Practical Management of Atopic Dermatitis: Nurse Practitioner and Physician Assistant Perspectives - Episode 4
Non-pharmacological strategies that can help patients with atopic dermatitis cope with symptoms and advice to help healthcare professionals counsel patients on proper use of these products and techniques.
Melodie Young, MSN, RN, ANP-C: We know that giving the right products can sometimes be a challenge. Keri, would you talk about some of the non-pharmacologic approaches and management, trigger avoidance, and how you coach those patients and families lifestyle-wise?
Keri Holyoak, PA-C, MPH: My recommendations are simple. The skin is dry and irritated, so we have to treat both of those components. I recommend that patients moisturize throughout the day, whenever their skin starts to feel dry or itchy—it’s especially helpful after a shower—and that method is called soap and seal. This combats the dry skin and helps to reduce the flares. This is a technique where I have patients shower for 10 minutes, use a gentle cleanser, wash but don’t scrub, their skin then they’ll pat their skin dry and leave it slightly damp and put the topical moisturizer on over that, all over the body. You don’t have to spend a lot of money to get a great product, and these are products that mostly have water and ceramides, no fragrances or dyes. They usually come in a tub, but not always. If spending more money will encourage my patient to use them, then that’s half the battle.
I have a list of my favorite things that I give to my patients. I write everything down, because this world can be confusing to them, especially when they go to the store and see piles of products. I like common products, things like CeraVe, Eucerin, and Vanicream. Another technique I do often is wet wraps. When patients are itchy, I’ll tell them to put on their moisturizer and do a wet wrap therapy, which is putting a wet towel over that area for 10 minutes. It rehydrates and calms the skin and can boost the effect of topical medications when you use it in combination with that. We also want to decrease the irritants—things like water softeners, air purifiers, and laundry techniques. We need more studies to support those techniques. They’re interesting thoughts, but those aren’t the things that I run to first. I run to my moisturizers. I run to my avoidance of irritants. If patients don’t like topical creams because it’s too cold, I‘ll tell them to float that tub of cream in a bath of warm water. If it burns, I tell them to put it in the fridge to cool it down.
Melodie Young, MSN, RN, ANP-C: Another problem that we see is that if we don’t give patients the guidance on those over-the-counter products, they’re going to get things that they think are good—maybe homeopathic, or what they call natural products—which sometimes have a lot of seed extracts, oils, fragrances, and other things. We’re all familiar with that. Susan, I know you’re on the West Coast, Douglas is on the East Coast, and Keri and I are in between. What guidance do you give to your patients for accessing the over-the-counter types of things that can be an adjunctive therapy to the prescriptive medicinal products that you’re going to recommend?
Susan Tofte, DNP, MS, FNP-C: I do a lot of the same things that Keri mentioned. But the other thing I want to interject is that I encourage my atopic patients—or any patient that comes in that has sensitive skin or dry skin—to look for products that have the National Eczema Association seal of acceptance. They’re not endorsing products, but they have a panel of people that have reviewed ingredients for any company that wants to promote their product and have it used for patients with eczema. Aveeno products have it, and Cetaphil, CeraVe, and all those common ones, like Vanicream, also have it. The seal of acceptance from the National Eczema Association means there’s no fragrance, no irritating ingredients, and it should be safe for most sensitive skin and eczema patients. I strongly recommend that. I also like products that come in big jars because people run out of them quickly. I will say, you must find a product that your skin likes and that you can stick with. It has to be a lifetime thing. They’re never going to not be able to get in and out of water and not put something on their skin.
Melodie Young, MSN, RN, ANP-C: What about petroleum jelly or coconut oil?
Susan Tofte, DNP, MS, FNP-C: For sure, yes. Coconut oil is a big thing right now. Sometimes I’ll say oils aren’t going to be enough, but if you combine them with something else, sure.
Douglas DiRuggiero, DMSc, PA-C: Susan and Keri, are you guys recommending that they use bleach in their baths, and how much and how often, if you do? I’m curious.
Susan Tofte, DNP, MS, FNP-C: If patients have multiple staph reinfections, the literature doesn’t support that, but it doesn’t say that it’s going to be colonized staph on their skin. But I have used it, yes—maybe, for people who continually get staph infections, regular chlorine bleach in a bath once or twice a week.
Melodie Young, MSN, RN, ANP-C: We do a quarter cup of bleach to a full tub of water and have some anecdotal reports of it also helping to reduce itch.
Keri Holyoak, PA-C, MPH: Let me chime in here, talking about bleach baths, because this is a game changer for me and my patients. After they soak in the water for 15 minutes and apply moisturizers afterward, they then use freshly laundered towels, sheets, and pajamas. That's been a real change for my patients that needed that boost with the help of colonization of staph.
Melodie Young, MSN, RN, ANP-C: When we had a day care center for psoriasis and eczema or atopic dermatitis patients at Baylor [University Medical Center] in Dallas, we did the soak and seal techniques for sure. We would have them get their pajamas wet or damp and put that on after they bathed, then put their topical medications and emollients on. Then we would put wet cotton pajamas, particularly on the children, and wrap them in some sort of plastic wrap to try to get that penetration, and we can turn them around within about 3 days of doing that. There are some data in the dermatology nursing literature about how to do it and why it helps. It’s probably 25 years old. The same things that you’re recommending can be helpful and low cost but labor intensive for the family.
Keri Holyoak, PA-C, MPH: I’ll tell you guys a quick story. I had a patient that came in to see me recently, and he had spent hundreds of dollars on prescription medications and never got better. So, he came to me, I looked at his skin and his skin was incredibly dry. I asked if he had used a moisturizer and he said he had never been recommended that. Now, I simply said, “Let’s go with the techniques that we mentioned. Let’s use something in a tub.” I saw him 6 weeks later, and just by giving him the instruction, he started using a moisturizer, and his skin was 50% better. Patients may forget, when it’s such a critical and important part of therapy.
Melodie Young, MSN, RN, ANP-C: Handouts and other literature can be very helpful.
Melodie Young, MSN, RN, ANP-C: Thank you for watching this HCPLive® Peer Exchange. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming peer exchange segments and other great content right in your in-box.
Transcript Edited for Clarity