Beyond Medications: Treatments for Atopic Dermatitis

By Peter A. Lio

Anyone afflicted with even a mild, occasional case of atopic dermatitis (AD) or eczema knows how annoying and distracting it can be. The skin is our primary defense against the world, and is well armed to fight off irritants and infections. Every square inch of the skin is equipped with first responders—immune cells that can neutralize harmful bacteria and viruses before they have a chance to fight their way into the blood stream. However, when these defenses go haywire and start to fight big battles against small invaders like allergens, the result can not only be irritating, but debilitating, disfiguring and even dangerous.

In those with chronic AD, the skin is already an imperfect barrier and thus vulnerable to a range of allergens and other irritants, the way inflamed sinuses and lungs are with airborne particles, ranging from pollen to diesel smoke. Like those conditions, managing AD requires an integrated strategy, of which medication is only a part.

Navigating the line between risk and benefit can be difficult for more powerful medications such as immunosuppressing systemic steroids, but the search for non-pharmacologic treatments is ongoing. Creative application of these more physical therapies might minimize the pharmacologic treatments and their side effects, and possibly even create synergy with other treatments. As part of my dermatology practice I have been surveying the field, and have discovered a number of physical, behavioral, and psychological interventions, although as you will see, not all of them hold out immediate hope of relief for everyone.

Textiles and Clothing
It has long been known that AD and wool don’t go well together. Some people are undoubtedly allergic to wool itself (usually the oil lanolin associated with the wool), but others suffer even in absence of true allergy because the fibers irritate nerves in the skin, directly causing itch. This raises the question of whether certain textiles could actually be helpful in managing AD. Cotton has often been the mainstay for dressing AD patients. However, in the past decade, a number of interesting studies suggest there may be superior alternatives.

In 2007, a study compared children wearing a specially designed and coated silk garment around their elbows (a site especially eczema prone) to a control group wearing cotton. The experimental group did consistently better at weeks 4, 8, and 12. Silk is hypothesized to aid wound healing by enhancing collagen synthesis and reducing edema and inflammation; this specially coated silk also has antimicrobial properties, which is significant since the skin normally has staphylococcus aureus (staph) germs sitting on it that can penetrate when scratched and cause infections, and may fuel inflammation by its very presence. Other research with silk has been less exciting, but it remains a possible improvement over cotton.[1]

Silver-coated textiles have been shown to have an antibacterial effect on staph bacteria. A recent randomized double-blind controlled study of 19 children compared placebo clothing to a new textile made of “silver-seaweed-cotton” fibers. The study found that by day 7 there was significant improvement in the eczema in the treatment group, and that by day 90, there was 45 % decrease in eczema severity (measured by a tool called the SCORAD*) as well as reduced itchiness and improvement in sleep.[2]

Several brands of silver-coated clothing and silk-based garments are available that are targeted towards eczema. They tend to be fairly expensive, ranging from $60–80 USD for some of the different pajamas or body suits designed for infants, but may be washed multiple times without losing efficacy.

Climate and Temperature
There is a body of evidence to support the connection between cold and dry climate factors and AD, and remarkably, the exact opposite—heat and humidity–has also been convincingly demonstrated.

A study of 56 children with severe AD evaluated the effect of moving from a subarctic/temperate climate in Norway to a sunny subtropical climate for 4 weeks. They found that there was significant improvement in SCORAD and quality of life for the patients who spent time in in the warm, sunny climate compared to controls. [3]

A unique and somewhat incredible study using whole-body cooling (cryotherapy) in a specialized chamber at temperatures down to 110 °C (166 °F) three times weekly demonstrated significant benefit to patients with severe atopic dermatitis. The authors suggested that the effect was related to reduced nerve conduction velocity and decreased synthesis of acetylcholine in the nerve ganglia, both of which could influence itch. The need of a specialized chamber and the thrice-weekly treatment regimen makes this approach much less feasible, unfortunately.[4]

A more recent study examined the effect of a water-filled passive cooling pillow on sleep quality in patients with severe head and neck AD [5]. While there was a trend towards improvement in sleep quality and severity of the AD in the experimental group, the study size was small and the results were not statistically significant. A portable home-based cooling therapy like this could have therapeutic potential and is an area warranting further investigation.

