OFFICIAL JOURNAL OF THE DERMATOLOGY NURSES' ASSOCIATION

October 2008

SUPPLEMENT Successful Strategies In Atopic Dermatitis Management

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A supplement to Dermatology Nursing OFFICIAL JOURNAL OF THE DERMATOLOGY NURSES' ASSOCIATION

Supplement ® October 2008

Successful Strategies in Atopic Dermatitis Management

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SUPPLEMENT Successful Strategies in Atopic Dermatitis Management ...... 3 Noreen Heer Nicol and Mark Boguniewicz

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Disclosures Noreen Heer Nicol, MS, RN, FNP, disclosed that she is a consultant and on the presenters’ bureau for Unilever and OrthoNeutrogena. Mark Boguniewicz, MD, disclosed that he has received grant/research support from Novartis and Sinclair; and is on the advisory board of Graceway and Unilever. The Editor, Marcia J. Hill, MSN, RN, disclosed that she is an employee of Genentech. All other Dermatology Nursing Editorial Board members reported no actual or potential conflict of interest in relation to this continuing nursing education article.

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Noreen Heer Nicol Mark Boguniewicz

Successful strategies for OBJECTIVES managing atopic dermatitis Objectives This continuing nursing educational (CNE) activity is designed for nurs- require an accurate diagnosis, es and other health care providers who care for and educate patients and identification and elimination their families regarding atopic dermatitis. For those wishing to obtain CNE credit, an evaluation follows. After studying the information presented in this of exacerbating factors including article, the nurse will be able to: irritants and allergens, adequate 1. Heighten his/her awareness of the prevalence of atopic dermatitis, its impact on quality of life, and association with asthma and allergies. hydration of the skin, control of 2. Examine a multi-faceted approach to management of patients with pruritus and infections, and atopic dermatitis including non-pharmacologic and pharmacologic appropriate use of topical anti- interventions. 3. Summarize common interventions including hydration, moisturiz- inflammatory and other ers, and pharmaceutical agents. medications. Proper patient 4. Discuss appropriate safety issues related to topical and systemic ther- education increases the chances apies. of successful therapy. s the Dermatology Nursing jour- given them confusing information or nal celebrates its 20th anniver- conflicting treatment plans. Frus- sary, the authors of this review trated, they come to the next evalua- Acelebrate working together for tion hoping not only for consistency 20 years caring for patients with atopic and answers, but also a cure. If a dermatitis (AD). Over the past 2 patient has had AD for months or decades, a great deal of progress has years, it is important that he/she Noreen Heer Nicol, MS, RN, FNP, is a been made in the understanding of understands that current treatment is Dermatology Nurse Practitioner, National Jewish Health, and Clinical Senior Instructor, AD. Atopic dermatitis remains the focused on levels of control, not a University of Colorado School of Nursing, most common chronic, relapsing skin cure. Learning about the chronic Denver, CO. disorder of infants and children, but relapsing nature of atopic dermatitis, can affect patients of any age. The exacerbating factors, and appropriate Mark Boguniewicz, MD, is a Professor, prevalence of AD has increased glob- treatment options is important for Pediatric Allergy and Immunology, National Jewish Health, University of Colorado School of ally and more than half of these both patients and family members Medicine, Denver, CO. patients go on to develop asthma and (Nicol & Boguniewicz, 1999). The allergies (Kapoor et al., 2008). Atopic purpose of this article is to review a Acknowledgments: The authors thank dermatitis places a significant eco- treatment model developed and uti- Barry Silverstein for taking photos of patients nomic burden on the patient, family, lized by the Atopic Dermatitis and techniques in the Atopic Dermatitis Program at National Jewish for the past 2 and society (Boguniewicz et al., 2007). Program (ADP) at National Jewish decades. They also thank the many nurses and Successful strategies, particularly in Health in Denver, Colorado for more staff working with patients experiencing atopic those patients with moderate-to- than 20 years. dermatitis for their caring, dedication, and severe disease, have been dependent teaching atopic dermatitis class every week. on the commitment and expertise of Epidemiology: Too Much Hygiene? Additionally, they thank Gabriele Cheathan for the multidisciplinary approach led by The prevalence of atopic dermati- her assistance with manuscript preparation. physicians and nurses (Boguniewicz, tis has increased more than three-fold Nicol, Kelsay, & Leung, 2008; Nicol, since the 1960s (Schultz-Larsen & 1990) (see Figures 1a, 1b, 1c, & 1d). This article and the CNE answer/ Hanifin, 2002). Atopic dermatitis is a evaluation form are also available The patient and family with chronic global public health problem, with online at AD have usually seen multiple health prevalence up to 20% in children and www.dermatologynursing.net care providers who at times have approximately 3% of adults in the

Complimentary CNE for this Supplement is available on page 19 and at www.dermatologynursing.net

DERMATOLOGY NURSING/October 2008/Supplement 3 DERMATOLOGY NURSING

Figures 1a & 1b. Figures 1c & 1d. Adolescent male with severe atopic dermatitis on Same patient as in Figures 1a & 1b after 1 week in admission to ADP. ADP using wet-wrap therapy.

United States and other industrialized allergic diseases, often prior to age 3 hypothesis” suggests that allergic dis- countries (Williams et al., 1999). There (Kapoor et al., 2008). Since wide vari- eases (“T helper-2-type”) might result is also a female preponderance for ations in prevalence have been from a lack of infections in early child- AD, with an overall female/male ratio observed within countries inhabited hood (Leung, Boguniewicz, Howell, of 1.3:1. There is evidence that atopy by similar ethnic groups, environmen- Nomura, & Hamid, 2004). More comes before the appearance of AD tal factors seem to play a key role in recently, this theory has been modi- and that the skin disorder often pre- determining disease expression. Some fied to account for the concomitant cedes the development of other atopic of the potential risk factors that have increase in autoimmune (“T helper-1- diseases including asthma and allergic been associated with the rise in AD type”) diseases, and abnormalities in rhinitis, known as the “atopic march” include small family size, increased regulatory T cells (Chatila, 2005). (Boguniewicz, Eichenfield, & Hultsch, income and education, migration Although the outcome of AD 2003; Nicol, 2005a). Epidemiologic from rural to urban environments, may be difficult to predict in any studies indicate that more than 50% of and increased use of antibiotics (a given patient, the disease generally children with AD will go on to devel- “Western lifestyle”) (Strachan, 1989; progresses to periods of remission as op asthma, allergic rhinitis, and other von Mutius, 2000). The “hygiene the patient grows older. Spontaneous

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resolution of AD has been reported to been strongly associated with AD, as Clinical Findings: Recognizing the occur after age 5 years in 40%-60% of well as ichthyosis vulgaris (Palmer et Disease patients affected during infancy, par- al., 2006). In addition, these patients Despite all the advances over the ticularly if their disease is mild. In have an increased risk of asthma but past 20 years in understanding the addition, more than half of adoles- only when it occurs in patients with pathogenesis of atopic dermatitis, cents treated for mild dermatitis may AD who have the filaggrin gene muta- there continues to be no single distin- experience a relapse of disease as tions. In patients with AD, an guishing feature of AD or a diagnostic adults. impaired skin barrier will allow laboratory test. The diagnosis is still increased transepidermal water loss based on the constellation of clinical Pathophysiology and Genetics: and, importantly, increased entry of findings described in 1980 by Hanifin Outside-In or Inside-Out? allergens, antigens, and chemicals and Rajka (1980) and major criteria Atopic dermatitis is an inflamma- from the environment resulting in listed in Table 1. Laboratory testing is tory skin disease that occurs in geneti- inflammatory responses. These points not needed in the routine evaluation cally prone individuals resulting in a emphasize the importance of skin care and treatment of uncomplicated AD. defective skin barrier, defects in the measures directed at maintaining a Serum IgE is elevated in the majority innate immune system, and abnormal healthy skin barrier. It is important to of patients with AD but levels do not immunologic responses to irritants, note that beside filaggrin gene muta- always correlate with disease severity allergens, and microbial organisms tions, other gene mutations affecting and do not point to specific triggers. (Leung et al., 2004). Whether the the skin barrier can occur. In addition, Atopic dermatitis typically pres- pathophysiology of this disease favors T helper-2-type cytokines can ents during infancy and early child- an “inside-out” (immunologic dysreg- decrease expression of filaggrin and hood. These children frequently have ulation leading to skin barrier abnor- other skin barrier proteins (Howell et a family history of asthma or allergies. mality) or an “outside-in” explanation al., 2007; Kim, Leung, Boguniewicz, The key feature of AD is pruritus that (barrier dysfunction causing immuno- & Howell, 2008). Thus other gene can disrupt sleep and interfere with logic perturbations), remains an area products must also be involved in AD daily activities. Atopic dermatitis in of active research. pathology. The “outside-in” or infants usually presents on the cheeks Atopic dermatitis is characterized “inside-out” debate remains to be or scalp. Involvement of the extensor by abnormal skin barrier function resolved. aspects of extremities and trunk is associated with abnormalities in corni- common, but the diaper area is typi- fied envelope genes, reduced Innate Immunity and Atopic cally spared. Infantile AD lesions tend ceramide levels, increased levels of Dermatitis: The Basic Immune to be symmetric, scaly, and erythema- endogenous proteolytic enzymes, and Response tous. Weeping and crusting may be enhanced transepidermal water loss An intact skin barrier is the first present in more severe or infected (Cork et al., 2006). Use of soaps and line of defense against microbial cases. Generalized dryness is com- detergents that raise skin pH can organisms. In addition, we are born mon. The childhood phase occurs increase activity of endogenous pro- with an innate immune system which, from age 2 to puberty. Flexural sur- teases, leading to further breakdown unlike our adaptive immune system, faces of the extremities, especially the of epidermal barrier function. The does not require prior exposure and antecubital and popliteal fossae, are epidermal barrier may also be dam- education to respond appropriately. most typically affected. Other aged by exposure to exogenous pro- Keratinocytes play a key role in the involved skin areas include the neck, teases from house dust mites and skin’s innate immune response. They wrists and ankles, and the creases Staphylococcus aureus. This is worsened express toll-like receptors and secrete between the thighs and buttocks. by the lack of certain endogenous pro- pro-inflammatory cytokines, as well as Lichenification or an accentuation of tease inhibitors in atopic skin. These anti-microbial peptides (such as skin markings associated with thicken- epidermal changes may contribute to human beta defensins and catheli- ing of the skin due to repeated scratch- increased allergen absorption into the cidins) in response to tissue injury or ing can be a prominent feature (Nicol, skin and microbial colonization. invading microbes (McGirt & Beck, 2003). Although most children out- Exposing the immune system of the 2006). Several studies have now grow their atopic dermatitis, almost all skin to allergen compared to systemic demonstrated that keratinocytes from patients have persistent dry skin and or airway sensitization to allergen patients with AD produce reduced some patients continue to have AD in results in a higher allergic antibody amounts of antimicrobial peptides adulthood or, in a minority of cases, response and could predispose sus- due to suppression by Th2-type have their onset after puberty. The ceptible children to developing asth- cytokines and this may predispose adult form usually involves flexural ma and allergic rhinitis later in life such individuals to skin colonization aspects of the extremities and can be (Spergel & Paller, 2003). and infection with S. aureus, viruses, focal although, in some patients, it can Recently, mutations of the epider- and fungi (Ong et al., 2002). be more diffuse. Hand and foot der- mal barrier protein, filaggrin, have matitis can be a difficult-to-treat com-

