Atopic Dermatitis Update: The Role of Therapeutic Patient Education and Adjunctive Therapies in Atopic Dermatitis

Atopic dermatitis (AD) is a pruritic skin disease of unknown origin that usually starts in early infancy. It is the first step in the Atopic March theory. According to this theory, AD may later develop into other types of allergies.1 Because AD is one of the most common skin diseases in the world, may researches and clinical trials have been done in order to discover the most effective treatment. During the 27th of February, 2015 on the Galderma Scientific Night, “New Updates on The Therapy for Atopic Dermatitis” was presented by Donna Marie Leelin-Sarrosa, MD, FPDS.

“There are three hallmarks of AD, the first is that it has a Typical distribution and morphology, the sufferers experience an Intense itch, and it has is a Chronic disease, or in short, TIC,” said Leelin-Sarrosa. The distribution and morphology of AD depends on the age of the patient. In infants, the manifestations are erythema and oozing on the face (particularly the cheeks) and the extensor surfaces of the extremities. While in older children, it manifests as dry skin and lichenification on the flexure surfaces of the extremities. The treatment also depends on the age of the patient and, therefore, the chronicity of the disease itself. The mainstay of therapy is to prevent the skin from becoming dry and cracked, through the use of topical moisturizers and treating the inflammation, through the use of topical corticosteroids, antibiotics, or using immunomodulators such as tacrolimus. One can also use other types of adjunct therapies such as bleach baths or vitamin D supplementation, which will be discussed later on.

However, first and foremost is moisturizing the skin. Moisturizing the skin is important because it maintains the “brick and mortar” structure of the skin barrier. Without adequate hydration, the “mortar” would not be able to act as a glue for the corneocytes and an abnormal desquamation process would occur. For people with AD, the ideal moisturizer should be ‘safe’ to use, as in, it does not absorbs to below the skin layers, it does not contain any toxic materials, it is longlasting, is cosmetically elegant and acceptable, and last but not least, it does not cause any allergic reactions nor is it irritating to the skin. This is also influenced by the degree of dryness of the skin. For lightly dry skin to moderate dry skin, emollients are usually sufficient. But those with severely dry skin or cracked skin, may also require occlusives or the newer moisturizers. The benefits of using the newer types of moisturizers, in addition to be fragrance free and non irritating, is that is lasts longer, more soothing, prevents the loss of moisture from the skin, absorbs quicker, and is non-greasy.2

A correct moisturizing regiment would prevent the exacerbation of AD. According to Del Rosso and Kircik, the newer moisturizers that contain physiological lipids such as sunflower seed oil and ceramide precursors (pseudoceramide 5), filaggrin degradation products such as arginine and pyrrolidone carboxylic acid (PCA), and ‘skin-barrier friendly’ excipients such as thea butter, niacinamide, and glecerine as a humectant may be able to repair the damaged epidermal barrier that commonly occurs in AD or, in other words, act as a ‘barrier repair therapy’. These types of moisturizers while, not yet widely used, would be able to improve the condition of the patient and prevent exacerbations of the disease in the long term.3

The other step is using topical corticosteroids to mitigate the inflammation. Topical corticosteroids should be used wisely, it may be used 1-2 times daily for 1-3 weeks, then a maintenance therapy must be set. The patient and family/caretaker must be aware that corticosteroids are NOT a moisturizer. It must be used WITH moisturizers and AD itself is a chronic and relapsing disease, thus the patient must have realistic expectations, and must be aware that at certain conditions and situations that his/her disease will relapse. However, it is during this step that many patients and their parent often hesitate. In a research by Aubert-Wastiaux, et al. that involved 208 patients and their caretakers, 80.7% of the patients have a fear of using topical corticosteroids or topical corticosteroid phobia and, therefore the level of non-adherence was quite high (36%). This research also determined that there was a correlation between topical steroid phobia and the need for reassurance, the belief that topical steroids would pass into the bloodstream, prior adverse events, inconsistent information about the quantity of the cream to apply, a desire to self-treat for the shortest time possible, and poor treatment adherence.4 According to Leelin-Sarrosa, this would lead to treatment failure, which would indicate that there is a large need for patient education on the type of drug used for the patient. The patient and their caretakers must receive information on the medication that they are using, how to use it, how long will it be used, and its possible side effects.

