Prevent or Reduce Atopic Dermatitis Flare-Ups

Pharmacists can provide advice to patients who are seeking guidance on how to prevent and treat atopic dermatitis (AD), given the many topical nonprescription products on the market, such as antihistamines, low-potency topical hydrocortisone products, moisturizers, and skin cleansers.

Self-management using a combination of OTC products and non- pharmacological measures is appropriate for most patients with mild to moderate AD. However, encourage patients who exhibit severe signs of or worsening AD to seek further medical evaluation and treatment.

The American Academy of Dermatology (AAD) indicates that AD is a chronic, pruritic inflammatory dermatological condition that occurs most commonly in pediatric patients but also affects many adults.¹ AD is often seen in patients with a personal or family history of allergic rhinitis and asthma.¹

AD is the most common form of eczema, affecting more than 9.6 million pediatric patients and an estimated 16.5 million adults in the United States, according to the National Eczema Association (NEA).²

Its pathogenesis is often multifaceted and may involve environmental factors, epidermal and immunologic barrier dysfunction, and a genetic predisposition.^3-5 An estimated 50% of patients receive a diagnosis within the first year of life, and up to 85% present with symptoms before the age of 5 years.⁴

Patients with AD often experience flare-ups that may exacerbate their conditions. Common triggers include dry skin, exposure to environmental or food allergens, exposure to extreme temperatures, skin irritants, and stress.⁶

More than 85% of those with AD experience itching on a daily basis, which can also cause pain and sleep issues, according to the NEA.²

Clinical Studies, Recent News

Investigators attempted to compare the clinical effectiveness and safety of the 4 primary emollient types used for pediatric eczema, which are creams, gels, lotions, and ointments. The study involved 550 participants aged 6 months to 12 years. The subjects were randomly assigned to use 1 of the 4 types of emollients, and parents reported their observations weekly for 16 weeks and followed up every 4 weeks for 52 weeks.

Findings published in The Lancet Child & Adolescent Health indicated that there was no difference regarding the efficacy and safety among the 4 primary types of emollients commonly used in pediatric eczema. The authors also noted that the total number of adverse events did not significantly vary between the treatment groups, though stinging was less common with ointments than with creams, gels, or lotions.⁷

Findings published in The Journal of Allergy and Clinical Immunology: In Practice indicated that although having a history of food allergies is common among pediatric patients with AD, only a small percentage of subjects in the study had food-triggered AD (FTAD). FTAD, defined by a physician-noted sustained improvement in AD after removal of a food, appeared uncommon, occurring in just 3% of the total cohort and 2% of patients with mild AD, 6% of those with moderate AD and 4% with severe AD.⁸

Study findings published in the Journal of the American Academy of Dermatology indicate that individuals with AD exhibited a small but increased risk of incident dementia compared with the general population, and AD severity was correlated with a greater risk. The study involved individuals aged 60 to 99 years. In the adjusted Cox proportional-hazard models, patients with AD exhibited a 27% enhanced risk of dementia, and the incidence of dementia was 57 per 10,000 person-years among those with AD during follow-up compared with 44 per 10,000 person-years in the control group.

The investigators also noted that the correlation persisted even after adjusting for the use of systemic corticosteroids and potential mediators, and severe eczema was associated with a greater risk of dementia.⁹

Living With AD

Establishing a routine skin care regimen is critical to maintaining healthy, hydrated skin, and incorporating preventive measures can help prevent or reduce flare-ups.

The AAD and NEA provide several tips that patients can use to manage and prevent AD symptoms. These include the following^2,10:

• Bathe daily, taking a 5- to 10-minute bath or shower in lukewarm, but never hot, water.
• Identify triggers to AD flare-ups and avoid when feasible.
• Eat a healthy diet, manage stress, and obtain sufficient sleep.
• Moisturize after bathing and when skin feels dry.
• Protect the skin from extreme temperatures.
• Seek care from a dermatologist if symptoms do not improve or if they worsen.
• Select fragrance-free skin care products.
• Test all skin care products before using them.
• Wash new clothing in detergent that is dye- and fragrance-free before wearing.
• Wear clothing that is loose fitting and 100% cotton, as cotton is less irritating and lets the skin breathe.

More information can be found on the AAD website (https://www.aad.org/ public/diseases/eczema/atopic-dermatitis-coping).

The NEA also has a helpful application called EczemaWise to keep track of symptoms and triggers (https://nationaleczema.org/turn-your-whys-into- wise-with-eczemawise/).

Conclusion

To effectively counsel patients, pharmacists should be familiar with guidelines for the management and treatment of AD that were published in early 2022 by the AAD (https://www.aad.org/member/clinical-quality/guidelines/atopic-dermatitis).

Pharmacists can educate patients about the best OTC products for AD and the importance of using OTC skin care products that contain ceramides, which can be beneficial in maintaining, protecting, and restoring the natural skin barrier function and overall dermatological health. Pharmacists can also direct patients to the NEA website that lists skin care products for AD that have received the NEA Seal of Acceptance (https://nationaleczema.org/ eczema-products/about-nea-seal-of-acceptance/).

About The Author

Yvette C. Terrie, BSPharm, RPh, is a consulting pharmacist and medical writer in Haymarket, Virginia.

References

1. Davis DMR, Drucker AM, Alikhan A, et al. American Academy of Dermatology Guidelines: awareness of comorbidities associated with atopic dermatitis in adults. J Am Acad Dermatol. 2022;86(6):1335-1336.e18. doi:10.1016/j.jaad.2022.01.009

2. Atopic dermatitis. National Eczema Association. 2022. Accessed June 28, 2022. https://nationaleczema.org/eczema/types-of-eczema/atopic-dermatitis/

3. Kim BE, Leung DYM. Significance of skin barrier dysfunction in atopic dermatitis. Allergy Asthma Immunol Res. 2018;10(3):207-215. doi:10.4168/aair.2018.10.3.207

4. Benner KW. Atopic dermatitis and dry skin. In: Krinsky DL, Ferreri SP, Hemstreet BA, Hume AL, Rollins CJ, Tietze KJ[NL1] , eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 20th ed. American Pharmacists Association; 2021:689-699.

5. Kim J, Kim BE, Leung DYM. Pathophysiology of atopic dermatitis: clinical implications. Allergy Asthma Proc. 2019;40(2):84-92. doi:10.2500/aap.2019.40.4202

6. Eczema causes and triggers. National Eczema Association. Accessed June 28, 2022. https://nationaleczema.org/eczema/causes-and-triggers-of-eczema/

7. Ridd MJ, Santer M, MacNeill SJ, et al. Effectiveness and safety of lotion, cream, gel, and ointment emollients for childhood eczema: a pragmatic, randomised, phase 4, superiority trial. Lancet Child Adolesc Health. 2022;6(8):522-532[NL2] . doi:10.1016/S2352-4642(22)00146-8

8. Li JC, Arkin LM, Makhija MM, Singh AM. Prevalence of food allergy diagnosis in pediatric patients with atopic dermatitis referred to allergy and/or dermatology subspecialty clinics. J Allergy Clin Immunol Pract. 2022;S2213-2198(22)00577-3. doi:10.1016/j.jaip.2022.05.028

9. Magyari A, Ye M, Margolis DJ, et al. Adult atopic eczema and the risk of dementia: a population-based cohort study. J Am Acad Dermatol. 2022;87(2):314-322. doi:10.1016/j.jaad.2022.03.049

10. Eczema types: atopic dermatitis: tips for coping. American Academy of Dermatology. Accessed June 28, 2022. https://www.aad.org/public/diseases/eczema/atopic-dermatitis-coping