Water and Bathing (Balneotherapy)

As skin dehydration is one of the fundamental characteristics of AD, it is not surprising that there are interventions involving water and bathing. Since therapeutic bathing was a big feature of life in the Roman Empire, we should find it no surprise that a number of studies have been attempted in Italy, the Dead Sea, and France, where Roman conquerors always took advantage of whatever mineral bath opportunities the local geology presented. For example, an open, randomized trial in Trentino, Italy, of 104 children with mild to moderate AD received either balenotherapy (total immersion into thermal spring water rich with calcium, magnesium, and other minerals for 20 min once daily) for 2 weeks, or topical corticosteroid treatment for the same period. Both groups had significant improvement in eczema severity and quality of life measures, with the corticosteroid group showing a significantly larger reduction in the SCORAD, but with similar effect in the quality of life indices. At month 4, however, there was a significant difference in the number and duration of relapses favoring the balneotherapy group [6].

However, the evidence is somewhat limited. There may be something more to mineral baths, but the effect beyond sunshine and relaxation is probably modest at best.

Phototherapy
Perhaps the most important part of visiting the Dead Sea (and other similar experiences) is the sunlight. Phototherapy—the use of ultraviolet light therapeutically—has long been shown to be effective for AD [7]. For refractory cases or when corticosteroid dependence is developing, NB-UVB phototherapy is a relatively safe treatment that can postpone or avert the need for systemic medications in select patients, and may even relieve AD as it does for psoriasis [8].

However, long-term exposure to intense sunlight also has some proven detrimental effects, such as premature aging of the skin and an increased risk of skin cancer.

Hypnosis/Biofeedback/Support Groups
Atopic dermatitis can affect the entire family, beyond just the patient, and is known to have significant psychological ramifications. Scratching may become a behavioral, conditioned response triggered by anxiety. Stress seems to play a role in the disease, opening up new possibilities for treatment. Many patients report that one of the main triggers to itching is to start worrying about itching.

A 1993 study examined biofeedback and hypnotherapy on eczema severity in 44 children. Those in the active groups showed a significant reduction in a severity score compared to controls at 8 and 20 weeks. Progressive muscle relaxation therapy (PMR) was studied in 25 patients with AD compared to a randomized control group. After 1 month, there was improvement of itch, sleep, and anxiety in the PRM group but not in controls [9]. A behavioral method of habit reversal was applied to scratching in patients with AD in a randomized controlled trial in combination with hydrocortisone cream compared to hydrocortisone cream alone. While both groups improved, there was a significant difference in favor of the behavioral intervention. Support groups have also been studied. Thirty-two patients were randomized to join a support group or not, and after 6 months, the pattern of itch was significantly improved in the experimental group, as was the quality of life score.

While the examples reviewed are hopeful, these methods require further study.

Education
Educational interventions such as written literature, audiovisual material, workshops, or more traditional didactics can empower patients and allow for better self-management. Additionally, better education may enhance medication adherence, which with AD as with much chronic disease management, is generally poor. Notably there is perhaps much greater emphasis on therapeutic education in AD elsewhere in the world than in the United States.

Several randomized controlled trials have demonstrated improvement with different educational measures, including a nurse-led eczema workshop on 99 new patients compared to a dermatologist-led clinic. At 4 weeks after the intervention, the mean improvement in SCORAD was significantly better in those attending the workshop, as was adherence. A large, multicenter randomized controlled trial of 992 patients in Germany found that education for children with AD resulted in improved quality of life and disease severity.

A 2011 study used an online video education program to improve knowledge and understanding of disease severity in AD for 80 patients, and compared this to a pamphlet of written material; the online program showed better results.

A recent study examined the effect of using a written “eczema action plan” (akin to an “asthma action plan”) that delineates the medications, the order of application (a point of endless questioning in the clinical realm: “Which do I apply first?”), the location of application, and, finally, a plan for when things are “flaring up” and a maintenance plan for when things are better. This was compared to verbally instructing the patients on the same information. Though it was a small study with no clinical follow-up, there were significant gains in understanding of the plan, risks, and benefits of the medications, anatomic location of medication use, duration of treatment, and adjusting treatment based on disease severity with the written action plan.

Immunotherapy
The recently published practice parameter for atopic dermatitis assigns a strength of recommendation “B” to immunotherapy for AD; that is, good but not great. Interestingly, in one double-blind, placebo-controlled study of 48 children with AD treated with dust mite sublingual immunotherapy [SLIT], the mild-to-moderate severity group showed more impressive improvement than the severe group, suggesting that the effect may be too small to make a significant difference in more severe cases. Because of the variations with study design, immunotherapy regimens, and outcomes, immunotherapy remains more of a niche treatment for specific, motivated patients.

