Atopic Dermatitis, Eczema

Introduction:

Atopic dermatitis is a skin condition characterized by a scaly rash, redness, swelling, dryness, and itching of the skin. The terms eczema and atopic dermatitis are often used interchangeably to describe many different types of rashes. There are many forms of atopic dermatitis related to both irritants and allergens. Specific forms of atopic dermatitis may be categorized based on various characteristics. Some examples include: contact dermatitis caused by skin exposure to poison ivy, metals, and cosmetics; seborrheic dermatitis also known as dandruff; and dyshidrotic dermatitis due to blistering itchy skin reaction of the hands and feet. Atopic dermatitis is common in infants as early as age 2 months, children and teenagers. The condition is usually more common in patients with allergic asthma and seasonal allergies. The cause of atopic dermatitis is incompletely understood but may be related to irritation, poor immunity, hereditary factors, and exposures to the environment. Possible triggers for atopic dermatitis include contact with foods, metals such as nickel, soaps, fragrances, bleach, detergent, plastics, stress, dry air, and sun exposure.

Atopic Dermatitis Treatment:

Moisturize:

1. Moisturize the skin as much as necessary to avoid dryness with a fragrance free high quality, natural moisturizing lotion.

2. Shower only briefly with a moisturizing body wash such as Dove at the lowest tolerable water temperature. Prolonged contact with water or hot water will worsen dryness and atopic dermatitis.

Avoid the following in Atopic Dermatitis:

1. Avoid scrubbing of the skin.

2. Do not use perfumes or strong detergents on skin or for washing clothing.

3. Avoid any triggers which are believed to result in dry skin or skin irritation

Discuss with your physician options for treatment:

Avoid topical and especially systemic steroids unless absolutely necessary. If steroid treatment is required, withdrawal of steroids or steroid cream may result in a worsening of the condition for a few weeks and can consider tapering the steroid cream over 2-3 weeks rather than stopping abruptly.

Atopic dermatitis prevention:

Atopic dermatitis and breastfeeding: Thygarajan A et al performed a review of studies by searching for clinical trials completed from 1980 through 2007 on the prevention of atopic (allergy related) disease in infants and children. Research has found that for infants at high risk of developing atopic disease, there is evidence that exclusive breastfeeding for at least 4 months compared with feeding intact cow milk protein formula decreases the cumulative incidence of atopic disease and cow milk allergy in the first 2 years of life. Furthermore, among babies breastfed or formula fed exclusively for 4 to 6 months, there is modest evidence that atopic disease may be delayed or prevented by the use of extensively or partially hydrolyzed formulas, compared with cow milk formula, in early childhood. For infants after 4 to 6 months of age, there are insufficient data to support a protective effect of any dietary intervention for the development of atopic disease. (1)

Atopic dermatitis and hydrolyzed whey protein:

If an infant will not be breastfed, use a formula with hydrolyzed whey protein. Alexander DD et al performed a systematic review of 18 articles which assessed the evidence that 100% whey protein partially hydrolyzed formula (PHWF) may help reduce atopic dermatitis (AD), an inflammatory, non-contagious itchy skin disorder in infants. Researchers report a significant 44% reduction in AD symptoms in infants receiving PHWF compared to infants receiving cow’s milk formula. An additional analysis of studies considered superior in methodological quality reported a 55% reduction in AD incidence in infants given PHWF. (2)

Atopic dermatitis and probiotics:

In a study, Pelucchi C et al looked for trials testing whether or not probiotic supplements use during pregnancy and early life can prevent atopic dermatitis in infants and young children. Probiotics are “friendly bacteria” naturally found in yogurt. Probiotic tablets or liquid supplements can be used by pregnant women or by babies. The reviewers found 14 studies, mostly done between 2007 and 2011. They found a roughly 20% reduction in the rate of atopic dermatitis (RR = 0.79). The results suggested that probiotics have a moderate role in the prevention of atopic dermatitis. It does not appear to matter at what time the probiotics are consumed (pregnancy or early life) nor who consumed them – child, mother or both. (3)

The effectiveness of probiotics for pediatric atopic dermatitis (PAD) was examined in a review of 21 studies (n=2,134). Results showed that probiotics significantly reduced the occurrence of PAD by 34% after intervention, when compared to placebo. Authors concluded that current evidence on probiotic use is more convincing for prevention rather than treatment of pediatric atopic dermatitis. (4)