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Table 1. emphasizes patient education; identi- Overview of Atopic Dermatitis fying and eliminating flare factors such as irritants, allergens, and emo- • Increasing prevalence globally with a peak of 15%-20% in early tional stressors; and incorporates skin childhood in industrialized countries with more than 50% of patients hydration, pharmacologic, and non- with AD developing asthma and allergic diseases pharmacologic therapies (Bogunie- • Three major features of this chronic disorder include: wicz, Nicol et al., 2008; Boguniewicz ° Pruritus (itchiness) & Nicol, 2002). Treatment plans ° Personal or family history of atopy (allergic rhinitis, asthma, atopic should be individualized to address dermatitis) each patient’s skin disease reaction ° Eczematous dermatitis (acute, subacute, or chronic) with typical pattern, including the acuity of the morphology and age-specific patterns rash. In patients refractory to conven- Facial and extensor involvement in infancy (although flexural tional forms of therapy, alternative anti-inflammatory and immunomod- involvement does occur) ulatory agents may be necessary. Flexural eczema/lichenification in children and adults • Commonly associated or minor features include: Multidisciplinary Approach ° Xerosis/skin barrier dysfunction While patients with atopic der- ° IgE reactivity matitis of all severities could benefit ° Early age of onset from a multidisciplinary approach, the • Genetic basis influenced by environmental factors with alterations in current health care system often cre- immunologic responses ates roadblocks to such an approach • Individualized treatment approach based on patient’s age and severity by requiring or denying consults to including: appropriate specialists. Patients who ° Identification and elimination of exacerbating factors including are “failing” conventional therapy, irritants and allergens those labeled as polyallergic (especial- ° Hydration of the skin and use of appropriate cleansers and ly those believed to be allergic to mul- moisturizers tiple foods), patients with recurrent ° Control of pruritus and infections skin infections or on frequent courses ° Appropriate use of topical anti-inflammatory and other medications of antibiotics, patients with concerns ° Patient education with written instructions and demonstrations as about medication side effects, patients needed whose disease is causing a significant ° Psychosocial support and spend time listening to patient and/or impact on their or their family’s QOL, caregiver and those with need for in-depth edu- cation are all candidates for multidisci- plinary management. It is worth remembering that families may have ponent of eczema and in adults may presents with an eczematous dermati- different levels of tolerance for a dis- be the only manifestation of AD for tis with no history of childhood ease, thus, this approach may benefit some patients. Patients may also have eczema, respiratory allergy, or atopic more than just patients with severe eyelid dermatitis. Lichenification is family history, cutaneous T-cell lym- AD. more prominent in older patients with phoma must be ruled out. Allergic At National Jewish Health in chronic eczema. contact dermatitis may also be in the Denver, CO, the team is composed of differential. Ideally, biopsies should be pediatric allergist-immunologists with Differential Diagnosis: Getting the obtained whenever the diagnosis is in Diagnosis Right extensive experience in basic and clin- question. The biopsies should be ical research in AD, a nurse practition- A number of inflammatory skin taken from three separate sites, er/dermatology clinical specialist, diseases (e.g., psoriasis), immunodefi- because the histology may show spon- pediatric psychiatrist, psychologists, ciencies (e.g., Wiskott-Aldrich syn- giosis and cellular infiltrate similar to allergy-immunology fellows-in-train- drome), skin malignancies (e.g., cuta- AD. ing, physician assistants, nurse educa- neous T-cell lymphoma), genetic dis- tors, child life specialists, creative art orders (e.g., immune dysregulation Current Management of Atopic therapist, social workers, dietitians, polyendocrinopathy X-linked syn- Dermatitis: The Nuts and Bolts and and rehabilitation therapists. Derm- drome), infectious diseases (e.g., Beyond atologists are available for consulta- HIV), and infestations (e.g., scabies) Successful strategies for manag- tion if the diagnosis of AD is in ques- may have symptoms and signs similar ing AD require a systematic, multi- tion or alternative therapies, such as to atopic dermatitis. In an adult who pronged approach. This approach phototherapy, are being considered.

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The philosophy of care is in keeping ease. The EPR-3 emphasizes the use graphs, reflecting stages of disease and with the center’s approach to individ- of a stepwise approach for a chronic remission of each patient with appro- ualized medicine and patients under- disease like asthma, and has provided priate skin care (see Figure 2). While go comprehensive evaluation and a good model for AD. current home care plans continue to treatment tailored to their needs and Education strategies include one- be individualized, they follow a more goals of the patient. The ADP pro- on-one communication, direct de- standardized format and address treat- vides single-day consultations, multi- monstration with reinforcement, ment in a step-care manner (see Table day outpatient clinic visits or day pro- group discussions, classroom teach- 2). Since patients or caregivers may grams for more extensive evaluation, ing, written materials, and Atopic forget or confuse skin care recommen- education, and treatment. This unique Dermatitis Home Care or Action Plan dations given to them without a writ- program allows for comprehensive (see Table 2). This treatment model ten plan, it should be reviewed and evaluation and treatment of patients in requires that all members of the multi- modified at followup visits. Clinical an outpatient setting, typically over 5 disciplinary team teach the same key improvements achieved in the ADP to 10 days. In this controlled environ- concepts and reinforce the messages are typically sustained for an extended ment, patients and caregivers interact being delivered to the patients and period of time based on an outcomes with members of the multidisciplinary caregivers regardless of which educa- study (Kelsay et al., 2006). team between 8 a.m. and 5 p.m., as tional strategy is incorporated. Direct demonstration of proper well as overnight, if necessary, espe- National Jewish has been providing skin care includes topical application cially when evaluating sleep distur- patients who have participated in the of agents and techniques such as wet bance and response to interventions ADP detailed, written, home step-care wrap therapy. Watching the patient’s (Bender, Ballard, Canono, Murphy, & plans for the 20-year history of the or caregiver’s current technique often Leung, 2008). Importantly, patients program. Historically, these individu- reveals fundamental errors which and caregivers interact with other alized teaching tools were extremely helps providers understand why a patients and families in formal and labor intensive and included a person- patient may not be showing the informal settings. The ongoing evalua- alized booklet with annotated photo- expected therapeutic response. The tion and response to therapy in the day program are reviewed in clinical Table 2. review meetings with the patient/care- National Jewish Atopic Dermatitis Program Step-Care “AD Action” Plan giver and plan of care conference that involves input from the various servic- MAINTENANCE OR DAILY CARE es. Rarely, patients may also be admit- Take at least one bath or shower per day; use warm water, for 10-15 minutes. ted as inpatients. By educating and Use a gentle cleansing bar or wash in the sensitive skin formulation as needed such caring for patients and families, the as Dove® or Oil of Olay®. ADP can lead to sustained improve- Pat away excess water and immediately (within 3 minutes) apply moisturizer, sealer, ments in outcomes and quality of life or maintenance medication if directed. Fragrance-free moisturizers available in one (Kelsay, Carel, Bratton, Gelfand, & pound jars include Aquaphor® Ointment, Eucerin® Crème, Vanicream®, CeraVe® Klinnert, 2006). Cream or Cetaphil® Cream. Vaseline® is a good occlusive preparation to seal in the water; however, it contains no water so it only works effectively after a bathing. Use Educating Patients and Caregivers moisturizers liberally throughout the day. Moisturizers and sealers should not be applied over any topical medication. National Jewish, as a center of Avoid skin irritants and proven allergens. excellence for both asthma and atopic dermatitis, has used a similar multidis- MILD-TO-MODERATE ATOPIC DERMATITIS ciplinary care approach for these Bathe as above for 10-15 minutes, once (and possibly twice) daily. chronic inflammatory diseases. This Use cleansers as above. approach confirms the importance of Use moisturizers as above to healed and unaffected skin, twice daily especially after teaching patients skills to self-monitor baths and at mid-day total body. and manage disease in a stepwise Apply to affected areas of face, groin and underarms twice daily especially manner and to use a written action after baths ______(low-potency topical corticosteroid), plan. The National Asthma Education or______(topical calcineurin inhibitors), or other topical and Prevention Program’s Expert Panel preparation as directed ______(topical barrier repair cream, Report 3 (EPR-3) (2007) confirms the eg., Atopiclair® three times daily). importance of teaching patients skills Apply to other affected areas of the body twice daily especially after baths to self-monitor and manage asthma ______(low to mid- potency topical corticosteroid), or and to use a written asthma action ______(topical calcineurin inhibitors), or other topical preparation plan, which should include instruc- as directed ______. tions for daily treatment and ways to recognize and handle worsening dis- table continues on page 8

