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Supplements Atopic Dermatitis: Focusing on the Patient Care Strategy in the Managed Care Setting
Overview of Atopic Dermatitis
Carmela Avena-Woods, BS Pharm, PharmD, BCGP
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Treatment and Managed Care Issues of Atopic Dermatitis
Danielle Ezzo, PharmD, BCPS
Atopic Dermatitis: Focusing on the Patient Care Strategy in the Managed Care Setting

Treatment and Managed Care Issues of Atopic Dermatitis

Danielle Ezzo, PharmD, BCPS
Bathing and Wet Wrap Therapy
While the daily application of topical moisturizers is an integral part of managing AD, bathing and wet wrap therapy are additional interventions that can reduce disease severity. There are no data to suggest an appropriate frequency or duration of bathing. Expert consensus indicates that bathing up to 1 time daily for 5 to 10 minutes with warm water can remove excess scale.8 Hypoallergenic and fragrance-free cleansers that support optimal skin surface pH are recommended for use on a limited basis. After bathing, topical moisturizers should be applied after gently toweling skin to improve skin hydration.8 For areas of the body with significant lesions, the nighttime soak-and-smear technique has proved to be a simple, inexpensive method that provides symptomatic improvement.16 This technique involves a 20-minute soak with plain water followed immediately (no drying skin) by smearing a mid- to high-potency TCS ointment on damp skin; this functions to trap water, allowing deeper penetration of the corticosteroid. Time to symptomatic improvement correlates with underlying disease severity, although most patients show improvement within several days to 2 weeks of continued application. If the patient has moderate-to-severe disease and a history of Staphylococcus aureus infection, bleach baths 2 to 3 times weekly may help decrease the number of local skin infections and reduce the need for antibiotics in patients with AD. Bleach baths are prepared by adding a quarter cup to a half cup of common bleach solution to approximately 1 full tub of bath water.17 Huang et al conducted a randomized, investigator-blinded, placebo-controlled study (N = 31) that showed a greater mean reduction in Eczema Area and Severity Index (EASI-75) scores in patients who received diluted bleach bath treatment compared with placebo group at both 1-month and 3-month follow-ups.18

Wet wrap therapy has proved to be an effective treatment in patients with moderate-to-severe disease, especially during periods of significant flares.19 Application techniques that have been reported in literature vary. Briefly, most wet wrap dressings involve the application of a TCS that is covered by wet gauze or bandages; a dry cotton second layer is then applied to maintain skin hydration. Wet wraps are typically worn for several hours to 1 full day and repeated for several days to 2 weeks. The impact of wet wrap therapy was evaluated in 72 children with moderate-to-severe disease treated with wet wrap therapy and monitored for outcomes within a supervised multidisciplinary AD treatment program. Wet wraps were left in place a minimum of 2 hours and were generally removed after 4 to 6 hours. Improvement in disease severity was assessed using the Scoring Atopic Dermatitis (SCORAD) instrument. Disease severity at admission and at discharge showed significant differences in mean ± SD values, of 49.68 ± 17.72 versus 14.83 ± 7.45, respectively (t, 18.93; df, 71; P <.001). The average duration of treatment was 7.5 days, ranging from 2 days up to a maximum of 16 days.20 Due to the occlusive barrier that is created with wet wrap therapy, secondary infections, maceration of the skin, and systemic bioactivity of TCSs can occur when wet wraps are overused or used incorrectly.8,17 Consequently, patients must be supervised closely, ideally by a medical provider who has expertise in the use of wet wrap interventions.

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