ATOPIC DERMATITIS ----------------------------------------- I've got good experience with Reactine (Zyretec, cetirizine) 40 mg / d for atopic dermatitis (but the useful property is not the antihistamine but the mast cell stabilizingone). KC Smith MD FRCPC ----------------- At forty mg it is also quite sedating. Diane Thaler ------------ I have an 8 year old patient with an atopic dermatitis resistant to all the treatments I have tried. I have read and heard that TACROLIMUS could be one new possibility of treatment , but unfortunately in this far away land we cannot find it. The patient is hospitalized and is getting worse everyday. I have tried to look for other possible causes but there is nothing. The only thing left is TACROLIMUS. I would really appreciate if any of you could give me the information on where to obtain it. DR. DANIEL PASMANIK -------------------- Have you tried phototherapy? Robert M. Peppercorn, M.D. -------------------------- I'm quite surprised that the patient is not improving while in the hospital Is the diagnosis, in fact, atopic dermatitis, or is it some "mimic" (such as an immunodeficiency disease, nutritional deficiency, etc.)? If it indeed is (refractory) atopic dermatitis, then suggested therapies in the literature include cyclosporine, azathioprine, PUVA, or "narrow band" UV (in addition to in-hospital baths, antibiotics, and topical steroids/systemic steroids). I'd certainly check for other diseases, and wish you well in your therapeutic assault! Robert I. Rudolph, M.D., FACP ----------------------------- Try cyclosporine or azathioprine - these should be available. PUVA could also be used. Tacrolimus ointment probably won't be available until 1997 at the earliest. Kevin C. Smith MD FRCPC ----------------------- Has a biopsy been done? This would help interms of Dr. Rudolph's differential and additional issues of impetiginization, herpes simplex, scabies, pemphigus foliaceous (though very rare in children). And now add topical steroid or preservative allergy, or for some of us, food allery. Diane Thaler ------------ Although tacrolimus ointment is not yet available, perhaps you can have it compounded. If I am not mistaken, it is marketed in the US in capsule form under the brand name Prograf for use in renal and liver transplant patients. I think I saw on a medline search where it was used in an ointment base at 0.1% . I believe that it probably would yield some interesting results in some other diseases of the skin and would not be adverse to trying it. On the side of caution, I have no information(yet) on the degree of systemic absorption when used topically, so careful, controlled application on atopic skin is warranted. I suppose that to ponder the possibility of low dose oral tacrolimus/Prograf in Dermatology is not unrealistic. Edward Zabawski, DO, R.Ph ------------------------- A patient I saw today told me about a therapy she received in Germany for eczema when she was a little girl. She thought the product was called tectodyn (not sure of the spelling) produced by a factory that was in Hamburg. The product was derived from the dried skin cells of unborn lambs. She said her severe generalized eczema was clear after three injections. I was wondering if any of our German colleagues have heard of this product, and is it still being used today in Deutschland. Steve Wiener ---------------- 40 year-old caucasian male with atopic dermatitis for 40 years. has any one ever used azathioprine for this? dosage? results? jerry litt ---------- Do you know if he has a dust mite allergy. Some atopics who are dust mite sensitive cannot clear until they have their beds and pillows mite proofed-there was even the case of the atopic who cleared when he bought a waterbed. I have every recalcitrant atopic allergy tested. Diane Thaler No, but gamma interferon has worked wonders in a few. It is expensive, but I've justified it to a couple of third party payers Guy Webster ---------------- Beware of pancreatitis with doses needed--50 to 150mg/day. gary salenger ---------------- No experience with Azathioprine. I have had great results with the use of 0.1% triamcinolone ointment and oral antibiotics that cover staph (generic keflex, cephalexin). The only non-responders I've seen have been patients who were poorly compliant with taking the antibiotic. They respond to in-patient therapy with the same drugs or with an admonition to take the antibiotic as directed (showing them the result of a skin swab culture showing the presence of staph often gets them to take the drug). Steve Feldman, MD, PhD ------------------------------- In Denmark azathioprine is occasionally used for severe atopic dermatitis and usually with excellent results, keeping patients virtually free of symptoms. Dosage is 100 mg daily and you shall keep this treatment for at least 3 months before evaluating therapeutic results. If the patient benefits, the medication should then be continued for 2 years with the normal hematological control once a month, once a week for the first month. Mads Nielsen, MD ---------------------- Do you use antimalarials before you get rid of the staph and the dustmites? I absolutely agree about the staph. Even dead staph makes atopics itch. Even dead sweat makes atopics itch. But still look for that dustmite allergy. I've used Imuran with good results in atopics, but my favorite drug is hydroxychloroquine or chloroquine -- they work great in many cases, and after a few months patients are down to 1 tab every other day or twice a week, and in a few years many are in long-term drug-free remission. Smith KC: Hydroxychloroquine is useful in the management of atopic dermatitis. Br J Dermatol 1992;126(1):93-94. Doring HF et al: Treatment of atopic dermatitis with chloroquine. Z Hautkr 1987;62(16)1205-1213. Kevin C. Smith MD FRCPC ---------------------------------- Our center got a couple of recalcitrant adult atopic and the so called = "hypersensitivity dermatitis" (the waste-basket that these people get = labeled when nobody can categorize