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Understanding Atopic Know Your Skin – From the Inside Out

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Who We Are & Network is the leading nonprofit patient outreach, education, advocacy and research organization for people with asthma, and related conditions. 8229 Boone Blvd. Suite 260 Our patient-centered network Vienna, VA 22182 unites individuals, families, 800.878.4403 healthcare professionals, industry AllergyAsthmaNetwork.org leaders and government decision- [email protected] makers to improve and quality of life for the millions of Understanding Atopic Dermatitis people affected by asthma and – Allergy & Asthma Today Special allergies. Edition is published by Allergy & Asthma Network, Copyright An innovator in encouraging 2018. All rights reserved. family participation in treatment plans, Allergy & Asthma Network Call 800.878.4403 to order specializes in making accurate copies; shipping and handling medical information relevant charges apply. and understandable to all while promoting standards of care that are proven to work. We believe PUBLISHER that integrating prevention with Allergy & Asthma Network treatment helps reduce emergency healthcare visits, keep children in PRESIDENT AND CEO school and adults at work, and Tonya Winders allow participation in sports and other activities of daily life. MANAGING EDITOR Gary Fitzgerald Our Mission CREATIVE DIRECTOR To end needless death and suffering Paul Tury due to asthma, allergies and related conditions through outreach, DIRECTOR OF EDUCATION education, advocacy and research. Sally Schoessler CONTRIBUTORS Allergy & Asthma Network is a Allie Bahn 501(c)(3) organization. Tracy Bush Kortney Kwong Hing Join Allergy & Asthma Network Abby Lai today, as we work to help Kimberly Pellicore patients and families Laurie Ross breathe better together. AllergyAsthmaNetwork.org/join Comments and Questions [email protected]

Editorial reviewed by: Luz Fonacier, MD Purvi Parikh, MD Weily Soong, MD Dennis Williams, PharmD

2 Allergy & Asthma Today Special Edition AllergyAsthmaNetwork.org INSIDE:

Beyond Skin Deep ATOPIC DERMATITIS DEFINED Dry, cracked, inflamed skin. A red, bumpy that won’t go away. The near-constant itching and sleepless nights. Living with atopic 4 What is Atopic Dermatitis? dermatitis (AD) – the most common form of eczema – isn’t easy. It’s 7 Atopic Dermatitis Fast Facts often unpredictable, with skin symptoms arising when you least 8 The Allergic March expect it. 9 Maybe you’re in your mid-20s and eager to go on dates, but also apprehensive because red splotches are visible on your cheek, chin and SYMPTOMS neck. Perhaps you’re the parent of a 10-month-old girl who scratched the rough, scaly skin on her arms so hard it started bleeding. Or maybe 10 What to Watch For... you’re a 40-something with seasonal allergies, 11 A Clear Diagnosis perplexed by the onset of skin inflammation on 12 What’s Worsening My Eczema? your hands and feet. 14 When to See a Specialist Atopic dermatitis is a lifelong condition – there is no cure. The goal of care is to provide TREATMENTS & MEDICATIONS relief. More than 18 million adults and 9.6 million children have it. Doctors believe AD 15 Repair the Skin Barrier may actually be underdiagnosed – many people 16 To Bathe Or Not to Bathe? are unaware they have it or don’t seek out 17 Under Wraps medical care, thinking symptoms will go away 18 Come Together: How Doctor-Patient on their own. Partnerships Are Transforming Further, atopic dermatitis can impact Healthcare patients’ mental health and quality of life. Even those with mild 19 What’s the Best Treatment For My Atopic Dermatitis? symptoms report it limits their lifestyle and participation in social 20 Find Your Relief activities. 23 Let There Be Light Where to start in terms of managing the condition?

First things first: see a doctor – specialists who treat atopic dermatitis include board-certified allergists and dermatologists. You’ll undergo MANAGING YOUR CONDITION tests to confirm the condition and find out what your triggers are. Since AD is believed to be genetic, your family history will be part of the 24 Calming the discussion. 25 Sleep Tight Then you’ll work together with your doctor to develop a practical 26 The Heat Is On management and treatment plan specific to your needs and values. 26 Baby It’s Cold Outside The key, as you’ll learn in this guidebook, is to keep your skin 27 Don’t Keep It a Secret 28 -Busters moisturized, regardless of the severity of the condition. If your atopic 29 Recipe for Success dermatitis persists, there is hope. New, innovative medications give 30 Coping With Eczema doctors and patients better tools to keep symptoms in check. 31 Dating and Intimacy You don’t have to struggle – physically or emotionally – with atopic 32 When Eczema Goes to School dermatitis. Clear, healthy skin is possible. Help is here. 33 Come Clean

ADDITIONAL RESOURCES

Tonya Winders 34 Dictionary, Websites and President/CEO Publications Allergy & Asthma Network

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“Every time work “My 3-year- is stressful, I break old son has out in red, scaly had problem splotches. It’s really skin since he itchy and painful was born. We on my hand and bathe him every arms – it’s hard not other night with to scratch – but it’s water only, then most embarrassing moisturize and when it shows up let it soak in on my cheek and before he puts chin.” on his pajamas. – Destiny, 26 Moisturizing is really the key for us!” – Marcie, 39

What is Atopic Dermatitis?

f you’ve had it, you know it: the dry, red, scaly, AD symptoms will come and go, but even when unbearably itchy called atopic your skin appears clear, there may be inflammation Idermatitis, or AD – the most common form of eczema. underneath the surface, waiting to flare. You are not alone: 18 million adults (7.2 percent) and Atopic dermatitis often develops in early childhood 9.6 million children under the age of 18 (13 percent) – appearing during the first 6 months or within the first have AD, according to the National Eczema Association. 5 years. Among children, 3.2 million have moderate-to-severe symptoms. Under the Skin Atopic dermatitis is a chronic inflammatory skin While its cause is unknown, doctors believe AD is disease. It can cause red patches on the skin that itch; related to genetics, an that is sensitive dry and scaly skin; thickened skin; and open, oozing, to and irritants, and a defective skin barrier crusty sores. AD symptoms often appear on the face, that allows moisture to escape and allergens and bacteria neck, hands, wrists, elbows, knees, ankles and feet. to invade. Seventy percent of people with AD report a

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“My skin breaks “My daughter out with red, had severe atopic itchy bumps dermatitis from when my dog birth until she jumps on me. It was about 6 hurts pretty bad months old. Within when I scratch 24 hours after it. One time it switching her diet got infected. I to a hypoallergenic try to avoid our formula, her skin dog now, but it’s was silky smooth hard.” and has been for – Dev, 16 almost two years. I encourage parents to explore food allergies if their child has atopic dermatitis.” – Whitney, 32

family history of the condition. Some people with atopic The most common TRUE OR FALSE? dermatitis may lack a specific environmental allergens that Atopic dermatitis is contagious. type of protein, called , trigger symptoms include dust in their skin. This protein serves as FALSE! , pet dander, pollen and mold. a protective barrier from allergens, You cannot “catch it” or spread Food allergens are also possible irritants and infections. When it to others through physical triggers, especially in children. Irritants filaggrin is lacking, it weakens the skin contact. Atopic dermatitis such as wool or man-made fibers, barrier function of the skin. Some people does tend to run detergents, soaps, cleaning products, some with atopic dermatitis also have high blood in families, but skin care products and tobacco smoke are also levels of (IgE), this is due to common triggers. produced by the immune system that set off genetics. Exposure to these allergens and irritants allergy symptoms. triggers immune cells to release , and other chemicals to rid the irritants On the Skin from the body. The resulting inflammation signals the Early diagnosis and treatment are essential to avoid brain to move your hand to the itchy spot and scratch skin complications and improve quality of life. … and scratch. That only makes it worse, resulting in an Treatment begins with avoiding or reducing exposures endless cycle. to known allergens and irritants – immunotherapy Too much scratching can lead to infection if the to build tolerance to allergens is one option. Then, surface of the skin is broken. Signs of infection include keep your skin moisturized with creams or ointments, yellowish, crusty skin (often on top of the eczema), red, especially during hot summers and dry winters, to lock swollen bumps and pus-filled . moisture in your skin and protect against future .

