EczemaNet Update

Personal Cleansing Agents for the Atopic Dermatitis Patient

Atopic dermatitis (AD) is a disease characterized by recurring remissions and relapses, often with no clear indication as to why the disease cleared or worsened. While the presence of increased levels of immune cells and immunoglobulins in AD patients is an indication that atopic dermatitis has an immune basis, no single laboratory test provides a definitive diagnosis of AD. The diagnosis is usually based on clinical features that may include chronic pruritus (itching), chronic or relapsing dermatitis, personal or family history of atopic disease such as AD, asthma or hay fever, positive laboratory tests for immune involvement, and a history of the disease worsening in the presence of environmental factors such as excessively dry air, physical factors such as excessively dry skin, or emotional stress.

A treatment plan for AD usually includes (1) maintenance of adequately moisturized skin, and (2) avoidance of some drying soaps, detergents or other chemicals that dehydrate or irritate the skin. Dry, irritated skin can be a provoking factor in initiation or worsening of AD.

To maintain adequately moisturized skin the following guidelines are recommended:

• lukewarm, soaking baths followed by application of an emollient to retain moisture in the skin; and,
• regular use of a cream or ointment moisturizer, avoiding those that contain irritants such as added preservatives or fragrances.

It’s recommended that patients with atopic dermatitis avoid contact with harsh dish-washing or household cleansers. If you use such cleansers, wear protective gloves but don’t use rubber gloves if you have an allergy to latex. Soaps used for washing hands and face and bathing should be mild and non-drying to the skin.

The basic function of soaps and detergents used as personal cleansing agents (hands, face, whole-body bathing) is to remove environmental "dirt," sweat, excessive skin oils, dead skin cells and bacteria or other micro-organisms. Manufacturers of personal cleaning products often seek marketing advantages by adding fragrances, antibacterial agents or other chemicals that make their products appear to be unique and desirable. An unintended side-effect of these added chemicals can be skin irritation.

For any person with an inflammatory skin condition such as atopic dermatitis or psoriasis that can be worsened by skin irritation, the best choice of a personal cleaning agent is one that accomplishes the basic cleansing function without causing excessive skin dryness or roughness. Bar soap or liquid cleansers and gels that use blends of fatty acids and polymers are notably mild personal cleansing products. Look for these ingredients on the product label. However, the individual user of a personal cleansing product, must judge "mildness" by the feel and appearance of the skin and the absence of any tendency to cause worsening of a skin condition.

Other factors that can cause skin irritation include use of a harsh sponge or washcloth, water temperature that burns and reddens the skin, and drying of the skin by bathing or washing too frequently.

Individual patients have reported instances of atopic dermatitis clearing or worsening during pregnancy, but no controlled studies have confirmed pregnancy as a physical or emotional stress factor in AD. Female patients have also reported clearing or worsening of atopic dermatitis in association with their menstrual cycle, but no studies clearly document the menstrual cycle as a factor in AD. Women who note changes of their atopic dermatitis with pregnancy or the menstrual cycle should discuss this association with their dermatologist or other treating physician.

Over the years, a number of studies have suggested that breast-feeding may have a protective effect against the onset of AD during childhood. A systematic review of 18 of these studies confirmed that breast-feeding has a substantial protective effect against atopic dermatitis in children with a first-order family history of atopic disease such as AD or asthma—that is, a history of atopy in parents, brothers or sisters. The protective effect was found to be less in children who did not have a first-order family history of atopy. [Gdalevich M et al. Breast-feeding and the onset of atopic dermatitis in childhood: A systematic review and meta-analysis of prospective studies. J Amer Acad Dermatol 2001; 45:520-527.]

A question frequently asked by female AD patients concerns the safety of AD medications during pregnancy.

The immunomodulating medication tacrolimus is available in topical form to treat AD. Used systemically (in pill form) it is one of the immunomodulators used to prevent rejection of transplanted organs. In either topical or systemic form, tacrolimus is recommended for use during pregnancy only if the benefit to the pregnant woman justifies potential risk to the fetus. However, there are no adequate and well-controlled studies of fetal effects in humans. These recommendations are based on studies of tacrolimus in laboratory animals. [Bornhovd E et al. Macrolactam immunomodulators for topical treatment of inflammatory skin diseases. J Amer Acad Dermatol 2001; 45:736-743] A woman who is pregnant or who may become pregnant during a course of treatment with tacrolimus should discuss safety issues with her dermatologist.

Glucocorticoid (steroid) medications cross the placenta, and while they are not known to cause birth defects, their metabolites may appear in the tissue of a fetus. Glucocorticoids given systemically (in pill form) are more likely to be present at higher levels in maternal tissue than glucocorticoids applied topically. High-potency topical glucocorticoids used on large body areas over a period of time may affect maternal pituitary and adrenal hormone levels and may cross the placenta. Glucocorticoids also can appear in tissues of a breast-fed infant of a mother being treated with the medication. Newborn or breast-fed infants that may have been exposed to glucocorticoids before birth or while being breast-fed should be monitored for suppression of adrenal and pituitary hormones. It is not known whether glucocorticoids applied topically are excreted in breast milk. A woman who is pregnant or who may become pregnant during a course of systemic or high-potency topical glucocorticoid therapy should discuss safety issues with her dermatologist [PDR 2001].