In honor of national Eczema Awareness Month, Dr. Long discusses treatment strategies for atopic dermatitis – a common form of eczema in children and adults.
In the U.S., atopic dermatitis affects 10-25% of children and up to 7.2% of adults. In my household, the poor deprived middle child was picked. What caused this? Could I have prevented it? What does a skincare regimen look like when your child has eczema?
What is Atopic Dermatitis?
Atopic dermatitis is a common type of eczema that usually begins in the first two years of life. In the US, it affects nearly 28,000,000 people of all ages. The word “atopic” refers to a tendency to develop excess inflammation in the skin, linings of the nose, and lungs. This inflammation results in allergies (such as hay fever) and asthma, but can also result in itchy sensitive skin. The condition frequently improves in childhood; however, an estimated 50% of people are affected throughout life, though not as severely as during childhood.
What Does Atopic Dermatitis Look Like?
Redness and itching are the earliest skin manifestations of atopic dermatitis. Classic areas of involvement include the face in infants, the body creases of young children, and the hands and feet of adults. The itching leads to scratching which causes the skin to become thickened and more itchy. The itch-scratch-rash-itch cycle is typical of atopic dermatitis.
What Causes Atopic Dermatitis?
The exact cause is unknown. Environmental and genetic mechanisms play a role. Breaks in the skin barrier allow irritants and allergens to enter the skin and the immune system overacts to these stimuli to create inflammation and itch. Atopic dermatitis is NOT contagious, but it does often run in families. If one parent has a history of allergies, asthma, or atopic dermatitis, the child has a 50% chance of developing one of the conditions. Not all atopic dermatitis is allergic in nature as some people may also have a defect in the filaggrin gene. Filaggrin is an essential protein for maintaining the outer skin barrier. In other words, some people are born with a faulty barrier and others have an overactive immune system and some may have both.
How to Treat Atopic Dermatitis
Essential Components of a Treatment Strategy
- Skin barrier optimization through proper daily cleansing and moisturizing.
- Avoidance of irritants and allergens that can trigger flares.
- Controlling the signs of inflammation with prescription medications.
In infancy and early childhood, the treatment plan depends upon the parents/caregivers. Skin moisturization EVERY day is ESSENTIAL to prevent flares. Flares must be addressed ASAP to prevent worsening and thickening of the skin. Skin itch can affect sleep patterns and lead to *****decreased quality of life, behavior issues and neurocognitive problems. Atopic dermatitis is more a “skin disease”.
How to Repair (or Optimize) Your Barrier
Healthy skin serves as a protective barrier to hold in moisture and protect against common irritants. In atopic dermatitis, the top layer of the skin is unable to hold and retain moisture, breaking this natural barrier, and resulting in dry, cracked, itchy red skin.
- Avoid irritants and known allergens.
- Avoid harsh soaps, cleansers, and alcohol-based toners on the skin. Natural lye soaps like Ivory and Dial are too good at cleaning the skin and strip the skin of essential fats. Choose gentle synthetic detergents (“syndets”) such as: Aveeno, Cetaphil, or CeraVe.
- Replace the stratum corneum lipids: Use a moisturizing cream or lotion that contains more than just an occlusive agent. Choose one with a mix of fatty acids, cholesterol and ceramides. The best time to moisturize is after baths or showers.
- Acidify inflamed skin with vinegar baths.
- Stop scratching! This only worsens skin irritation. Use OTC medicated anti-itch lotions, such as Sarna or CeraVe Itch Relief. Use prescription anti-inflammatory molecules such as topical immunomodulators or topical steroids as needed to control severe inflammation and itching.
- Daily sun protection: wear protective clothing and sunscreen with SPF 30 or higher. Sun-damaged skin is more susceptible to barrier breakdown — especially as we age.
- Increase dietary sources of fatty acids via salmon or flax seeds or supplements such as borage seed oil, fish oil, evening primrose oil.
To better understand “The Barrier” click here for our prior post.
Understand and Avoid Irritants + Allergens
- Consider a sensitive skin laundry detergent (Cheer-Free, Dreft, etc…) or use a double rinse cycle to remove irritants.
- Avoid fabric softeners. These products are designed to stay in the fabric and can be a source of allergens or irritants.
- Run clothes through a second rinse cycle to remove any residual detergents and chemicals.
- Avoid wool clothing.
- Avoid heavily scented or perfumed items.
- Avoid becoming too hot or sweating (sweat is an irritant) or keeping the house too cool and dry (may make skin drier).
- Avoid NICKEL as people with atopic dermatitis are more likely to develop nickel allergy. Nickel allergy can cause systemic contact dermatitis and be flared by eating foods with nickel.
- Go to dermatitisacademy.com for information on P.E.A.S. – Preventative Eczema Avoidance Strategies. Atopic dermatitis increases the risk of allergic contact dermatitis as inflamed skin is more easily sensitized than intact skin.
