Main Issue August 2011

Therapies in Action: Non-Prescription Approaches to Atopic Dermatitis

From wet wraps to bleach baths, here is a primer on some more practical steps to take in AD management.

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Management of atopic dermatitis (AD) typically requires a multi-faceted approach. While prescription agents constitute the majority of first-line therapies, patients can also try a number of other practical approaches. Some of these, such as wet wraps and bleach baths, have proven useful as adjuncts to other therapies and have garnered more attention in clinical practice and research. Ahead, we will provide a glimpse of the latest in non-prescription approaches to AD care.

As a companion to this article, video content demonstrating the techniques described is available at DermTube.com. The videos are part of a video training module at the Rady Children's Hospital Eczema Center Website (www.eczemacenter.org), and they provide an essential visual aid for administering and discussing techniques, such as a wet wraps and bleach baths.

Proper Bathing and Moisturizing Techniques

There are varying viewpoints on when and how often patients with AD should be moisturizing and bathing. In particular, much discrepancy exists regarding bathing, because while the bathing process itself can hydrate the outer layer and can also help take off crusts, scale, etc., it also dries out the skin once the water evaporates post-bathing. This can cause patients greater discomfort. But the key when bathing is for patients to apply ample amounts of moisturizers immediately after bathing, before all the water dries or is toweled off. This can help maintain hydration/decrease water loss. Regarding moisturization, our general advice is to moisturize at least three times daily and especially after bathing/showers.

For babies, it is sometimes helpful to tell parents to check for any dry areas at diaper changes and apply emollients to any such areas. This seems to help in terms of timing and frequency. Parents should choose a dye-free, fragrance-free emollient, such as a cream, ointment, or oil, but not lotion. A good rule of thumb is to use the formulation that your child will let you apply, because even if something is fancier or more expensive, if it doesn’t actually get applied on the skin, it will not help. Also, we find that kids are more amenable to moisturization when the parents try to make it a fun process, like giving small treats or having the child play an active part in the process.

Wet Wraps

Wet wrap therapy has been a focus of renewed interest and can be helpful especially for acute or severe flares. It can help to calm inflammation quickly. The ideal patients for wet wrap therapy are actually infants, because they are less able to self-remove the wraps, which allows for longer duration of application. Also, if most of the body is affected, it is much easier to use a one-piece all cotton pajama as the “wrap.” Wet wraps also have the potential to help localized areas that the child keeps scratching, (such as an arm or leg) to reduce access to that area. In addition, wet wraps can be particularly useful for children with moderate to severe AD, because of the time involved; those with only mild disease often improve with topical agents alone.

It is important to note that the literature varies in terms of how to perform wet wrap therapy. Most experts advocate wet wrap therapy following application of topical corticosteroids, while others use emollients underneath the wet wraps. Much of the literature shows the utility of topical corticosteroids directly to wet skin, with wet wraps placed on top of the corticosteroids, often followed with a dry wrap.

When it comes to technique, we see creativity on the part of parents in how they “wrap”—from special garments to even one parent using a cotton towel with holes cut for the eyes, nose, and mouth to use for the face!

Bleach Baths

Periodic use of bleach baths has been shown to be effective in improving AD, perhaps by influencing S aureus colonization and infection. In one study, 0.5 cup of household bleach per full tub of water was used several times per week, in addition to mupirocin ointment twice daily to the nares for five days each month. We find bleach baths most beneficial when used one to two times per week in those with frequent infections, or those with a lot of open, excoriated areas at risk for infection. Importantly, rinsing off the chlorinated water well after bathing and applying a lot of emollients as it is drying is key to success. Interestingly, speculation appears to be growing that bleach baths, in addition to reducing harmful S aureus colonization, may also affect the normal skin flora and in turn have negative effects. This will likely be clarified in greater detail when more research is done on the subject.

Lawrence Eichenfield, MD is Chief of Pediatric and Adolescent Dermatology at Rady Children's Hospital–San Diego, and Professor of Pediatrics and Medicine (Dermatology) at the University of California, San Diego (UCSD) School of Medicine.

Wynnis Tom, MD is Assistant Clinical Professor in the Departments of Pediatrics and Medicine (Dermatology) at the University of California, San Diego and Rady Children’s Hospital, San Diego.

Take-Home Tips.

While prescription agents constitute the majority of first-line therapies, patients can also try a number of other practical approaches. Some of these, such as wet wraps and bleach baths, have proven useful as adjuncts to other therapies and have garnered more attention in clinical practice and research.

Notable Developments

New studies highlight the latest developments and trends in the realm of non-prescription AD care. Among these are reports detailing the potential for botanical agents to play a role in AD management.1,2 While some of these data are encouraging, controlled studies are few.

Also worth noting are the new NIAID food allergy guidelines, released in late 2010. The guidelines indicate that testing for food allergies should really only be considered in children less than five years old with moderate to severe AD (for milk, egg, peanut, wheat, and soy allergy). A patient should have persistent AD in spite of optimized management and topical therapy or a reliable history of an immediate reaction after ingestion of a specific food. Importantly, a positive RAST blood test alone does not constitute a food allergy.

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