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Table 2. (continued) patient or caregiver needs to show an National Jewish Atopic Dermatitis Program Step-Care “AD Action” Plan appropriate level of understanding of information through verbal confirma- MODERATE-TO-SEVERE ATOPIC DERMATITIS tion or direct demonstration at fol- Bathe as above for 10-15 minutes, two times a day, once before bedtime. lowup to help ensure a good outcome. Use cleansers as above or consider an antibacterial cleanser (eg., Lever 2000®) Group or class instruction is Use moisturizers as above to healed and unaffected skin, twice daily especially after another teaching strategy. Presenta- baths and at mid-day total body. tions at international dermatology and Apply to affected areas of face, groin and underarms twice daily especially allergy meetings have touted the ben- after baths ______(low-potency topical corticosteroid), efits of attending eczema schools. For or______(topical calcineurin inhibitors), or other topical many years National Jewish has held a preparation as directed ______(topical barrier repair cream, weekly 1-hour class addressing vari- eg., Atopiclair® three times daily). ous aspects of AD. This class is taught Apply to other affected areas of the body twice daily especially after baths by dedicated registered nurses and ______(mid-to-high-potency topical corticosteroid), or ______supplements teaching that occur in the topical calcineurin inhibitors), or other topical preparation as directed. clinic, day program, or inpatient set- Use wet wraps to involved areas selectively as directed. tings. Content of the slide lecture Add other medications as directed: ______(eg., oral sedating reflects input from the multidiscipli- antihistamines, topical or oral antimicrobial therapy) nary team and is routinely reviewed and updated. The success of this Pay close attention to things that seem to irritate the skin or make condition worse. approach is due to the competency Contact your health care provider for additional evaluation or therapies. Oral steroids and consistency of the staff providing are not usually recommended. these lectures or group activities; the Step down to moderate plan above as the skin heals. average length of employment at REDUCE SKIN IRRITATION National Jewish for the three nurse educators is 13.5 years. Additionally, Wash all new clothes before wearing them. This removes formaldehyde and other irri- tating chemicals. patients and parents attending the class enjoy the opportunity to ask Add a second rinse cycle to ensure removal of detergent. Residual laundry deter- questions and recognize they have gent, particularly perfume or dye, may be irritating when it remains in the clothing. Changing to a liquid and fragrance-free, dye-free detergent may be helpful. common questions and experiences. Regular support groups are often diffi- Wear garments that allow air to pass freely to your skin. Open weave, loose-fitting, cult to sustain but patients enjoy even cotton-blend clothing may be most comfortable. short-term group activities. Work and sleep in comfortable surroundings with a fairly constant temperature and It is imperative to offer patients humidity level. good resources, otherwise they will Keep fingernails very short and smooth to help prevent damage due to scratching. find their own, potentially less reliable Carry a small tube of moisturizer/sunscreen at all times. Daycare/school/work should ones. The National Eczema Associa- have a separate supply of moisturizer. tion, a national patient organization for those with AD, has educational After swimming in chlorinated pool or using hot tub, shower or bathe using a gentle brochures and videos (800-818-7546; cleanser to remove chemicals, then apply moisturizer. www.nationaleczema.org). National NOTES: ______Jewish has multiple forms of patient ______information, instruction sheets, and ______brochures including a comprehensive ______“Understanding Atopic Dermatitis” ______booklet that has been available since Seek psychosocial support. 1999. A new video emphasizing Use reliable resources for information on atopic dermatitis: bathing and wet wrap therapy has just National Jewish Health National Eczema Association been made available. Additionally, 1400 Jackson Street 4460 Redwood Hwy. Ste. 16-D there is a new online AD course. For Denver, CO 80206 San Rafael, CA 94903-1953 1.800.222.LUNG 415.499.3474 / 800.818.7546 information, go to the National Jewish www.nationaljewish.org www.nationaleczema.org Web site (www.njc.org or www.nation aljewish.org) or contact the National © Developed by Noreen Nicol, MS, RN, FNP, Mark Boguniewicz, MD, and Donald Jewish Lung Line (1-800-222-LUNG Leung, MD, PhD; Atopic Dermatitis Program, National Jewish Health, Denver, or 1-800-222-5864). Colorado. Updated 2008 It is important to stress to patients This may be modified and used for patient care citing National Jewish Health Atopic Dermatitis Program as source. and caregivers that they should review

8 DERMATOLOGY NURSING/October 2008/Supplement DERMATOLOGY NURSING

Figure 2. 1987; Nicol & Boguniewicz, 1999). Individualized skin care for patients with atopic dermatitis from Unfortunately, there has been confu- National Jewish from 1988. sion about how to hydrate and mois- turize the skin. Thus, water avoidance is often mistakenly recommended even for patients with severe xerosis. Typically, evaporation and microfis- suring occur when wet skin is not immediately covered by a protective layer of moisturizer, occlusive, or medication. In contrast, proper soak- and-seal method leads to re-hydra- tion, sealing in of moisture, and repair of the damaged epidermal barrier. Proper bathing or soaking the affected area should be done at least once per day for approximately 15 minutes in warm water making sure that involved areas are covered to avoid evaporation. A wet washcloth or towel can be used to cover face, head, neck, or body not covered my water to increase hydration (see Figure 3). Adding age-appropriate toys will help young children cooper- ate with the bath. Baths can be increased to up to three times daily during AD flares. Young children advice or tips from outside sources is increasingly difficult to accomplish must be supervised during baths. with their clinicians. Even small in the typical clinic visit due to time Water temperature should feel com- changes to a treatment regimen can constraints. Studies have shown that fortable to the patient, as the oft rec- be detrimental or of little benefit, and patients fail to receive adequate expla- ommended “tepid” is usually too cool can add significantly to the cost of nation of the causes and triggers of for most patients. Showers may be therapy. Often, patients are switched AD or are not taught how to apply appropriate in patients with mild dis- to new prescriptive treatments on fol- topicals, even though instruction and ease. lowup visit if the treatment response practical demonstrations may be asso- Bathing may also remove aller- has not been optimal without first ciated with dramatic improvement in gens from the skin surface and reduce reviewing current care to see if it is the treatment outcomes (Nicol, general colonization by S. aureus. being done properly and what else 2005b). Additives to the bath remain at times might be contributing to poor thera- unproven or controversial. Addition peutic response (ongoing exposure to Hydration of oatmeal to the bath water may be an irritant, etc.). The costs of these Xerosis contributes to the devel- soothing to patients but does not pro- changes are often borne by the family opment of epithelial microfissures, mote skin hydration, while bath oils and contribute to non-adherence and which favors the entry of microbial may give the patient a false sense of frustration. An open and ongoing dia- organisms, irritants, and allergens. lubrication and can make the tub slip- log between patients, caregivers, and This problem can become aggravated pery. The addition of bleach to bath their clinician improves the likelihood during the dry winter months and in water may be beneficial to patients of adherence with the treatment plan certain work environments. with recurrent infections, particularly and leads to improved outcomes. Proper daily skin care emphasiz- methicillin-resistant S. aureus infec- ing hydration remains a cornerstone tions; however, the amount of bleach Proper Daily Skin Care to a successful treatment plan. At the per volume of water and frequency of Patients often are unclear about authors’ center, “soak and seal” was baths have not been well studied. the role of skin care in management of developed as a fundamental concept Bleach baths have the potential to atopic dermatitis. They frequently to teach proper skin care emphasizing cause significant skin irritation. state that little time has been spent use of hydration, moisturizers, cleans- Another important reason why clarifying skin care instructions. ers, topicals, and medications to help bathing is avoided is that patients may Education regarding proper skin care maintain an intact skin barrier (Nicol, complain of discomfort or pain when

