Conference Coverage

Nonpharmaceutical therapies offer alternatives for atopic dermatitis


 

EXPERT ANALYSIS FROM SUMMER AAD 2018

– When topical and oral medications alone don’t meet the needs of patients with atopic dermatitis, nonpharmaceutical options may benefit patients as adjunctive therapies, according to Peter A. Lio, MD, of Northwestern University, Chicago.

Dr. Peter A. Lio

Dr. Peter A. Lio

Cryotherapy and silk or silver fabrics have seen some good results, according to Dr. Lio, who cited his paper on nonpharmacologic therapies for atopic dermatitis. “There is another world of nonpharmacologic treatments that is perhaps nearly as extensive, though less well known, and likely underutilized by some clinicians.”

Dr. Lio described the treatment options for atopic dermatitis as the four points of a tetrahedron: anti-inflammatories, antibiotics, antipruritics, and moisturization.

Moisturization

“More moisturizer means less eczema,” Dr. Lio said. If patients find the moisturizer too cold, they can float the jar in a hot bath before applying it. On the flip side, patients who feel hotter or itchier when applying moisturizer may prefer keeping it in the refrigerator.

Evidence also supports balneotherapy and spa therapy, Dr. Lio said, though limited data exist to guide clinicians on the frequency or duration of baths or how soon to apply moisturizer after a bath. Research indicates benefit from bath and spa therapy lasting up to 3-6 months for mild to moderate eczema.

However, it’s hard to distinguish between the possible benefits of the spa therapy itself versus possible confounding benefits from what often accompanies spa therapy, such as climatotherapy (warm weather), heliotherapy (sunshine), and relaxation from being in a vacation setting.

It’s also unclear whether the minerals in the water matter. Balneotherapy studies have shown benefits from mineral-rich water, but research has shown no benefit from using a water softener to remove minerals from hard water. Furthermore, balneotherapy and spa therapy are expensive, time-consuming, and temporary.

Using wet wraps overnight is an easy and cheap alternative treatment. Dr. Lio recommended soaking onesies, pajamas, gloves, or socks (depending on the location of affected skin) in warm water and then wringing them out until slightly damp. The person puts on the damp clothes and dry pajamas, gloves, or socks over them, and ensures the room is warm enough before going to sleep.

Antibacterial agents

Some research has found an association between environmental Staphylococcus aureus and severe atopic dermatitis, suggesting a role for antibacterial agents, Dr. Lio said. Though the mechanism is unclear, a dilute bleach bath may help.

In a small, randomized, controlled trial of 31 children with moderate to severe eczema, all received oral antibiotics and were then randomized to receive either intranasal mupirocin and a dilute bleach bath twice weekly for 4 weeks or intranasal vaseline and a placebo bath. Those in the mupirocin/bleach bath group showed significant greater improvement, compared with the placebo group.

Yet other research has shown regular baths are superior to dilute bleach baths. It seems more likely that dilute bleach baths act more as an anti-inflammatory than an antibacterial agent, Dr. Lio said at the American Academy of Dermatology summer meeting.

Probiotics “is an area that’s teeming with potential, but right now we don’t really write a prescription for probiotics,” Dr. Lio told attendees. He shared a systematic review supporting probiotics’ use in pregnant mothers and newborns for preventing atopic dermatitis.

“I’m convinced there actually is significant evidence that, if you give expecting moms probiotics and then give it to the baby as soon as they come out, you can prevent or at least reduce the severity of the atopic dermatitis in a measurable portion of patients,” Dr. Lio said. However, he acknowledged other research suggesting probiotics simply delay onset of atopic dermatitis.

“The bacteria in our gut are quite different than [the bacteria] on our skin,” Dr. Lio said. Topical probiotics are under study, and “could be a nonpharmacologic adjunctive therapy.”

Silver and silver-coated clothing are anecdotally successful in select patients. One small study compared silk with topical steroids and implied good results, but most studies with silk remain small and underpowered. If patients want to try textile therapy, they can purchase small silk sleep sacs similar to a sleeping bag.

Silver-impregnated products display true antibacterial effects and do seem to improve atopic dermatitis and pruritus scores, he added, but there are downsides. “These products are pricey, and there’s an environmental issue when you wash these silver clothes and the silver hangs out in the water supply.”

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