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“I play basketball in a men’s league The Eczema Umbrella every winter, and Eczema is often used interchangeably with about an hour after atopic dermatitis. The word has Greek origins – it the game is over, means “to over.” It applies broadly to a range of persistent skin conditions: my neck, arms and knee turn red, • Atopic dermatitis: a chronic and recurrent inflammatory skin condition that causes red, scaly and itchy. dry, itchy, painful skin and oozy, scaly rashes. I have trouble • Contact dermatitis: a reaction to an sleeping at night or irritant (detergent, soap, scratchy because of it.” clothes, fragrances or nickel jewelry) that – Ron, 35 touches the skin. • Dyshidrotic eczema: fluid-filled blisters that appear mostly on hands and feet, usually caused by sweat, water or exposure to nick- el; more common among women and rarely appears in children under 10. • Nummular eczema: itchy, coin-shaped spots or that appear on the hands, arms, chest or legs. • Seborrheic dermatitis: red, greasy swollen skin and white crusty flakes that occur in areas of the body that tend to be oily. It’s found in infants on the scalp or the folds of the skin; it’s known as in older children and are the first-line therapy for treating adults. atopic dermatitis. They work best if used frequently • Stasis dermatitis: pressure build-up in to prevent itching; other treatments include topical blood veins, often in the lower legs, forcing that target inflammation. Topical fluid to leak out of the veins and into the skin; immunomodulators, which regulate the local immune it can cause redness, discolored skin, oozing, response of the skin, help reduce the redness and itching infection, ankle swelling and scaly, dry, itchy of inflamed skin. Antibiotics are used to treat skin skin. infections. Biologics are medications that target cells dermatitis, especially if they are and pathways that cause inflammation. moderate or severe. Communication (Dupixent ®) is the first Because atopic is as important as treatment in biologic approved by the U.S. Food dermatitis can be coping with AD; studies show and Drug Administration (FDA) for the condition has a significant atopic dermatitis – it is currently long lasting, it’s important impact on mental health and approved for adults with moderate- to learn how to take care of quality of life. to-severe atopic dermatitis when With time and treatment, topical treatments have not your skin. Treatment and good and as children mature, worked. Dupilumab is taken every skin care can relieve much atopic dermatitis may go two weeks by injection. away – but it sometimes of the discomfort. continues into adulthood. Doc Talk – American Academy of Between 10 and 30 percent of Talk with your primary care doctor, pediatric patients will experience an allergist or a dermatologist if you symptoms in adulthood. or your child develop symptoms of atopic

6 Allergy & Asthma Today Special Edition AllergyAsthmaNetwork.org ATOPIC DERMATITIS DEFINED

Atopic Dermatitis Fast Facts Eczema in the 27.6 million people in the U.S. have United States AD, the most common form of eczema. • Adults: 18 million 31.6 – 6.6 million have million moderate-to-severe AD As people • Children: a chronic SLOVAKIA 9.6 million disease with – Symptoms by age 1: 60% no cure, AD is one U.S. Healthcare Burden – Symptoms by age 5: 90% of the most common – 3.2 million have Overall cost to treat AD skin diseases moderate-to-severe AD globally. patients (2016): SLOVAKIA $314 million

SLOVAKIA

Family History Gender Race/Ethnicity Outgrow AD? GENETICS• 70% of people GENDERAD prevalence is split RACE/ETHNICITYAD affects people of OUTGROWMany children AD? outgrow • 70%with ADof people report a ADevenly is slightly among more men and ADall races affects but people it is more •AD Many , but children10-30%

withfamily AD historSLOVAKIA reporty of a the commonwomen. among women ofcommon all races among but it isAfrican continueoutgrow to AD, experience but familycondition history of the than• Mild men. symptoms: moreAmericans common (especially among relapses10-30% as continue adults. to • condition.Children born into • MildMore symptoms: women multiracialchildren) and and A African-sian/ experience relapses • Childrenfamilies thatborn h intoave a • MoreModerate women to severe AmericanPacific Islanders populations than as adults. familieshistory ofthat asthma have aor • Moderate-to-severesymptoms: slightly thanCaucasians. Caucasians. • Do not disregard historyallergic ofrhinitis asthma are or symptoms:more men slightly treatment expecting allergicat an increased are risk more men your child to outgrow atfor an d evincreasedeloping AD risk AD. Follow your for developing AD. treatment plan.

QualityQuality of ofLif eLife Impact Impact On People with AD... People with AD – • • are increased at an increased risk of risk of e•xperiencing more sleep anxiety and depression• less productivity • feelings of • experienceexperiencing more anxiety sleep disturbances,disturbances, including trouble fatalling school asleep or work embarrassment or • reportand depression less productivity at scincludinghool or w orktrouble anger about their • report feeling embarrassed orfalling angry asleep about their appearance appearance

1 in 5 children diagnosed with1 inAD 5 fchildrenace bullying diagnosed. with AD face bullying. Sources: American Academy of Dermatology; American College of Allergy, Asthma & ; Sources:National American Eczema Academy Association; of Dermatology; U.S. Centers American for Disease College Control of Allergy and ,Prevention; Asthma & Immunology;National Institutes National of Health Eczema Association; U.S. Centers for Disease Control and Prevention; National Institutes of Health

800.878.4403 Understanding Atopic Dermatitis 7 ATOPIC DERMATITIS DEFINED The Allergic March llergies often first express themselves as atopic vegetables, fish and may reduce the risk of dermatitis in young children. The skin condition a child developing eczema, according to the American Ais associated with food allergies, Academy of Dermatology. Taking a during and asthma – the so-called allergic march. About 50 pregnancy may also slightly lower a child’s AD risk. percent of children with AD develop asthma and 33 And regular breastfeeding in the baby’s first year of life percent develop food allergies. Children with AD are may decrease the likelihood of the child developing AD. also at higher risk of developing allergic rhinitis. Talk with your doctor before considering any Is it possible for parents to stop AD before it starts interventions, especially involving diet during and halt the allergic march? pregnancy.

Breaking the Link Atopic dermatitis is common among infants and it often runs in families. Infants around 3-6 months of age may start to show dry, itchy skin and formation of red, irritated patches. The daily application of an unscented to the baby’s skin shortly after birth may delay and possibly prevent the onset of AD, doctors say. The treatment can prevent moisture loss and damage to the skin, as well as serve as a protective barrier from allergens and irritants. AD often takes a waxing and waning course and it can be worsened by many different factors including fragranced soaps, detergents and lotions; serious illness; severe weather; or exposure to allergens. Symptoms can be very severe for some children. In addition to intense itching, their skin can become so dry and irritated that it may bleed from scratching, which can lead to infection. As researchers continue to study what causes AD, as well as allergies and asthma, they are discovering interventions may be possible. While no specific diet or food can prevent AD, recent studies suggest expectant moms who eat a healthy diet rich in fruits and

The Peanut Problem Infants and young children with moderate-to-severe eczema are at risk for developing , according to multiple studies. New peanut allergy prevention guidelines from the National Institutes of Health say infants with severe eczema, or both are at high risk for peanut allergy and should be given peanut-containing foods as early as 4-6 months of age to reduce the risk. Infants with mild to moderate eczema should be given peanut-containing foods around 6 months of age to reduce the risk of peanut allergy. Always talk with a board-certified allergist before introducing peanut to a child at risk for peanut allergy. Studies addressing eczema and early introduction of other food allergens – such as cow’s milk and egg – are ongoing.

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Type 2 Inflammation

A systemic allergic response known to play a role in classic allergic diseases – including moderate-to-severe atopic dermatitis (AD), asthma and nasal allergies.

Who has Type 2?

50- 50% 80% 70% patients with AD patients asthma patients nasal polyps

Other conditions believed to be People with AD may have high levels impacted by Type 2 inflammation: of Immunoglobulin E (IgE), antibodies produced by the immune system AERD, sinusitis, rhinitis, GERD, sleep apnea that set off allergy symptoms.

Genetics Play a Role

If one or both parents have AD, asthma or nasal allergies related to Type 2 inflammation, their child is += MORE 4X more likely to have one or more of the conditions. 4X LIKELY

Impact

50%% >50%% >2/3 of children with AD of AD patients report feeling say AD interferes also develop asthma frustrated with the disease with daily life and activities

Pathways to Type 2 Treatment

The cytokines IL-4, IL-5, IL-13 and ILC2 The biologic dupilumab (for moderate to severe AD) (secreted proteins that signal cells and inhibits the pathways of IL-4 and IL-13. The medication: begin the immune response) are major • reduces inflammation contributors to Type 2 inflammation. • calms the immune system • improves quality of life

800.878.4403 UnderstandingUnderstanding AtopicAtopic DermatitisDermatitis 9 SYMPTOMSSYMPTOMS

What to Watch For...

Atopic dermatitis SYMPTOMS OTHER SIGNS typically starts in early • Itchy skin • Infants may rub childhood. It’s a chronic • Red patches of sensitive skin against bedding to condition that is often • Dry, cracked skin relieve itching hereditary and can last • A rash that feels very leathery or scaly • Itchiness may into adulthood. • Open, crusty or weepy sores impact sleep

Common Areas Affected Infants and Young Children Older Children, Teens and Adults

• Eyelids• Eyelids

• Scalp• Scalp • Face• Face • Behind• B theehind ears the ears • Neck• Neck • Cheeks• Cheeks • Arms• Arms • Folds• ofFolds elbo ofws elbows • Wrists• Wrists • Wrists• Wrists • Knees• Knees • Hands• Hands • Back• of Ba kneesck of knees

• Feet• Feet

A of atopic dermatitis is atopic keratoconjunctivitis, a chronic inflammatory disease of the eye that affects patients with atopic dermatitis. All severe AD patients should get a routine eye exam.

Signs of Infection Constant scratching due to atopic dermatitis can lead to an infection.

Symptoms If symptoms occur, seek immediate medical help • Oozing skin from a healthcare professional. • Blistering An infection – especially in infants and young children • White or yellow pus from open sores – can lead to complications such as a prolonged flare, • Severe symptoms may include a intense itchiness and blisters, scarring, drug resistance fever, achiness and fatigue and a severe blood infection called sepsis.

Sources: American Academy of Dermatology; American College of Allergy, Asthma & Immunology; National Eczema Association; National Institutes of Health

1010 AllergyAllergy && AsthmaAsthma TodayToday SpecialSpecial EditionEdition AllergyAsthmaNetwork.org SYMPTOMS A Clear Diagnosis

he red, itchy rash on your child’s arm – it’s atopic dermatitis, for sure. But what’s triggering it? T Patients can undergo testing to find out what allergens and irritants are worsening symptoms. Knowing what triggers your AD puts you one step closer to reducing symptoms, whether through avoidance, medication or other treatments.

