Atopic Dermatitis: Pathophysiology Driving Management Decisions - Episode 6
Experts in dermatology review the use of skincare treatments, emollients, and topical corticosteroids in atopic dermatitis.
Peter A. Lio, MD: I love the way that you segued perfectly into the next section, which is going to be about nonpharmacological approaches, and then we’re quickly going to get to pharmacological approaches to managing atopic dermatitis.
That’s a perfect story because there is a mind-body connection, and even if that sounds a bit out there, we know concretely that, if patients are under stress and if they’re not getting adequate sleep, you can measure the skin barrier damage that results and the lack of healing.
We know there are some concrete ways to think about this, but there is also a bit of a more holistic piece too with the patient’s state of mind, their optimism, their hope, and their ability to be excited about buying-in. We know that therapeutic alliance is important to getting it done. If they’re not on board with our treatment plan, they are probably not going to use the medicines. It’s obviously not going to help them if the jar is sitting on the counter.
This all plays a role, but there are a few nonpharmacologic things that I like, and I think are helpful. First of all, I find that certain types of clothing can be soothing to certain patients. For example, we’ve known for a long time that wool is often uncomfortable for our patients with atopic dermatitis when they put it on their skin. In fact, it is one of the softer diagnostic criteria in the Hanifin and Rajka Diagnostic Criteria for Atopic Dermatitis, that wool makes the patient feel itchy.
You might say, let’s pick something in the middle, something reasonable, like the idea that cotton is nice and gentle. It also may be that certain garments can be even better than cotton alone. For example, silk: there’s a small but interesting piece of literature on silk clothing, and it may even apply to some of the new silk-like materials like Tencel, which is a bamboo-type fabric that is silky, smooth, and cooling. I have some patients who like that. Wet wrap therapy is another form of nonpharmacologic management. It’s powerful: you don’t need to use it with any medicine. You sometimes don’t even have to put a moisturizer on, just a cooling compress.
One of my favorite new things is something that I just learned in the last 2 years from a small study out of Germany. They did a black tea compress for facial eczema. They had patients brew up, good old-fashioned black tea and do a second steeping, so it’s a little diluted. The patient then lets it cool, of course, and they then use it as a cool compress on the face, and it’s amazing. That may be a pseudo-botanical, but the act of cooling the skin and doing a compress is powerful.
Of course, there are many other things that we can discuss here, but I wanted to move a bit into the state of the art in terms of prescriptions or what we might recommend in a conventional setting for atopic dermatitis. We know that the skin barrier is often critically important, and it’s often damaged. I might even argue that it’s always abnormal in these patients. Emma, could you talk to us a bit about strengthening the skin barrier, how we might use emollients, and what they might be doing in our patients with atopic dermatitis?
Emma Guttman, MD, PhD: Definitely. We published a paper a few years ago showing that petrolatum is so inexpensive, and it improves immune abnormalities, and improves the barrier abnormalities in patients with atopic dermatitis. Like you, I believe in a holistic approach. Even for patients with moderate to severe disease who I treat with biologics or systemic medications, we still need to make sure that we moisturize and do simple approaches to prevent additional lesions. I always tell patients, “If you want 100% improvement, you’ll never achieve 100% just by taking the systemic medication. If you really want 100%, you need to make sure that, if you have some lesions, you put on your topical agents, you do your moisturizers, and you avoid long showers.”
There are many things that they need to think about. It’s true that, when they are on a good treatment, it’s not a full-time job. When you don’t have a good treatment on board, when you have moderate to severe disease, many patients tell us that it’s like a full-time job. They need to smear the topical agents all over the body. But they still need to do the simple things like emollients, and make sure they don’t take long showers, and so on.
Peter A. Lio, MD: I agree. It’s so funny; sometimes when people shadow me, they roll their eyes and say, “I thought you had all of these secret tricks and magical things you were going to do to get these patients better.” Largely what I’m doing is cheerleading for them to put on moisturizers because it works. It’s not glamorous, but it works. That brings us into the topical therapy. Linda, could you take us through your general approach with topical therapies and how you might build a regimen for these patients?
Linda Stein Gold, MD: First of all, I agree with the whole conversation here; it is a complicated system to get these patients better, and it is part of the way you approach life. You’ve talked to the patient about removing all their fragrance products and shopping with their fingers, not with their eyes, you’ve told them not to buy the wool products, and we’re using good emollients. I then think about topical therapy, especially if somebody is flaring and has localized disease. My first step is probably going to be a topical therapy. I utilize all the topical agents that we have available. I still use topical steroids. If somebody is flaring, I’m not hesitant to use a potent topical steroid. The topical immunomodulators are wonderful, both in helping to get patients under control, especially in areas like the face, as well as maintaining control over time.
Crisaborole still has a place. It has to be used carefully because a lot of the topical immunomodulators and the topical phosphodiesterase inhibitor crisaborole can sting and burn. I tell my patients up front what my expectations are. With some of these medications, I might say that they will have some burning. You tell them up front. For a patient with atopic dermatitis, the most important thing is that they have to understand they’re not having an allergic reaction. If they have some stinging, they’ll understand and say, “I was told this could happen.” I’ll normally start with a steroid initially. Especially if there’s a lot of excoriation, I’ll calm that down first before I introduce one of the other topical agents.