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Figure 3. use it (Ersser, Maguire, Nicol, Penzer, Bathing of child with atopic dermatitis with & Peters, 2007). head involvement. Following hydration of the skin, patients should gently pat away excess water with a soft towel and apply the appropriate topical moisturizer or medication to prevent evaporation which completes “soak and seal.” Application of appropriate moisturiz- ers or medications should occur with- in 3 minutes (“3 minute rule”). This rule has been promoted to patients by organizations such as the National Eczema Association (www.national eczema.org). Moisturizers should be obtained in the largest size available (typically one pound/480 g jars) since they typically need to be applied sev- eral times each day on a chronic basis. Plastic spoons or wooden tongue bathing and thus this fundamental Moisturizers depressors should be used to remove skin care measure is avoided. This Patients frequently do not under- topicals, especially ointments or often results in progressive worsening stand how the various vehicles of skin creams from large jars to avoid con- of the atopic dermatitis. For pain and care products such as ointments, tamination. Recommended moisturiz- discomfort, patient or caregiver creams, lotions, and oils can affect ers which are available in a one pound should be taught to avoid any irritat- treatment outcomes. In general, oint- jar include Aquaphor® Ointment, ing additives to the bath and to consid- ments seal the best and can be the Vanicream®, CeraVe® Cream, Ceta- er premedication for pain relief. This most hydrating when used after phil® Cream, and Eucerin® Crème. may include acetominophen or bathing and they are formulated with Vegetable shortening (Crisco®) can be ibuprofen, sedating agent (under close the fewest additives. Since they are the used as an inexpensive moisturizer. supervision in the tub!), or anxiolytic. most occlusive, in a hot, humid envi- Patients and caregivers need to un- However, distraction or other means ronment, they may trap perspiration, derstand that petroleum jelly (Vase- of comforting the child are preferred which may result in increased pruri- line®) is a good occlusive preparation by the therapists in our ADP. tus. Lotions and creams may be irritat- to seal in water; however, since it is a ing due to added preservatives or fra- sealer, not moisturizer, it should be Cleansers grances. In addition, lotions contain used after hydrating the skin. Of note, The use of appropriate cleansers more water than creams and may even young patients can be taught to plays an important role in dry skin have a drying effect due to evapora- apply moisturizers, which allows them conditions such as atopic dermatitis. It tion. While oils may go on easily, they to participate in their skin care. is important that patients with AD are are often less-effective moisturizers. Moisturizers should be applied rou- not using cleansers that have ingredi- Patients should be encouraged to tinely rather than over or immediate- ents which are drying or irritating. carry moisturizers in small tubes with ly prior to topical medications to Cleansers with minimal defatting them at all times and to keep a sepa- avoid dilution or blocking of penetra- activity and a neutral pH are pre- rate supply in the daycare, school, or tion of medication into skin. ferred. Formulations that are dye-free work environment. Patients and caregivers should and fragrance-free are less irritating Topical therapy to replace abnor- understand that frequent and proper and more appropriate for atopic skin. mal epidermal lipids, improve skin use of moisturizers together with Our center recommends sensitive hydration, and decrease skin barrier hydration may help re-establish and skin formulations of Dove®, Oil of preserve the skin barrier (Lodén, ® ® dysfunction may be useful therapeuti- Olay , Vanicream , and others. cally. Recommending the use of mois- 1995). Moisturizers can improve skin Antibacterial cleansers such as Lever barrier function and reduce suscepti- ® turizers together with hydration may 2000 may be helpful for patients with help re-establish and preserve the skin bility to irritants (Lodén, Andersson, frequent folliculitis or recurrent skin barrier. Patients, caregivers, as well as & Lindberg, 1999). Adding a moistur- infections. Patients should be instruct- health care providers all over the izer to a low-potency topical cortico- ed not to scrub with a washcloth. world acknowledge they are frequent- steroid can improve clinical para- ly confused about which moisturizer meters in patients with AD (Hanifin et or emollient to use and how to best al., 1998). Moisturizers can also

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decrease the need for topical cortico- sometimes due in part to an inade- tion, ointments have a greater poten- steroids (Lucky, Leach, Laskarzewski, quate supply. It is important to tial to occlude the epidermis, resulting & Wenck, 1997). remember that it takes approximately in enhanced systemic absorption A number of studies suggest that 30 g of cream or ointment to cover the when compared to creams. Side AD is associated with decreased levels entire skin surface of an adult once. To effects from topical corticosteroids can of ceramides, contributing not only to treat the entire body twice daily for 2 be divided into local side effects and a damaged permeability barrier, but weeks would require approximately systemic side effects resulting from also making the stratum corneum sus- two pounds or 900 grams of topical suppression of the hypothalamic-pitu- ceptible to colonization by S. aureus corticosteroids. An alternative that has itary-adrenal axis. Local side effects (Macheleidt, Kaiser, & Sandhoff, been advocated for use in pediatrics is include the development of striae, 2002). A ceramide-dominant emol- the finger tip unit (FTU), recently skin atrophy, perioral dermatitis, and lient added to standard therapy in reviewed in detail by the British acne rosacea. The potential for potent place of moisturizer in children with Dermatology Working Group topical glucocorticoid to cause adrenal “stubborn-to-recalcitrant” atopic der- (Bewley, 2008). The FTU — the suppression is greatest in infants and matitis resulted in clinical improve- amount of cream or ointment young children because of exposure ment (Chamlin et al., 2002). expressed from a 5-mm diameter noz- to relatively larger body surface area. Ceramide-containing creams include zle, applied from the distal skin-crease Of note, a study of children as young TriCeram®, EpiCeram®, and Cera- to the tip of the patient’s index finger as 3 months of age found that flutica- Ve ®. In addition, patients may benefit — can be used to calculate how much sone propionate 0.05% cream, a mid- from other non-steroidal creams product is needed to cover affected potency formulation, was safe and such as MAS063DP (Atopiclair®) areas, such as the face and neck, and effective even when applied on the (Boguniewicz, Zeichner et al., 2008), hence the quantity which should be face and over significant areas of the especially given concerns of some prescribed. body for up to 1 month (Friedlander, patients and caregivers regarding use Topical corticosteroids are ranked Hebert, & Allen, 2002). It has been of topical corticosteroids and topical into seven potency classes based on a approved for use in children as young calcineurin inhibitors. vasoconstrictor assay. Because of their as 3 months for up to 4 weeks with flu- potential side effects, the ultra high- ticasone lotion approved for use in Topical Corticosteroids potency glucocorticoids should be children 12 months and older. Topical Topical corticosteroids have been used only for very short periods of corticosteroids continue to play a role the mainstay of treatment for atopic time and in areas that are lichenified in the management of AD, but with all dermatitis for many years. Because of but not on the face or intertriginous the additional choices, patients and potential side effects, most physicians areas. Mid-potency topical cortico- care providers need to be clear how use topical corticosteroids primarily to steroids can be used for longer periods and where they fit into the treatment control acute exacerbations. Studies of time to treat chronic AD involving plan (Bewley, 2008). suggest that once control of AD is the trunk and extremities. Topical cor- achieved, long-term control can be ticosteroids in gels are often in a Topical Calcineurin Inhibitors maintained with twice weekly applica- propylene glycol base and may be Topical tacrolimus and pime- tions of topical corticosteroid to areas irritating to the skin in addition to pro- crolimus have been developed as that have healed, but are prone to moting dryness, thus limiting their use nonsteroidal topical calcineurin relapse (Berth-Jones et al., 2003; Van to the scalp and beard areas. inhibitors (TCIs). The approval of the Der Meer, Glazenburg, Mulder, Topical corticosteroid potency TCIs, tacrolimus ointment 0.03% and Eggink, & Coenraads, 1999). and side effects are influenced by the 0.1% and pimecrolimus cream 1%, as Patients should be instructed molecular structure of the compound, nonsteroidal agents for treating AD carefully in the use of topical cortico- the vehicle, the amount of medication has represented a milestone in the steroids to avoid potential side effects applied, the duration of application, management of this disease (Nicol, (Nicol & Baumeister, 1997). On the occlusion, as well as host factors Hanifin, Tofte, & Boguniewicz, 2003). face, the genitalia, and the intertrigi- including age, body surface area and Both drugs have proven effective with nous areas, only a low-potency topical weight, skin inflammation, anatomic a good safety profile for treatment up corticosteroid is generally recom- location of treated skin, and individual to 4 years with tacrolimus ointment mended. Patients should be instructed differences in cutaneous or systemic (Berger et al., 2006) and up to 2 years to apply topical corticosteroids to their metabolism. Side effects from topical with pimecrolimus cream (Paul et al., skin lesions and to use emollients on corticosteroids are directly related to 2006). A fairly common side effect uninvolved skin. Patients should be the potency ranking of the compound with TCIs is a transient burning sen- instructed to avoid placing moisturizer and the length of use, so it is incum- sation of the skin, although some immediately over or under the topical bent on the clinician to balance the patients may report more prolonged corticosteroid. Failure of a patient to need for a more potent steroid with burning or stinging. Since treatment respond to topical corticosteroids is the potential for side effects. In addi- with TCIs is not associated with skin