Skin Prick Test Droplets of suspected allergens are placed on or just under the skin surface. Raised bumps (about the size of a mosquito bite) strongly indicate an allergy to the substance. Skin prick testing is commonly used by allergists because of its accuracy, ease of use and immediate results. Results are typically Oral Food Challenge known within 20 minutes. If it’s believed a is causing symptoms, the doctor may want Blood Test to perform an oral food After a blood sample is challenge. In this test, the drawn, it is analyzed to detect patient is asked to eat a IgE antibodies directed at tiny amount of a suspected specific allergens. Tests may allergen, and then gradually larger amounts, to measure specific or overall determine if there’s an allergic reaction. The challenge levels of IgE. Some may also should only be conducted by a doctor and at a medical break down common allergens facility that has access to epinephrine and other and measure IgE to specific components. Lab results may emergency treatments. take several days. Consult with your doctor to ensure the blood test is The Results Are In... interpreted correctly. AD typically results in very high After testing, your doctor will compile all of the IgE levels and may falsely elevate results. evidence together – test results, your personal and family health history, physical exam, home and work environments, activities that might expose you to Chambers containing allergens – to reach a diagnosis. chemicals of potential triggers on adhesive strips are placed onto the patient’s back. Other Tests After 2-3 days, the patches • Buccal swabs – used to detect mutations in the are removed by the doctor filaggrin gene, the protein that helps protect the and the skin is evaluated for body from allergens and bacteria; a lack of filaggrin reactions. If symptoms appear, then it’s confirmation of weakens the skin barrier, leading to eczema. an allergy. Patch testing is commonly used for contact • Skin biopsy – a tiny piece of skin is removed and allergies to fragrances, detergents, metals and other analyzed under a microscope; it can rule out other chemical sensitizers. skin diseases such as skin cancer or .

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What’s Worsening My Eczema? Common Triggers and How to Avoid Them

n important part of an eczema treatment plan Once you’ve identified a potential trigger, try is preventing exposure to allergens and irritants avoiding it to see whether your skin improves. Athat set off skin problems. First things first – you must identify what is triggering your symptoms. Trigger Points Triggers and symptoms are different for everyone. What makes identifying them so challenging is CONTACT ALLERGIES – Eczema is sometimes set off sometimes a flare-up can occur hours after the initial by something a person is in contact with on a regular exposure. Some people may experience symptoms on basis. It could be a piece of jewelry that contains certain areas of the body or only at certain times of the nickel; rubber; or chemicals used in cosmetics, year. disinfectants and skin products. If Trigger avoidance is essential in managing eczema, necessary, an allergist can do a patch test but it’s important to remember that, since eczema is a to identify the specific allergens causing the systemic condition, it is not a cure. problem. Other potential skin allergens include: • Antibacterial ointments such as neomycin and Be a Detective bacitracin Use a daily diary to keep track of symptoms and what • Formaldehyde, which is found in household may have set them off. Here’s a checklist of questions to disinfectants, glues and adhesives. ask yourself: • Do certain fabrics cause my skin to itch? DRY SKIN – When your skin is dry, it can lead • What time of year is it? Do changes in weather to eczema symptoms. Some people have a genetic lead to eczema symptoms? condition associated with a skin protein called • What foods do I eat that cause my skin to break filaggrin that causes their skin to lose moisture out in a rash? and allow allergens and bacteria to enter • Do I itch after working out? the skin more easily. The best way to • Do my eczema symptoms flare up around pets? prevent an eczema flare is to keep your skin • Does my skin flare up after using certain well moisturized. Recent research suggests that cosmetics, moisturizers, soaps or fragrances? moisturizing a baby’s skin from birth may help prevent • How was I feeling when the symptoms appeared? eczema from developing.

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DUST MITES – These tiny insects live in mattresses, FURRY PETS – Pet dander (dead skin cells), saliva pillows, upholstered furniture – anywhere they can find or urine are normally harmless proteins, but for people moisture along with their favorite food, tiny bits of with eczema they can trigger skin symptoms in shed human skin. Atopic dermatitis patients addition to respiratory problems. may be allergic to them. Allergens from Early exposure to pet dander may their droppings and dead bodies collect contribute to the development of atopic in bedding, furnishings and house dust, dermatitis in children who are prone to the then irritate skin, airways and eyes on contact. condition. When atopic dermatitis is already flaring, dust Finding a new home for the furry pet is the most allergens can worsen the problem. Encase your bed’s effective way to reduce levels of pet allergens in the pillows and mattress with allergen-proof covers to put home, but if that’s not a consideration, bathe your pet a barrier between you and the dust mites. Wash linens at least once a week and set up no-pet zones, including weekly and vacuum carpets, floors and furnishings with the bedroom. a HEPA vacuum. HORMONES – In women, hormone fluctuations ENVIRONMENTAL ALLERGIES – People with may trigger or worsen eczema symptoms. eczema may experience symptoms after exposure to Hormone changes occur just before and certain grass, tree or pollen and/or indoor during menstruation, during pregnancy, or outdoor mold. It’s best to treat symptoms after pregnancy, or when transitioning to that arise from environmental allergens menopause. with aggressive moisturizing, along with and topical corticosteroids OUTDOOR TEMPERATURES – Whether because it if necessary. dries out skin or causes sweating, heat is a common Skin prick or blood testing for environmental eczema trigger. Sweat, in particular, can collect allergies will help identify specific allergens to in your armpits or inner part of your elbow, avoid. Some patients may do well with allergen leading to skin irritation. Meantime, in immunotherapy (allergy shots or tablets), in which a winter months, humidity that provides patient is given a gradually increasing amount of an moisture in the air decreases, resulting in dry allergen to build tolerance and reduce symptoms. skin. In addition, a sudden rise or drop in temperature can FOOD ALLERGIES – Food allergens can play a role in trigger an eczema flare. the onset of eczema symptoms, particularly for infants Strategies to keep comfortable in hot and cold and young children. Between 35 and 60 percent of weather include: young children with moderate to severe eczema HOT WEATHER also have food allergies. It’s believed the • Wear appropriate clothing: light, breathable breakdown of the skin barrier contributes clothes in the summer. to an allergic response when a food allergen • Avoid going outside during peak heat times is consumed. during the day, usually between 10 a.m. and 3 Among children under the age of 2, eczema is most p.m. If you do go outside, keep a small towel often related to milk or egg allergy, but it can occur with you to wipe away excess sweat. with any food. Other common food allergens include • Stay hydrated to moisturize from the inside out. peanut, tree nuts, fish, shellfish, soy and . Consult with a board-certified allergist for a diagnosis and then COLD WEATHER develop a plan to avoid the food allergen. • Wear gloves in the winter (since hands are Food-allergic patients are also at risk for , particularly sensitive and often exposed to cold). a severe allergic reaction. Always carry two epinephrine • Consider a humidifier to moisturize the indoor auto-injectors, the treatment for anaphylaxis, if you air. have a food allergy.

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SKIN IRRITANTS – While they are not true allergens, TOBACCO SMOKE – Cigarette smoke, including some soaps, shampoos, detergents, fragrances and wool secondhand smoke, can irritate skin in or synthetic clothing can significantly irritate addition to the lungs and eyes. Set a no- sensitive skin. Heavy or tight clothing that smoking policy both inside and outside rubs against the skin can also cause your home; smoking is a major health issue for symptoms. everyone. Use gentle, nonirritating products and stick with them. Natural fiber clothing such as cotton VIRAL AND BACTERIAL INFECTIONS – The or silk is usually most comfortable. Once an area gets common cold can cause an eczema flare. In addition, irritated, it can take a long time for it to calm down. the herpes virus, which can cause cold sores in and around the mouth, can lead to flares – including STRESS – An increase in stress levels may either , a potentially serious cause an eczema flare or worsen an existing one. infection that can spread core sores on Some patients may scratch more often when other areas of the body. Also, exposure to they’re feeling pressure. bacteria can cause harmful toxins to secrete into Managing stress effectively can reduce the skin, prompting an immune reaction and causing flares. Coping strategies such as meditation skin inflammation. One of the more common bacteria or yoga, regular exercise, getting enough sleep, and is (staph infection, also known connecting with family and friends are great ways to as MRSA), which can not only worsen eczema but also take your mind off your worries. slow skin healing.