A meta-analysis suggested a moderate role for probiotics in pediatric atopic dermatitis (AD), a skin disorder causing inflammation and itchy skin. Ten randomly controlled trials were examined (n=678). Probiotic treatment was associated with a statistically significant improvement in the Scoring of Atopic Dermatitis Severity Index score compared with control. There were no significant differences between groups in duration of therapy, types of probiotics used and effects of age. AD was found to be more effective at treating moderately severe AD compared with mild AD. (5)

Atopic dermatitis and phototherapy:

Ultraviolet phototherapy with medium-dose (50 J/cm(2)) ultraviolet A1 (UVA1) may be the most effective treatment for acute atopic dermatitis (AD), while narrow-band ultraviolet B (UVB) may be most effective for managing chronic AD. Nine studies were included in this review. (6)

Atopic dermatitis and phytoceramides:

Consider the use of phytoceramides for atopic dermatitis in adults due to the ability of this oral supplement to hydrate the skin from the inside out. Hydration of the skin is paramount in the improvement of this condition. Plant ceramides are derived from sweet potatoes, rice, or wheat. The typical dose used has been 350 mg oral daily, with positive skin hydrating effects beginning in several weeks after starting supplementation. There is potential for phytoceramides derived from wheat to contain gluten which may be of concern by an individual has a gluten-related disorder, but the amount of gluten, if present, is likely too low to be of concern. Caution in patients taking this supplement if allergic to the plants from which they are derived. There are few known adverse effects of plant ceramides, the median lethal dose of phytoceramides has been determined to be 5000 mg per kilogram, and plant sterols, a similar substance, has been established to be “generally recognized as safe” by the FDA (7). Plant ceramides are not recommended in children because of the lack of standardization and safety data.

Wheat extract oil ceramides and skin hydration:

Guillou S, et al evaluated wheat extract oil for its effect on hydration of the skin in a double-blind, randomized, placebo-controlled study. The study included 51 women between the ages of 20 and 63 given either 350 mg of wheat extract oil or placebo over 3 months. The capsule contained 87 mg of wheat extract oil ceramides, 44 mg of hydrogenated vegetable fat, 44 mg of fatty acid, starch and silicon. The skin was evaluated by both dermatologists using corneometry to measure hydration and by the self-assessment of the subjects using a visual analogue scale. The wheat extract oil was determined to be more effective than placebo for hydration, less redness, and less dryness of the skin after 3 months. (8)

Plant ceramides and skin hydration:

A study in Japan use 2 separate methods to assess the water holding ability of the skin after treatment by both topical rice-derived ceramides, and oral corn-derived ceramides. One method used to test the hydration of the stratum corneum, and another tested for transepidermal loss of water. The rice ceramides were used topically for 3 weeks on 23 subjects, and found that the ceramides increased hydration by 41% verses placebo which increased hydration by 11%. The corn ceramides were taken by mouth at a dose of either 20 mg, 40 mg, or placebo. It was determined that the ceramides increased the amount of hydration by 190% and 294% more than baseline respectively for ceramides, and 41% higher for placebo. There was also much lower transepidermal water losses in the treatment groups compared to placebo.  (9)

Assessment and Plan: Atopic dermatitis (Eczema)

• Moisturize the skin as much as necessary to avoid dryness with a fragrance free high quality, natural moisturizing lotion.

• Shower only briefly with a moisturizing body wash such as Dove at the lowest tolerable water temperature. Prolonged contact with water or hot water will worsen dryness and atopic dermatitis.

• Avoid scrubbing of the skin.

• Do not use perfumes or strong detergents on skin or for washing clothing.

• Avoid any triggers which are believed to result in dry skin or skin irritation

• Discuss with physician options for treatment. Avoid topical and especially systemic steroids unless absolutely necessary. Withdrawal of steroids or steroid cream may result in a worsening of the condition for a few weeks and can consider tapering steroid cream over time rather than stopping abruptly.

• Research has found that for infants at high risk of developing atopic disease, there is evidence that exclusive breastfeeding for at least 4 months compared with feeding intact cow milk protein formula decreases the cumulative incidence of atopic disease and cow milk allergy in the first 2 years of life.

• If an infant will not be breastfed, use a formula with hydrolyzed whey protein.