them) on Imuran 25-100 mg/d, doing = fairly well with frequent lab monitoring and follow-up long term. = Haven't seen much of side effects but then these patients were passed on = from previous attendings and have been on Imuran for 2-5 years. We = tried to wean a few off of Imuran and their dermatitis came right back. Mychael Luu ---------------- Be sure he does not have mycosis fungoides. Have not used azathioprine for AD alone. Barbara R. Reed, MD -------------------------- I have not been impressed with my own use of azathioprine as a primary therapy in a limited number of severe cases of atopic dermatitis. I would be more inclined to use pulse steroids or cyclosporin in really difficult cases nowdays (e.g., that I couldn't control with some combination of decreased washing, topical steroids, hydroxazine or cetirizine and intermittant triamcinolone injections IM--which isn't all that many--usually the severe stress-driven ones). Watch out for hypertension developing in cyclosporin use in addition to nephrotoxicity. Mark Naylor, M.D. ------------------------ Mark, tell me about decreased washing. I recommend that atopics soak atleast 20 minutes per night in the tub and use soap, albeit mild soap. The soak is to get the water in that they lose, and the soap is an attempt to decrease their bacterial overgrowth. Then they seal in the water with a steroid ointment and some moisturelocking moisturizer. I dont use azathioprine for anything as it either doesn't work the way I use it or the patients don't tolerate it. It is my least favorite immunosuppressant . Diane Thaler I've never tried azathioprine, but recently brought an atopic out of an erythrodermic quandary with methotrexate on the advice of Dr. Hanifin in Oregon. It took about two months to work, but was dramatically effective. Just when I was about to give up and switch to cyclosporine, he started to improve. We used a low dosage for three consecutive days each week, rather than the single weekly dose I usually employ for prosiasis. We ran into problems with stomatitis, but this resolved off drug, and now he is back on a lower dosage. Mark Valentine ------------------ Based upon limited use, I had it fail in one teenager [even at adequate blood levels] and I think the reason is that her home environment did not change. When she was brought into the hospital, she began to improve off drug. Based upon this somewhat less than 100 cases, I truly believe, as did my teachers, that home environment plays a major role: Dermatophagoides, dust, pollen, smoking, soaps, wool, carpet with wool, emotional instability (synonomous with being a teenager), etc. Just my two cents . . . Recent literature suggests therapeutic trials of everything from azathioprine to extracorporeal photophoresis to gamma interferon ( the last of which makes the most sense for a TH2 disease). I'll be interested to follow replys to this query. Patrick R. Carrington I do exactly the opposite. I contend that the issue with atopic skin is defective barrier function, which is made more defective by external hydration. The issue then is not to restore water (which the body has lots of), but to restore the barrier through which water leaks (TEWL) and irritants enter. I tell 'em to avoid as much bathing as is socially acceptable and grease-up (within reasonable limits of course). Guy webster ---------------- This is an interesting subject. The way I think of this there are two schools of thought about atopic therapy, the "wet" school and the "dry" school. I am a mainly a proponent of the "dry" school which says that because frequent wetting damages the stratum corneum barrier, causes irritation and triggers a rash in hypersensitive atopics, you are better off bathing them less rather than more. I use the example of chapped lips with patients to illustrate this point (which is of course caused almost entirely by frequent wetting [licking] of the lips, helped along by low humidity in cold winter climates). The "wet" school says to try and hydrate atopic skin because they are typically xerotic (which indeed they are because their barriers don't work as well as a non-atopic person). This can and does work in experienced hands, but it is a higher risk strategy in the sense that you take some chance of making them worse by causing more barrier damage than you improve them by better hydration. It certainly is important to try and cover them with emollients during or immediately after bathing if this is going to work. This approach does give better access of steroids to the wet skin, although I don't think this is critical in most situations. Since it is my belief that damage to the stratum corneum barrier in atopics is one of the most common exogenous triggers for the inflammation we see in atopy, I generally try to do everything I can to limit barrier damage, meaning limiting their exposure to frequent wetting, strong detergents, solvents and just about anything that is an irritant. The other side of the coin is that the better shape the barrier is, the less xerotic their skin is whether you are using emollients or not (and I do encourage their use). I also think this is more important than any antibacterial effect from washing or antibacterial soaps; if the barrier is in good shape the staph goes away whether you treat it specifically or not (although I use lots of oral antibiotics in treating severe exacerbations). I agree that staph is a major inflammatory stimulus in active atopic rash. Interestingly, it has been shown a number of times that topical steroids alone will reduce culturable staph dramatically, I think because steroids help to heal the broken barrier, and the healthy skin eliminates the bugs [1] . Although the wet approach can get good results in experienced hands, I personally think that it is easier for most people to get good results by a reduced bathing schedule (no more often the q.o.d. ideally) than by trying the multiple soak/hydration approach. Simpler is frequently better in many situations. The biggest problem with this is that Americans love to bathe (it's a cultural thing) and patients are sometimes incensed when you suggest that they skip a day between baths (cleanliness is next to godliness?). Reduced bathing really helps most atopics if you can get them to do it (or not do it more accurately). 