When to See a Specialist ost people with atopic dermatitis, whether a worsen, as well as about the types of soap, detergent and child or adult, get their initial diagnosis from a skin care products you use. Mprimary care doctor. If the red, itchy rash stays the same or worsens after initial treatment, it may be Allergist or Dermatologist? time to see a specialist – either a board-certified allergist Allergists are trained to treat skin conditions (such or dermatologist. Both possess skilled knowledge and as atopic dermatitis) related to an allergic response, experience to treat atopic dermatitis and other eczema- as well as food allergies, environmental allergies and related skin conditions. asthma – the allergic march. If you or your child display moderate-to-severe Dermatologists are specially trained to treat symptoms, then it’s likely you need a treatment plan conditions related to the skin, hair, nails and mucous beyond what standard over-the-counter creams, membranes (the lining inside the nose, mouth and ointments and other medications can provide. A eyelids). specialist can best make that determination. Both specialists can conduct tests to identify Whether you see an allergist or dermatologist, you’ll allergens and irritants that trigger skin symptoms and likely be asked similar questions about environmental put together a comprehensive treatment plan. exposures that may be making your atopic dermatitis

14 Allergy & Asthma Today Special Edition AllergyAsthmaNetwork.org TREATMENT & MEDICATIONS

Repair the Skin Barrier How Moisturizing Helps

eople with atopic dermatitis have a damaged skin Look for products that do not contain added barrier that makes it harder to retain water. As a ingredients – such as fragrances, dyes or alcohols – that Presult, their skin becomes dry and itchy – and more can irritate the skin. sensitive to harmful allergens, irritants and bacteria. • Ointments Moisturizers are the first-line therapy in treating Ointments typically contain the most oil and are atopic dermatitis. They help protect the outer layer of effective at sealing in moisture. Mineral oil and the skin by sealing in moisture, combatting dryness, petroleum jelly are recommended, as is coconut keeping out allergens, irritants and bacteria and oil as long as you or your child are not allergic to preventing flare-ups. And they soothe the skin for coconut. long-lasting hydration. • Creams Doctors recommend you apply a Creams contain less oil than ointments. If you moisturizer at least twice per day, don’t like the greasy or sticky feeling from using including once after a bath or shower. ointments, then consider using a cream. Develop a schedule so that moisturizing • Lotions becomes part of your skincare routine. If you Lotions contain more water than oil. As a result, experience symptoms on your hands, keep moisturizer these do not seal in the moisture as well as by all sinks in the home or carry a small tube with you. ointments and creams. Lotions also are more likely This way you can easily moisturize every time you wash to contain fragrances, preservatives and other your hands throughout the day. ingredients that can harm sensitive skin. Important: If your doctor prescribed a topical Important: Always check the product label before medication to treat your atopic dermatitis, make sure to you buy a moisturizer – not only to confirm its beneficial use it as directed before you put on a moisturizer. ingredients but also to find out if it has any allergens or irritants. Hydrate the Skin When considering a moisturizer, the first thing to look for is how much oil it contains. The more oil in a How to Apply moisturizer, the better it is for treating atopic dermatitis. If your skin feels greasy or sticky after applying a Moisturizer moisturizer, that means the product likely contains 1. Soften the moisturizer by rubbing it between plenty of oil. your hands. Types of ingredients in moisturizers include: 2. Apply it to affected areas using your palm, in a humectants (ceramides, glycerin, sorbitol), which help downward stroke. draw in moisture; petroleum jelly, mineral oil, coconut 3. Use a thick layer; the skin will absorb any oil, silicone and/or lanolin, which help seal in moisture; excess moisturizer within a minute. and emollients (linoleic and lauric acids), which help smooth the skin.

800.878.4403 Understanding Atopic Dermatitis 15 TREATMENT & MEDICATIONS To Bathe or Not to Bathe?

topic dermatitis is more than just dry skin. Flares erupt unpredictably: dry, scaly, irritated spots Aon the face or hands, or inside the crease of the elbow or knee. The itch is almost unbearable – and scratching makes it worse, resulting in what feels like an endless cycle. AD has no cure, so preventing and managing flare- ups becomes a priority. The trick is figuring out how to get moisture back into the skin and keep it there. Slathering on moisturizer by itself usually won’t do it; neither will 3-Step Soak and Seal simply soaking in a bath. In fact, some people think bathing dries out the skin 1. Soak your skin in lukewarm water (not hot and makes it worse: We all know how frequent water), either a bath or a shower, for 10-15 hand-washing dries out the hands. The reason minutes. Skip the soap or bubble bath: stick to for this is not the water itself, however, clear water. If necessary, use a gentle cleanser free but the soaps we use and the fact that of fragrances and chemicals. For areas like your we often just wash and dry – forgetting to face that can’t be soaked in a tub, apply a wet add a moisturizer to seal in the water. washcloth for at least 5 minutes. It may be true that bathing too frequently can dry 2. Gently pat the skin dry with a soft towel – don’t out skin and exacerbate AD, but rather than skipping rub, as that will irritate the sensitive areas. baths, doctors recommend shorter ones. 3. Apply moisturizer immediately (within 3 minutes To ease the itch and rehydrate the skin, doctors is the rule) to seal the water in. If you have a recommend a “soak and seal” method. Soak the prescription skin medication, use that first on skin to allow water to absorb, then use a moisturizer affected areas. Then use a high-oil-content immediately to seal in the wetness. ointment. Petroleum jelly may be messy, but it’s often the best solution for AD flares. In general, use fragrance-free, dye-free or clear ointments. Body Washes Lotions contain too much water or Most soaps tend to dry out the skin, so finding a and easily evaporate, while some creams have quality soap that keeps the skin moist is important preservatives or fragrances to which you may be for people with eczema. (Do not use bubble bath – sensitive. they use chemicals to bring on the bubbles.) Liquid cleansers are much less harmful to the skin Extra Help than bar soaps. Emollient-rich liquid cleansers dry out Some doctors suggest putting a half-cup of household the skin the least and add moisture. bleach or a cup of vinegar into the bath water. The For those using bar soaps, the American Academy of theory is that bleach and vinegar may help kill bacteria Allergy, Asthma & Immunology (AAAAI) recommends and prevent infection. nonsoap cleansers because they are usually free of Others suggest adding bath oil, salt, baking soda or sodium lauryl sulfate, a chemical that creates the oatmeal to help ease persistent itching. Baking soda soap’s foam and can irritate the skin. and oatmeal can also be made into a paste that can be Avoid using washcloths, sponges or loofahs that may applied to the skin. scrape the skin. Talk with your doctor about whether you should try these specific baths.

16 Allergy & Asthma Today Special Edition AllergyAsthmaNetwork.org TREATMENT & MEDICATIONS Under Wraps eople with atopic dermatitis often have two After sealing topical medication under the wraps, problems: a defective skin barrier that dries out they found the treatment: Peasily and is more open to invasion from allergens • Relieved inflammation and itching rapidly and germs than normal; and an overly sensitive immune • Kept patients off of systemic corticosteroids system. • Protected skin to allow healing That means treatment needs to be twofold: “Wet wrap therapy provided a lasting benefit, even • Repair the damaged skin though it was used on average only 4-5 days,” • Avoid exposure to allergens and irritants Dr. Boguniewicz says. Sounds simple, but anyone who deals with AD knows that it is anything but easy. Stopping the itch is key, as the itch-scratch cycle feeds upon itself. For patients with difficult-to- manage AD, one treatment option is wet wrap therapy. After doing a soak-and-seal warm bath and applying medication, the patient’s eczema-damaged skin is wrapped in a layer of wet cloths, topped often by dry clothes – such as pajamas, sweatshirt or tube socks. Plenty of videos demonstrating wet wrap therapy for eczema are available online. Doctors recommend wet wrap therapy as an intervention for moderate-to-severe cases. Wet wrap therapy can reduce the need for medication, but it should be done only after consulting with a physician.

‘A Lasting Benefit’ National Jewish Health eczema expert Mark Boguniewicz, MD, says most patients and caregivers have difficulty understanding the chronic nature of eczema, with its frequent relapses, lack of a real cure, and limitations of prescription medications. He also says it can be a challenge to know what to put on the skin and when, where and how much. In a recent study, Boguniewicz and his colleagues tested wet wrap therapy on a large group of children with moderate-to-severe eczema.

800.878.4403 Understanding Atopic Dermatitis 17 TREATMENT & MEDICATIONS Come Together How Doctor-Patient Partnerships Are Transforming Healthcare

ealthcare works best with collaboration and coordination to arrive at the best care for you. HThis practice is called Shared Decision Making – and it benefits doctors and patients alike. Shared Decision Making encourages patients and families to take a central and active role in their care by working with doctors to select tests and treatment plans. It is evidence-based and balances risks and results with a patient’s preferences and values. In short, it personalizes care. Studies show when patients and families work closely with doctors and make healthcare decisions together, it improves their knowledge of the condition and they are more likely to adhere to treatment plans and go to follow-up appointments. Allergy & Asthma Network has partnered with the American College of Allergy, Asthma & Immunology (ACAAI) to develop an interactive Shared Decision Making Tool for atopic dermatitis patients. The tool is available at EczemaRelief.acaai.org.

Benefits of Shared Decision Making • Improves patient outcomes and satisfaction • Increases patient knowledge • Improves self-management skills • Creates more certainty, less anxiety • Ensures follow-through on treatment plan • Aligns with patient preferences and cultural values • Builds a trusting relationship with the doctor

New Treatment Guidance Innovations in atopic dermatitis therapy the last few step up or adjust therapy. It offers practical years have provided doctors and patients with new recommendations about which medications are treatment options. appropriate at which stage of diagnosis. Leading board-certified allergists and dermatologists The Yardstick includes guidelines for prescribing new combined these treatment options into the Atopic medications on the market, including the injectable Dermatitis Yardstick, published in the January 2018 biologic dupilumab (Dupixent®) for patients 18 years Annals of Allergy, Asthma and Immunology. or older with moderate-to-severe atopic dermatitis. The Yardstick uses patient profiles to help doctors The complete Atopic Dermatitis Yardstick can be determine what steps should be taken to start, found at www.annallergy.org.

18 Allergy & Asthma Today Special Edition AllergyAsthmaNetwork.org TREATMENT & MEDICATIONS

What’s the Best Treatment for My Atopic Dermatitis? If moisturization (including soak-and-seal after bathing) and management strategies (reducing exposures to allergens and irritants) are not fully effective in treating your atopic dermatitis, your doctor may recommend topical or systemic medications. Discuss the pros and cons of each medication option.

