Transcript: Atopic Dermatitis Treatment for New NPs | Pearls of Practice

​Liz Rohr:
I have a confession to make, and actually I'm sure that you have this as well. There are certain topics that I'm just not as excited about. I really like the intricate diagnostic puzzles and atopic dermatitis is not necessarily one of them. Hold that thought, though, because eczema... Dermatology is hard, but eczema may or may not be easier to diagnose than some other ones, but the real magic comes in the treatment, because I think that, as a community, as a profession, we don't necessarily serve our eczema patients to the highest level that we could. I did some CEUs recently and I really wanted to share all these beautiful pearls that I got in my own care. I don't know if you've ever been in this situation, but I frequently get little kiddos... This applies to adults too, by the way, but little kiddos that are coming in, the parents are just exhausted and near tears.

The kids are crying the whole visit, they're covered in eczema. You have a huge role to help those kinds of people. This happens all the time in my family practice clinic. If you're new here, I'm Liz Rohr from Real World NP and you're watching NP Practice Made Simple. The weekly videos help save you time, frustration, and help you learn faster, so you can take the best care of your patients. In this video, I'm going to be breaking it down with some really helpful paradigms, insights, and clinical pearls to really practically apply to your care of these patients, knowing when to refer them to dermatology, the care that they should be doing at home, and answering questions like what creams to use and what allergies should be testing for. All that stuff. Stick around, I want to share my screen with you.

Eczema has a huge impact on the quality of life. I just want to start with this, because I think it really helps you. If you haven't experienced that screaming baby or the adult that comes in asking you again for the injectable steroids that their dermatologist gives them when they have eczema flares, I just want to paint this picture for you of how distressing this is as a diagnosis. As a condition, rather. Most patients have daily itching and it sounds like a minor symptom, but it can drive people absolutely crazy. It also impairs their sleep and I think that's especially important for kiddos, for babies that are up crying all night and the parents are exhausted, or the kids that aren't performing well in school, because they're not sleeping well. Also, school-aged kids can have things like lack of self-esteem, bullying, impaired school performance due to lack of sleep or related to the other issues that are coming up for them.

It's exhausting and a lot of parents feel really inadequate, because they feel like they can't get a handle on it, they can't get control over it, and it's a lot of maintenance. You're going to see that in a second. A lot of patients come in and they'll say, "We've tried everything," and I've definitely experienced that myself. Something you want to think about, a lot of times, primary care clinicians are throwing spaghetti against the wall, and I feel like that's what I was doing as well, even though I understood how to treat eczema. Hold on and we'll go through it. The main point with that is that we need to try things in the right combination and that's my main takeaway of what I've learned. That that gives patients a lot of hope and, hopefully, it'll give you a lot of hope too, putting this all together.

Before I go any further, there's a cheat sheet down below this video, if you want to download that, to follow along with this presentation and also to keep it your desk for quick reference. Eczema, it's really important to think about it as a lifelong rollercoaster. I've always said to my patients, "This is a chronic illness, it's not going to go away," but when you paint the picture of, "It is a rollercoaster for everybody," there are guaranteed ups and downs. People try their best to maintain it, but in some ways, it's out of our hands, when things have flares. If you set the expectation of, "It's going to be like this," that can be a little bit easier as well. A helpful reframe that I've learned for myself is that it's similar to asthma, in that there's flared rescue treatment as well as the maintenance care. The maintenance care is so key and I think that it's also the most exhausting part.

You'll see that in a second. Also, the main thing about when it comes to asthma, or to eczema rather, is about breaking that itch scratch cycle when it comes to flares, which I'll talk about in a second, so just stick with me. Treatment for eczema works best when it's used consistently and all at the same time, but it can, again, be hard and it can be exhausting. The goals of care. Number one is all about maintaining and repairing the skin barrier. The main thing is moisturizing with emollient, but we'll talk about the other skin care, and that is the underlying ultimate key, because when you protect that skin barrier, then it tends to... There's just a lot of research that supports that it can have so many positive effects and reduces the risks of further flares and other complications.

On a very, very small level too. Number two is, again, controlling the itch, because when you have patients that are itching, it's going to make it worse and it's just going to get into this nasty cycle. Helping with sleep, that's got to be a really important component to your treatment. Treating and preventing infection, which I'll talk about. Just being mindful of when it's infection and when it's not, and then treating flares and inflammation on a preventative basis. Stick with me and we'll talk about all of these things. Maintenance care. This is going to look like a lot, but it's not that bad. It really comes down to skincare and avoiding triggers. Skincare is daily use of emollient. Hold that thought, we'll talk about that. Basically, it just means creams that are thick enough that you can't use a pump, because if you are using a pump, those are more like lotions and they're not typically enough to be considered an emollient.