1. Korting HC, Zienicke H, Braun-Falco O, et al.: Modern topical glucocorticoids and anti-infectives for superinfected atopic eczema: do prednicarbate and didecyldimethylammoniumchloride form a rational combination? Infection 22(6):390-394, 1994. Mark Naylor, M.D. ------------------------ Ooooooo, have you ever taken a tepid bath? Or tepid anything? I remember when I was a resident a terrible atopic was admitted, and a young and brilliant attending who had been trained at Indiana had the child wrapped in warmed up wet sheets, then wrapped in many blankets, and rocked all night long-In the morning the skin was essentially clear. I think the key is to keep them in the bath (nice and warm so they will stay-and with a few drops of food coloring to help the children stay) for atleast twenty minutes until their fingers wrinkle to indicate they are full of water-then jump out and within one minute (after one minute 50% of the water is gone that they just spent 20 minutes getting in) slop on moisturizers-ointments. I have never seen a failure with this. That may be why azothiaprine has never entered my mind. I discuss prunes with patients. If you put a dried up prune in moisturizer for five years, what you get is a greasy dried prune. If you put it in warm-hot water for 20 minutes, you get a plump pruney plum-then you seal in the plumpness with the moisturizer. I think there is more to lip licking dryness that water. There is all of the junk in the saliva (and we know from drooling atopics that this is a big time irritant) plus the nibbling lip lickers do. If they Aquaphor or Vaseline (petrolatum) their lips every fifteen minutes-and especially right after the shower while the lips are still wet-the lips become perfecto. We had a case of a very neurotic nurse who never washed her lips and she had such incredible layers of desquamating skin that one of the derms thought the process was lethal and lasered her-he was young enough to not have experienced such insanity before. In my practice I always get the patients who dont bathe and who dont use soaps as has been recommended for years, especially by pediatricians, and I say "it looks like it hasn't worked, because here you are!" Do fish get eczema? Diane Thaler --------------- I see both points: soaking in a tub doesn't increase evaporation from the skin because the skin is exposed to constant 100% humidity. If the humectant is placed on the skin before towelling dry, this barrier may be effective in inhibiting evaporation. The one concern I have is that general heating of the skin in hot baths or showers would lead to a greater surface area for sticky activated lymphocytes, mast cells and macrophages to adhere to because of cutaneous vascular dilatation. I tell atopics to limit soap the the hair bearing areas, palms, fingernails and feet with tepid short rinses of the rest of the skin hair shampoo ad lib. I recommend that they apply an ointment to their still wet skin before towelling dry, in short order. I emphasize the speed of the process. I use the explanation that their skin is coated with cholesterol, which is like butter or animal fat on a plate. The analogy is strong, as everyone knows how to remove butter from a plate: with hot water, soap and scrubbing. I explain that if you do this to the skin, the barrier function of the skin will be impaired and thus the skin will lose its natural saran wrap and start to leak. I explain that this leaking or evaporation is the skin's alarm system which brings on inflammation, itching and eventually, pain. Rhett Drugge, M.D. Jerry, don't forget that long hot (ignore that temp suggestion Rhett) luxurious bath. Tell him to turn the lights down low, sip a glass of Zinfandel, and soak soak soak. Not to drink so much that he forgets the Aquaphor (unless he is allergic to wool wax alcohol). PS The last recalcitrant atopic I had was applying Lachydrin from her allergist. She had a contact to the Quaternium 15. So allergy test and patch test. Diane Thaler --------------- I have always subscribed to the idea that the less bathing the better. I tell then to take a quick shower with soap (Dove) only to the underarms, groin and feet. Get out and moisturize immediately, with a urea-containing cream. Philip Hughes, M.D. ------------------------- There is a difference that you may not have picked up on between a dried prune and a human being. One is alive and the other is dead. This means that prunes do not breathe, do not eat or drink , do not have a blood circulation and do not have excretory functions. Atopics have an increased rate of Trans-epidermal-Water-Loss (TEWL) therefore simple occlusion will in fact hydrate. Philip Bekhor ------------------ I am on the side of the fence that says get in water as much as you want but grease up immediately after. Ask any parent who has a child with atopic derm and they will think you are much smarter if you first recognize how much kids generally like bathing (young kids anyway) and give them positive feedback about how to make their kids better at the same time. Eliot Mostow ---------------- I only recommend short tepid showers. Clearly this isn't appropriate for atopic babies. Transepidermal water loss only occurs after the bath, and is completely inhibited by the water soaking. The only problem with immersion is the potential loss of barrier function due to the dissolution of lipid into water, albeit the solubility of cholesterol in water is very low. If the lipid barrier is not reinforced before drying, the skin encounters extremely high rates of evaporation. I am currently 15 minutes after my morning shower, and I can feel my skin drying and contracting which I believe is stimulating the inflammatory cascade, lymphokines, adhesion