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AD is a chronic disease for which there is no cure as yet. The aim
symptomatic relief--making AD patients as comfortable as possible during
an exacerbation of the disease. It is important to educate the patient
and his/her family about this fact to forestall a round of "physician
shopping" by the patient in a misguided effort to find a "cure."
Parents will often insist that food plays a vital role in the
exacerbations of their child's AD. Explain to them that foods tend to
play an insignificant role in all but the most severely affected
patient, and that testing is not indicated. If they persist in this
argument, it is often prudent to advise withholding the "offending" food
and to suggest its re-introducion at a later date.
Topical Treatment
Treatment of the xerosis (dry skin) is the main focus in AD management.
This is best accomplished by having the patient establish a "once-a-day"
bathing routine which incorporates the application of an emollient
immediately after the bath or shower. Often patients report taking two
or more baths or showers per day--swimming also counts as a bath. This
frequency of bathing would aggravate xerosis and stimulate pruritus in
most individuals, but especially in atopics. Suggest the following:
- taking a warm, not hot, bath once a day with added
lubrication in the form of an oil - e.g., Aveeno oil, oilated Aveeno
powder (for severe disease), Oilatum oil, mineral oil, Crisco oil
(less expensive the others)
- using a bland non-irritating soap for washing the skin, e.g.,
non-scented Dove (the least irritating on the market), Oilatum [Cetphil,
Spectrogel--are useful in severe disease]. Patients can make their own
oilated Aveeno powder by placing 1 cup of oatmeal in the toe of a nylon
stocking and swirling it in the bathtub water or tying it to the faucet
as the water runs; then add 1/4 of a cup of mineral or Crisco
oil
- patting the skin dry after the bath so as not to remove all the
oil and applying a lubricant before the skin has had time to dry out,
e.g., Eucerin 40% + Glycerin 10% + Water 50%--no perfume, preservatives,
emulsifiers, etc. (**Eucerin is related to lanolin and several
atopics are sensitive to it--some lanolin-free products are:
Vaseline, Glaxal base, Moisturel cream,
Lubriderm, Nutriderm, Aquaderm, [olive oil for those sensitive to the
others])
- in some cases, using a humidifier in the home over the winter
months.
The mainstays in topical AD treatment are corticosteroid ointments and
creams. An ointment is the ideal vehicle for rehydrating the skin, but
patients often object because it is greasy, stains clothing, and causes
"slippery" hands. One solution is to suggest using an ointment at night
and a cream alternative during the day for the affected areas.
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The identification of certain over-the-counter products should not be
considered in any way to be an endorsement of these products by the MSNS
or Dalhousie CME. They are included only as suggestions from the content
specialist for this unit.
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Some general rules:
- Hydrocorticone (HC) cream is used on the face and genital areas of
children and adults. Fluorinated steroids are generally to be avoided
because of their frequent side effects, e.g., atrophy of the skin,
increased absorption and secondary infection.
- When eczema is severe on the body, a mid-strength steroid should be
applied to the involved areas only, i.e., Betamethazone 1/4 to 1/2
strength cream or ointment tid. A new steroid,
Elocom 0.1% is very good but expensive.
- When the eczema is chronic (lichenified), and when the lesions are
nummular (round), tar is a useful compound. You should order 3-5% LCD
in Betamethazone ung. or cream 0.05% tid. Remember that it
stains!
- Scalp treatment involves lotions usually, but many are alcohol-based
and so may cause dryness and stinging. One example of a water-based
lotion is Amcinonide lotion 0.1%. A steroid cream is a possibility as
well. Remember that ointments do not wash out of hair easily.
- Cotton clothing is recommended even during the winter months.
Nylon, polyester, and wool all tend to irritate the skin. The preferred
detergents for washing clothes are Ivory Snow and ABC brands. Bleach
and fabric softeners are to be avoided, as is bubble bath.
- Sun is beneficial to atopics provided the weather is not too hot or
humid. Perspiration and heat can trigger itch, as can strenuous
exercise.
- Swimming will dry out the skin of atopic patients. You should
advise these patients to apply Vaseline prior to swimming in a lake or
the ocean. In public swimming pools, they can apply the emollient after
a quick shower.
Systemic Treatment
- Antihistamines help to reduce the pruritus, erythema, and
lichenification. The most common ones to use are: Hydroxyzine Hcl
(Atarax) 10-25 mg qid, Trimeprazine tartrate (Panectyl) 2.5-5.0 mg bid.
Less common ones include Ketotifen and Doxepin; Methotrimeprazine
(Nozinan) has helped some patients.
- Antibiotics may be necessary if there is any sign of impetigo over
the exzema or there is marked lymphadenopathy associated with fever.
The usual choices are Cloxacillin or Erythromycin.
- In cases of severe AD a specialist may advise:
- - PUVA therapy (ultraviolet light)
- - a variety of antihistamines in combinations
- - admission to hospital
- - Cyclosporin (occasionally helpful in the odd very severe
case)
- - Interferon (immunotherapy currently under
investigation)
Two hand-outs are available for patients. One explains Atopic
Dermatitis, and the other outlines the steps to be taken to ensure a
dust-free bedroom. These are listed under the "Resources" button on the
left menu bar.
STOP!Review Questions
- What are the mainstays of topical therapy for AD?
- What antibiotics are used most commonly in secondary
bacterial
infection in AD?
- How do you treat the itch and erythema of AD?
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