It's important that they're hypoallergenic, fragrance and dye-free. Daily bathing, there's been some confusion and controversy whether or not patients should go every other day with their bathing versus daily bathing, and I think the general recommendation now is that... It depends, you have to work with your family, so if they're insistent of, "You know what? This is what works for me," that's fine. There are a couple of moving parts here, right? Yeah, it's generally recommended that they do daily bathing, 10 minutes of lukewarm water, but the most important thing is that you're patting them dry and quickly applying emollient right afterwards. Bleach baths are another component of skincare maintenance, and we'll talk about that in just one second. Wet wraps, which is another terrifying thought or phrase, but hold on for a second and we'll talk about that. Hopefully, I can empower you to recommend this to your families and make a big impact in their lives.

Again, avoiding allergens and triggers. The main triggers that we can be controlling of are things like low humidity, sweat, friction, and saliva. That's a little bit harder with the babies, because they drool and drool, but just knowing that that's an irritant, and then potential of topical allergens. Myself personally, I get a little overwhelmed with this sometimes, because the dermatologist that I was learning from spewed off this really long chemical name that she was familiar with, that was within a certain number of lotions, creams, and all this stuff. I don't know, I don't think that that's the expectation that we know all those things in primary care. I definitely covered that level of knowledge, but I think it's just important to think about, what are they noticing that seems to get worse, or are there certain soaps, dyes, or things like that?

That's maintenance care. That's a lot, but basically comes down to daily bathing, emollient, and some other extra add-ons like those bleach baths and wet wraps, which I'll talk about in a second. Flare treatment is typically when you're going to see them in primary care, but you need to encourage the maintenance treatment. It's the same skincare, but you want to put out the fire. You want to add things like topical steroids, which I have another slide on that, so just hold that thought. You want to stop the itch and scratch cycle, so the steroids are going to help with that, but you are also going to consider adding an antihistamine. The dosing for that... I feel a little hesitant with this myself, because I don't giving antihistamines to little kids, but hydroxyzine... If they're up all night itching and scratching, that's going to help them break that cycle.

The dosing that was recommended was hydroxyzine, half a milligram per kilogram during the day, and then one milligram per kilogram dosing at night as needed. Again, wet wraps, which I'll talk about in a second. In terms of asking the kiddos not to scratch, that doesn't work, so you have to think about all these other things. Cool and cold packs can definitely help with itching as well as distraction. Yeah, that's the main flare treatment. The suggestion that was really helpful that the dermatologist was talking about that I learned from was saying that she does a flare treatment visit to put out the fire, then she has them come back in about two to three weeks to assess how they're doing, to talk further about that maintenance treatment, and making sure that that's all working for them.

I want to talk about emollients for a second, people have a lot of questions about that. Again, it's something that's really thick, hypoallergenic, fragrance and dye-free. White petroleum, basically no one has any allergies to it. That's also known as Vaseline, it's one of the brand names. I'm trying not to be partial to any brands here. Just on FYI, people really love Aquaphor and it's a really awesome type of treatment, but it has white petroleum and it also has lanolin in it. If somebody is using that and they're having reactions, it's not working, or the eczema's getting worse, some people can have a reaction to lanolin. Eucerins, cerave, and vanicream, these can all be good options too, but you want to look at ingredients, because there are different lines for different types. Eucerin tends to be the more bland ones.

Cerave just has so many different types of lines within that brand, so it's important to think about that. I didn't get any clear suggestions, because it was a CEU, so it wasn't really recommended to do any brand names, so I was reading between the lines there. Vanicream, I've been familiar with. Again, this is really not cheap stuff, so something to think about with your patients, but white petroleum is pretty cheap. Things to avoid, calendula is a really popular ingredient right now, but this can be really allergenic for some people, so consider avoiding. Also, it can come in things that have a fragrance in them. Olive oil apparently can increase staph, so it's not recommended. Coconut oil, again, is another trendy thing, but maybe just is the preference of your patient. That's okay, to use coconut oil, but you want to use the quote "Beauty" kind and not necessarily the cooking kind.

Apparently, there are differences. If patients want to be using an oil like olive oil, the recommendation that I got from the dermatologist was sunflower extract oil, but I cannot imagine how expensive that must be, especially if you're using large bottles of it all over your child. Something to think about there. Bleach baths. Someone told me about this and I was familiar with it, but I just felt like I didn't have good guidance on it, so I didn't feel like I could recommend it to patients. Basically, what this is is a bath one to two times per week. There's some variable evidence. There's evidence that it's helpful, there's evidence that it's not necessarily more effective than regular bathing. Nothing has come back harmful as far as I understand, but it's actually recommended by the IDSA, the Infectious Disease Society of America, for recurrent MRSA infections.