molecules, transendothelial diapedesis, exocytosis, spongiosis and acanthosis. This cascade is probably initiated by the release of membrane associated TNF-alpha in the stratum granulosum in direct response to TEWL. Of course, once the skin associated lymphocytes become stickey, the "angry skin phenomenon supervenes, and the skin suffers from exocytosis of the "angry lymphs" at the slightest provocation. The accessibility of the skin to direct therapy allows us to treat a large fraction of these angry exocytosed lymphocytes by addressing the entire field of the skin. Practically this means that I prefer to give patients large quanitities of medicated ointment to put on their entire bodies, rather than recommending spot treatment. I taper these highly inflammed patients off of the topical corticosteroids rapidly under close supervision in order to insure that they don't get stuck in the "more is better" trap. I use TMC 0.1% ointment in adults, disp. 454 g, cost= USD 25-35, and taper on the following schedule: QD x one week, (see patient, if clear, QOD times one week, Q3d, times one week, Q4th times one week, (see patient, if clear D/C medication). If the patient doesn't clear at any time in this taper, I am most likely to add oral antibiotics, with erythromycin 500 BID (adult dosage) being my first choice. Severe intermittent flares of brittle atopics usually get IM kenalog and oral antibiotics up front, although I would substitute Cyclosporine for those who can afford it. These patients still require topical emollients, as dermatitis is like chapped lips, and it usually gets better with frequent applications of grease independent of other modalities. Atopics always require consideration of potential contributing factors such as contact allergies, etc., as well as other possible diagnoses, especially when cutaneous abscesses occur. Rhett Drugge, M.D. ------------------------ Drugge's Sign in atopic dermatitis: Central upper incisors have flecks of white associated with chronic mouth breathing. Look for it by asking the patient to smile. It is present in about 80% of atopics by simple repetitive observations. I have reviewed the literature. It has not been published to date. Rhett Drugge, M.D. I do just the opposite too. I recommend alternate day baths with Dial and Dove. Immediately after the bath I have them apply some non-lanolin containing cream (cream only). My favorite is Nutraderm Cream but I also use Dermovan Cream when I can find it. I like the triclocarban in the Dial to help decrease surface skin flora and the immediate hydration-entrapment with the cream seems in my experience to negate the drying effects of the soap. Of course, ANY atopic that flares gets nasal cultures and is started on antibiotics and bactroban intranasally even in the absence of furuncles, impetigo, folliculitis, etc. Patrick R. Carrington -------------------------- Even better than hair shampoo to 'clean' the body in atopic, I tell my = patients to use hair conditioner to 'clean' their body. Cheap, no-soap = substitute. Water alone can clean, I figured. This way they have their = skin 'conditioned' just like their hair and scalp. Works great for = those people with pruritus scroti who were brought up to always use soap = in intertriginous places. Mychael Luu ---------------- Atopic Dermatitis must be different East of the Mississippi--I have all too many failures with Triamcinalone Ointment (or cream) along with anti-staph antibiotics. It's a good therapy, but not helpful for a lot of folks. Having trained in New York and practiced in Hawaii and California, I find that the local climate and humidity has a lot to do with the amount of bathing patients can tolerate with all other things being equal. gary salenger ---------------- my vote is with diane...i have my atopes bathe daily (and with my japanese patients it is almost impossible to have them not bathe daily) and then use a thick cream on their just dried off skin...but not too thick..trying to spread vaseline for example irritates the skin from the friction of the rubbing... actually my dad liked crisco as an emollient cream...is it still available?...i too detest tepid baths...btw one of my patients put a water filter, for chlorine, in the line with the bath water and said that it helped his atopy immensely.... Steve Emmet ---------------- This is very interesting. What do you use as first line agents in Hawaii? Perhaps there is a great deal of climate dependence to the response to treatments for atopic dermatitis. I am sure that the low relative humidity of the cold northern winters drives TEWL to a much higher rate, thus the potential for humectant based therapy. As TEWL is not such a factor in high relative humidity Hawaii, my therapeutic approaches wouldn't work for you. Rhett Drugge, M.D. ------------------------ It is obvious that both the dry and wet techniques can work. I find better compliance by allowing the patient to bathe then rinsing the washcloth competely several times to get the soap residue out, then pour in a capful of Robathol (a bath oil that is miscible in water, contains no lanolin) and use the washcloth to dry. It's easy, takes very little or no extra time. Of course I advise the patients that when the cloth is saturated to wring it out and add more oil. I used to recommend Mapo until I had some exacerbations and realized that it contained lanolin. I will try to determine the manufacturer if anyone is interested. I agree that stress aggraves existing conditions and may play a role in the onset of symptoms of latent conditions, but I do not feel that it is a cause of any particular skin disease. Most if not all of us experience significant amounts of stress, and conditions such as LP are no more common among prisoners, who are certainly under stress, than the general population to my knowledge and experience (having been the prison dermatologist for Orleans parish for 1 1/2 yrs. when patients suggest that stress is causing their problem (often after hearing this rubbish from