Eczema: An Itchy Nuisance Part 2
By Darrel Arthurs, ARNP, DCNP
This month some of the treatment options available to the nurse practitioner in treating atopic dermatitis (AD) will be reviewed. One of the cardinal features of AD is dry skin or xerosis. Using topical moisturizers reverses this dryness of the skin by increasing hydration.
Over the years a number of clinical trials have concluded topical moisturizers lessen the symptoms and signs of AD including erythema, pruritus, fissuring and lichenification. There is no side effect profile for these moisturizers or a limit to their daily use; therefore they should be the mainstay of treatment for all patients with AD. In addition, they reduce the amount of prescription medication needed to decrease inflammation. For mild disease moisturizers can be the primary treatment, but they also should be an integral part of the plan for moderate to severe condition as well.
Bathing practices can have a huge effect on atopic dermatitis depending on the manner in which it is carried out. For instance, water can hydrate the skin as well as remove scale, crust, allergens and irritant contacts which can be helpful to the patient. However, if the water is left to evaporate from the skin after bathing it will increase the transepidermal water loss. This causes the skin to be even dryer than it was prior to the bath and the reason that moisturizers must be applied immediately after the bath to lock in moisture. There are no recommendations as to how many baths per week a patient with AD should have, but the length of bathing should be kept to a minimum of 5-10 minutes.
One exception is that for patients with extreme inflammation in which soaking the skin for 20 minutes immediately followed by application of a topical steroid can dramatically improve symptoms. Most soaps are alkaline and cause damage, dry skin and irritation to the skin. Therefore, use of non-soap cleansers that have a low pH, fragrance free and hypoallergenic should be used.
Individuals with atopic dermatitis are predisposed to skin infections because of their compromised skin barriers. A common colonizer Staphylococcus aureus is the most prevalent bacteria present on the skin. Its presence, even without active infection, triggers multiple inflammatory cascades that further damage the epidermal barrier. A review of the literature found no support for use of oral or topical antibiotics, antiseptics, antibacterial soaps or bath additives in the setting of AD. One exception to this is the use of bleach baths in pateints with moderate to severe AD. The current recommendation is one-quarter cup plain bleach to a full bathtub of water twice per week for treatment resistant cases.
There are many treatment options available for atopic dermatitis. However, not all treatments work for all patients and finding the right mixture of treatments can be a daunting task. A through understanding of the mechanisms affecting atopic skin and a wide variety of treatment options will better prepare the nurse practitioner to effectively treat these patients.
Arthurs' passion for dermatology developed while he was serving in active duty in the U.S. Navy. Since then he has accumulated over 11 years' experience in medical and surgical dermatology. Currently he works independently in a small city in northeastern Oklahoma. Arthurs is on the NADNP Board of Directors.