This is conveyed through a process called Therapeutic Patient Education or TPE. According to the World Health Organization (WHO), TPE helps patients with chronic disease to acquire or to maintain the skills required to manage living with a chronic disease in the best possible way. TPE has been used in many chronic diseases, such asthma, diabetes, and cardiovascular diseases. It is a component of therapeutic management. However, the transfer of skills to the patient or caretakers should not be confused with medical advice or a mere provision of information. TPE is a patient-centered process that consists of organized activities that includes psychosocial support, hospital organization and procedures, and health/disease-related behaviors. It helps the patient and their caretakers/families to understand their disease, its treatment, and how to manage it, therefore improving the patient’s quality of life.5

Because it is patient-centered, TPE is personalized for each patient and each of their problems personally. During this process, the goals and benefits of each step of the therapy is explained, both orally or through printed media, such as leaflets, that the patient or family can take home. However, the patient’s consent is necessary for this process and the patient and their families or caretakers must be informed on where the process will take place. After obtaining the patients’/family’s consent, a personalized initial session, collective workshop, or an information meeting (lecture) is proposed. The patient/family/caretaker can select which type he/she prefers.5

During the initial visit, the following information must be obtained:5

  • The history of the patient’s disease,
  • What he/she thinks that caused their disease,
  • What factors that would alleviate or aggravate their disease,
  • The aspects of their disease that bothers them most,
  • What is the treatment that the patient receives? And what are their concerns on their treatment?
  • How is their treatment going? Also, ask the patient to describe in DETAIL on what they do when applying their treatment and their habits.
  • What things that the patient cannot do because of their disease?
  • How is the patient’s relationship with their families, friends and work colleagues?
  • What does the patient do when they need help? Whom they turn to?
  • What are the patient’s expectations with this visit?

The information gathered may seem personal, but it is necessary, since stress also plays a large factor in AD. According to Leelin-Sarrosa, within the 11 countries and 23 hospitals that TPE has been used, TPE has proven to have beneficial effects on the patient’s quality of life and the severity of their disease in treating children with moderate to severe AD. Eight randomized controlled trials (RCTs) on TPE programs for children with AD or their patients have been published. In the Staab study, the authors randomized 992 children aged between 3 months to 12 years old and adolescents with moderate to severe AD (SCORAD >20) to group sessions of standardized intervention programs once a week for 6 weeks or no education (control group). This study reported that the all the groups that received the intervention experienced significant improvements over a 12 month period in their quality of life and the severity of their disease compared to the control group (SCORAD: 3mos-7 yrs, -17.5, 95% Confidence

Interval [CI] = -19.6 to -15.3 vs. -12.2, 95% CI = -14.3 to -10.1; 8-12 yrs, -16.0, 95% CI = -20,0 to -12.0 vs. -7.8, 95% CI = -11.4 to -4.3; 13-18 yrs, -19.7, 95% CI = -23.7 to -15.7 vs. -5.2, 95% CI = -10.5 to 0,1). Children younger than 7 years old experienced a significantly better improvement in all five quality of life subscales, while children between the age of 8 to 12 years old experienced a significant improvement in only three of the five quality of life subscales.5

Nevertheless, everything has its drawbacks. TPE also has its limitations. Patients and parents may refuse TPE, whether because of their schedules or its availability, because TPE is time consuming. It is also a ‘holistic’ process, therefore the use of medication is also included, it should not begin before the flare-ups are treated properly. Other limitations are the costs for TPE, not only the traveling cost for the patient and their families/caretakers, but also the cost for training the people involved in the program and the time necessary for organizing and administering the programs in the hospitals and clinics. Then, of course, the cost to address the common barriers in adherence, such as poor literacy, learning difficulties, social difficulties, cultural backgrounds, limited access to healthcare, the high cost for treatment, psychiatric illnesses, or emotional problems. These are the reasons for tailoring TPE according to the patient’s requirements.5

Another point that Leelin-Sarrosa discussed during the Galderma Scientific Night at the Ritz-Carlton Hotel was the role of vitamin D supplementation in treating AD. In several notable researches, we have discovered that vitamin D deficiency might be related to the severity of AD. In a trial involving 107 children in Mongolia, Camargo, et al. discovered that vitamin D supplementation improved winter-related AD among Mongolian children, a population that is likely to suffer from vitamin D deficiency in winter.5 According to Leelin-Sarrosa, this is because vitamin D improves barrier maintenance, therefore, preventing allergens and microbes from penetrating to the layers below, and causing less activation of the inflammatory cascade.