I didn't find anything that recommended it specifically for eczema, but the thought is that it's antiinflammatory and it can kill the germs, which is one of the pillars of eczema treatment. If you're going to fill a tub, and again, there are different tub sizes, but approximately, it's a half tub full of water with a quarter cup of bleach. If it's a baby bath, it's just one teaspoon. A very, very tiny amount. The way that the dermatologist referred to it as, which I loved, was a swimming pool bath, which I totally will use in my clinical practice. I feel conflicted about this, because it's odd to me to use bleach, but I think that seeing the number of patients that I've seen come in with really severe eczema, just really suffering, I think I going to add this to my repertoire.

Wet wraps is another thing, which I just felt like, "Really? Does that actually work?" Apparently, it does. It doesn't have to be anything fancy, but basically, what it involves is just... The cheapest version is to dress the patient in damp cotton pajamas that have been put in water, rung out, or just damp now, and then they just go to bed wearing that, which sounds super strange, but apparently is really effective. Another suggestion, this is actually a mom's group hack, is that cotton pajamas, depending on the season, but you could cover them with a pair of fleece pajamas, so it didn't get the be all wet, or you could cover it with a sweatshirt or something like that. That's the moral of the story with wet wraps. There are a ton of fancy types of things that people can buy.

I don't know, I don't even know the brand names, but yeah, I don't think you have to get fancy about it, you can just wrap it up. Topical steroids I feel like is the main question. Topical steroids, you can use these up to about 15 days per month. There are different formulations, there are creams, oils, ointments. Oils and ointments tend to be the preference, but again, I always defer back to cost, because just from the patient population that I work with, but also, who wants to spend a ton of money on this? I don't know, it seems like it will add up. Oils, apparently, there is a fluocinonide oil. Anyway, I haven't ordered that myself yet, but I'm going to. Ointments and then, also, you can wrap those up. With eczema, you can get those lichenified plaques where they're really, really thickened from all the repeated excoriation and it can be hard to penetrate that.

A suggestion is that you can put the topical steroid on and then just wrap their arm or wherever it is with some sort of plastic wrap. For 15 minutes or something like that, just to help it penetrate a little bit better. The thought behind the 15 days is that, if it's more than that, they might need a different maintenance plan than what you have in front of you. They might need a dermatology referral if you're getting a little bit fancy here or they're getting a little bit more complicated and more on the moderate to severe side versus a mild eczema. Another thing to think about is, do we have the right diagnosis here? Do they have a bacterial infection on top of it? Signs of that would be things like increased redness, drainage. You could consider mupirocin, which is a topical antibiotic treatment for that.

Another thing that the dermatologist sees a lot is that there's post-inflammatory hyper or hypopigmentation that people can tend to think that this is still eczema, but the rule of thumb there is that it really should feel like something. If it feels like sandpaper, then you can go ahead and apply it, but if it feels just like normal skin that's a different color, then don't use the steroids anymore. That's really important with... There are many different types of skin tones and different presentations that you'll see eczema in, and it really comes down to itch and then the feel as well. There's also a table of steroid potencies. Instead of giving you specific names of the different steroids to use, I'll give you the classes that are recommended. Class one is the most potent, which is also in the cheat sheet.

Hands and feet can use the most potent topical steroid. Class four tends to be for the rest of the body. I have the note here, 80 grams, because depending on the tubes that you're used to sending to the pharmacy, 15 grams is not enough to use on somebody's body. That was the recommendation of the dermatologist, to use at least 80 grams, a large enough tube, so that they have enough supply. Class six, which is close to the bottom. Seven is the least potent. Those are for the flexural areas and for the face. You can use a smaller gram amount for the tube for that, so about 30 grams. Food allergies, this is another big question, "Should I test them for food allergies? Do they have a food allergy, is that what's causing it?" Basically, no, but you want to consider food allergy in kids under five with moderate to severe eczema if one or more applies.

They have persistent symptoms despite optimized maintenance and flare treatment. The reason I say no is because, most of the time, they're not optimized in their maintenance and flare treatment. When you send them to dermatology, they get them to a point where it's under control. Reliable history of food reaction, they need at least one of those. Yeah. Actually, I think those are the only two. I thought there were three, but there's only two there. Yeah, if they visibly had a food reaction, if they have other things consistent with a milk allergy, or other allergy where they have blood in their stool or something like that, they can be evaluated for milk, eggs, peanut, wheat, and soy allergies.

However, definitely send them to derm first, because derm is going to make sure that they're optimized in their eczema treatment, because if they undergo all that testing, there's just a lot of extra burden for the families to test for that, then to try to evaluate them, and all that stuff, especially breastfeeding moms that are deciding whether or not to eliminate foods from their diet, change formulas, or things like that. Definitely send them to dermatology first. That's it for this presentation.

Definitely download the cheat sheet down below this video if you haven't already, or head over to a realworldnp.com/guide to grab the ultimate resource guide for the new NP. You'll also get these videos sent straight to your inbox every week and some bonus content that I just don't share anywhere else. Patient stories, insights, extra videos, things like that. Thanks so much for hanging out. Definitely let me know if you have any questions and I'll see you soon.