Optimizing Treatment of Pediatric Atopic Dermatitis - Episode 6
Lawrence Eichenfield, MD: I’m going to move from the nonpharmacological skin care to the state of the skin care and bathing. You had mentioned the bathing issue, and we’ll discuss emollients to a degree. There was this group of experts who advised people to avoid bathing because bathing can dry out the skin. We continue to try to put the stake in the heart of that philosophy because I don’t think it really helps patients, for reasons that Peter just mentioned. But there was a really well-designed study that was published earlier this year, where groups bothered to do a really aggressive trial involving a frequent bathing and moisturizing. They basically did bathing every day versus twice a week bathing with moisturizers, and the rest of the regimen in the groups were kept the same from a standardized topical corticosteroid regimen, and then they crossed over. Everyone went to the other thing, and the punch line was a really impressive decrease in their objective eczema scores with the more frequent bathing compared with the less frequent bathing. Pairing that with studies we did years ago that show that if you moisturize after bathing, you end up with moisture in your skin and you dry out with bathing only if you bathe and don’t moisturize, I think it sets up the reasonable approach toward bathing. I’m still not totally didactic about people needing to bathe every day, but I tell them there’s no reason not to bathe. In general, daily bathing or every-other-day bathing might make sense. Fred or Elaine, anything different that you do in your practices?
Elaine Siegfried, MD: No. It’s great that we can finally have some data to support what everybody has been noticing for many years. When you put kids in a hospital and bathe them frequently, in 3 or 4 days they always get way better. I always try to boil down those triggers for parents, because everyone wants to know. They just want to eliminate something, and skin care is so important in the equation. I always say, the products you put on your skin, the germs on your skin, and the ambient humidity. Bathing really has an impact on all that stuff. You have to go over that when you’re teaching them skin care.
Lawrence Eichenfield, MD: Let’s move over to practical aspects of moisturizer and emollient recommendations. We have different environments. Fred lives in Texas, Elaine is in St Louis, Peter is in Chicago, where it gets really dry in the winter and really humid in the summer. San Diego—you think it’s dry, but our humidity is in the same spot. We can have 35% humidity in 1 part of San Diego and 9% and another. A ride to the mall can create a variation in humidity. The question is, how gooey do you go with moisturizers? How didactic are you in pushing them to ointments as opposed to creams or lotions? What do you do practically?
Fred Ghali, MD:I can answer that. You alluded to where I practice, in Texas, where the heat hits triple digits. Today, for instance, it’s the end of June and we’re already hitting triple-digit weather, so we’re going to have difficulty a lot of times with our patients applying thick ointments, especially in the infants and young children. They often come in with prickly heat, and the prickly heat is so oppressive that it overlaps with the atopic dermatitis, so we may have to use more of a lotion vehicle in the warmer months in the Texas environment. For other patients, in the wintertime creams and ointments do quite well. As the kids get older, you need to consider patient preference. Some patients don’t want to use an ointment. If it’s a teenager, they prefer a cream, where they are self-applying medication. Oftentimes it’s important to get the patient input on what vehicle they like as well.
Lawrence Eichenfield, MD: Peter, is that style similar?
Peter Lio, MD: Very much. Part of the art—I think my teachers in this regard would often say, “Just pick a nice moisturizer.” Pick something you like, but I really think it’s important to give some very specific examples, and 1 of my favorite things to do is to bring a little palette of choices and let them try. Especially if the patient says, “Everything burns. I hate everything.” Well, let’s try this together. I’ll put my glove on and rub a little, and the best part is when the kid says, “Oh, I like that 1.” Then I turned to the family and say, “OK, this is the 1, and you can get this at the grocery store.” I’m not using anything fancy, but it’s so nice to be able to customize it to each patient and each time of year. I totally agree. In hot and sweaty times, many patients say that it feels occlusive and hot and makes them itch. We don’t want that, so they might need something later in the summer and heavier in the winter. I try to go heavier when I can. Of course we know that good old-fashioned petrolatum does a lot by itself, and it’s very inexpensive. We have to weigh all these factors of safety, expense, and accessibility when we make these decisions.
Lawrence Eichenfield, MD: Elaine, anything to add?
Elaine Siegfried, MD: I’m wary of what I call the cosmeceutical industrial complex. I am always really wary of occult generalized distribution, or even patchy, secondary contact allergic dermatitis. You’ve got to weigh the preference of the patient, because they have to want to use this medicine, but they have to really understand that that a lot of lotions and creams just have emulsifiers, preservatives, and even occult fragrance in there. It can really trigger a contact dermatitis, which they’re never going to clear if they have that.
Lawrence Eichenfield, MD: For specialists, this is 1 place where it’s nice that we have samples. I don’t have samples for prescriptions anymore. I agree with Peter that physically putting stuff on in the room is really helpful. It’s like old-fashioned doctoring. You’re doing some touching there, and it does go a long way. There’s a power to that little bit of application of a few different moisturizers. Certainly, with toddlers I tell my parents straightforwardly that it’s not yes or no; it’s which one. It’s a way to try to get them to elect something. But it’s a practical point that can make a big difference in patient care.
Transcript Edited for Clarity