Topical Treatments Medicated ointments, creams, lotions, gels, oils or sprays that you apply to the skin.

Corticosteroids inhibitors Crisaborole 2% Use: Controls redness and itching; For use on eyelids, armpits, For use on eyelids, armpits, apply 1-2X per day; approved mouth area, groin; apply 1-2X mouth area, groin; apply 1-2X for children, including infants as per day; approved for children per day; approved for children young as 3 months ages 2 or older ages 2 or older Side Redness, stretch marks, skin Stinging or burning may occur Stinging or burning sensation effects: thinning, spider veins, face rash upon first use; very slight risk of may occur infection Cost*: Low to moderate cost Moderate cost High cost

Systemic Treatments Injectable biologics, oral corticosteroids or phototherapy designed to treat the entire body – typically prescribed for patients with persistent, moderate-to-severe atopic dermatitis who need more than topical treatments.

Dupilumab Oral or injectable Phototherapy (Dupixent®) corticosteroids () Use: Biologic medication injected Daily pill or long-acting injection Exposure to (UV) light under the skin every 2 weeks; given at doctor’s office – should to reduce inflammation and itch not currently available for not be used long-term due and boost the body’s ability to children to side effects; approved for fight bacteria; can be applied children to specific areas or entire body; approved for children ages 6 and older

Side Redness or itching at injection Weakened muscles; bone ; skin aging; risk of skin effects: site; eye or eyelid inflammation; thinning; eye problems; diabetes; cancer allergic reaction sleep problems; mood swings or behavior changes; symptoms may worsen post-treatment Cost*: High cost Low cost Moderate to high cost

* May depend on your health insurance coverage

You Make the Call Take the complete Shared Decision Making Tool at EczemaRelief.acaai.org. Share the results with your doctor so that you both come to a decision on the best treatment plan for you.

800.878.4403 Understanding Atopic Dermatitis 19 TREATMENT & MEDICATIONS

Find Your Relief Many over-the-counter and prescription medications are available to treat atopic dermatitis

he first approach to managing atopic dermatitis is vigilant skin care and hygiene, but many patients Corticosteroids (Topical) Trequire more. While there are no medications that “cure” the condition, the good news is that there are Many prescription and over-the-counter corticosteroids many medications both over the counter and by are available prescription that can relieve symptoms. Every individual’s AD is unique, WHAT THEY DO with different triggers and different • Relieve itch symptoms. As a result, treatments • Reduce inflammation will vary from one person to another • Reduce dryness – and even from one flare to another. • Prevent flares from recurring What works for you one time may need to be changed in the future. WHAT YOU NEED TO KNOW It’s important to work with your physician on a • Often the first line of treatment for eczema. personalized treatment plan. Then get to know your • Available as creams, solutions, foams and medications so you understand how to manage your ointments. symptoms most effectively. Talk with your doctor or • Low potency doses available without a prescription. pharmacist about any possible side effects. Read labels • Can cause thinning of skin. carefully and follow dosing and safety instructions. • If recommended by physician, may be used 1-2 times per week to prevent outbreaks in areas that commonly flare.

20 Allergy & Asthma Today Special Edition AllergyAsthmaNetwork.org TREATMENT & MEDICATIONS

• They come in different strengths; do not substitute • Avoid sunlight and sunlamps – calcineurin one for another without consulting a doctor. inhibitors may cause skin to be more sensitive to • Children’s skin absorbs medicine more quickly light. and thoroughly than adult skin, so recommended • May cause skin pain (such as a burning sensation), medications and dosages differ according to age. especially when applied to acutely inflamed skin. • For best and long-lasting results, use the medication • FDA warning: May increase risk of skin cancer for the full amount of time recommended by your and non-Hodgkin’s lymphoma. The American physician. Discuss any concerns about side effects Academy of Dermatology says this risk applies to before discontinuing use. oral forms of the medication taken at high doses • Always tell your physician and pharmacist about for long periods of time; the risk is lower with current or recent use of all forms of corticosteroids, limited topical use. including oral, inhaled, nasal, topical and eyedrops. PDE4 Inhibitors (Topical) Corticosteroids (Oral or Injection) Eucrisa® (crisaborole) ointment

Prednisone; ; ; WHAT THEY DO dexamethasone • Reduce inflammation • Reduce swelling WHAT THEY DO • Target PDE4 enzymes deep within the skin to • Relieve itching and inflammation reduce inflammation

WHAT YOU NEED TO KNOW WHAT YOU NEED TO KNOW • Should be used short-term only; follow • Approved to treat mild-to-moderate atopic recommended dosing schedule closely. dermatitis in adults and children ages 2 and up. • Approved for severe or difficult-to-treat eczema. • Works differently than other topical treatments • Side effects may include bone loss, diabetes, weight such as ointments and calcineurin gain and eye problems. inhibitors. • Skin may flare when medication is stopped. • PDE4 is produced by cells in our immune system • To prevent health risks from overuse of and helps the body regulate inflammation. corticosteroids, tell your doctor or pharmacist about all current or recent use of corticosteroids, including oral, inhaled, nasal, topical and eyedrops. Antibiotics (Oral or Topical) WHAT THEY DO Calcineurin Inhibitors (Topical) • Treat bacterial or staph skin infections

® ® Protopic () ointment; Elidel WHAT YOU NEED TO KNOW () cream • Topical antibiotics are used for small, localized bacterial infections; oral antibiotics are used for WHAT THEY DO more extensive or severe skin infections. • Reduce inflammation • Topical antibiotics are sometimes not • Reduce itch recommended, as they can be associated with • Combat dryness and may contribute to antibiotic • Prevent flares from recurring drug resistance. • Mupirocin is a prescription topical antibiotic WHAT YOU NEED TO KNOW usually applied to the affected area three times per • An alternative to topical corticosteroids, when day for 1-2 weeks. skin is being damaged or there is concern about • Bleach baths may also be effective in treating and overuse of steroids. preventing infection. • Approved for adults and children age 2 and up. • May be used 2-4 times weekly as maintenance/ preventive treatment.

800.878.4403 Understanding Atopic Dermatitis 21 TREATMENT & MEDICATIONS

Antihistamines (Oral) WHAT THEY DO • Relieve allergy symptoms related to atopic dermatitis • May help with sleep

WHAT YOU NEED TO KNOW • “First generation” sedating antihistamines such as (®) and chlopheniramine (Chlor-Trimeton®) may help with sleep and itch, especially at night Healing Power when itching is often at its worst. Nonsedating The potency of topical corticosteroids vary antihistamines may help with itching throughout according to the active ingredient and the the day without the drowsiness. dosage, as well as the formulation and type of • Topical skin creams are not application, such as cream or ointment. recommended as they may irritate the skin or result in a future allergy to oral or topical forms of LOW POTENCY Benadryl or (Zonolon®). •  acetate; 1%; cream/ ointment • ; 0.05%; cream/ointment Biologic (Injection) MID POTENCY Dupixent® (dupilumab) • betamethasone valerate 0.05% or 0.1%; cream/ointment WHAT THEY DO • mometasone furoate; 0.1%; cream • Reduce inflammation • hydrocortisone valerate; 0.2%; cream/ • Calm the immune system ointment HIGH POTENCY WHAT YOU NEED TO KNOW • fluocinonide; 0.05%; cream/ointment/gel • Administered by injection every 14 days. • mometasone furoate; 0.1%; ointment • Approved for adults with uncontrolled moderate- • desoximetasone; 0.25%; cream/ointment/ to-severe eczema. gel • Can be used with or without topical corticosteroid • diflorasone diacetate; 0.05%; cream creams or ointments. • Expensive; not always covered by insurance. VERY HIGH POTENCY • Risk of eye-related side effects. • betamethasone dipropionate glycol; 0.05%; ointment • clobetasol propionate; 0.05%; cream/ Systemic Immunosuppressants ointment (Oral or Injection) • halobetasol propionate; 0.05%; cream/ ointment ; cyclosporine; ; mycophenolate mofetil Source: National Institutes for Health Guidelines for Pharmacists. WHAT THEY DO • Suppress the immune system • Reduce inflammation • Very strong medications, developed for chemotherapy and to prevent organ rejection after WHAT YOU NEED TO KNOW transplants • Not specifically approved to treat atopic dermatitis; • Require short-term use and regular blood test sometimes used off-label for moderate-to-severe monitoring by a doctor eczema. • Side effects may include blood pressure and kidney • Sometimes used as an alternative to phototherapy. or liver problems.

