological management include reduction in severity of illness and flare episodes, to maintain remission and improvement in quality of life of patient with atopic dermatitis. This can be achieved by patient education, modification of atopic skin, its triggers, and psychological interventions wherever needed.,,, The aim of this article is to give an update on the various nonpharmacological approaches in atopic dermatitis.
The education of patient and family enables them to have a realistic approach to the disease and its outcome. Literature review has shown that educational interventions can decrease the severity of atopic dermatitis, improve patient adherence leading to a positive long-term outcome, and thus improve the quality of life of patients.,
Educational intervention should be included in the first visit of a patient to a dermatologists' office. It involves education of the family regarding the chronic relapsing and remitting course of the disease, about the triggering factors and importance of its modification. The crucial role of intact skin and importance of its maintenance should be given thrust. Instructions are to be given regarding the drug therapy and the importance of adherence to treatment regimen. Initiative should be taken to address any misconception regarding the disease and its management. Furthermore, the role of family as a support system for the child should be emphasized.
Furthermore, the child should be encouraged to attend school. Parents are advised to inform the noninfectiousness of the condition to the school authorities and the importance of school and peers as a support system in a child with atopic dermatitis. Educational interventions can be also done in group workshops, using educational pamphlets and videos.
Modification of Atopic Skin
One of the primary objectives of the management of atopic dermatitis is modification of atopic skin. This includes maintenance of barrier integrity and modification of various factors which curtail the integrity. It is achieved by the use of emollients, wet wraps, bleach bath, and using various avoidance strategies.
Use of Emollients
The remarkable ability of emollient in recovery of barrier integrity and its maintenance makes it the mainstay in treatment of atopic dermatitis. It has been observed in number of clinical trials that they lessen symptoms and signs of atopic dermatitis and decrease the requirement of other anti-inflammatory treatments for disease control.,,, An ideal emollient would repair the skin barrier, maintain skin integrity and appearance, reduce transepidermal water loss (TEWL), and restore the lipid barrier's ability to attract, hold, and redistribute water., However, the market abundance of emollients ranging from traditional to the designer ones makes the choice of an ideal product confusing.
The choice of emollient should be according to the preference of the patient. Ideally, the emollient of choice should be dispensed with pump dispensers. If the emollient is in a pot or jar, the required amount should be removed with a clean spoon or spatula. Fingers should not be inserted into pots, to prevent contamination. Emollients should not be shared with others. The patient is advised to use emollient liberally and frequently as and when the child feels dry and itchy. It is particularly important to use emollient immediately following bathing and soft pat drying. The products of choice have to be applied just sufficient enough to smear the skin, in the general direction of growth of body hair, to prevent folliculitis.
The cost of high-quality emollient therapies often restricts its use. Hence, in resource-poor settings, the use of any vegetable oil of patient preference can be encouraged. The patient may be advised to apply warmed vegetable oil for 10-15 min before bathing and frequently thereafter.
Wet Wrap Therapy
Wet wrap therapy is a relatively safe and effective intervention in atopic dermatitis. It is a treatment modality using a double layer of tubular bandages or gauze, with a moist first layer and a dry second layer. Despite this general definition, there is considerable variation in methodology across various centers, in the topical products and bandages used, occlusion time, and the treatment duration.,,,,, Wet wrap therapy increases the penetration of topical agent by occlusion, decreases TEWL, has a soothing effect, and provides a physical barrier against scratching. Except for occasional adverse effects such as discomfort, chills, folliculitis, and other minor skin infections, wet wrap therapy can be considered a safe short-term intervention in atopic dermatitis.
The conventional wet wrap therapy advocates the use of topical products with double-layer bandage for 3–24 h a day with frequent wetting, claiming the better efficacy with longer application, though not proved. However, this is often feasible only in patient setting. In Amala Institute of Medical Sciences, we use a modified regimen to circumvent the disadvantages of this conventional regimen. According to Amala modification of conventional wet wrap therapy, we recommend a 2 h wet wrap therapy thrice daily which includes twice wet wrap with a mid-potent topical steroid such as fluticasone propionate cream and once daily with emollient, and the rest of the time of the day, the patient is asked to leave the area open with frequent application of emollient. We have found this modified regimen to be efficacious in short-term management of moderate-to-severe atopic dermatitis and also as a maintenance and proactive therapy. Both objective and subjective improvement in severity of atopic dermatitis was noted with minimal to nil side effects (personal data).