• Multiple systematic reviews and meta-analyses found a significant reduction in the rate of atopic dermatitis with consumption of probiotics containing a variety of bacterial strains. The yogurt or probiotics consumed should specify that a variety of live active cultures are present. The studies mentioned above included strains of bacteria such as Bifidobacterium lactis, Lactobacillus GG, Lactobacillus rhamnosus, Bifidobacterium breve, Propionibacteriurial freudenreichi, Lactobacillus reuteri, and Lactobacillus fermentum.

• Consider the use of phytoceramides for atopic dermatitis in adults due to the ability of this oral supplement to hydrate the skin from the inside out. Hydration of the skin is paramount in the improvement of this condition.

• The typical dose used has been 350 mg oral daily, with positive effects beginning in several weeks after starting supplementation. Caution in patients allergic to the plants from which they are derived. There are few known adverse effects of plant ceramides (7). Plant ceramides are not recommended for children.

• Guillou S, et al performed a double-blind, randomized, placebo-controlled study, and found that 350 mg of wheat extract oil containing ceramides was more effective than placebo and resulted in better hydration, less redness, and less dryness of the skin after 3 months. (8)

• Corn ceramides at a dose of either 20 mg or 40 mg daily increased the amount of hydration by 190% and 294% more than baseline respectively compared to 41% higher for placebo. Lower transepidermal water loss was also seen in the treatment groups compared to placebo.  (9)

• Dermatology referral is required for severe cases of atopic dermatitis.

References:

1.Thygarajan A, Burks AW. American Academy of Pediatrics recommendations on the effects of early nutritional interventions on the development of atopic disease. Curr Opin Pediatr. 2008 Dec;20(6):698-702. http://www.ncbi.nlm.nih.gov/pubmed/19005338

2.Alexander DD, Cabana MD. Partially hydrolyzed 100% whey protein infant formula and reduced risk of atopic dermatitis: a meta-analysis. J. Pediatr. Gastroenterol. Nutr. 2010; 50(4), 422–430. http://www.ncbi.nlm.nih.gov/pubmed/20216095

3.Pelucchi C, Chatenoud L, Turati F, Galeone C, Moja L, Bach JF, La Vecchia C. Probiotics supplementation during pregnancy or infancy for the prevention of atopic dermatitis: a meta-analysis. Epidemiology. 2012 May;23(3):402-14. http://www.ncbi.nlm.nih.gov/pubmed/22441545

4.Lee J, Seto D, Bielory L. Meta-analysis of clinical trials of probiotics for prevention and treatment of pediatric atopic dermatitis. Journal of Allergy and Clinical Immunology 2008 Jan; 121(1): 116-121.e11. http://www.ncbi.nlm.nih.gov/pubmed/18206506

5.Michail S K, Stolfi A, Johnson T, Onady G M. Efficacy of probiotics in the treatment of pediatric atopic dermatitis: a meta-analysis of randomized controlled trials. Annals of Allergy, Asthma and Immunology 2008 Nov; 101(5): 508-516. http://www.ncbi.nlm.nih.gov/pubmed/19055205

6.Meduri N B, Vandergriff T, Rasmussen H, Jacobe H. Phototherapy in the management of atopic dermatitis: a systematic review. Photodermatology, Photoimmunology and Photomedicine 2007; 23(4): 106-112. http://www.ncbi.nlm.nih.gov/pubmed/17598862

7.Soft Gel Technologies, Inc. Phyto-derived ceramides, New Ingredient Notification. April 2, 2004. http://www.fda.gov/ohrms/dockets/dockets/95s0316/95s-0316-rpt0240-05-Udell-vol175.pdf

8.Guillou S, Ghabri S, Jannot C, Gaillard E, Lamour I, Boisnic S.The moisturizing effect of a wheat extract food supplement on women’s skin: a randomized, double-blind placebo-controlled trial. Int J Cosmet Sci. 2011 Apr;33(2):138-43. http://www.ncbi.nlm.nih.gov/pubmed/20646083

9.Asai S1, Miyachi H. Evaluation of skin-moisturizing effects of oral or percutaneous use of plant ceramides. Article in Japanese. Rinsho Byori. 2007 Mar;55(3):209-15. http://www.ncbi.nlm.nih.gov/pubmed/17441463