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What's the latest in managing atopic dermatitis?
Atopic dermatitis (AD), or eczema, is the most common condition seen in our dermatology clinics, occurring in nearly one in five children. Taking a careful history is an important initial step in effectively managing AD. Efforts should be made to consider other diagnostic possibilities, especially in infants, since immunodeficiency states can present with severe eczema (Wiskott-Aldrich syndrome), and to identify potential environmental triggers. Take a dietary history to identify food exposures that could be linked to skin flares and make certain children are receiving adequate nutritional intake in the wake of parental food allergy fear. Bathing and moisturizing properly are essential and an emollient should be applied immediately following a bath.
Greasy emollients like Vaseline or Aquaphor are most effective.
Topical steroids (TS) are the first line of prescription defense. Their safe, effective use depends on: A) matching potency to age and body site (weaker class VI agents such as hydrocortisone 2.5% are appropriate for younger children or facial use;
mid-potency Class IV or V agents such as triamcinolone 0.1% ointment are appropriate for older children with trunk or extremity involvement); B) introducing mandatory breaks from TS use.
Practitioners should be familiar with second line agents such as the non-steroidal anti-inflammatory alternatives tacrolimus (Protopic) and pimecrolimus (Elidel).
Adjunctive therapies such as antihistamines and antibiotics are appropriate in some patients. If itch leads to significant sleep loss, a sedating antihistamine at bedtime may help. Similarly, if eczematous plaques develop yellow crusts or pustules, topical mupirocin ointment or a systemic anti-staphylococcal antibiotic (cephalosporin) may be indicated. Staphylococcal infection frequently exacerbates AD-culturing and treating otherwise refractory patients for bacterial infection may be useful even in the absence of clear signs of infection. Nasal staphylococcal carriage and methicillen resistant strains may complicate these efforts.
Parents frequently ask about sunscreen and swimming in chlorinated pools. Chlorinated pools can irritate atopic skin, however, if children quickly rinse and apply moisturizer their eczema should do fine. No one sunscreen agrees with all patients, but fragrance-free, hypoallergenic products are preferred.
Robert Sidbury, MD, MPH
Assistant in Medicine, Dermatology Program
Atopic Dermatitis Center: 617-355-6180
More information: childrenshospital.org/atopic
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