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atrophy, they are particularly useful infants and children are ongoing. Wet-Wrap Therapy for treating eczema on the face, inter- Surveillance and recent reports have Wet-wrap dressings have been triginous regions, and atrophied skin. not shown a trend for increased fre- used successfully in managing recalci- Use of tacrolimus ointment was asso- quency of viral superinfections espe- trant atopic dermatitis at National ciated with decreased colonization by cially eczema herpeticum (Hultsch, Jewish for over 2 decades (Nicol, 1987, S. aureus. Importantly, ongoing sur- Kapp, & Spergel, 2005). The approval 1990). They reduce pruritus and veillance has not shown any trends of topical calcineurin inhibitors for inflammation by cooling the skin and towards increased frequency of viral treating AD represents a significant improving penetration of topical corti- infections especially eczema her- addition to the management of this dis- costeroids. They also act as a protec- peticum or problems with responses ease. There are situations in which top- tive barrier from the trauma associated to childhood vaccinations (Paul et al., ical calcineurin inhibitors may be with scratching. These actions can help 2006). advantageous over topical cortico- the significant sleep disruption accom- Currently, tacrolimus ointment steroids. These include treatment of panying AD. Importantly, recent work 0.03% is approved for intermittent patients who are poorly responsive to has pointed to a beneficial effect of wet treatment of moderate-severe AD in topical steroids, patients with steroid wrap therapy on the skin barrier with children aged 2 years and older, phobia, and the treatment of face and benefits continuing even after discon- tacrolimus ointment 0.1% for intermit- neck dermatitis where ineffective, low- tinuation of this treatment modality tent treatment of moderate-severe AD potency topical corticosteroids are usu- (Lee, Lee, Kim, & Bang, 2007). Of in adults, and pimecrolimus cream 1% ally used due to fears of steroid- note, wet-wrap therapy should be is approved for intermittent treatment induced skin atrophy. The potential reserved for flares of AD and not used of patients aged 2 years and older with use of topical calcineurin inhibitors as as routine maintenance therapy. mild-moderate atopic dermatitis. maintenance therapy is also intriguing While different variations of this While there is no evidence of a causal for preventing AD flares. However, treatment have been described, at link of cancer and the use of TCIs, the guidelines for use of topical cortico- National Jewish, we use wet clothing, United States Food and Drug steroids versus calcineurin inhibitors in such as long underwear, turtle necks, Administration has issued a “black the management of atopic dermatitis pajamas, and cotton socks placed over box or boxed” warning for tacrolimus are still needed. The PRACTALL an undiluted layer of topical cortico- ointment 0.03% and 0.1% (Protopic®, Guidelines, an international initiative steroids applied after bathing followed Astellas) and pimecrolimus cream 1% of the European and American by a dry layer of clothing such as sweat (Elidel®, Novartis) because of a lack of Academies of Allergy, address a num- suits or footed pajamas on top (see long-term safety data (see U.S. pack- ber of therapeutic issues in a step-wise Table 3). When doing total body wraps age inserts for Protopic®, Astellas and fashion (Akdis et al., 2006). on small children, place wet tube socks Elidel®, Novartis). The new labeling over hands first (see Figure 4), followed also states that these drugs are recom- Tar Preparations by wet layer of thinner cotton pajamas. mended as second-line treatments and Coal tar preparations may have Then, place the dry pair of socks over that their use in children under the age antipruritic and anti-inflammatory the hands followed by the heavier-foot- of 2 years is currently not recom- effects on the skin although usually not ed pajamas (see Figure 5). At present, mended. Of note, a Joint Task Force of as pronounced as those of topical glu- wet-wrap therapy is not indicated over the American College of Allergy, cocorticoids (Langeveld-Wildschut et topical calcineurin inhibitors. Treat- Asthma and Immunology and the al., 2000). Tar preparations may be ment of the head requires skilled nurs- American Academy of Allergy, useful in reducing the potency of topi- ing care with use of gauze bandages Asthma and Immunology reviewed cal glucocorticoids required in chronic (Kerlix®) and surgical netting the available data and concluded that maintenance therapy of AD. Newer (Spandage®) (see Figure 6). It is impor- the risk/benefit ratios of tacrolimus coal tar products have been developed tant to emphasize that wet-wrap thera- ointment 0.03% and 0.1% and pime- that are more acceptable with respect py is not the wet-to-dry dressings used crolimus cream 1% are similar to to odor and staining of clothes than for debridement of wounds. Specifics those of most conventional therapies some older products. Tar shampoos of the procedure with detailed pictures for treating chronic relapsing eczema can be beneficial for scalp dermatitis, showing step-by-step have been previ- (Fonacier et al., 2005). In a recent particularly with redness and inflam- ously published and are now also avail- case-control study of a large database mation, and are often helpful in reduc- able in a new video from National that identified a cohort of 293,253 ing the concentration and frequency of Jewish (Boguniewicz & Nicol, 2002, patients with AD, no increased risk of topical glucocorticoid applications. Tar 2008). Children tolerate both selective lymphoma was found with the use of preparations should be used carefully areas of the body wrapped as well as TCIs (Arellano, Wentworth, Arana, on acutely inflamed or denuded skin, total body wraps, which are rarely Fernandez, & Paul, 2007). because this often results in skin irrita- needed. Wet-wrap therapy is not only Long-term safety studies with tion. Side effects associated with tars accepted but can be enjoyed when it is TCIs in patients with AD including include folliculitis and photosensitivity. done with the proper education and

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Table 3. Wet-Wrap Therapy PURPOSE Wet wrap therapy will be used to relieve inflammation, itching, and burning of atopic dermatitis. Wet wraps facilitate the removal of scale and increase penetration of topical medications in age-appropriate explanation (e.g., the stratum corneum. Skin protection provided by the wraps allows healing to take place. Wet telling a 6-year-old child that he is wrap therapy should only be used during flares of atopic dermatitis under the supervision of dressing as a superhero such as Spider- a health care provider. They should not be used as routine maintenance therapy. Man or a Power Ranger). SUPPLIES Wraps may be removed when Topical medications and moisturizers they dry out (typically after 1-2 hours) Tap water at comfortably warm temperature or they may be re-wet. However, it is Basin for dampening of dressings often practical to apply them at bed- time and most patients are able to Clean dressings of approximate size to cover involved area: sleep with them on. The rule of never a. Face: 2 to 3 layers of wet Kerlix® gauze held in place with SurgiNet®. b. Arms, Legs, Hands & Feet: 2 to 3 layers of wet Kerlix® gauze held in place with wake a sleeping child applies here as Ace® bandages or tube socks, or cotton gloves, or wet tube socks followed by dry well; leave wraps on until the child tube socks. Tube socks may be used for wraps for hands and feet, and larger ones awakes, even if it is overnight. Patients work as leg/arm covers. occasionally will complain of feeling c. Total Body: Combination of above, or wet pajamas or long underwear and chilled, which can be prevented by turtleneck shirts covered by dry pajamas or sweat suit. Pajamas with feet work well appropriate bundling and use of for the outer layer. warm blankets. Maceration of the skin Blankets to prevent chilling. and secondary infections are uncom- Non-sterile gloves if desired. mon in the authors’ experience, when PROCEDURE wraps are applied properly. In fact, S. Be certain that the patient’s room is warm and insure privacy. Gather supplies appropriate aureus colonization decreased in a con- to the individual. trolled study of wet-wrap dressings with topical corticosteroid (Schnopp If wraps are to be applied to a large portion of the body, work with two people if possible. It is necessary to work rapidly to prevent chilling. et al., 2002). This therapy is best reserved for acute exacerbations of Explain the procedure to the patient and parent. AD (see Figures 1a & 1b), although it Fill the basin with warm tap water. can also be used selectively to areas of Usually, the patient will have had a soaking bath prior to this procedure or will soak the area resistant eczema especially of the in basin to be wrapped. Pat skin dry with a towel. hands and feet with minimal incon- Apply the appropriate topical medications to affected areas and moisturizer to non-affected venience. The extent and frequency areas immediately after pat drying the skin. Use clean plastic spoons or tongue depressor of use should be reviewed regularly to avoid contamination of products in jars.This allows large areas to be covered quickly and by the health care team, as benefits prevent caregivers from unnecessary exposure to topical medications. may be rapid and dramatic (see Soak the dressings in warm water. Squeeze out excess water. Dressings should be wet, Figures 1a, 1b, 1c, & 1d). not dripping. Phototherapy Cover an area with wet dressing chosen for the area and the patient. Immediately after wrapping, cover with appropriate dry material such as an Ace bandage, socks, or pajamas. Natural sunlight is frequently ben- Start at the feet and move upward. Use wet, long underwear or wet pajamas covered by eficial to patients with atopic dermati- dry pajamas or sweatsuit with total body involvement in place of wet gauze. tis. However, if the sunlight occurs in Take steps to avoid chilling. Blanket can be put in a dryer to warm up and cover patient, but the setting of high heat or humidity, do not overheat the patient. Wraps can be removed after 1-2 hours or can be re-wet. A thereby triggering sweating and pruri- warm blanket and snuggling help pass the time. tus, it may be deleterious to patients. If patient is known or suspected to have an infection of the involved areas, place dressings Broad-band ultraviolet B, broad-band in appropriate bag and dispose according to infection control procedure. ultraviolet A, narrow-band ultraviolet B (311 nm), UVA-1 (340 to 400 nm), After all dressings are removed, moisturizers may be applied to the entire body. and combined UVAB phototherapy REFERENCES can be useful adjuncts in treating AD. Boguniewicz, M., & Nicol, N. (2002). Conventional therapy for atopic dermatitis. Immunology and Allergy Photochemotherapy with PUVA may Clinics of North America, 22(1), 107-124. be indicated in patients with severe, Boguniewicz, M., & Nicol, N.H. (2008). General management of patients with atopic dermatitis. In S. Reitamo, T.A. Luger, & M. Steinhoff (Eds.), Textbook of atopic dermatitis (pp. 147-164). Andover, UK: widespread AD, although studies Informa UK Ltd. comparing it with other modes of Boguniewicz, M., Nicol, N.H., Kelsay, K., & Leung, D.Y.M. (2008). A multidisciplinary approach to evaluation phototherapy are limited. Short-term and treatment of atopic dermatitis. Seminars in Cutaneous Medicine and Surgery, 27(2), 115-127. adverse effects with phototherapy Nicol, N.H. (1987). Atopic dermatitis: The (wet) wrap-up. American Journal of Nursing, 87(12), 1560-1563. may include erythema, skin pain, pru- ritus, and pigmentation. Long-term © National Jewish Health Institutional Policy and Procedure, 2008. adverse effects include premature skin This may be modified and used for patient care citing National Jewish Health Atopic Dermatitis aging and cutaneous malignancies. Program as source.

