What are the optimal therapies for treating mild to moderate atopic dermatitis? Zelma Chiesa Fuxench, MD, MSCE, discusses when and where basic skin care, soak and smear techniques, and topical therapies are useful tools for managing eczema.
Dr Chiesa Fuxench is an assistant professor of dermatology at the University of Pennsylvania in Philadelphia.
Transcript
Dr Chiesa Fuxench: Another great question that our patients ask us in terms of skin care practices is bathing. We see this all over the place, from patients who bathe maybe once a week to those who do it every day. Bathing can have very different effects on the skin depending on the manner in which it's carried out. For example, we do know that if you bath with water, you can hydrate the skin. You can help remove scale, crusting, other allergens that may be in contact with the skin. We also know that when water evaporates from the skin, we have increased transepidermal water loss, which can result in worsening the skin dryness.
When we look at the evidence to determine what are the best bathing practices, we see that there's very little objective data. There's no clear guidance in terms of what should be the frequency or the duration of bathing that is optimal for patients with atopic dermatitis. It is recommended, though, that patients with atopic dermatitis bathe at least once a day, especially if they have signs of crusting on the skin, as long as moisturizers follow the application of the bath. That is a very key important step. Another important topic in terms of bathing practices is the soak-and-smear approach. Again, there's not a lot of objective data to support its use.
From personal experience and that of my colleagues, we have seen that in cases where there's widespread and significantly inflamed skin, you can soak in plain water followed by immediate application of your prescribed anti-inflammatory medication, such as topical corticosteroids, without drying the skin off. This can sometimes be helpful.
Some patients ask me about what soaps they should be using. Typically, when I counsel patients on this, I say try to use something that's referred to as a non-soap-based cleanser. You're looking for something that has a more new neutral to lower pH that's similar to that of the skin and also important keywords that say hypoallergenic or fragrance free. There's also multiple products out there that have the National Eczema Association Seal of Acceptance. That might be something to look out when we're in the pharmacy purchasing these types of products.
How do we select appropriate topical prescription treatment options for our patients with atopic dermatitis?
Nowadays, we have three different options to choose from. We have topical corticosteroids. We have topical calcineurin inhibitors. We also have phosphodiesterase-4 inhibitors, which is crisaborole. The decision of which topical agent to use does depend on many different factors. For example, it will depend on the age of the patient, if you're treating an adult patient vs a pediatric patients. For example, in the case of topical calcineurin inhibitors, we do have ones that are approved primarily for children, such as, for example, tacrolimus 0.03%, which is approved for children between the ages of 5 and 16. Then we have tacrolimus 0.01%, which is approved for adults.
Then, also, thinking about the anticipated duration of treatment. Are you treating an acute flare, or is this more for maintenance therapy? If we are treating an acute flare, we might decide to use a higher-potency topical corticosteroid for a shorter period of time to help calm the symptoms down and then potentially transition over to a mid- or lower-potency topical steroid or a calcineurin or PDE4 inhibitor.
Also, the patient preference, it's another very important factor if you look at the vehicle of these types of medications. When we talk about vehicle, we're talking about is this an ointment? Is this a cream? Is this a gel? Is this a lotion? Is this a solution? Is this a shampoo?
All those things need to come together. Because if my patient does not like to use ointments and I prescribe an ointment, they're probably not going to use their prescription. The patient needs to be involved in that decision as well. Also, the number of applications. Most of these topical medications are prescribed for twice-daily use. However, in some cases, once-daily use is also perfectly acceptable. Another important point to consider is the potential risk for topical treatments. Is there a risk of systemic absorption?
This is also very important, particularly in children, because children do tend to have proportionately greater body surface area-to-weight ratio. As a result, they may have a higher degree of absorption for the same amount apply. You do want to be careful if you're using very high-potency topical steroids in children.
