Using at atopic dermatitis
Here we know about treatment of atopic Dermatitis, Atopic Dermatitis also known as Eczema so eczema is one of the most steroid-responsive dermatoses. A midpotent corticosteroid preparation will generally suppress the inflammation and clear the rash. If the condition has not improved susbstantially within 2-4 weeks, a more potent corticosteroid may be selected. Topical antibiotics such as mupirocin may be used for significant crusting and exudation.
Antibacterial compounds or maneuvers such as bleach gels, bleach baths, iodinated ointments, and quinoline-containing ointments may also be used to good efffect. Oral antibiotics may be prescribed, but the resident staphylococci are conceptually better in light of the concept that staphylococci and their biofilms play the major role in this disease. These organism are part of the normal flora, so even if they are killed, they will return at some point. Heresy enters the discussion of treatment regarding skin care during and especially after the rash.
Even though we believe the rash is initiated by staphylococci and their biofilms occludinng the sweat ducts, it is easier to help prevent the disease by treating the genetic component gently and severely limiting soap, hot water bathing, frequent bathing, and scrubbing. Aggressive moisturizing is also needed. Azathioprine, methotrexate, or another immunosuppressive agent may be needed in severe cases.
Keywords:– Antibacterial, Antibiotics, corticosteroids, moisturization, skin care, staphylococcus.
Type of Eczema
The may types of eczema that are encountered include flexural, facial-extensor, nummular, pityriasis alba, lichen planus-like, and mycotic.
Physician have long done an excellent job in treatment eczema in all its presentations, for it is one of the most steroid-responsive dermatoses. What that implies is that any midpotent corticosteroid preparation (cream, ointment, lotion, spray, or foam) will generally suppress the inflammation that is so readily “apparent” part is redness (erythema), edema, vesiculation, and excoriations (from scratching; this is the “itch that rashes”) chronic forms of the disease show lichenification, or thickening of the skin with accentuated skin markings, along with the ever-present excoriations.
often the itch is so severe, scratching will occur even during the dermatologic examination. If the condition has not improved substantially within 2-4 weeks, a more potent corticosteroid may be selcted.
if used cautiously, evne strong corticosteroid, may be appied to sensitive areas of the skin. This is a relatively rare occurrence and fortunately the stronger corticosteroids are usually unnecessary. As the disease improvs, less potent topicals, such as hydrocortisone acetate and calcineurin inhinbitors, may be employed. These latter agents may be used first if the disease is mild to moderate.
If there is significant crusting and exudation, a topical antibiotics such as mupirocin may be utilized. Antibacterial compounds or maneuvers such as bleach gels, bleach baths, iodinated ointments, and quinoline-containing ointments may also be used to good effect.
Oral antibiotics may be prescribed, but all the resident staphylococci, including staphylococcus aureus and staphylococcus, epidermidis, are multidrug resistant. All are 60% methicillin resistant in our protocols, as well. The staphylococcal organism share the genes for drug resistance and pass them back and forth.
The Topical antibacteral approaches are conceptually better in light of the concept that staphylococci and their bioflms play ther major role in this disease. These organisms are part of the normal flora, so even if they are killed, they will return at some point. The biofilms themselves are exceeding difficult to treat; in the case of an indwelling catheter coated with S. epidermis, for instance, the device must be “pulled” because of the “resistant” status of the bacteria and biofilm. The gene related to the attachment of the biofilm to surface has been identified, and the antidote to this gene has been incorporated into some catheters. These repulse the organism’s attachment, leaving the infection considerably more amenable to treatment.
Heresy enters the discussion of treatment regarding skin care duirng and especially after the rash. Even though we believe the rash is initiated by staphylococci and their biofilms occluding the swear ducts, it is easier to help prevent the disease by treating the genetic component of the condition. This is done by treating the skin exceedingly gently. “Gently” has several implications.
First, there is no soaps, gels, and foaming washes are all too strong. They all cause drying and scaling and perpertuate the itching. It is of the utmost importance that the patient limit soap use not only during the treatment of the acute disease, but also in all phases of eczema. Soap, in all its forms, is inimical. Even after the lesions have cleared, the use must still be restricted.
Second, hot water bathing: third, frequent bathing; and fourth, scrubbing are also very deleterious. With children all caregivers need to be “on board” and practice good skin care. One of our most challenging patients was an 18-month-old boy who was frequently being bathed (independent) by a grandparent who took care of the baby during the daytime hours. The parent were unware of this soap and water exposure. When the bathing was corrected, the baby rapidly went into remission of his severe, previously unresponsive facial-extensor eczema.
we advise patient to decrease the bathing by at least one “notch” for instance, if the bathing is twice daily, decrease to once daily. if once daily, every other day should be sufficient. We also recommend soap be used with hands (not a wash cloth, or other bathing tool such as a loofah) and be used only where necessary. The less bathing, the better the skin will be. On a lighter note, our residents, after hearing this litany so frequently, wrote a “rap” song: “No soap is good soap…”
Fifth, aggressive moisturizing is also an exceedingly important component of skin care. This has been recently confirmed by chiang an eichenfied, who studied the impact of bathing and moisturizing in atopic dermatitis. They found that bathing alone without any moisturizer was markedly inferior as to water content in the skin as compared to no bathing and application of moisturizer. Bathing with application of moisturizer was intermediate.
The answer to what is the best moisturizer is “whatever feels good” on the skin because the patient will use that more faithfully. The truth is petroleum is a superior topical, with mineral oil and wool wax alcohol (lanolin) not far behind.
In the 1960’s O’Brien showed that swealing in miliaria could be restored by the application of lanolin. Any associated itching was also likely relived. Presumably, in eczema, similar finding would be present after the application of moisturizers, just as in miliaria. The recent addition of ceramides and hyaluronic acid to various moisturizers appears to be an important addition to our armamentarium in caring for patients with atopy.
This is especially true where many of the products are truly and hyaluronic acid are constituents in the “mortar” between the corneocytes in the stratum corneum. Whether the application topically allows them to become repositioned in that location in vivo is unknown, but thier application is certainly helpful, regardless of the mechanism.
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