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Figure 4. Figure 5. Wet-wrap therapy with application of first wet layer. Wet-wrap therapy with application of second dry layer.

Systemic Therapy Figure 6. irritants, allergens, and psychosocial The use of systemic cortico- Full-body wet-wrap therapy of an events can elicit the itch sensation in steroids, such as oral prednisone, is infant with severe generalized patients with AD and set off the itch- rarely indicated in the treatment of a atopic dermatitis. scratch cycle that results in a flare of chronic, relapsing disease such as eczema. atopic dermatitis. Some patients and physicians prefer the use of systemic Irritants corticosteroids to avoid the time-con- Patients with atopic dermatitis are suming skin care involving hydration more susceptible to irritants than other and topical therapy. However, the individuals. Irritants can be almost dramatic clinical improvement that anything and may include soaps or may occur with systemic cortico- detergents, chemicals, smoke, abrasive steroids is frequently associated with clothing, and exposure to extremes of a severe rebound flare of AD follow- temperature and humidity. Alcohol ing the discontinuation of systemic and astringents found in toiletries can corticosteroids. Short courses of oral be drying. When soaps or cleansers corticosteroids may be appropriate are used, they should have minimal for an acute exacerbation of AD defatting activity and a neutral pH. while other treatment measures are New clothing may be laundered prior being instituted. If a short course of to wearing to decrease levels of oral corticosteroids is given, it is formaldehyde and other added chem- important to taper the dosage and to icals. Residual laundry detergent in begin intensified skin care, particular- clothing may be irritating. Using a liq- ly with frequent bathing followed by uid rather than powder detergent and application of topicals, to prevent adding a second rinse cycle will facili- rebound flaring of AD. tate removal of the detergent. Cyclosporine is a potent im- Patients with AD often develop a munosuppressive drug. Multiple nonspecific, irritant hand dermatitis. It studies demonstrated that children remission. Elevated serum creatinine is frequently aggravated by repeated and adults with severe refractory AD or more significant renal impairment wetting without use of moisturizer and can benefit from oral cyclosporine and hypertension are specific side by washing of the hands with harsh treatment (Bunikowski et al., 2001). effects of concern with cyclosporine soaps, detergents, and disinfectants. Treatment with cyclosporine is asso- use. Atopic individuals with occupations ciated with reduced skin disease and involving wet work are prone to an improved quality of life. Dis- Role of Trigger Factors develop an intractable hand dermati- continuation of treatment may result Skin hyperreactivity is and has tis in the occupational setting. This is a in relapse of skin disease, although been an important feature of atopic common cause of occupational dis- some patients may have sustained dermatitis. Many triggers including ability (Shmunes, 1986).

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Recommendations regarding en- have clinically relevant food allergy to ment in AD as well as reduction in vironmental living conditions should only a small number of foods irrespec- topical steroid use (Werfel et al., 2006). include temperature and humidity tive of the number of positive skin or However, well-controlled studies are control to avoid problems related to in vitro tests. In children who have still required to determine the role for heat, humidity, and perspiration. undergone double-blind, placebo- immunotherapy with this disease. Changes in the environment, which controlled food challenges, milk, egg, might not affect normal individuals, peanut, soy, wheat, and fish account Psychosocial Factors can elicit the itch sensation in patients for approximately 90% of the food Patients with atopic dermatitis with AD. Every attempt should be allergens found to exacerbate AD often respond to stressful events with made to allow patients to be as nor- (Sicherer & Sampson, 2006). The increased pruritus and scratching. mally active as possible. Certain sports dietician plays a key role in evaluating Scratching can become habitual and such as swimming may be better toler- patients’ diets and educating patients occasionally is associated with second- ated than other sports involving and caregivers regarding appropriate ary gain. Psychological evaluation or intense perspiration, physical contact, diets (Boguniewicz, Moore, & counseling should be considered for or heavy clothing and equipment, but Paranto, 2008). Avoidance of foods patients and families. It may be espe- chlorine should be rinsed off immedi- implicated in controlled challenges cially useful in adolescents and young ately after swimming and the skin results in clinical improvement. adults who consider their skin disease moisturized. While ultraviolet light Extensive elimination diets are rarely disfiguring. Relaxation, behavioral may be beneficial to some patients required. Organizations such as Food modification, or biofeedback may be with AD, sunscreens should be used Allergy and Anaphylaxis Network helpful in patients with chronic pruri- to avoid sunburn. However, because (www.foodallergy.org) can provide tus. sunscreens can be irritants, care valuable information on hidden should be used to identify a nonirritat- sources of common food allergens, Role of Itch in Atopic Dermatitis ing product. recognizing specific food proteins by Atopic dermatitis is frequently various names on food labels and referred to as “the itch that rashes.” It Allergens methods of preparing foods with safe continues to be debated whether the Foods and aeroallergens such as substitution of allergenic ingredients. itch or rash comes first. Itching or pru- dust mites, animal danders, molds, In dust mite-allergic patients with ritus is the key symptom of AD. and pollens have been demonstrated AD, prolonged avoidance of dust Control of itch is important because to exacerbate atopic dermatitis. mites results in improvement of their injury from scratching can induce skin Although patients with AD often have skin disease (Arlian & Platts-Mills, cells to release pro-inflammatory high serum IgE levels which measures 2001). Avoidance measures include cytokines leading to a vicious itch- total IgE, it is not useful for identifying use of dust mite proof encasings on scratch cycle that perpetuates the allergens. Potential allergens can be pillows, mattresses, and box springs; eczematous rash. The mechanisms of identified by taking a careful history washing bedding in hot water weekly; itch or pruritus in AD are not fully and carrying out selective skin prick removal of bedroom carpeting; and understood. Allergen-triggered hista- tests or measuring specific serum IgE decreasing indoor humidity levels mine release from mast cells is only levels. Negative skin tests or serum with air conditioning. Because there one cause of pruritus in AD, and tests for allergen-specific IgE have a are many triggers contributing to the because of this, antihistamines are high predictive value for ruling out flares of AD, attention should be only partially effective in controlling suspected allergens. focused on identifying and controlling the itch of AD (Klein & Clark, 1999). The role that food allergies play the flare factors that are important to T-cell derived cytokines such as IL-31 in flares of AD remains an area of the individual patient. Infants and have recently been shown to play an active research and discussion. Food young children are more likely to important role in AD-associated pruri- allergens may play a role in a subset of have food allergies, whereas older tus (Sonkoly et al., 2006). patients with AD, particularly those children and adults are more likely to The treatment of pruritus in AD under the age of 3 years (Sicherer & be sensitive to environmental aeroal- should be directed primarily at the Sampson, 2006). Controlled food lergens. underlying causes (Nicol, Huether, & challenges were first reported at the Unlike allergic rhinitis and extrin- Weber, 2006). Inhaled and ingested authors’ center in the 1970s, recogniz- sic asthma, immunotherapy with allergens should be eliminated if doc- ing that a positive skin test to a food aeroallergens has not proven effica- umented to cause itching and skin allergen did not necessarily define cious in treating AD. There are anec- rash in controlled challenges. clinical relevance (May, 1976). dotal reports of both disease exacerba- Reduction of dryness and skin inflam- Removal of proven food allergens on tion and improvement. A recent study mation with moisturization and use of the other hand from the patient’s diet of specific immunotherapy over 12 topical anti-inflammatory drugs, such can lead to significant clinical months in adults with AD sensitized to as topical corticosteroids and topical improvement. Patients typically will dust mite allergen showed improve- calcineurin inhibitors, will often