another doctor-why is it that some doctors can't admit that the cause is not known?) I use the analogy that stress can indeed make conditions worse, such as high blood pressure and diabetes, as well as preexisting skin conditions. None have yet challenged this, and I conclude by stating that as advanced as medicine seems, there is much that is unknown and doctors don't have all the answers, even though some will give an answer because it may sound reasonable. Sorry to be so long winded, but the "stress explanation" is a very common and annoying subject. Ben Treen ------------ One of the most frequent causes of eczema in my practice is due the migration of Caribbeans to the cold North East. These patients have severe winter asteatosis from their two shower a day regimens. My partner tells them not to shower for a week. I am less draconian and recommend a modified sponge bath. >my vote is with diane...i have my atopes bathe daily (and with my japanese >patients it is almost impossible to have them not bathe daily) and then use >a thick cream on their just dried off skin...but not too thick..trying to >spread vaseline for example irritates the skin from the friction of the >rubbing... This is why you must instruct them not to dry before applying ointments such as vaseline. The problem with creams and lotions is that they require emulsifiers to work. Emulsifiers impair the barrier function of the skin. >actually my dad liked crisco as an emollient cream...is it still >available?... I have used Crisco. However, after one of my patients describing his clothes going rancid and then walking out on him, I quit its use. I still laugh about it though. >i too detest tepid baths... I apologize, my reference was to tepid showers. >btw one of my patients put a water filter, for chlorine, in the line with the >bath water and said that it helped his atopy immensely... Apparently Calcium Chloride salts deposit on the skin and can cause quite an itch. Has anyone else heard of this? Rhett Drugge, M.D. ------------------------ I think that the crux of the arguement is to determine whether dry skin is actually dry. I contend that it isn't. It may be scaly, but this is just a response to inflammation not the cause of the problem or even a true sign of dryness. Consider a recent sunburn. It is dry and scaly, but clearly the sun didn't dry the skin, it inflamed it. Measurements of transepidermal water loss show great elevations in dry-looking skin. It is therefore not dry at all but actually very wet. Guy Webster ---------------- I must vote emphatically for wet. One of the best techniques I know for cooling off out of control eczema is "wet wraps," akin to the Indiana technique. As a resident when we had derm inpatients with horripilating generalized eczema we'd apply .1% TAC 1:1 or 1:2 with Eucerin, wrap in warm, wet (half-way wrung out) towels, cover with blankets and then have the pt stay wraped up for 20-30 minutes. The crucial step was re-application of the TAC/Eucerin to the damp skin immediately on unwrapping. (Obvious but important: warm room, plently of blankets, protection for the mattress, antibiotics if needed, etc.). I still use this technique, but I have patients use 100% cotton thermal underwear instead of towels. Much easier to deal with than 10 wet towels. And I teach this technique to less severely affected atopics to use for hot spots using hand towels or washcloths to fit the size of the treatment site. It's a production, but when the simple things aren't working, this generally does. And a mini-testimonial: I'm atopic, and when I wake up in the middle of the night scratching, it's always a pain, but unless I haul myself out of bed and dampen my skin before applying whatever I'm using, it just doesn't provide relief. And if I'm really going nuts, I have to drag myself downstairs, get an ice cube to use for a few minutes, then put on the cream. Amen. Tom Sattler -------------- As indicated previously do not believe that the "Soap and 20 min. soak Thaler regime" is physiological in concept. The fact that this regime works for some is most likely related to the fact that the post bath "super hydrated skin" allows for a massive increase in the penetration/potency of the subsequently applied topical steroid. This is similar to what is achieved with occlusion or wet dressing regimes. I do not believe that it relates to hydration per se. I also suspect it may not enhance long term rebuilding of the epidermal barrier. It may however be useful in certain resistant cases. I do not believe that there is any panacea in the management of atopic eczema. Any dermatologist who states that all cases will respond to topical steroid plus antibiotic regime stretches credibility. Most cases will respond but certainly not all cases. In my opinion PUVA, Azathioprene MTX and Cyclosporin are all under consideration for those rare resistant cases. I personally like PUVA the best as in my hands it seems to eventually induce remission. Philip Bekhor ----------------- Philip Hughes, M.D. wrote "shower with soap (Dove) only to the underarms, groin and feet. Get out and moisturize immediately, with a urea-containing cream." I agree, mostly. But Dove is not a soap - it contains syndets (synthetic detergents) which is why it is closer to normal skin pH than soaps. Also, I have almost abandoned the use of urea-containing creams - and now I use Vaseline Petroleum Jelly Creamy Formula with Vitamin E *(Vaseline Creamy) - patients generally rave about it, recommend it to friends, - but it must be applied in the brief window following exiting the tub or shiower. FWD fwdanby@adan.kingston.net ------------------------------------ ...sort of fun to see that lots of you weren't around when Jud Scholtz popularized "the Scholtz regime" in the late sixties: no water at all, and Cetaphil lotion for cleansing. Yeh, great. It worked ok in the hospital (where *all* derm patients seemed to get better no matter what we did), but in real life they just got dryer.... So now I'm a "wetter". Mike Eichwald ------------------ I have bee a great fan of the modified Scholtz regimen which was popularized by Alvin Jacobs - a great ped derm at Stanford. I have used it for 15+ years with success but it requires a great deal of patient education during the first visit to go over and demonstrate the use of cetaphil or aquanil as a moisturizer and cleansing agent. The patient takes as few regular bathes as possible. No soap at all. Quick showers are better. As much cetaphil or aquanil as desired and not washed off. Hydrocortisone cream or equiv for faces - TAC 0.025 or similar for body areas. Higher strengths of corticosteriod creams can be used but never the ultrapotent. Heavy doses of hydroxyzine HCl to suppress the pruritus and all get an antibiotic such as diclox, erythromycin, or keflex for 7-10 days to suppress staph. It can work and it usually does once the patient or parent is properly taught. Time spent with the patient during the first visit is well made up for later with this approach. By the way, it has worked great also for my 4 year old daughter who inherited my atopic background. She has never used any cleaning agent except for cetaphil or aquanil and now uses it in her bath. Robert M. Peppercorn, M.D ---------------------------------- Fifteen minutes and you are back to being a dried out prune, or, you are no longer a wet noodle! I tell my patients slop the emollient/med on WITHIN ONE MINUTE, with the door to the bathroom still closed, with the mist still on the mirror. Erythromycin is not my drug of choice because it hurts my stomach (which easily deals with Thai Food), and, there is 70% resistance in our community. Well, it looks like we will agree to disagree. Do you avoid Lanolin due to the fact that Atopics have problems with wool or based on wool wax alcohol patch tests. The itchiness in wool is due to the barbs, and now wool is being made that is "washable" and non prickly itchy. So, Aquaphor is usually ok by me. Alot of Atopics like "Albolene" which doesn't have wool wax alcohol in it. It is quite an old product and can be found on the "cleanser" shelf, as it is improperly labelled as such. Crisco is great in a pinch. (sorry about brand USA names) I did not mean to imply there is a panacea. But even water soak and moisturizer without the steroid works, so it cannot be steroid penetration enhancement. And in addition, remember, antibiotics, contact and allergy tests. And get rid of the kitty and buy a poodle. Diane Thaler --------------- Generally dryness is a lesser factor in Hawaii. Heat, humidity, and sweating especially in the folds of the skin that can dry out (like the antecubiatal fossae) seem to be more important. I find that I need moderately potent creams with an emollient at times. Ointments are not tolerated as a rule by most of my patients. I find I use a fair amount of Injectable Kenalog, used monthly for one or two months. gary salenger ---------------- Any thoughts on the use of long term azathioprine for AD in relation to its risk of inducing lymphomas ? This is my main reservation in using it for my young patients with severe AD. Ken Ho ---------- I would suggest that many of these patients were told, by the other doctor, just what YOU are telling them. Patients often hear what they want to hear, and by the time the encounter is relayed to you, the patient tells you his other doctor said it was "caused by stress." I hate to think how much my discussions with patients are distorted by the time they are retold for the umpteenth time. Unfortunately, since we cannot categorically state lichen planus, for example, is NEVER triggered by stress, patients will remember that we honestly told them that this was a possibility. I have no solution to this dilemma. Mark Valentine ------------------- One of my pet peeves with some of my highly esteemed pediatric dermatology colleagues is their relentless insistance on aggressive hydration of the skin in all atopic patients, regardless of the clinical findings or history. This may be nit picking, but there are some youngsters who fit the major criteria for atopic dermatitis who are not clinically dry by any stretch of the imagination, and who do not seem to flare from low humidity in the ambient air. Parents are savvy enough to figure out that all that grease doesn't accomplish anything, and eventually they may lose faith in the dermatologist for giving this worthless advice. Am I out in left field on this one???? Mark Valentine ------------------ Does anyone know the origin of the therapeutic quotation "If it's wet,dry it; if it's dry, wet it"? As a resident at the U of Chicago, I constantly heard Drs. Rothman and Lorincz explaining to the patients that "You are too clean. You are drying out your skin by bathing too much, and that is why you itch." We recommended that atopics and elderly pruritics take only 2 quick baths or showers weekly. When I came to Kings County Hospital in Brooklyn, many of the patients didn't bathe or shower even twice a week, and their atopic dermatitis was just as severe! The party line from the local NYU-trained dermatologists was "Soak in a bathtub for about 20 minutes, pat yourself dry gently, and immediately put on ointment -- Eucerin, petrolatum, or even Crisco shortening). My opinion is that it makes very little difference, compared to the improvement obtainable with a topical steroid! Yelva Lynfield, MD ------------------------ I think the responses to the discussion about wet vs. dry treatment of atopics is indicative of the fact that there is more than one way to get improvement. I am a proponent of the dry approach, mainly because the logic is compelling (along with the fact that I have learned to use this approach to great success). I recognize that good results can be obtained with either approach. I tell my residents to try the other approach if one does not work well in a given patient. I think the main factor involved in success is experience in applying either the wet or dry method. I think the dry apprach is simpler and more