22 Allergy & Asthma Today Special Edition AllergyAsthmaNetwork.org TREATMENT & MEDICATIONS

Let There Be Light

Phototherapy, also called light therapy, can reduce phototherapy have positive results, but it’s important to the inflammation that is a part of atopic dermatitis. note that this treatment is not for everybody. It can both lessen the itch and help boost the body’s bacteria-fighting abilities. It can be used in specific areas Medical Supervision that aren’t responding to other treatments, or over the It is important for the doctor to determine what entire body if needed. type of UV light is right for you in order to time the treatments and avoid risks to your health. The amount The Basics of light exposure is timed and increased as treatment Phototherapy is an in-office procedure conducted progresses. by either an allergist or dermatologist. It Phototherapy may start with very short sessions, involves exposing the skin that is affected delivered often, making it difficult for some people to fit by atopic dermatitis to ultraviolet this into their busy schedules. (UV) light. Phototherapy is Some areas may not have phototherapy readily considered a second-line treatment available and accessible. Talk with your doctor. A trip to and is used only for patients who haven’t the tanning bed is not a replacement for phototherapy. had success with other measures. A special light machine is used to deliver Benefits targeted bands of UV light just where it’s needed. Phototherapy often provides relief from the itching, Nearly 70 percent of patients who are treated with swelling and tenderness of atopic dermatitis, with fewer potential side effects than some other treatments. Phototherapy often allows the skin time to heal, UV Light Treatment although it does not make AD go away permanently. Patients should always talk with their doctor to see if Narrow Band Ultraviolet B (UVB) phototherapy is right for them. • Effective with fewer side effects • Uses a very small part of the UVB spectrum • Given 3-5 times per week Potential Side Effects Phototherapy, when done under the direction of Broadband UVB a doctor, is considered safe, but there are several side • Requires treatment 3 times per week initially effects that can occur. As with any exposure to UV light, the skin can get PUVA sunburned or appear to age more rapidly. There are • Medication (psoralen) must be taken with some reports this treatment can lead to skin cancer. this treatment to make it effective One important precaution to take is to wear appropriate • Given 2-3 times per week for 12-15 weeks goggles to prevent injury to the eyes. • Risk of skin cancer; side effect of nausea Moisturizers must be applied following therapy since this procedure can dry out the skin.

800.878.4403 Understanding Atopic Dermatitis 23 MANAGING YOUR CONDITION

The Itch-Scratch Cycle

Skin barrier Scratch damaged Calming

the Itch Itch Allergens, The eczema on your skin is itchy. You scratch. irritants and It again. You scratch again. bacteria enter The cycle seems unending. What doctors now realize is when you scratch skin impacted by eczema, you perpetuate the itch and worsen the condition. Inflammation Here’s how it happens: When you scratch, you break and redness down the outer layer of skin, allowing allergens, irritants and bacteria to enter. Your immune system responds by sending signals to the surface of the skin, causing • Sedative antihistamines can help during sleep; more inflammation, redness … and more itching. This nonsedating ones are available as well and may increases your risk of infection. help relieve itching in some patients. Be sure to Near-constant scratching can also affect quality of confirm the correct antihistamine dosage when life and impact sleep, especially in children. administering it to a child. • Keep fingernails cut very short – especially for Common Triggers infants and young children. Put eczema mittens on a baby’s hands; your baby still may try to scratch, • Sweating but not with fingernails. • Heat • Wear loose-fitting clothes. • Hot water • Keep yourself busy and your hands occupied so you • Exposure to allergens and irritant don’t focus on itching. For children, distract them • Dust with games. • Dry skin • Cooling can relieve itching. Keep cool packs stored • Wool fibers in the refrigerator and place one on itchy areas as • Soaps and detergents needed. Apply a cool compress to the skin or take • Stress a cool shower or bath. If you prefer a bath, stir in colloidal oatmeal, cider vinegar or a half- Break the Cycle cup of baking powder and bathe for 10 minutes. ‘Just stop scratching’ is easier said than done. It may Remember to pat yourself dry and use a moisturizer even cause unnecessary stress, worsening symptoms. within 3 minutes of bathing. Here are strategies and treatments to help relieve or • It may be helpful to keep moisturizers or topical minimize itch in patients with atopic dermatitis. medications cool in the refrigerator as well. • Frequent moisturization can not only soothe the • For temporary relief, rub the skin with vinegar skin but also reduce the itch. water (one tablespoon of vinegar to one quart of • Medications include topical corticosteroids, topical water). calcineurin inhibitors and immunomodulators. • If you must scratch, try stroking the itchy area Talk with your doctor about using these using the top side of the hand instead of your medications for your AD. fingernails.

24 Allergy & Asthma Today Special Edition AllergyAsthmaNetwork.org MANAGING YOUR CONDITION

Sleep Tight

uality sleep is often elusive for people with eczema. It’s a sign that symptoms are not well Treat your symptoms with anti-inflammatories Qcontrolled. such as topical corticosteroids. The goal with anti- Sleep disruption can have a significant impact on 3inflammatories is to break the itch-scratch cycle. well being, especially with kids, because it’s critical to Eczema is an inflammatory condition, so the more you overall health. According to the nonprofit National scratch, the worse the inflammation. Sleep Foundation, lack of sleep can result in: Topical corticosteroids are a very common eczema • Severe fatigue, depression and memory loss treatment. There is a range of strengths (or potency) • Inability to concentrate, listen, learn and problem depending on the location and severity of your AD; solve you can start with a mild-strength topical corticosteroid • Impatience, poor judgment and aggressiveness and then switch to a stronger one if mild is not working • Increased likelihood of contracting colds and the well. flu Some mild topical corticosteroids are available Itching is often at its worst at night, when there are over-the-counter while higher-strength topical no activities to distract your mind and body. Here are corticosteroids require a prescription from a doctor. Talk four strategies to develop a bedtime routine and help with your doctor about these medications. ease the itch: Anti-inflammatories are typically used in conjunction with moisturizers. They control the Moisturize the skin. When bathing, wet the skin inflammation when the skin is moisturized. with lukewarm water – just enough for the moisture An overnight wet wrap using cool or refrigerated 1to soak into the skin. Then, pat the skin dry – clothing may also help relieve itiching. don’t wipe it dry. Apply hypoallergenic moisturizers immediately. This will help the skin trap the moisture. Identify what is causing the itching. The Hypoallergenic moisturizers are recommended triggers can be physical, such as getting hot and because fragrance-based products can sometimes further 4sweaty; contact with a fabric such as wool or irritate the skin. polyester that irritates the skin; soaps or household cleaners; and even emotional stress. Control the itch. Antihistamines, such as The triggers could also be related to environmental diphenhydramine, may help induce sleep and allergies (seasonal pollen, mold, dust mites or pet 2decrease the itch. It may reduce the amount of time dander) or food allergies. Skin testing can help identify it takes to fall asleep, as well as help you get a longer which environmental allergens are causing flare-ups; and better night’s sleep – which is also beneficial for the oral food challenges are used to diagnose food allergies. immune system. Work with your doctor to identify triggers and Always consult your doctor before taking or develop avoidance strategies to better manage the administering medication. condition.

800.878.4403 Understanding Atopic Dermatitis 25 MANAGING YOUR CONDITION The Heat Is On oes your atopic dermatitis flare up during the summer? Dry heat and sweat are common factors Din setting off symptoms. Summer wardrobes such as sleeveless tops and shorts expose it all. Control AD in warm weather by conditioning the skin and soothing the itch. Some tips: • Keep up with moisturizers. Just because summer humidity feels clammy doesn’t mean you can let up on keeping skin hydrated. Follow the 3-minute rule: Apply moisturizers right after a warm (not hot!) bath to seal in water in your skin. • Skip harsh deodorizing soaps and products that contain alcohol, fragrances, retinoids or alpha- hydroxy acid (AHA). Here Comes the Sun • Screen wisely. Sunshine eases eczema for some Can someone be allergic to the sun? Probably not. people, but skin cancer prevention remains crucial. Allergic reactions to the sun’s rays are very rare. If Choose and use sunscreen without fragrances, dyes you develop a skin rash or after being in the and alcohols. (If you’re a new parent, don’t put sun, you are more likely experiencing photosensitivity sunscreen on your baby until after 6 months of age.) – a nonallergic reaction to the sun’s ultraviolet rays. • The more you moisturize at the beach, pool or If you think you’ve experienced photosensitivity, stay out of the sun as much as possible, use a broad- club, the better. Rinse off periodically to wash away spectrum sunscreen that blocks both UVA and UVB allergens, irritants (salt! sand! chlorine!) and sweat rays, wear protective clothing to cover your skin, and on your skin, then reapply moisturizing sunscreen. consult your physician. • Drink plenty of fluids to avoid becoming too hot. Baby It’s Cold Outside uring the winter, our skin loses moisture much more quickly than in the summer, spring or Dfall. This is a problem for people with atopic dermatitis. What are some preventive measures to keep your skin from over-drying in wintertime? • Increase your moisturizing routine. If you normally moisturize once a day, such as after a bath or shower, do it two or even three times a day during winter so skin does not become dry and cracked. • Talk with your doctor about using a stronger medication during wintertime. • Consider a humidifier. Running heaters during the winter makes indoor air even drier; humidifiers are designed to put moisture back in the air. As you dress warmly for the outdoors, make sure you put on hats, scarves, sweaters and gloves that are not made from wool, as these can irritate and increase itching.