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reduce pruritus. Because pruritus is Deep-seated abscesses occur rarely in has been reported. Acyclovir or one of usually worse at night, the sedating AD and should raise the possibility of the newer antiviral medications can antihistamines or other sedating med- an immunodeficiency such as hyper- be given orally. Intravenous treatment ications may offer an advantage IgE syndrome. may be necessary for severe eczema through their sedating side effects The importance of S. aureus in herpeticum. when used at bedtime. The sedating atopic dermatitis is supported by the Superficial fungal or dermato- antihistamines, hydroxyzine and observation that patients with severe phyte infections are also more com- diphenhydramine, remain useful AD, even those without overt infec- mon in atopic individuals and may treatment adjuncts. Doxepin hydro- tion, can show clinical response to contribute to the exacerbation of dis- chloride has both tricyclic antidepres- combined treatment with anti-staphy- ease activity. There has been renewed sant and H1 and H2-histamine recep- lococcal antibiotics and topical corti- interest in the yeast Malassezia sympodi- tor-blocking effects. If nocturnal pruri- costeroids (Nilsson, Henning, & alis in AD. IgE antibodies against M. tus remains severe, short-term use of a Magnusson, 1992). Cephalosporins or sympodialis are commonly found in sedative to allow adequate rest may be penicillinase-resistant penicillins (dic- patients with AD and most frequently appropriate. Studies of nonsedating loxacillin, oxacillin, or cloxacillin) are in patients with head and neck der- antihistamines show variable results in usually beneficial for patients who are matitis. Positive allergen patch test the effectiveness of controlling pruri- not colonized with resistant S. aureus reactions to this yeast have also been tus in atopic dermatitis, although they strains. Because erythromycin-resist- demonstrated. The potential impor- may be useful in the subset of patients ant S. aureus are common, erythromy- tance of M. sympodialis as well as other with AD and concomitant urticaria or cin and newer macrolide antibiotics dermatophyte infections is further concurrent allergies. Topical antihista- are usually of limited utility. Topical supported by the improvement of AD mines, as well as topical anesthetics, mupirocin is useful for treating local- in some patients following treatment are not recommended as they are fre- ized impetiginized lesions; however, with topical or systemic antifungal quent cutaneous sensitizers in patients in patients with extensive skin infec- therapy (Boguniewicz, Schmid- with AD. tion, a course of systemic antibiotics is Grendelmeier, & Leung, 2006). more practical. Additionally, patients It is worth remembering that a Role of Infections given topical mupirocin require spe- healthy skin barrier is the best defense Bacterial, viral, and fungal infec- cific instruction, reinforcing the need against all pathogens. Basic skin care tions are common problems for to use this topical three times daily to measures cannot be overemphasized, patients with atopic dermatitis. avoid developing resistance to this particularly bathing and use of mois- Staphylococcus aureus is found on more medication. Methicillin-resistant S. turizers which aid in the repair and than 90% of AD skin lesions; even aureus may require culture and sensi- maintenance of the skin barrier. normal-appearing skin of patients tivity testing to assist in appropriate Additionally, teaching patients to with AD is often heavily colonized. In antibiotic selection. avoid sharing hygiene and skin care contrast, fewer than 5% of normal sub- Infection caused by the virus her- products from washcloths and towels jects have S. aureus on their skin. pes simplex can result in a generalized to topicals is important to avoid Researchers at National Jewish found eruption termed eczema herpeticum. spreading infections. Dramatic clear- that an important strategy by which S. Herpes simplex can provoke recur- ing of S. aureus-infected eczema can aureus enhances skin inflammation in rent dermatitis and may be misdiag- occur in 1 week using twice daily soak- AD is by secreting toxins. These tox- nosed as a bacterial infection. ing baths including a wet washcloth to ins act as super-antigens which cause Vesicular lesions are umbilicated, tend the face, lower-potency topical corti- marked activation of T cells and anti- to crop, and become crusted. The costeroids followed by wet-wrap thera- gen-presenting cells in the skin leading presence of punched-out erosions, py, and oral antibiotics (see Figures 1a, to significant skin inflammation vesicles, and/or infected skin lesions, 1b, 1c, & 1d). This illustrates what can (Leung, 2003). Honey-colored crust- especially those that fail to respond to be accomplished when proper skin ing, folliculitis, or pustules can all be oral antibiotics, should initiate a care is combined with appropriate indicative of secondary bacterial skin search for herpes simplex virus. This anti-infective therapy in infection- infection, usually due to S. aureus that can be diagnosed by a Tzanck smear prone patients with AD. requires antibiotic therapy. Methi- of cells scraped from the vesicle base, cillin-resistant S. aureus is becoming an direct immunofluorescence assay, Summary increasingly important pathogen in polymerase chain reaction identifica- Successful strategies for managing patients with AD. It has also been a tion of herpes genetic material, or by atopic dermatitis require an accurate difficult surveillance and treatment viral culture. Antiviral treatment for diagnosis, identification and elimina- issue for health care institutions to disseminated cutaneous herpes sim- tion of exacerbating factors including address when treating patients with plex infections is of critical importance irritants and allergens, adequate AD. Culture and sensitivities may be in the patient with AD because severe, hydration of the skin, control of pruri- helpful in managing these patients. even life-threatening dissemination tus and infections, and appropriate

