Skin Care With Moisturizers

Topical moisturizers are the cornerstone of AD therapy as they help combat dry skin caused by skin barrier dysfunction. The following questions are frequently posed by patients in dermatology clinics about the use of moisturizers in the setting of AD.

  • How do moisturizers help treat AD?

Moisturizers contain unique ingredients, each having individual benefits for improving the skin health of an individual with AD. Water provides temporary hydration; propylene glycol, glyceryl stearate, and soy sterols soften the skin; petrolatum, mineral oil, and dimethicone provide occlusive effects; and glycerol, lactic acid, and urea lock in water.

  • How often should one apply moisturizer?

Liberal and frequent reapplication of moisturizer is necessary so that xerosis is minimal. Moisturizers should be applied after every bath or shower while the skin is still damp.

  • Which moisturizer is the best?

Moisturizers come in different forms such as creams, ointments, oils, gels, and lotions. Although ointments are the most occlusive products and have the advantage of not containing preservatives that may cause stinging when applied to inflamed skin, they may be too greasy for some patients with AD. A cream formula may be more acceptable for daily use.

In summary, moisturizers eventually help decrease clinical signs and symptoms of AD such as itching, redness, thickening and fissuring of the skin.

Topical Anti‐inflammatory Therapy

Topical corticosteroids. Randomized control trials have shown that topical corticosteroids (TCS) are the mainstay of anti-inflammatory therapy in the management of AD, and they have been used to lessen the symptoms of AD in patients of all ages. TCS is the next step in the management of AD when the first step of skin care and liberal use of moisturizers does not provide adequate control. Lower-potency steroids should be tried first, with higher-strength TCS being reserved for more severe local disease flares.

The following questions are frequently posed by patients in dermatology clinics about the use of TCS in the setting of AD.

  • How do TCS work?

As mentioned above, TCS are anti-inflammatory agents that stop inflammation by acting against cells like T lymphocytes, monocytes, macrophages, and dendritic cells. They interfere with antigen processing and hence decrease the release of proinflammatory cytokines.

  • What are the different types of TCS?

TCS are classified based on their strength. Hydrocortisone and dexamethasone are the least potent TCS and therefore recommended for use on the face and in skin creases. Betamethasone available in all forms of TCS is of medium potency. Clobetasol, halobetasol, and fluocinonide are high-potency corticosteroids recommended for use on body areas other than face, genitalia, and skin creases.

  • How often should TCS should be applied to the skin?

Multiple clinical trials have shown that the efficacy of TCS in AD management involves twice-daily application; however, in some cases one daily application works as well.7 Instead of sudden withdrawal, it is now recommended to taper from daily administration to 2- to 3-times weekly and then stop once control is achieved.

  • What are the side effects of TCS?

Patients should be informed about the adverse events every time they are prescribed TCS; these include purpura, telangiectasia, striae, hypopigmentation, focal hypertrichosis, and acneiform or rosacea-like eruptions. One serious side effect is atrophy, which can be induced by higher-strength TCS when they are used in thin cutaneous areas like the face and in skin folds. Long-term widespread use can be associated with hypothalamic-pituitary-adrenal axis suppression, especially in children because of their large surface area-to-volume ratio.

Topical calcineurin inhibitors. Topical calcineurin inhibitors (TCIs) are also anti-inflammatory drugs; tacrolimus and pimecrolimus are the 2 TCIs available in the United States.  A significant benefit of the use of TCIs is the avoidance of the adverse events experienced with topical steroid therapy.

The following questions are frequently posed by patients in dermatology clinics about the use of TCIs in the setting of AD.

  • How do TCIs work?

The mechanism of action of TCIs involves blockage of calcineurin-dependent T-cell activation. Streptomyces are natural bacteria that produce calcineurin. When T-cell activation is blocked, downstream cytokines and inflammatory cells are also blocked, helping control the symptoms of AD.

  • How often should TCIs be applied?

TCIs should be applied twice daily.

  • What are common side effects of TCI?

The most commonly reported adverse events of TCIs are local reactions. Patients may report burning and stinging; these events are usually seen when TCIs are used after TCS. These effects are temporary and tend to decrease after continuous use. Less common adverse events include contact dermatitis or a rosacea-like granulomatous reaction.

Topical antimicrobials and antiseptics. Topical antimicrobials are not recommended for routine management of AD as they have not shown significant benefits, and adverse events effects are not uncommon. The only recommended antimicrobial treatments are bleach baths and intranasal mupirocin to decrease nasal colonization with S aureus and reduce disease severity.