predictable as a rule, and is usually therefore easier to use to good effect. Mark Naylor, M.D. ------------------------ Lymphoma seems to be a risk mainly in the rheumatoid arthritis population, who have a higher incidence of lymphoproliferative disorders anyway, and who are also frequently treated with prednisone. I explain that the risk in atopics seems to be very low. Kevin C. Smith MD FRCPC ---------------------------------- Can someone please review 1) The original Scholtz regimen (references?) and 2) The modified Scholtz regimen(s) - (as modified by who? and references?) I recall a modified Scholtz regimen that I thought was from Dr. Jacobs at Stanford that used Synalar (fluocinolone 0.01%) solution rather than creams or ointments and Cetaphil lotion as cleanser with no bathing. Instead of this, I usually recommend showers or baths with Dove cleanser only for groin, feet, and axilla. After thougrough rinsing ointment is then applied to the moistened skin immediately after the bathing. Walter H. Wood, M.D. ---------------------------- I'm skeptical of claims that a 20 minute soak is needed to hydrate the skin optimally. After one minute in the tub or shower I feel wet all over, and I doubt I'd be much wetter if I burned off another 19 minutes in the bath. Kevin C. Smith MD FRCPC ---------------------------------- are you ready for this? i think the use of immunosuppressives in any disease is abject display of failure to understand the cause and treatment of the disease and will soon (i hope) be looked on as we would view purging and bleeding as treatments. for example, the first umpteen cases of lyme disease were tx'ed as 'juvenile rheumatoid arthrititis'...with the implications that dx has...until someone learned you could cure them with antibiotics! would you rather take mtx or antibiotics? i think that when we pat ourselves on the back for treating an atope with cyclosporine or mtx or whatever...we are really pointing to our failure to understand the disease!...which is not to say that occasionally it is both necessary and expedient, but should always always be a last resort. re: vitamin e: i don't use it on the skin at all, as it doesn't seem to have any beneficial effects and clearly is an allergen to some patients Steve Emmet --------------- I agree that Robathol is great stuff (you can order it from a Mayo Clinic related company in Rochester MN) but I warn patients NEVER to put oil in the tub, because: 1. oil makes the tub slippery, increasing the risk of falling a breaking something like a hip or a tooth, and 2. oil makes an awful mess of the tub, and 3. not much of the oil gets on YOU, so its not very efficient. What you SHOULD do is have a short, not-too-hot bath or shower WITH NO SOAP OR BUBBLEBATH then get your sweetheart to rub you down from head to toe right after bathing while your skin is still moist with (0.5% hydrocortisone cream or ointment, Robathol, etc) to LOCK IN THE MOISTURE. The skin to skin contact is very pleasing to patients (on this note I remind you of: Touching: the Human Significance of the Skin, by Ashley Montague, 3rd edition, Harper & Rowe, New York, $15, ISBN 0-06-096028-0, availabe from Amazon.com. As an offshoot of the atopic thread, I want to remind everyone of the great value and utility of having the patient apply a wrung-out warm moist wash-cloth to the treated area for 10 minutes after applying a topical medication. The warmth and the moisture DRIVES the medication deeply into the skin, and is soothing. Applyig a warm, moist dressing for longer than 10 minutes does not seem to add value. Works great for bad dermatitis, and often reduces or eliminates the need for intralesional triamcinolone acetonide 3 mg / ml injections and for systemic medications like prednisone or cyclosporine (eg. to settle down terrible hand dermatitis). Patients are often VERY impressed -- I have them back in a few days because I enjoy seeing how fast they respond, and because I want to taper them down on the frequency and potency of the Rx as fast as possible to reduce the long term risk of skin atrophy. Recently I've done this for palmar and plantar psoriasis using Dovonex (calcipotriol, calcipotriene) ointment (sometimes with 10% urea and 2.5% hydrocortisone) and it works nicely, but not as dramatic as when used with something like clobetasol propionate ointment. Kevin C. Smith MD FRCPC - --------------- I get good results advising people to have a short, not-too-hot bath or shower WITH NO SOAP AT ALL (except maybe a bit of Dove for the hands and armpits), then right after you dry off get your sweetheart to rub you down from head to toe with 0.5% hydrocortisone cream (I order a 1 pound jar with 99 refills). The SRORT exposure to water hydrates the skin just as much as a 1 hour bath (I figure you don't get any wetter after the first 2 seconds), and limits damage to the stratum corneum. I explain that prolonged contact with even plain water (never mind soap or bubble bath) removes all the natural oils which are necessary to protect the skin. "If you could have WASHED this problem away I'm sure you'd have washed it away by now! So lets back off a bit on the washing." I also prescribe Elocom (mometasone) OINTMENT "to be applied to severe eczema after bathing prn. Do not use on the face." Excellent long term results -- no problems. I always give them the eczema or childhood eczema brochures from the Eczema Foundation in Portland OR. I explain that exposure to furry animals can make eczema harder to manage, but I don't do any allergy testing or send them on a witch hunt for house dust mites (yes, I know housedust mites are important - I conducted one of the Intervent (Gore-Tex) trials and the stuff really works) but my patients do great following the above program. No often does someone need chloroquine or hydroxychloroquine, and in only a few cases have I had to add azathioprine to the antimalarials. I have a few people who prefer cyclosporine, but that does not produce the long-term drug free remissions I've come to expect