Meeting the Challenges of Eczema in the Winter

With falling temperatures heralding the beginning of winter, many people are excited to begin outdoor snow activities. Unfortunately, this changing weather can exacerbate some common skin conditions, such as, atopic dermatitis or eczema, a chronic inflammatory skin condition characterized by itching, redness, scaling, and clustered bumps, usually in the elbows and knees. Nearly 2% of Americans suffer from atopic dermatitis. Often beginning in early childhood its symptoms wax and wane. The majority of affected individuals attain resolution of the disease by adulthood, but up to 30% do not. The exact cause for atopic dermatitis is not determined, but is likely the result of a complex interplay of environmental and genetic factors. Recently, scientists and physicians are developing a better understanding of atopic dermatitis and significant innovations have been made in therapies for this complicated condition.

Dryness and itching, resulting from a dysfunctional skin barrier, are one of the most important features of atopic dermatitis. Skin barrier compromise leads to water loss and unwanted exposure to environmental bacteria and noxious irritants. Atopic dermatitis and its associated itching impact patients’ quality of life frequently interfering with sleep and normal day-to-day activities which can lead to anxiety, depression and sleep deprivation. Chronic itch and atopic dermatitis have been shown to activate areas of the brain similar to those areas observed in chronic stress and pain. Moisturization to repair the skin barrier and decrease water loss and itching remains paramount in the treatment of atopic dermatitis. Moisturizers decrease symptoms of itching and redness, decreasing the amount of prescription medication required. Recent scientific studies are unclear exactly how much or how often moisturizer should be applied, but, in general, more liberal and frequent application is thought to minimize dryness. Often, greasier products such as ointments and oils are better tolerated than creams or lotions as they possess fewer preservatives and are less likely to cause irritation.

Bathing can have several effects on the skin. Bathing with water can hydrate the skin and remove irritants, thereby helping patients with atopic dermatitis; however, if the water is left to evaporate, worsening dryness can occur. Once daily, warm water, bathing for five to ten minutes, followed by prompt moisturizer application is recommended to maintain adequate skin hydration. In addition, as traditional soap pH differs from the skin’s normal pH of 4-5.5, nonsoap cleansers that are hypoallergenic, fragrance free and with neutral to low pH (closer to the skin pH) are recommended.

Skin infection risk resulting from a dysfunctional skin barrier increases in atopic dermatitis patients. The bacteria Staphylococcus aureus is often found to be a skin colonizer. Its presence, alone, on the skin does not guarantee infection, but can be a source for tremendous inflammation. Bleach is antibacterial and reduces bacterial colonization, thereby helping to prevent infection. Although bleach-enriched bath treatment has been controversial, recent studies revealed a significant decrease in infection and inflammation disease burden within six weeks of starting therapy. Further, using prescription mupirocin inside the nose, where this specific Staphylococcus bacteria often resides, in conjunction with bleach baths reduces disease burden more than simple bathing alone.

If proper skin care and regular emollient usage are not sufficient for adequate skin control for atopic dermatitis, prescription therapy is needed. Topical corticosteroids represent the mainstay of anti-inflammatory therapy for children and adults. Multiple scientific studies over the past sixty years have demonstrated topical corticosteroid’s ability to decrease itching and inflammation. Twice daily application is generally recommended, but once daily application may be sufficient. When the atopic dermatitis is controlled, maintenance therapy one to two times per week, on previous inflamed areas, may prevent relapsing and be more effective than topical moisturizers alone. As there are potential side effects for prolonged topical steroid usage, patient and parental concern should be recognized and addressed to improve adherence and avoid under-treatment.

Topical calcineurin inhibitors (TCI) represent another anti-inflammatory therapeutic option. These medications are recommended for acute and maintenance treatment of atopic dermatitis in adults and children. TCI do not cause skin thinning, as opposed to corticosteroids, so they can be used as steroid-sparing agents to reduce the need for topical corticosteroids. In addition, TCI are particularly useful in sensitive skin sites, i.e. face, under arms, groin, where the skin is thinner and there is a greater risk for adverse effects from topical corticosteroids. Often, using TCI two to three times per week in areas that commonly flare is recommended to reduce the need for topical corticosteroids and prevent recurrence of disease. Using with topical steroid may be recommended, but potential side effects should be discussed with your physician before starting therapy.

Atopic dermatitis is a complex disease and involves multiple therapies. Many parents and adult patients, concerned that physicians do not fully understand atopic dermatitis, may ignore all treatment recommendations or turn to unproven alternate therapies. In search for a “cure” to their disease, patients often seek allergy testing. A certain percentage of children (much smaller percentage in adults) suffering from atopic dermatitis possess food allergies. The exact role of food exposure to atopic dermatitis is unclear, but atopic dermatitis patients have an increased rate of food and environmental allergies compared to non-atopic individuals. If significant symptoms from allergy are present, hives, difficulty breathing, etc., formal evaluation with an allergist is paramount. Although many patients with atopic dermatitis are sensitized to certain foods and house dust mites, there is insufficient evidence, currently, to recommend any dietary modification or dust mite avoidance programs, respectively, as effective in preventing atopic dermatitis. In addition, the use of topical antihistamines is not recommended for patients with atopic dermatitis as there is a risk of skin irritation and systemic absorption.

Many patients are often inadequately or improperly treated for their atopic dermatitis. Sustained compliance remains challenging. Many new and exciting treatment options that are designed to decrease inflammation may be available in the next few years. Therefore, continued teaching and education is needed for patients to achieve a good response to treatment and remain compliant with long-term therapy for this chronic and troubling skin condition.

Daniel M. Peraza, M.D.