Cleansing and Bathing Recommendations
The patients and family should be advised about the importance of skin hygiene. Bathing with soap and water helps to remove the dirt, scale, crust, and irritants. Besides the primary aim of cleansing skin, bathing also helps in reduction of the abnormal bacterial colonization in atopic dermatitis. Moreover, there have been many studies showing improvement in severity of atopic dermatitis with daily bathing.,, Application of emollient after bathing, as a soak and smear approach, has shown benefit when compared to bathing without emollients. However, there are conflicting opinions about the frequency and duration of bath and the type of cleansing agent to be used.,
Most soaps available in market are of high alkaline pH. They adversely affect the skin by increasing skin pH, impairing the barrier function, altering skin bacterial flora, desiccating the stratum corneum, and inducing symptoms of subjective irritation. Instead, nonsoap-based surfactants and synthetic detergents (syndets) are often recommended for better tolerance although this is based on only a few supportive clinical studies.,
The patients should be advised to take bath once or twice daily for maximum 10–15 min duration. The recommended temperature of bath is 27°C–30°C, which is usually the temperature of water which the child enjoys to play in. Bathing should be a pleasurable experience for the child. An ideal cleansing agent is a low pH, hypoallergenic, fragrance-free agent. The patient may be advised to use syndet bars or lipid-free cleansers. However, based on our personal observation, we suggest the use of any soap as per the choice of patient, provided they remain in contact with the skin for shorter period and produce less lather. The patient may be advised to use warmed coconut oil or any other vegetable oil 10–15 min before bath and the application of the same or any emollient of choice immediately after bathing and soft pat drying (personal data). Caution must be taken while using vegetable oils as these can cause the bathroom floor to be slippery.
Adding sodium hypochlorite or bleach to bath water has shown to reduce the Staphylococcus aureus counts and hence the severity of atopic dermatitis and frequency of its relapses., The antimicrobial effect of bleach is based on the property of hypochlorous acid to aggregate the essential bacterial proteins.
The patient may be advised to take bleach bath daily when there is overt infection as evidenced by heavy crusting and oozing, and then, the frequency may be reduced to alternate day, twice a week, and once a week as the condition improves, as a maintenance treatment, to prolong the remission period. The bleach solution is to be prepared by adding one tablespoon of household bleaching powder to one liter of water, and this should be diluted to a bucket of water (20 L). Care should be taken to ensure that bleaching powder has completely dissolved in water.
The course of atopic dermatitis is characterized by periods of acute worsening (flare) and periods of quiescence. Identification and avoidance of triggers for these flares is one of the crucial steps in the long-term management of atopic dermatitis, and their avoidance leads to longer periods of remission. The common triggers are summarized in [Table 1].
Numerous factors and substances in the environment irritate the sensitive skin of atopic dermatitis patients and can result in flares. They may be physical, such as mechanic irritants (e.g., wool), chemical (acids, bleaches, solvents, and water), or biological (microbes) in nature. Other nonspecific provocative factors which have been demonstrated to trigger atopic dermatitis are tobacco smoke or volatile organic compounds in indoor environments and traffic exhaust in the outdoor air. Irritability and irritant potential of these substances differs among patients. Hence, identification of possible triggers in a particular patient is important in planning avoidance strategies.
Certain fabrics used as dressings or bedding may produce worsening of atopic dermatitis. Acute and cumulative irritation, allergic contact dermatitis, exacerbation of atopic dermatitis, and contact urticaria have been reported to have been caused by textile fibers. Owing to their hygienic properties, fabrics produced from natural fibers are preferred.
Wool intolerance due to spiky nature of its fibers is considered characteristic of atopic dermatitis. Loose-fitting cotton clothing is the most suitable in tropics, due to its wide availability, better conduction of heat and excellent moisture absorption. However, recent studies have suggested that damp absorption and transfer occur by extension and contraction of the single cotton fibers producing a movement that may irritate and scratch the skin. Silk, on the other hand, has a perfectly smooth fiber, does not cause friction or irritate skin. Silk also helps to maintain the body temperature, by reducing the excessive sweating and moisture loss that can worsen xerosis.,, Special type of fabrics such as anion textiles, modified silk fabrics with elastic fibers and antibacterial properties, and silver-coated fabrics are also being investigated for their suitability in atopic dermatitis. But so far, there is no strong evidence to support its use.
Loose-fitting cotton or silk fabrics are more suitable for patients with atopic dermatitis. Too occlusive clothing inducing heat sensations should be avoided., If patient wants to use wool, they may be advised to use cotton inner clothes before wearing wool. There is limited evidence to support the use of specialized clothing fabrics in the treatment of atopic dermatitis.