26 Allergy & Asthma Today Special Edition AllergyAsthmaNetwork.org MANAGING YOUR CONDITION

Don’t Keep It a Secret Peter Moffat, executive producer of HBO’s ‘The Night Of,’ encourages patients and families to talk openly about atopic dermatitis

or years, wherever Peter Moffat went, he covered up Q: What misconceptions do you think many the red and itchy rashes, dryness, skin flakes, bumps people have about AD? Fand peeling that defined his severe atopic dermatitis A: The biggest one – and the one that hits me hardest (AD). – is that people think it’s contagious. It really speaks to “I did all the classic things – I kept it a secret, I was the lack of knowledge about the disease, that in 2017 ashamed and humiliated by it, and I didn’t want people there are people who believe you can catch AD or other to look at me,” Moffat says. forms of eczema by coming into contact with it. Some Moffat no longer hides his atopic dermatitis. An people will lead their children away from me because accomplished English playwright, screenwriter and they think their kids might catch it. It would be great to producer, he even instills it in his TV characters – most undo that misconception. notably criminal defense attorney John Stone (played by John Turturro) in the HBO series “The Night Of.” Q: What did you learn about AD through writing Now Moffat is raising awareness of atopic dermatitis about it for a TV character? via UnderstandAD.com, a website that educates the A: I have come into contact with so many more people public about the severe and chronic nature of the who have AD and I’m much better informed about their disease. individual relationship with the disease. “I want to help people to be able to talk about it – so I talked to a man who had a job in retail but gave it that it becomes less of a secretive disease, so they don’t up because people would come in, look at his face and feel there’s a stigma attached to it and they don’t feel walk out – and he couldn’t take that. A parent told me socially isolated because of it,” Moffat says. “The more their son doesn’t want to go to school because of how he people talk about it, the better the chance of achieving feels about the way classmates and teachers look at him. that goal.” These stories are incredibly profound. And these Allergy & Asthma Network talked with Peter in a Q&A stories really affected me. interview: Q: What triggers your flare-ups? Read the full Q&A on AllergyAsthmaNetwork.org. A: Often it’s changes in temperatures and heat. When we turn central heating on due to cold weather, it dries my skin. I wear sandals during cold months because it’s better for the AD on my feet to be left open to the air. If I wear socks and shoes all day, my feet are in terrible pain by evening. It’s also not good to have wool next to my skin. And here’s a weird one – contact with a potato peel can cause a flare.

800.878.4403 Understanding Atopic Dermatitis 27 MANAGING YOUR CONDITION Stress-Busters any doctors cite stress as a significant factor in causing eczema flare-ups. Stress does not always Practice mindfulness Mcome from an outside factor; sometimes it’s Meditation and breathing triggered by how you are feeling about your eczema, thus exercises help focus the mind creating a cycle that is hard to break. and can keep you from thinking New York City allergist Payel Gupta, MD, an negative thoughts or jumping to eczema patient herself, explains: “If you focus the worst outcomes. By calming on your skin and the thought that you are the mind and body, you can itchy, then your mind automatically stays also help decrease the severity with those thoughts. But if you can help of an eczema exacerbation. your mind divert from those thoughts, that Meditation may feel odd if you’re a beginner, but there can sometimes help.” are plenty of apps available to teach you how to get Developing coping mechanisms for your stress is an started. Try a couple to find the right one for you. essential tool in managing your eczema. Exercise Connect with others From jogging to yoga to Getting eczema off your playing sports, exercise can mind is a great way to reduce improve your mood and stress. Talk with someone physical and emotional well- close to you or join an online being, as well as increase your community to connect with energy. Make sure to wear other people going through loose, light-fitting clothes to similar situations. Spending avoid overheating and irritating your skin. time with family and friends is also a great way to take your mind off any worries. Get plenty of sleep Lack of sleep can negatively Keep a journal impact your state of mind and Journaling helps you ability to focus. A good night’s decompress and let out any sleep will help you go into each troubles you may be feeling. It day feeling regenerated. can also help uncover the roots of stress. Additionally, writing down daily success stories or what you are thankful for is a If you suspect stress is triggering your eczema, keep positive way to lift you up. a diary to help identify what stressors may be causing your flares. Track your emotional state, energy levels, Take time for self-care diet, people you meet, significant events, and the state Slow down and do of your eczema. Look for any patterns to help you make something for yourself. the right changes at the right time as you manage your Whether it is a bath, watching eczema. your favorite TV show, painting, knitting, cooking, Written by Kortney Kwong Hing, founder of the Allergy Girl Eats reading or another activity, blog (allergygirleats.com) and co-founder of AllergyTravels. shifting your focus elsewhere com. Kortney lives with multiple food allergies, asthma and can make a difference. eczema.

28 Allergy & Asthma Today Special Edition AllergyAsthmaNetwork.org MANAGING YOUR CONDITION Recipe For Success Celebrity chef Elizabeth Falkner explains how she manages atopic dermatitis in and out of the kitchen.

lizabeth Falkner’s career was just starting to take I couldn’t scratch it because that made it worse. I off. It was the mid-1990s and she was owner couldn’t wear gloves because that made my hands sweat. Eand chef of a trendy San Francisco restaurant. I would hide my hands and hide the pain. My doctor Suddenly, she began to experience painful, itchy skin put me on over-the-counter and prescription lotions, rashes on her legs, arms and hands. creams and ointments, and I’ve tried some homeopathic “It was a burning sensation and it kept getting remedies. worse,” she says. “I went to my doctor and was Q: What lifestyle changes did you make to help diagnosed with moderate-to-severe atopic dermatitis.” ease your symptoms? Atopic dermatitis (AD) runs in Elizabeth’s family. She worked with her doctor to identify what causes her A: I stay active and eat healthy. I don’t eat fast food or skin to flare up – dry heat in the kitchen, certain foods processed food. Stress is a huge trigger for my flare-ups and stress were the most common triggers – and then and I’ve found that physical activity reduces my anxiety create a prevention and treatment plan. and tension. I do yoga, pilates and a swordfighting Now living in New York City, Elizabeth no longer fitness program. I’m certified in scuba diving. And I’ve works daily in restaurants, but she continues to run in the New York City Marathon. I enjoy staying cook as a celebrity chef and is a recognizable active – it’s fun. face on TV cooking shows. She is also a Q: Do you think AD is not taken as seriously as motivational speaker and author. it should be? Elizabeth is raising awareness of atopic A: Definitely. It’s a disease that affects so many people, dermatitis through UnderstandAD.com, but you don’t hear about it very often. Everyone thinks a website to educate people about moderate- it’s just a skin rash that you get – but it’s way more than to-severe atopic dermatitis and encourage them to a skin rash. It’s inflammation and it feels like it’s always see a doctor for treatment. “Having atopic dermatitis there. affects many aspects of a person’s life – physically and Atopic dermatitis is a big deal and being able to emotionally – and yet many people don’t understand talk about it openly with family, friends or colleagues is the severity and impact,” Elizabeth says. really important. Allergy & Asthma Network talked with Elizabeth in a Q&A interview: Q: What advice do you have for people with the disease? Q: How did working in restaurants impact your AD? A: There’s no cure for atopic dermatitis, but there are different ways to manage it effectively. With new A: Restaurants are a highly stressful line of work and and ongoing medical research on atopic dermatitis, it’s a hostile environment for your skin. When I had it’s important to discuss the disease with a doctor and itchy rashes on my hands, it was really painful. As a develop a treatment plan together. chef, you’re constantly working over heat and washing You can’t let atopic dermatitis take over your life. your hands. And you’re constantly around foods with And you don’t have to go it alone. different ingredients, from garlic and tomatoes to flour and lemon. It’s harsh activity for your skin. Read the full Q&A on AllergyAsthmaNetwork.org.

800.878.4403 Understanding Atopic Dermatitis 29 MANAGING YOUR CONDITION Coping with Eczema How to Handle Anxiety and Depression Anxiety. Fear. Depression. Self-consciousness. Unfortunately, I am not alone. If you’re struggling, People often underestimate how much eczema can here are some tips to help you mentally cope with affect mental health. They think it’s just a physical eczema: symptom that doesn’t go beyond affecting the skin. Besides the itch, the oozing rashes and the painful Find a great support group – this includes blisters, eczema affects finding people who can mental health much more help you through this. Talk than people realize. to other eczema patients, A recent survey by join Facebook support the National Eczema groups or speak with a Association revealed more psychologist. than 30 percent of people with eczema suffer from Use stress-coping depression and anxiety. techniques by doing Another survey showed something you love one-third of more than – for example, watch a 600 eczema patients felt movie, pray, take a nature dissatisfied with life. Slightly more than half of the walk, exercise or start writing in a journal – each of patients reported eczema limited their lifestyle, these activities can help reduce anxiety and depression. 43 percent said it impacted their activities and 39 percent said they avoid Practice gratitude – it will help you focus on the social interaction. Eczema also had a positive things in your life, so that you can stop focusing significant negative impact on quality of life on negativity. compared to other chronic illnesses, including heart disease, diabetes and high blood pressure. Use visualization, affirmations and Count me among eczema patients who can relate to meditation – these can all help you relax and reduce dissatisfaction with life. For years I experienced extreme stress. Regular meditation can also help you control eczema flare-ups and pain, so much so I was unable to anxiety by redirecting your thoughts. even move properly. Depression, anxiety, suicidal Don’t be afraid to cry – let thoughts and post-traumatic out your emotions, cry and scream if stress disorder (PTSD) are a you need to. Do whatever it takes so few ways this condition has you don’t suppress what you’re going affected myself and many through. others. There have been times when I was unable to leave Many people may not understand my house or attend social how mentally painful and draining activities due to symptoms. eczema can be. If you or a loved one When I did go out while are suffering with eczema, remember my eczema was flaring, I often felt extreme anxiety and that the more you support yourself mentally, the more discomfort – I would look at other people and wonder, you can cope with the challenges that eczema brings in ‘What are they thinking about my skin?’ or ‘Does my your life. skin really look that bad today?’

