Derm Tips from Dr. Fitz - Atopic Dermatitis

What is atopic dermatitis?

Atopic dermatitis (also called eczema) describes a condition that results in dry, red, and itchy skin. Patients with atopic dermatitis exhibit a skin barrier that is weakened and an immune system that is "hyper-excitable". This means that the skin's immune system is too reactive and responds to everyday things like dust, colors, and fragrance. When the inflammatory cells of the immune system populate the skin, it turns this area red. If you combine hyper-excitability of the skin with an inadequate skin barrier you get a rash and itching.

Why do people get this condition?

It is partly genetically determined so there may be other members of the family who suffer from eczema as well. There are also factors in the environment that trigger flare-ups. Irritating soaps, dust mites, and pet dander are some of the more common triggers.

How is it diagnosed?

Diagnosis is clinical. There is no blood test that can be done that would label people with this condition. A skin biopsy can also confirm the diagnosis but is only required in some cases if the presentation is not typical.

How can it be prevented from showing up?

• Keep the skin well moisturized.
• Avoid irritants and triggers.  
• Use prescribed medicine when there are red or rough areas to help the skin return to normal as quickly as possible.

Try to stop scratching!

Why does dermatitis keep flaring?

If you keep the skin well moisturized, and avoid things you know can irritate your skin, there will be fewer flares. However, eczema is NOT curable. While we can greatly control the number and severity of eczema flare-ups, an occasional flare of atopic dermatitis is to be expected. Tell your doctor if flare-ups are still a regular occurrence (>1x/week) so that he/she can consider other options for your child.

What are the triggers?

Triggers are different for everyone. Most commonly the triggers are:

• Temperature Extremes.
• House Dust Mites.
• Pet Fur.
• Wool and Synthetic Fabrics like Nylon and Polyester.
• Tobacco Smoke.
• Fragrances.

Can eczema be outgrown?

Most children do outgrow the condition. Many continue to have sensitive skin into adulthood.

Treatment: The main theme is that all treatments are designed to limit contact with irritating factors and to balance the immune system's reaction in the skin. There are many different options for prescriptions to improve the skin. Doctors can prescribe different medications and may advise slightly differently depending on experience. The main treatments are topical creams and ointments. The two main types of topical therapy are corticosteroids and the newer topical immunomodulators.

1. Use moisturizer all over the entire body at least twice a day. Sometimes three or four times a day. This keeps the skin moisturized to restore the barrier function. Find a cream or ointment that your child likes - this is the most important. The medicine does not do much good in the bottle. The thicker the moisturizer, generally the better barrier it provides. Ointments work better than creams. Creams work better than lotions. Lotions are more useful during the summer when thick creams can be unbearable. If you put moisturizer on the skin while the skin is damp, this is doubly effective. The moisturizer provides a seal holding the water in the skin. You may bathe in warm, not hot water, for short periods of time (no more than 5 minutes at a time) once a day if they like. Lightly pat your child dry with a towel then, while the skin is still damp, (within 3 minutes) apply a moisturizer from head to toe. If your child is using a medicated cream, apply that before you put the moisturizer on.
2. Apply the prescription medication twice a day to only the red, rough areas on skin. Put the medication on your fingers and gently rub it into areas. Usually the medicine will help an area within a few days’ time. Try to put the medicine on for two days after you have noticed that the redness is no longer present; this will help the redness from returning.
3. Avoid triggers. Some people have specific things that trigger itching and rashes, while others may have none that can be identified. It may require a little bit of trial and error to see what applies to your child. Also, triggers can change over time. The most common triggers are listed above; start with these. Avoid use of fabric softeners in the washing machine or as dryer sheets. Try to use laundry detergents, soaps and shampoos that are fragrance free. You may find that double rinsing the clothes helps. Some children are sensitive to house dust mites and they may benefit from a plastic mattress wrap. While food allergy is more common in children with eczema, foods are specific triggers for flares in only small percentage of children. If you notice that the skin flares after certain foods you can see if eliminating one food at a time makes a difference, as long as your child can still enjoy a well-balanced diet. A nutritionist may be useful as the child and adult develop to better balance their diet. 

 4) Consider using a medication by mouth to help control the itching. Scratching only makes the skin more reactive and the barrier function even more disrupted. There are different types of anti-itch medications. Most cause some drowsiness while controlling itch.

 5) About the prescription cream: Steroid creams and ointments (generally things with "-one" on the end of the name): The strength of the cream or ointment depends on the name of the active ingredient. The numbers at the end do not indicate the relative strength. For example, triamcinolone 0.1% ointment is much stronger than hydrocortisone 1% even though the number following the name is much lower. 

5a) Topical steroids are very effective in treating atopic dermatitis. When used in the manner prescribed (to only rashly areas of skin and for not more than a few weeks’ time to any one area) they are very safe. Remember that these are corticosteroids and are anti-inflammatory not "anabolic steroids" like those used illicitly.  

5b) Topical non-steroid creams and ointments (topical immunomodulators): These creams and ointments decrease itching and redness in the skin. Since they are so new, they are generally used as second-line medications, though they may be used alone or in conjunction with topical steroids. The good thing is that they do not have some of the side effects that misuse of steroids can have (thinning of skin and stretch marks when not used properly). Names of immunomodulators include Elidel and Protopic.

Atopic Dermatitis Care Plan

Skin Care Instructions:

     1) Bathe no more than once daily. Use Dove or Cetaphil cleanser. Do not use a washcloth. Use tepid or room temperature water because hot water is irritating to the skin. Do not use a bubble bath. Limit soaking in the tub to less than five minutes (in clean water, NOT soapy!) because water can dry skin when it evaporates. Pat skin dry with a towel.

      2) The topical steroids are used to control inflammation. A thin film of ointment should be applied to the affected areas two times a day when the skin feels rough and looks red. Massage it in well.

      3) Topical immunomodulators are non-steroid medications used to prevent inflammation in the first place. A thin film of ointment should be applied to the affected areas two times a day. Massage it in well.

Protopic 0.03%; 0.1% ointment                Elidel 1% cream

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    4) Apply a moisturizer after the steroid. Apply the moisturizer thickly to your child’s entire face and body.

  5) Antihistamines may also be used to decrease itching. They may be needed throughout the day or just in the evening to make you more comfortable. Be aware that antihistamines can make you sleepy, and you may not want to take them before or during school or work hours. Often the dose will have to be adjusted up or down, depending on your response to the medication. Benadryl can be increased in dosage depending on a person's weight and age. Please call the office if you want to change your regimen!

Antihistamine(s):    

 Atarax (Hydroxyzine) 

Over the Counter (OTC) - Zyrtec, Allegra, Zyzal, Claritin