Management of AD: Nonpharmacological Approaches

Lawrence F. Eichenfield, MD: Peter, let’s shift over to nonpharmacological approaches because that’s usually something that we have to deal with. I laugh because I’m going to give Peter 3 to 4 minutes to discuss this—he has given multihour discussions on what the nonpharmacological approaches are to management and lifestyle modifications that people can use to try to modify their symptoms or flares. 

Peter A. Lio, MD: Thank you, Larry. Yes, you know this is 1 of my favorite things to talk about. The truth is, these are often forgotten because as we’re hearing, there are so many things we have to talk about in a visit. There’s so much education that has to happen. Each new thing brings baggage.

One of the things I’ll keep pressing at is that it’s so stressful. Early in my career, I would go from room to room to room, do the same spiel, and answer the same questions. What was so tough was that each patient felt incredibly alone and isolated. I would think, “If only you could meet the people next door. In a good way, you’re not that unique. There are other people suffering.” That’s part of what prompted me to create these centers where we have our Saturday meetings and families come and gather up.

The nonpharmacological treatments are interesting because it’s important to know. These are the kinds of things that would not be suitable for monotherapy. You’re not going to make or break it with 1 of these things, but when we add them together as adjunctive treatments, we find that we can use them to leverage something that may be working a little to potentially help overall. 

This is a confusing thing, and I feel like our FDA is very picky. It says that if the medicine doesn’t get you clear or almost clear, you’re out; it didn’t work. But wait a second. We don’t have the luxury of it being all or nothing a lot of times. We’re going to use multifactorial treatment.

Some of my favorite things, like the basic things, are avoidance of known triggers. For a lot of people, they’re allergens they’ve identified but also clothing. The classic 1 that is part of the original Hanifin and Rajka criteria was that wool clothing causes itch. If we can, it’s beneficial to avoid scratchy fabrics and temperature extremes—heat, sweating. Sometimes we’ll have little kids who get all sweated up and then they start scratching like crazy because sweat and the heat can also trigger it. 

Then we can think about going toward the more proscriptive things like some of the clothing. There are certain eczema lines of clothing. Some are silk, some are like bamboo materials. We know that silver impregnating clothing has a literature that may help. We know that certain bathing routines can help. Moisturization, of course, is a huge topic we can delve into more. That is another nonpharmacological area that we can help. I try to bring together a number of these things and include them as part of that plan.

One of the things I also find important is giving very specific recommendations on products. This is not everybody’s style. In fact, my teachers would never do this. They would say, “Pick a good moisturizer, and use it.” There’s something good about that; you’re unbiased. But I also feel like that can be overwhelming. If you say to pick gentle clothing, what does that mean? The internet is filled with all sorts of examples. People make claims all the time.

Sometimes it’s really nice to cut through all that noise. I’ll often take a screenshot and print it. I’ll say, “This is the 1 I want you to use.” It’s really powerful, and it imbues this particular product with a little extra love because I picked it for them. I don’t have thousands of things I’m picking from, but I’m not doing the same thing over and over. I say, “I really think this will be a good fit for you.” Doing that gives it value.

Lawrence F. Eichenfield, MD: That’s great. Lisa, how about state-of-the-art skin-care treatments? Why don’t we include emollients and maybe traditional topical steroids?

Elizabeth A. Swanson, MD: Sure. I will start by saying that my sensitive skin-care recommendations are fairly plain. I have my list of Dr Swanson’s favorite things, and it has very common products like CeraVe and Vanicream. I’m a big fan of those lines. Most of the time, I’m not using fancy, state-of-the-art, over-the-counter topical remedies. I’m mostly sticking with the CeraVes and Vanicreams of the world.

But there is a lot of stuff out there. Avène has a whole line of thermal water and micellar water products. There’s a product available online called Gladskin that’s probiotic based. It’s a topical cream. There are clothes and suits that can be purchased for kids with eczema. There are CBD [cannabidiol] products coming from Colorado. There was a lot of interest in those when I lived in Colorado. 

The pile of things available online to treat sensitive skin and atopic dermatitis is overwhelming. Some of them can be good. Peter’s done some great studies on sunflower seed oil. A lot of those things are great, but it can be hard to find a certain preparation that’s amenable for your patient.

Then topical steroids are a necessary part of atopic dermatitis management. They must be used in an appropriate way and not all the time, but nothing works faster to calm down a bad flare than an appropriately used topical steroid. I go over that in detail with my patients and their families. I prescribe the appropriate 1 for the location we’re treating and the duration we think it’s going to be. I go over all that from a safety perspective.

Lawrence F. Eichenfield, MD: That’s useful. I have some patients who come doing moisturizers 9 or 10 times a day because they’re trying to fix the inflammatory disease with frequent moisturizers. I praise them for their hard work. Many times they’re using great standard moisturizers, but I say, “You have to understand that great moisturization won’t necessarily fix inflammatory disease.”

The other thing I do is a little trick that is really helpful with eczema. There is a lot of eczema, especially in younger kids, that’s bumpy but not necessarily directly visible to the eye. I take my otoscope light and shine it on the side of the skin. We have kids where they are diffusely bumpy. I point that out to the families to say, “There are cells here. There’s inflammation all along here.” It’s not clear. They can feel it. Once they see it, they know it. I say that we’re going to treat to clear the bumpiness. We have to stress that the inflammatory component is going to require adequate anti-inflammatory treatment for control, even though it’s so much maintenance that’s important to try to minimize flares, even if they are controlled.

Transcript Edited for Clarity