Margaret Bobonich, DNP, FNP-C, DCNP, FAANP, and Douglas DiRuggiero, DMSc, PA-C discuss best practices in the non-pharmacologic management of atopic dermatitis including elimination of triggers, bathing, and reducing infection risk.
Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: Let’s talk about some of the foundational non-pharmacologic treatments that we should be recommending and educating our patients about as well as how do we prevent those flares.
Douglas DiRuggiero, DMSc, PA-C: I mean we know that there are some very practical things that anyone should be educated to do in terms of – we know the skin is hypersensitive and is prone to flaring. A lot of exogenous factors can play into that, even patient sweat, chlorine in the pool, pollution outside has been implicated in studies. A lot of things are known to be triggers for atopic dermatitis. But we certainly want to eliminate as many as we can. So, you want to go with silk or smooth clothing, cotton clothing, nothing wool, nothing scratchy. You want to make sure that you're using detergents that are for – that are allergen-free. We want to use soaps inside the bath that are for dry, sensitive skin that are moisturizing. There is a debate on what to do with bath time. I think most people would say now that if – to bathe or not to bathe. We know that if you don’t bathe that can increase infections particularly in our severe atopic dermatitis patients; if you bathe too much, it can be worsening. I think there’s a balance that has to be there between the – our more severe patients probably shouldn’t be bathing every day or at minimum, every other day in order to decrease staff colonization but the bath time, the water should be tepid. The bath time should be short. You should be moisturizing right afterwards.
You should be applying your topical medications right afterwards for better absorption. I think there are some issues there. And I would just say lastly too, the issue of moisturizing daily or multiple times during the day is very important for barrier function. Unfortunately, we had some information come out last year, 2020 the BEEP trial, B-E-E-P trial that looked like it’s basically a daily barrier emollients for prevention of eczema or eczema prevention, BEP. And it showed when they put emollients on infants, on newborns within two weeks of age who had a parent with atopic dermatitis and applied emollients every day for the first two years of life decreased their chance of developing eczema. And unfortunately, there wasn’t a statistical difference between those two populations. I think the word is still out on that. I think we’re going to find that daily emulsifying the skin with people who are at high risk will eventually pan out in the larger numbers to show that it is preventive. What do you have to add to that?
Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: I agree. A couple things I’ll say. One of the things that I love about – I do recommend daily baths for – especially the children for a couple of reasons. First of all, children with atopic dermatitis as well as other skin diseases like psoriasis, people don’t touch these patients. They see open cracks or crusts, or scale and the truth is is that they aren’t touched by people. Their intimacy is decreased as they go into adulthood, and they carry these kinds of papulosquamous diseases. I think it’s an opportunity when we have our children bath time is great. It’s when people can calm down and it’s touch, it’s softening that scale. And then when they do get out, like you mentioned Doug, head to toe those emollients. We love to call it soak and smear. And that is – it’s a great time emotionally to reconnect. So that’s the second thing. The last thing I would say is just reiterating what you mentioned. The risk for infection is so, so important especially with these children. And I think historically some people would recommend bleach baths, which is very – it can be disputed by some and for children who have repeated MRSA infections, but I think the key is going back to let’s prevent the flare and let’s take advantage of not just the foundational aspects of skin care and avoidance of triggers but understanding what pharmacologic options do we have in order to treat those flares.
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Transcript Edited for Clarity