30 Allergy & Asthma Today Special Edition AllergyAsthmaNetwork.org MANAGING YOUR CONDITION Dating and Intimacy eing in a relationship with any type of skin problem is difficult – but especially when you have Beczema. The most traumatizing thing about eczema is how unattractive it can make you feel. How do you go about being in a relationship when you are suffering with eczema? For me – I remember all my fears and insecurities came out, and it was terrifying. I remember struggling with the idea that someone would even want to date me. I remember feeling so Tips for Eczema Patients scared that my significant other, Bryan, would leave me. Embrace their love: I’ve heard so many people I even recall feeling that Bryan would be repulsed by my tell me they are scared their partner will leave them. If skin. they’re willing to stay with you, then they want this to I was wrong. And here we are today – married! work out with you. Embrace it. Many people with eczema, no matter how severe, Have fun and enjoy life. Don’t let eczema struggle with dating and intimacy. These feelings are overwhelm you and turn you into a negative person. completely normal. Remember to enjoy life, relax and learn to laugh. However, you may be surprised at how much your Be confident. You may not feel attractive or self- partner is willing to support you. My whole body was confident – but you need to try. Eczema ruined many of covered in eczema when I was dating Bryan, but he my relationships growing up because I lacked confidence supported me, cooked for me, and even vacuumed the in myself. Act confident, even if you don’t feel it inside. flakes of skin that I was shedding. I was touched. Talk it out. If you’re dating someone and you’re Don’t let eczema keep you from being in a wondering if they are bothered by your eczema, be brave relationship. You deserve to be loved – regardless of how and talk to them about it. Communication is key. your skin looks! Tips for the Supportive Partner Always be encouraging. Your partner may feel very insecure about eczema. Be your partner’s greatest cheerleader. Your encouragement will lead to perseverance. Find support. Talk to someone so that you have support. It’s not always easy, but you need a support system as much as your partner does. Do something you love. If you feel you are consumed by your partner’s eczema, remember to do things that you enjoy. Life is about your dreams, too. Be adaptive. Your partner may have to make some lifestyle changes to improve their eczema – and this may affect you as well. Learn to be adaptive and flexible in order to help ease the transition.

Written by Abby Lai, a registered holistic nutritionist, eczema blogger and creator and host of The Eczema Podcast. Her website is PrimePhysiqueNutrition.com.

800.878.4403 Understanding Atopic Dermatitis 31 MANAGING YOUR CONDITION

When Eczema Goes to School…

illions of school-age children in the United States have eczema. Although the skin condition is not contagious, it can embarrass children and make it difficult for them to concentrate at school. What can Mparents and teachers do? Here are some suggestions: For Parents: Talk to your child’s teacher. Give the teacher a written list of things that trigger your child’s eczema, such as foods, Eczema is not allergens, fragrances, glue or other art/ contagious like a science supplies, heat or activities that cold. You can’t catch it. cause sweating and suggest ways to avoid them. For instance, It is like an allergy, such as your child may need hay fever, except it affects to sit away from your skin instead of windows, radiators and heating ducts if heat makes your nose. eczema worse. Some children may need a sheet to cover the carpet when sitting on the floor, or something to cover the desk chair. Make sure your child’s teachers know how your child behaves during a flare-up and suggest ways to handle it. If your child fidgets, becomes anxious, or is easily distracted during a flare, these behaviors may be For Teachers: misinterpreted as attention deficit disorder (ADD). Avoid telling the child not to scratch. Instead, Send a first aid kit to school containing adhesive work with the parents to brainstorm ways to distract the bandages, antibiotic ointment, moisturizer, sunscreen, child or to ease the itch. Some suggestions: petroleum jelly, gauze pads, and other items your child • Apply a moisturizer from the child’s first aid kit. might need. Explain to the teacher the importance of • Apply a cool washcloth to the itchy area. using only approved skin products, as some lotions and • Give a glass of cold water. creams may contain chemicals or fragrances that are • Encourage the student to walk around or leave the eczema triggers. classroom until itching calms down. • Bring the student to the school nurse’s office to Talk to your child. Teach your child about what place a covered ice pack on the itchy spot. triggers symptoms, how to prevent them, and why certain treatments help. Have a conversation every day Set up a signal and action plan. For many – talk about challenges faced at school or play and how students it is helpful to have a signal the teacher the child handled them. Encourage your child to share can give to them (or they to the teacher) during a his or her feelings with you, so that you can help. If your particularly itchy period. The teacher can give the child is angry, upset or discouraged, accept and validate agreed-upon hand signal that reminds the student to these feelings without dwelling on them, then move on. take a previously agreed-upon action to help bring relief.

32 Allergy & Asthma Today Special Edition AllergyAsthmaNetwork.org MANAGING YOUR CONDITION Come Clean ur bodies are in constant contact with clothing, Wash new clothing before wearing it so it only makes sense to take special care when Most new clothing contains fabric with finishes and Owashing clothes – especially if you have eczema. dyes that can irritate skin. The same goes for blankets, Laundry detergent often contains chemicals, toxins, bedding, towels, cloth napkins and stuffed animals. Give allergens and irritants that are left on the fabric after used or hand-me-down clothes a thorough washing as washing and drying. These can irritate sensitive skin. well before wearing them. If you have eczema, here are some laundry tips: Contact manufacturers Choose detergents carefully Not sure if there are skin irritants in a detergent Use hypoallergenic detergent products free of product? Check and doublecheck the ingredient list bleach, fragrances, preservatives and dyes. Liquid by calling or sending emails to companies. Shampoos, detergents leave less residue than powdered conditioners and dishwasher detergents may also detergents. Remember: Laundry contain allergens and irritants that can worsen eczema detergent that works for one eczema when exposed to the skin. patient may not work for another. It’s often a trial-and-error process. For example, one mother found that using a pure, mild soap instead of detergent was more beneficial for her baby’s sensitive skin.

Keep ‘em separate You may want to wash clothing of family members who have eczema separately from those who do not. This helps avoid cross contamination.

Rinse and repeat Consider giving clothes a second or extra rinse to fully wash away traces of detergent.

Don’t over-soap When measuring laundry detergent, use the amount recommended on the label. If you use too much, excess soap can stick to clothing. If you think you used too much detergent, consider doing a second or third rinse in the washer.

Forget fabric softeners Fabric softeners contain surfactants that can irritate sensitive skin. Some also contain fragrances, preservatives and dyes.

Dry ’em indoors If pollen is your eczema trigger, don’t air-dry your clothes outside. Pollen can attach to clothes.

800.878.4403 Understanding Atopic Dermatitis 33 ADDITIONAL RESOURCES

Dictionary Allergic rhinitis (hay fever): Inflammation of Atopic dermatitis: A chronic inflammatory the nasal passages, usually caused by the body’s skin disease caused by a skin barrier defect and an reactions to airborne allergens. It’s characterized by immune system reaction. It’s the most common and runny nose, swollen and congested nasal passages, severe form of eczema. Common triggers include postnasal drip and sneezing fits. Atopic dermatitis foods, pet dander, dust mites, pollen, mold and stress. is sometimes an initial indication that a child may Contact dermatitis: A type of eczema that occurs develop allergic rhinitis. when your skin touches an allergen or irritant. Asthma: A chronic disease that causes Common triggers include detergents and bleach, inflammation in the lungs and airways, leading to soaps, shampoos, solvents, nickel, rubbing alcohol, episodes of coughing, wheezing and shortness of fertilizers and pesticides. breath. Atopic dermatitis is sometimes an initial Eczema: A term that refers to a series of different indication that a child may later develop asthma. skin conditions (including atopic dermatitis) in which the skin develops a sensitive, red, itchy and irritated rash usually on the cheeks, arms and legs.

Websites

Allergy & Asthma Network – AllergyAsthmaNetwork.org American College of Allergy, Asthma & Immunology AltogetherEczema – AltogetherEczema.org acaai.org American Academy of Allergy, Asthma & Immunology Eczema Exposed – eczemaexposed.com aaaai.org National Eczema Association – nationaleczema.org American Academy of Dermatology – aad.org Understand AD – UnderstandAD.com Publications Understanding Understanding Living with Allergies: Prevent Asthma: and reduce A practical, easy- More than seasonal and to-understand 40,000 environmental guide for your products allergies – and journey to better contain latex, improve your breathing. Signs including quality of life. and symptoms of rubber bands, asthma, inhaler balloons and pacifiers and Understanding know-how, exercise tips, and more. medical gloves. Learn to Anaphylaxis: live a full, active life with Learn to recognize Order for $1 each; latex allergy by avoiding and prevent bulk orders available triggers. Order a free copy life-threatening (shipping & handling apply): (shipping & handling allergic reactions 800.878.4403 or apply): 800.878.4403 or to food, stinging AllergyAsthmaNetwork.org AllergyAsthmaNetwork. insects, latex and org. medications.

34 Allergy & Asthma Today Special Edition AllergyAsthmaNetwork.org Breathe Better Together! Allergy & Asthma Network engages, educates and empowers families to win over allergies and asthma.

Since 1985, it’s been our mission to end needless death and suffering due to asthma, allergies and related conditions.

Join at no cost to you by visiting AllergyAsthmaNetwork.org/join.

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Photo represents her condition. But did you know that a root moderate-to-severe eczema. cause may be inflammation that lies beneath your skin? An overactive immune system could be causing the itching, flare-ups and other symptoms you’re experiencing. Find out more at EczemaExposed.com.

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