Efficacy and Safety Considerations in Topical Treatments for Atopic Dermatitis

Noreen Heer Nicol, MS, RN, FNP


Dermatology Nursing. 2010;22(3):2-11. 

In This Article

Management of AD

Patient education is the foundation of the successful management of AD. However, the typical clinic visit may not provide adequate patient education or optimal patientprovider communication because of time constraints. Studies have demonstrated optimal education provided by a specialist dermatology nurse resulted in an 89% reduction in the severity of AD symptoms (Cork et al., 2003), further reinforcing the critical role of patientprovider communication.

Nurses and NPs should provide both oral and written instructions on the recommended skin care regimen. Since patients or caregivers may forget or confuse skin care regimens, these details should be reviewed and modified, if necessary, at followup visits. Patients also should understand the chronic and often relapsing nature of AD, so realistic treatment expectations and goals can be established.

Patients with moderate-to-severe chronic AD symptoms often search for a unique trigger whose avoidance will result in improved control of the disease. A key goal in the successful management of AD is to educate patients about irritants, allergens, and other potential triggers and help them identify circumstances to avoid, reducing the itch-and-scratch cycle (Leung, Boguniewicz, Howell, Nomura, & Hamid, 2004).

Common irritants include soaps, detergents, toiletries containing alcohol or astringents, solvents, alkalis, and acids. Clothing made from an irritating synthetic or wool material should be avoided in favor of loose-fitting, nonabrasive, and breathable cotton or cotton-blend materials. Hot water during showering or bathing can contribute to skin irritation when flushing occurs, as can excessive sun exposure, especially sunburn. When irritants are identified as triggers, cotton gloves may be used to prevent contact of the irritant with the hands. Cotton gloves also can be used to decrease scratching trauma to the skin and are commercially available in pediatric sizes.

Allergens include dust mites, animal dander, weeds, molds, and pollen. While complete avoidance of such aeroallergens may not be possible, control measures should be taken in patients with a documented sensitization by testing as well as clinical history. Food allergies may exacerbate AD as well, particularly in children less than 3 years of age. Foods that may trigger symptoms in sensitized patients include eggs, milk, wheat, soy, and peanuts. While there are no consensus guidelines on diet for patients with AD, dietary restrictions are recommended in patients with an established diagnosis of food allergy (Akdis et al., 2006). Care must be taken to only restrict specific food allergens that have been implicated in controlled challenges. Extensive elimination diets are rarely required.

In response to the wide variation in the diagnostic and therapeutic management of AD practiced by clinicians, the American Academy of Allergy, Asthma and Immunology and the European Academy of Allergy and Clinical Immunology issued consensus guidelines for clinical practice. These guidelines recommend three basic components of optimal skin care. First and foremost, the regular use of moisturizers or emollients in conjunction with skin hydration is essential to address the skin barrier defect. Second, identification and avoidance of specific and nonspecific triggers is critical in reducing symptoms. Third, depending on the severity of AD, topical therapeutic agents may be initiated in a stepwise fashion. These topical agents include glucocorticosteroids and calcineurin inhibitors. Severe refractory disease may be managed with systemic treatments (Akdis et al., 2006) (see Figure 2).

Figure 2.

Stepwise Management of Patients with Atopic Dermatitis. CyA, Cyclosporine A; TCS, Topical Corticosteroids; TCI, Topical Calcineurin Inhibitors
*Over the age of 2 years.
Source: Reprinted with permission from Akdis et al., 2006. © American Academy of Allergy, Asthma and Immunology and the European Academy of Allergology and Clinical Immunology.