with the antimalarials. Incidentally, John Voorhees has a good explanation for why antimalarials may make eczema better and psoriasis worse. Antimalarials alter the TH1 / TH2 balance in a way that inhibits eczema but exacerbates psoriasis. Kevin C. Smith MD FRCPC --------------- From owner-rxderm-l@ucdavis.edu Mon Dec 9 17:51 PST 1996 Received: from franc.ucdavis.edu by peseta.ucdavis.edu (8.8.3/UCD3.8.3) I am also a "dryer," because of my training and a history of good results. I do not have much experience with the wet approach. Like Dr. Naylor, I believe there is always "more than one way to skin a cat" (sorry). Generally, in the field of human medicine, when two issues are at odds without a clear-cut correct answer, it means we don't really understand the issue. Michael J. Yunakov, MD --------------- Someone wrote in the atopics should avoid fuzzy things. One fuzzy thing they can have is a poodle. And they come in three sizes to suit all homes and needs. Another fuzzy which many atopics can handle, believe it or not, is the Ragdoll Cat. The breeders will not guarantee this. The Ragdoll looks like a Himalayan. There is a physician in Philadelphia who has atopic allergic kids and cat allergies who has both of these fuzzies. There are other dogs which are probably ok too, but I have no experience with them and atopy. They are the Bichon, Komondor, Puli, and Wheaton (most). There are probably more. If you get wrinkly fingers after one minute then you are correct. If it takes you 20 minutes like most of us to get those fingertips plump and hydrated then feeling wet all over is purely cosmetic. And why burn off in the bath? Sip some wine, put on some music, have your moisturizer applier join you Diane Thaler --------------- Thinking about the gallons of oil bath I prescribed during the last years, I wonder why none of the patients broke his bones... Sure, I do warn them that the tub will be slippery, and recommend to use it instead of a shower gel. Maybe the effort to clean the tub prevents them from bathing twice a day. That's fine because I am neither a *wetter*, nor *drier*, rather a *greaser*. Have seen the best effects in pre- or post- eczema stages, that means atopics on the edge of a dermatitis. Hans J. Kammler --------------- personal experience in my household-my ragdoll cat seems to provoke as much sensitivity both cutaneous and respiratory as my other siamese cats and pound cat. i have had a devon rex cat. these cats have fragile hair syndrome and are hairless most of the time. they seem to be for the most part--hypoallergenic to those with atopic diathesis. i have been told sphynx cats are similar but i have no personal experience. bob aylesworth, m.d. ---------------------- Bob, if the cats have been around each other, how do you know if the ragdoll is allergenic or contaminated? Also, is it the hair/skin/saliva or all of it that is accused of being allergenic dander? I have asked several contact honchos and allergists about this , and always receive a different answer. Diane Thaler --------------- I agree with Diane on this. In fact, it is so successful that I was surprised that there was another "dry theory" out there. I thought it was just common knowledge to reverse the pediatrician's dictum for the child to avoid baths. Parents and patients love to hear that they can bathe. The difference is, avoid soap, and moisturize before the skin dries. In fact, I have a handout which compares human skin with a piece of leather. If the leather gets soaking wet, then dries in the sun, it cracks. IF it is oiled before it dries, it does not crack. The human skin is similar, but has its own oil production. However, in the case of the xerotic, it can't keep up. Like a diabetic who needs external insulin because his body can't keep up with demand, the xerotic needs extra moisture from an external source. I promote greasy moisturizers for their ability to lock in moisture. I suggest a daily shower if desired. Soap only used in groin, axillae etc. I have parents give little kids baths without soap in the bathwater. Put in rubber ducky and no bubble baths. Following this, apply corticosteroids while skin is still moist, then a layer of petroleum jelly or alternative thick moisturizer. I think pre-hydration works great. Jerry Eisner -------------- This may well be stating the obvious, but I think that a combination approach is needed in nearly all atopics, especially infants. Whether you believe in moisturizers on wet or dry skin (I favor wet), in most settings anti-inflammatory action (read: steroids) are needed. Mark Valentine makes a good point -- the patient will go elsewhere if you don't give them some relief. Having said that, I try to maintain my atopics on moisturizers chronically and topical steroids only in the acute setting -- and I have a very low threshold for using antibiotics. Chris Scholes --------------- Has anybody used evening primrose oil in the treatment of atopics? Myth? or does it work in a certain population of atopics. Jonathan Nevin Yu, MD --------------- It was very en vogue here a few years ago. Unfortunately, there was no clear improvement in most of the patients. Sometimes it works in children, the younger, the better. And the parents love it, too, because it is a *natural* approach. Sure the kiddies can't swallow the capsules, so it has to be mixed with food twice a day. My chief recommends this oil for treatment of eczematids in elderly patients. In my opinion, external urea ointment is at least comparable to the expensive systemic therapy. Hans J. Kammler --------------- Can't count on any animal NOT triggering an atopic response. We have an atopic kid, and she definitely triggers with Bichon puppies. Barbara R. Reed, MD --------------- Have you ever seen it with Poodles? Poodles are the only breed I can "guarantee"-in terms of ease of training and livability. I have only heard rumors of the others. Bichon are too difficult to train for me to recommend them, and too difficult to groom . Diane Thaler ---------------