Secondary infections by bacteria is also a concern in AD. Therefore, bathing is also an important step in treating AD. Because it will remove bacteria from the skin, provide some degree of exfoliation, and provides extra hydration. A trial by Huang, et al. that involved 31 patients between 6 months to 17 years of age with moderate to severe atopic dermatitis, proved that chronic use of diluted bleach baths with intermittent intranasal application of mupirocin ointment decreased the severity of AD in patients with secondary bacterial infections. Patients with AD do not seem to experience an increased susceptibility to resistant strains of Staphylococcus aureus.7 According to Leelin-Sarrosa, the bleach used should be common household bleach (6%) and NOT concentrated bleach. Mix the bleach with water until you reach a concentration of 0.005% or mix ¼ cup of bleach into a 40 gallon tub or ½ cup into a full tub or 30 cc of bleach into a gallon of water or 0.39ml of bleach into 500 ml of water.

In addition to bleach baths, systemic antibiotics has also proven to be beneficial in the treatment of AD with secondary infections. However, the 2008 Cochrane database review stated that topical antibiotics, antibacterial soaps, antibacterial bathadditives, or silver layered textiles provided NO benefit.8 Therefore, Leelin-Sarrosa recommends the use of systemic antibiotics such as cloxacillin, cephalexin, clavulanic acid, TMPSMX, or Clindamycin, depending on the type of bacterial infection. In addition to those two steps, minimalizing exposure to the bacteria by washing your hands before application or using a clean spoon for application and keeping the topical medication properly refrigerated and in a clean place is also important.

“The patient must also avoid from using products containing astringents and alcohol, use cleansers with minimal defatting activity with a neutral pH, also launder new clothes before wearing it to remove the formaldehyde, and also add a second rinse cycle. To note, liquid detergents are easier to rinse out,” says Leelin-Sarrosa. In addition, the patient must also avoid known allergens, use sunscreen with minimal irritating properties, shower with cleansers immediately after swimming, avoid extremes of temperature and humidity, and use moisturizers religiously. Even so, some patients experience refractory AD. This may be cause by an incorrect diagnosis or a coexisting disease, such as contact dermatitis or the patient was exposed to topical products that contain sensitizing agents. Therefore, detailed history on the patient’s habits are extremely important.

 

References

  1. Kim, BK. Atopic Dermatitis. Updated December 8, 2014. Downloaded from http://emedicine.medscape.com/article/1049085-overview#showall on 17th march 2015.
  2. Boediardja, SA. Moisturizer: Aplikasi di bidang dermatologi. Badan Penerbit Fakultas Kedokteran Universitas Indonesia. Jakarta, 2015.
  3. Del Rosso, JQ and Kircik, LH. The Integration of Physiologically Targeted Skin Care in the Management of Atopic Dermatitis: Focus in the Use of a Cleanser and Moisturizer System Incorporating a Ceramide Precursor, Filaggrin Degradation Products, and Specific “Skin Barrier-Friendly” Excipients. J Drugs Dermatol. 2013;12(7 suppl.):s85-s91.
  4. Aubert-Wastiaux H, Moret L, Le Rhun A, et al. Topical corticosteroid phobia in atopic dermatitis: A study of its nature, origins, and frequency. Br J Dermatol. 2011;165(4):808-814.
  5. Barbarot S, Bernier C, Deleuran M, et al. Therapeutic Patient Education in Children with Atopic Dermatitis: Position Paper on Obejctives and Recommendations. Ped Dermatol. 2013;30(2): 199-206.
  6. Camargo C, Ganmaa D, Sidbury R, et al. Randomized trial of vitamin D supplementation for winter-related atopic dermatitis in children. The journal of Allergy and Clinical Immunology. Received: December 17, 2013; Received in revised form: August 8, 2014; Accepted: August 8, 2014. Downloaded from http://www.jacionline.org/article/S0091-6749(14)01114-2/abstract .
  7. Huang JT, Abrams M, Tlougan B, et al. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics 2009 may;123(5):e808-14. Doi: 10.1542/peds.2008-2217.
  8. Birnie AJ, Bath-Hextall FJ, Ravenscroft JC, and Williams HC. Interventions to reduce Staphylococcus aureus in the management of atopic eczema. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD003871. Doi: 10.1002/146518858.CD003871.pub2.