Detergents and Other Chemicals
Detergents or washing powders are a frequently attributed triggering factor by mothers. However, till now, there is no conclusive evidence for the same.
The use of specific laundering techniques, such as double rinsing, detergents, or other laundry products such as fabric softeners is not recommended for atopic dermatitis management because of the lack of clinical studies. However, the mothers may be advised to use enzyme-free washing powders and also to ensure that the detergent powder is rinsed off completely from the clothing, for which double rinsing may be useful. There is often a concern regarding the use of chlorinated swimming pools. Children with atopic dermatitis should not be discouraged from swimming. The children may be advised to apply emollient before entering pool, shower well after swimming and reapply emollient to skin immediately.
Aeroallergens are airborne proteins associated predominantly with allergic reactions in the respiratory tract associated with asthma and rhinoconjunctivitis. The common aeroallergens include house dust mite, animal dander (cat and dog), molds, and pollen (allergens whose routes of exposure are primarily the respiratory epithelia and skin). Inhalant allergy is suspected in a child with atopic dermatitis associated with asthma or allergic rhinitis, having seasonal flares with lesions in the airborne distribution. There will be characteristic improvement of eczema when hospitalized or removed from the particular environment. Confirmation of diagnosis is by atopy patch test along with skin prick test (SPT) and radioallergosorbent assay.
House Dust Mite
Most common airborne allergens eliciting eczema are derived from house dust mites of the species Dermatophagoides pteronyssinus and Dermatophagoides farinae. Their principal habitat is fomites and their diet consists of human epidermal scale, animal dander, and micronutrients. They are found in carpets, fabric, pillows, and mattresses.
Removal of dust reservoirs such as heavy curtains, carpets, and soft toys is advised. Regular vacuuming and/or wet mopping with special attention to corners and crevices should be done accordingly. The bed clothes and soft toys should be washed in hot water (>55°C) and left in sun for drying. A reduced ambient humidity (<50%) should also be advised.
Allergen-specific immunotherapy with house dust mite allergens has shown positive effects in highly sensitized atopic dermatitis patients. It aims to induce allergen-specific tolerance otherwise known as allergen vaccination through acquiring immune tolerance with induction of allergen-specific regulatory T-cells (Tregs). The effectiveness of allergen-specific immunotherapy has been proved in several trials, but a consensus protocol and its application in clinical setting are not clear.,
Molds and Fungi
Mold exposure in damp indoor environment with poor air circulation has been found to be associated with increased eczema risk. Alternaria alternata, Aspergillus fumigatus, and Cladosporium herbarum are the common molds implicated as aeroallergens.
Avoidance of damp environment, repair of leaks, and removal sources of damp should be advised. Use heating in the winter and air conditioning in summer, ensuring good air circulation. Any contaminated area should be cleaned with bleach solution to prevent growth of mold.
Many patients are already aware that contact with animals is leading to a deterioration of the skin symptoms. Once a patient is sensitized and allergic to a pet, avoidance is absolutely necessary. Pet removal, pet washing, and usage of high-efficiency particulate filters are the recommended avoidance strategies. Cat epithelia exposure is regarded by most authors as a risk factor, so it should be avoided. There is no evidence that dogs increase the risk of atopic dermatitis in children.,
Pollen in the outdoor air can elicit flares of atopic dermatitis. Seasonality of disease severity is often a clue to pollen allergy., However, pollen avoidance is difficult under everyday conditions in most parts of India except when air conditioning with pollen filters is used in the indoor. However, we may advise such patients to use mask and nose plugs when going outdoors.
A commonly implicated and misunderstood concept in atopic dermatitis is food allergy, often resulting in improper elimination diets and thus leading to malnutrition. Avoidance of a particular food should be advised only based on a clear history and diagnosis of food allergy. The common food allergens are cow's milk, egg, wheat, soy, and peanut.
A diagnosis of food allergy should be considered in children with atopic eczema who have reacted previously to a food with immediate symptoms such as urticaria and anaphylaxis or in infants and young children with moderate or severe atopic eczema that has not been controlled by optimum management, particularly if associated with gut dysmotility or failure to thrive. Sensitizations to food can be identified by means of in vivo tests (SPT and atopy patch test) and in vitro tests (serum-specific IgE). The double-blind placebo-controlled food challenge is considered the gold standard for diagnosing food allergy.,
If there is consistent correlation of symptoms, a diagnostic elimination diet for up to 4–6 weeks with the suspected food item may be initiated. If the individual's atopic dermatitis remains stable or even increases in severity, it is unlikely that the food is a relevant atopic dermatitis trigger and additional testing is not necessary. If there is an improvement of the symptoms during a diagnostic elimination diet, an oral food challenge should be considered ideally. Children <5 years of age with moderate-to-severe atopic dermatitis should be considered for food allergy evaluation if they have persistent atopic dermatitis in spite of optimized treatment or they have a reliable history of immediate reaction after ingestion of a specific food.