- Environmental allergens like dust mites, pet dander, mold and pollen may trigger some flares as well.
- Food allergies often coexist, but are less likely to flare eczema unless gastrointestinal symptoms are present. Elimination diets are not routinely recommended.
- Avoid extreme temperatures – hot or cold.
When eczema does not improve with the Essential Daily Regimen (keep reading below), consider a topical skincare regimen free of common allergens including: fragrance, betaines, propylene glycol, neomycin, lanolin, formaldehyde, methylisothiazolinone, and methylchloroisothiazolinone. Skinsafeproducts.com is a helpful website for finding products without these ingredients.
How to Decrease Inflammation in the Skin
The cardinal signs of inflammation are: RUBOR = Redness, DOLOR = Pain or itch, CALOR = Increased warmth and TUMOR = Swelling. The following steps are used to decrease inflammation in the skin.
- Use of a good quality moisturizer can help repair the barrier and thus decrease inflammation.
- Prescription Medications:
- The use of topical corticosteroids and other topical immunomulators such as topical calcineurin inhibitors (pimecrolimus, tacrolimus) or PDE-4 inhibitors (crisaborole) can decrease the redness and itch associated with eczema.
- In severe cases, systemic medications such as prednisone, methotrexate, cyclosporine, and dupilimab are also used to decrease skin inflammation.
- Decreasing the load of bacteria on the skin (staphylococcus) through bleach baths or possibly vinegar baths can improve inflammation in the skin as well.
- For more severe itching, phototherapy with ultraviolet light can decrease the inflammation driving the desire to scratch.
CAVEAT: Inflammation can also signal infection. If you notice yellow crusting or tender bumps, add mupirocin ointment twice daily and bleach baths. If you note tender red knots or red areas with streaking, seek medical attention.
Essential Daily Maintenance
- Bathe with warm (not HOT) water for 5-10 minutes. Avoid scrubbing and rubbing the skin as this can cause flare-ups. Avoid exfoliants.
- Use a mild soap or soap-free cleanser. If not too dirty, use the cleanser only on hands, feet, armpits, and genital area, not all over. Our current picks for skin cleansers include:
- Cetaphil Restoraderm body wash
- Vanicream bar soap
- Aveeno Baby Cleansing Therapy Moisturizing Wash
- CeraVe Hydrating Cleanser
- CeraVe or Cetaphil bar soaps
- Unscented Castile bar soap (like Dr. Bronner)
- Cheryl Lee MD True Lipids Creamy Cleanser
- Apply prescription medicines to red, itchy, rashy areas 1-2 times daily as directed. (These are best applied right after bathing and then covered with an emollient). For severe flares or resistant areas, consider “wet wraps”.
- Apply a moisturizer at least 2 times a day (even if no bath is taken) and after every bath. After the bath, pat dry and apply the moisturizer RIGHT AWAY, within 3 minutes, all over the body. The protective barrier can be restored by applying water to the skin (during bathing) and then locking it in with a moisturizer = “SOAK and SMEAR”. Our favorite OTC moisturizers include:
- CeraVe Cream
- Cetaphil Cream
- Cheryl Lee MD True Lipids
- CeraVe Healing Ointment
- Elta Crème
- Vaniply Ointment
- Keep fingernails short, and avoid irritating clothing such as wool or other scratchy fabrics.
What Prevention Strategies Exist?
Can atopic dermatitis be prevented? Possibly. Your child is at higher risk for eczema if either parent has a history of asthma, allergies, or atopic dermatitis. Pregnant women could consider oral probiotics during pregnancy, breastfeeding, and possibly for the infant after birth. More recent studies suggest daily moisturization, starting within the first 3 weeks of life, decreases the risk of eczema.
There is weak evidence to suggest that maternal ingestion of probiotics during pregnancy and lactation, may decrease the incidence and severity of atopic dermatitis in high risk infants. More studies are needed to confirm these findings. Of note, the incidence of allergies and asthma risk was not decreased.
Emollient Enhancement of the Skin Barrier for the First 6 Months of Life
Daily use of full body emollients keeps the skin barrier intact and prevents cracks in the skin. Irritants and allergens are often large molecules that need a break in the barrier to get into the skin where they wreak havoc on the immune system. Theoretically, this prevents activation of the immune system. Vaseline was found to be the most cost effective emollient. If only I had known this to spare middle child from his itchy misery. Fortunately, he appears to have “outgrown” his atopic dermatitis for now, but the possibility of return remains.
For more information about atopic dermatitis, visit the following websites:
- The National Eczema Association
- The American Academy of Dermatology
- Dermatitis Academy
- The Society for Pediatric Dermatology
For help managing your or your little one’s eczema, contact us at Red River Dermatology 318-442-9395 to schedule an appointment.