Diet and Nutrition
Of all the aspects of AD, diet continues to be one of the most contentious, with many families (and healthcare practitioners) promoting the idea that foods are the “root cause” of eczema. While a very appealing concept—simply cut out certain foods and your skin will be clear!—the literature and clinical experience do not bear this out, sadly. Complicating this, however, is the fact that nearly one-third of moderate-to- severe AD patients have verifiable food allergies (type I hypersensitivity with resultant hives, angioedema, or anaphylaxis), which could certainly act as trigger for an AD flare. This is a dangerous area, because as much as any other condition, some families start a do-it-yourself program of food avoidance, which can result in malnutrition.

A piercing study by Thompson and Hanifin[10] nicely demonstrates that most (a resounding 80 %) of the concerns about foods that do not result in a type I hypersensitivity response, but are thought to exacerbate AD, disappear once better control of the eczema is achieved. When they add the food back into the diet once the skin calms down, they report no further reactivity. Indeed, more than any other study, this shines light on the complex area of food allergy and AD, and emphasizes the dangers of conflating IgE reactions with exacerbation of AD.

Clearly there are patients who find great benefit with specific food avoidance and this cannot be denied. However, when things continue to escalate to the point of malnutrition and obsession over multiple foods, despite ambiguous testing and no clear relief from dietary exclusion, it can be more deleterious to the patient than the AD itself.

Vitamin D
Vitamin supplements have been getting a bad rap lately, along with most of the supplement industry. One vitamin has escaped the general parade of criticism, and that is vitamin D.

A recent review analyzed 10 articles on the role of vitamin D in AD (culled from 58 articles total) that specifically addressed this relationship. They concluded:
–There is an inverse relationship between vitamin D levels and the severity of AD.
– Repletion with vitamin D promotes the epidermal barrier.
–Clinical trials suggest a therapeutic benefit from vitamin D supplementation, though the trials are small and limited.
Given the relative safety of vitamin D supplementation and its low cost, it seems reasonable to suggest this at least for patients who report worsening in the winter months, until larger studies can further validate this claim.

*SCORAD
SCORAD is a clinical tool used to assess the extent and severity of eczema (SCORing Atopic Dermatitis). Dermatologists may use this tool before and after treatment to determine whether the treatment has been effective.
Area
To determine extent, the sites affected by eczema are shaded on a drawing of a body. The rule of 9 is used to calculate the affected area (A) as a percentage of the whole body.
• Head and neck 9%
• Upper limbs 9% each
• Lower limbs 18% each
• Anterior trunk 18%
• Back 18%
• 1% for genitals
The score for each area is added up. The total area is ‘A’, which has a possible maximum of 100%.
Intensity
A representative area of eczema is selected. In this area, the intensity of each of the following signs is assessed as none (0), mild (1), moderate (2) or severe (3).
• Redness
• Swelling
• Oozing / crusting
• Scratch marks
• Skin thickening (lichenification)
• Dryness (this is assessed in an area where there is no inflammation)
The intensity scores are added together to give ‘B’ (maximum 18).
Subjective symptoms
Subjective symptoms i.e., itch and sleeplessness, are each scored by the patient or relative using a visual analogue scale where 0 is no itch (or no sleeplessness) and 10 is the worst imaginable itch (or sleeplessness). These scores are added to give ‘C’ (maximum 20).
http://www.dermnetnz.org/dermatitis/scorad.html

Peter A. Lio, MD is an Assistant Professor of Clinical Dermatology & Pediatrics at the Northwestern University Feinberg School of Medicine, and a Diplomate of the American Board of Dermatology. Dr. Lio received his medical degree from Harvard Medical School, completed his internship at Boston Children’s Hospital and his dermatology training at Harvard.

He served as a full-time faculty at Harvard (Beth Israel & Children’s Hospital Boston) from 2005-2008 before returning home to his native Chicago to join Northwestern and Children’s Memorial Hospital. He is also a trained acupuncturist and a leader in the Chicago integrative health care community.

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{Note: a longer version of this article can be found at Curr Allergy Asthma Rep DOI 10.1007/s11882-013-0371-y, published online July 24, 1013}