In a setting where the food allergy testing is not available, if there is a reliable history of food allergy, it is advisable to avoid that particular food and rechallenge may be done with all necessary precautions 2 weeks after complete recovery. If there is recurrence of symptoms, that particular food is to be avoided. Furthermore, any misconception about food allergy should be addressed and diet may be planned with the help of a dietician wherever necessary.
The most common contact allergens in patients with atopic dermatitis include nickel, neomycin, fragrance, formaldehyde and other preservatives, lanolin, and rubber chemicals., Patch testing should be considered in cases suggestive of allergic contact dermatitis, such as disease aggravated by topical medications or emollients or patterns that reflect application of, or exposure to, a consistent item, such as marked facial and/or eyelid involvement, increased severity at the flexures of the neck, and vesicular lesions on the dorsal surfaces of the hands and fingertips. Testing may also be considered where there is an unusual and atypical distribution of lesions of atopic dermatitis (e.g., on the sides of the feet), if there is later onset of disease or new significant worsening, if there is no family history of atopy, and in patients with persistent/recalcitrant disease that has not responded to standard atopic dermatitis therapies.
There is no other disease which exemplifies the psyche skin interaction, better than atopic dermatitis. The finding that psychological stress can alter permeability barrier homeostasis and stratum corneum integrity, justifies the reported exacerbation of atopic dermatitis in 30% patients following stressful situations.,, The initiation or exacerbation of atopic dermatitis is manifested by its characteristic symptom of itch, which is rewarded by the conscious subjective response of scratch. The initial relief of itch by scratching later on leads to lowering of itch threshold and perpetuation of the itch-scratch cycle resulting in maintenance of skin lesions. In due course of time, the conscious response of scratch becomes an unconscious act or a habit of scratching without genuine stimulus of itch. Thus, in a patient with atopic dermatitis, scratching may be due to true itching sensation or out of habit. The psychological intervention and behavioral therapy in atopic dermatitis are aimed at breaking this itch-scratch cycle., Hence, successful management of atopic dermatitis requires a team effort including a dermatologist and sensitized psychiatrist or a trained child psychologist.
Furthermore, atopic dermatitis is found to be associated with attention deficit hyperactivity disorder, depression, anxiety, and sleep disturbances. The impact of atopic dermatitis on the quality of life of patient and caregiver is also well documented.
The basic step in habit reversal behavioral therapy is counseling of the patient to make the unconscious habitual act of scratch conscious, by guiding the patient to register each act of scratch. Once this is achieved, the patient is trained on steps to avert scratching such as clenching the fist and counting to 10 or pinching the area of itch. This can only be achieved by regular visits, encouragement, and counseling. For younger children, their parents are to be actively involved in habit reversal therapy, and the child should be under supervision day and night. Parents are advised not to reprimand the child from scratching, but instead, a positive approach is undertaken to avoid the circumstances when the child usually scratches. The child should not be allowed to watch television alone. While dressing, undressing, and bathing, the child's hands should be kept busy and the child should be talked to in order to divert attention from scratching. Once this routine is accomplished for a few days, the habitual itch gets under control, thus breaking the itch-scratch cycle.
Depending on need as assessed by a trained psychiatrist, various other techniques such as stress management, role play, and relaxation techniques can also be implemented. Stress management psychotherapy includes a counseling intervention focusing on atopic dermatitis perception and related conflicts such as disfigurement, feelings of rejection from others, anxiety, and aggression related to itch-scratch patterns. These psychotherapies aided patients or their parents in realizing atopic dermatitis-related problems and restructuring their thinking patterns, thereby reducing the intensity of stress. Thus, the most effective psychological intervention will be a combination of all these techniques catered to the need of a particular patient., Hence, a close liaison with a psychologist or psychiatrist well versed in psychotherapeutic procedures will aid in control of atopic dermatitis and maintenance of its remission.
| Conclusion|| |
As a caregiver for a chronic relapsing condition affecting the formative years of childhood, dermatologist is in a unique position to help the child fulfill their social and developmental potential. This can only be attained by expanding our care to holistic proportions. The nonpharmacological management of atopic dermatitis is distinctly relevant in this regard.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
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