16 DERMATOLOGY NURSING/October 2008/Supplement DERMATOLOGY NURSING

use of topical anti-inflammatory and Bewley, A. (2008). Expert consensus: Time for dermal barrier dysfunction in atopic der- other medications. Patient education, a change in the way we advise our patients matitis: Gene-environment interactions. to use topical corticosteroids. British Journal of Allergy and Clinical Immunology, including the fundamentals of the dis- Journal of Dermatology, 158(5), 917-920. 118(1), 3-21. ease and how to do proper daily skin Boguniewicz, M., Abramovits, W., Paller, A., Ersser, S., Maguire, S., Nicol, N., Penzer, R., & care, increases the chances of success- Whitaker-Worth, D.L., Prendergast, M., Peters, J. (2007). Best practice in emollient ful therapy for patients and their care- Cheng, J.W., et al. (2007). A multiple- therapy: A statement for healthcare profession- domain framework of clinical, economic, als. Retrieved August 15, 2008 from givers. In addition, impact of illness on and patient-reported outcomes for evalu- http://www.dermatology-uk.com/down patient and family quality of life needs ating benefits of intervention in atopic der- loads/Emollient_Therapy_BP.pdf to be considered. Treatment should be matitis. Journal of Drugs in Dermatology, 6(4), Fonacier, L., Spergel, J., Charlesworth, E.N., individualized according to the sever- 416-423. Weldon, D., Beltrani, V., Bernhisel- ity of illness and factors that trigger Boguniewicz, M., Eichenfield, L., & Hultsch, T. Broadbent, J., et al. (2005). Report of the (2003). Current management of atopic Topical Calcineurin Inhibitor Task Force their atopic dermatitis. Whether at an dermatitis and interruption of the atopic of the American College of Allergy, academic center of excellence or a pri- march. Journal of Allergy and Clinical Asthma and Immunology and the vate practice setting, staff interested in Immunology, 112 (Suppl. 6), S140-S150. American Academy of Allergy, Asthma and willing to spend the additional Boguniewicz, M., Moore, N., & Paranto, K. and Immunology. Journal of Allergy and (2008). Allergic diseases, quality of life and Clinical Immunology, 115(6), 1249-1253. and necessary time educating patients the role of the dietician. Nutrition Today, Friedlander, S.F., Hebert, A.A., & Allen, D.B. and families about atopic dermatitis 43, 6-10. (2002). Safety of fluticasone propionate management is the key to successful Boguniewicz, M., Schmid-Grendelmeier, P., & cream 0.05% for the treatment of severe treatment strategies. Leung, D.Y.M. (2006). Clinical pearls: and extensive atopic dermatitis in children Atopic dermatitis. Journal of Allergy and as young as 3 months. Journal of the References Clinical Immunology, 118(1), 40-43. American Academy of Dermatology, 46(3), Boguniewicz, M., & Nicol, N. (2002). Con- 387-393. Akdis, C.A., Akdis, M., Bieber, T., Bindslev- ventional therapy for atopic dermatitis. Hanifin, J.M., Hebert, A.A., Mays, S.R., Paller, Jensen, C., Boguniewicz, M., Eigenmann, Immunology and Allergy Clinics of North A.S., Sherertz, E.F., Wagner, A.M., et al. P., et al. (2006). Diagnosis and treatment America, 22(1), 107-124. (1998). Effects of a low-potency cortico- of atopic dermatitis in children and adults: steroid lotion plus a moisturizing regimen European Academy of Allergology and Boguniewicz, M., & Nicol, N.H. (2008). General management of patients with in the treatment of atopic dermatitis. Clinical Immunology/American Acad- Current Therapeutic Research, 59(4), 227-233. emy of Allergy, Asthma and Immun- atopic dermatitis. In S. Reitamo, T.A. Luger, & M. Steinhoff (Eds.), Textbook of Hanifin, J.M., & Rajka, G. (1980). Diagnostic ology/PRACTALL Consensus Report. features of atopic dermatitis. Acta Dermato- atopic dermatitis (pp. 147-164). Andover, Journal of Allergy and Clinical Immunology, Venereologica, 92, 44-47. 118(1), 152-169. UK: Informa UK Ltd. 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The Boguniewicz, M., Zeichner, J.A., Eichenfield, Immunomodulation and safety of topical biology of dust mites and the remediation L.F., Herbert, A., Jaratt, M., Lucky, A.W., calcineurin inhibitors for the treatment of of mite allergens in allergic disease. Journal et al. (2008). MAS063DP is effective atopic dermatitis. Dermatology, 211(2), 174- of Allergy and Clinical Immunology, monotherapy for mild to moderate atopic 187. 107(Suppl. 3), S406-413. dermatitis in infants and children: A mul- Kapoor, R., Menon, C., Hoffstad, O., Bilker, Bender, B.G., Ballard, R., Canono, B., Murphy, ticenter, randomized, vehicle-controlled W., Leclerc, P., & Margolis, D.J. (2008). J.R., & Leung, D.Y. (2008). Disease sever- study. Journal of Pediatrics, 152(6), 854-959. The prevalence of atopic triad in children ity, scratching, and sleep quality in Bunikowski, R., Staab, D., Kussebi, F., with physician-confirmed atopic dermati- patients with atopic dermatitis. 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Loricrin and involu- Academy of Dermatology Association alleviate childhood atopic dermatitis: crin expression is down-regulated by Th2 Task Force. Journal of the American Academy Changes in barrier function provide a sen- cytokines through STAT-6. Clinical of Dermatology, 54(5), 818-823. sitive indicator of disease activity. Journal of Immunology, 126(3), 332-337. Berth-Jones, J., Damstra, R.J., Golsch, S., the American Academy of Dermatology, 47(2), Klein, P.A., & Clark, R.A. (1999). An evidence- Livden, J.K., Van Hotteghem, O., 198-208. based review of the efficacy of antihista- Allergra, F., et al. (2003). Twice weekly flu- Chatila, T.A. (2005). Role of regulatory T cells mines in relieving pruritus in atopic der- ticasone propionate added to emollient in human diseases. Journal of Allergy and matitis. 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Modulation of the atopy patch test reac- Nicol, N.H. (2003). Dermatitis/eczemas. In M.J. Shmunes, E. (1986). The role of atopy in occu- tion by topical corticosteroids and tar. Hill (Ed.), Dermatologic nursing essentials: A pational skin diseases. Occupational Journal of Allergy and Clinical Immunology, core curriculum (2nd ed., pp. 103-116). Medicine, 1(2), 219-228. 106(4), 737-743. Pitman, NJ: Dermatology Nurses’ Schnopp, C., Holtmann, C., Stock, S., Temling, Lee, J.H., Lee, S.J., Kim, D., & Bang, D. (2007). Association. R., Fölster-Holst, R., Ring, J., et al. (2002). The effect of wet-wrap dressing on epider- Nicol, N.H. (2005a). Atopic triad: Atopic der- Topical steroids under wet-wrap dressings mal barrier in patients with atopic der- matitis, allergic rhinitis and asthma. The in atopic dermatitis – A vehicle-controlled matitis. Journal of the European Academy of American Journal for Nurse Practitioners, trial. Dermatology, 204(1), 56-59. Dermatology and Venereology, 21(10), 1360- (Suppl.), 36-40. Schultz-Larsen, F., & Hanifin, J.M. (2002). 1368. Nicol, N.H. (2005b). Use of moisturizers in der- Epidemiology of atopic dermatitis. Leung, D.Y. (2003). Infection in atopic dermati- matologic disease: The role of healthcare Immunology and Allergy Clinics of North tis. Current Opinion in Pediatrics, 15(4), 399- providers in optimizing treatment out- America, 22, 1-24. 404. comes. Cutis, 76(Suppl. 6), 26-31. Sicherer, S.H., & Sampson, H.A. (2006). Food Leung, D.Y., Boguniewicz, M., Howell, M.D., Nicol, N.H., & Baumeister, L. (1997). Topical allergy. Journal of Allergy and Clinical Nomura, I., & Hamid, Q.A. (2004). New corticosteroid therapy: Considerations for Immunology, 117(Suppl. 2), S470-475. insights into atopic dermatitis. Journal of prescribing and use. Lippincott’s Primary Sonkoly, E., Muller, A., Lauerma, A.I., Pivarcsi, Clinical Investigation, 113(5), 651-657. Care Practice, 1(1), 62-69. A., Soto, H., Hemeny, L., et al. (2006). IL- Lodén, M. (1995). Biophysical properties of dry Nicol, N.H., & Boguniewicz, M. (1999). Un- 31: A new link between T cells and pruri- atopic and normal skin with special refer- derstanding and treating atopic dermatitis. tus in atopic skin inflammation. Journal of ence to effects of skin care products. Acta Nurse Practitioner Forum, 10(2), 48-55. Allergy and Clinical Immunology, 117(2), 411- Dermato-Venereologica, 192(Suppl.), 1-48. Nicol, N.H., Hanifin, J.M., Tofte, S., & 417. Lodén, M., Andersson, A.C., & Lindberg, M. Boguniewicz, M. (2003). Evolution in the Spergel, J.M., & Paller, A.S. (2003). Atopic der- (1999). Improvement in skin barrier func- treatment of atopic dermatitis: New matitis and the atopic march. Journal of tion in patients with atopic dermatitis after approaches to managing a chronic skin Allergy and Clinical Immunology, 112(Suppl. treatment with a moisturizing cream disease. Dermatology Nursing, 15(Suppl. 4), 6), S118-S127. (Canoderm). British Journal of Dermatology, 3-19. Strachan, D.P. (1989). Hay fever, hygiene, and 140(2), 264-267. Nicol, N.H., Huether, S.E., & Weber, R. (2006). household size. BMJ, 299(6710), 1259- Lucky, A.W., Leach, A.D., Laskarzewski, P., & Structure, function, and disorders of the 1260. Wenck, H. (1997). Use of an emollient as a integument. In K. McCance & S. Huether Van Der Meer, J.B., Glazenburg, E.J., Mulder, steroid-sparing agent in the treatment of (Eds.), Pathophysiology – The biologic basics for P.G., Eggink, H.F., & Coenraads, P.J. mild to moderate atopic dermatitis in chil- disease in adults and children (5th ed., pp. (1999). The management of moderate to dren. Pediatric Dermatology, 14(4), 321-324. 1573-1607). St. Louis: Mosby-Year Book, severe atopic dermatitis in adults with top- Macheleidt, O., Kaiser, H.W., & Sandhoff, K. Inc. ical fluticasone propionate. The (2002). Deficiency of epidermal protein- Nilsson, E.J., Henning, C.G., & Magnusson, J. Netherlands Adult Atopic Dermatitis bound omega-hydroxyceramides in (1992). Topical corticosteroids and Study Group. British Journal of Dermatology, atopic dermatitis. Journal of Investigative Staphylococcus aureus in atopic dermati- 140(6), 1114-1121. Dermatology, 119(1), 166-173. tis. Journal of the American Academy of von Mutius, E. (2000). The environmental pre- May, C.D. (1976). Objective clinical and labora- Dermatology, 27(1), 29-34. dictors of allergic disease. Journal of Allergy tory studies of immediate hypersensitivity Ong, P.Y., Ohtake, T., Brandt, C., Strickland, I., and Clinical Immunology, 105(1), 9-19. reactions to foods in asthmatic children. Boguniewicz, M., Ganz, T., et al. (2002). Werfel, T., Breuer, K., Rueff, F., Przybilla, B., Journal of Allergy and Clinical Immunology, Endogenous antimicrobial peptides and Worm, M., Grewe, M., et al. (2006). 58(4), 500-515. skin infections in atopic dermatitis. New Usefulness of specific immunotherapy in McGirt, L.Y., & Beck, L.A. (2006). Innate England Journal of Medicine, 347(15), 1151- patients with atopic dermatitis and allergic immune defects in atopic dermatitis. 1160. sensitization to house dust mites: A multi- Journal of Allergy and Clinical Immunology, Palmer, C.N., Irvine, A.D., Terron- centre, randomized, dose-response study. 118(1), 202-208. Kwiatkowski, A., Zhao, Y., Liao, H., Lee, Allergy, 61(2), 202-205. National Asthma Education and Prevention S.P., et al. (2006). Common loss-of-func- Williams, H., Robertson, C., Stewart, A., Aït- Program. (2007). Expert panel report 3 tion variants of the epidermal barrier pro- Khaled, N., Anabwani, G., Anderson, R., (EPR-3): Guidelines for the diagnosis and tein filaggrin are a major predisposing fac- et al. (1999). Worldwide variations in the management of asthma – Summary tor for atopic dermatitis. Nature Genetics, prevalence of symptoms of atopic eczema report 2007. Journal of Allergy and Clinical 38(4), 441-446. in the International Study of Asthma and Immunology, 120(Suppl. 5), S94-138. Paul, C., Cork, M., Rossi, A.B., Papp, K.A., Allergies in Childhood. Journal of Allergy Nicol, N.H. (1987). Atopic dermatitis: The Barbier, N., & de Prost, Y. (2006). Safety and Clinical Immunology, 103(1), 125-138. (wet) wrap-up. American Journal of and tolerability of 1% pimecrolimus Nursing, 87(12), 1560-1563.Nicol, N.H. cream among infants: Experience with (1990). Current considerations and 1133 patients treated for up to 2 years. management of atopic dermatitis. Pediatrics, 117(1), e118-128. Dermatology Nursing, 2(3), 129-138.

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ANSWER/EVALUATION FORM: Successful Strategies in Atopic Dermatitis Management DNJ J0805

Posttest Instructions 1. To receive continuing nursing education This test may be copied for use by others. (CNE) credit for individual study after reading the article, complete the answer/ COMPLETE THE FOLLOWING: evaluation form below. 2. Photocopy and send the answer/evalua- tion form to: Dermatology Nursing, East Name: ______Holly Avenue Box 56, Pitman, NJ 08071- 0056. Address: ______3. Test returns must be postmarked by October 31, 2010. Upon completion of City: ______State: ______Zip: ______the answer/evaluation form, a certificate for 1.5 contact hour(s) AND 75 minutes Telephone:______of pharmacology hours will be awarded and sent to you. Email: ______4. CNE tests can also completed online at www.dermatologynursing.net. This article was reviewed and formatted for CNE application fee: Complimentary contact hours and pharmacology minutes for contact hour credit by Marcia J. Hill, MSN, RN, this Supplement are made possible through an education Dermatology Nursing Editor; and Sally Russell, MN, CMSRN, Dermatology Nursing Education grant from Astellas Pharma US, Inc. Director.

Answer Form 1. If you could imagine that you have fully implemented what you learned from this activity into practice, what would be different?

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Strongly Strongly Evaluation disagree agree 2. By completing this offering, I am able to meet the stated objectives. a. Heighten his/her awareness of the prevalence of atopic dermatitis, its impact on quality 1 2 3 4 5 of life, and association with asthma and allergies. b. Examine a multi-faceted approach to management of patients with atopic dermatitis 1 2 3 4 5 including non-pharmacologic and pharmacologic interventions. c. Summarize common interventions including hydration, moisturizers, and pharmaceutical agents. 1 2 3 4 5 d. Discuss appropriate safety issues related to topical and systemic therapies. 1 2 3 4 5

3. The content was current and relevant. 1 2 3 4 5

4. The content was presented clearly. 1 2 3 4 5

5. The content was covered adequately. 1 2 3 4 5

6. I am more confident of my abilities since 1 2 3 4 5 completing this material.

7. The material was (check one) ■ new, ■ review for me

Comments ______8. Time required to complete reading assignment: ______minutes

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