Trigger Avoidance as a Basic Element in Atopic Dermatitis Management

Trigger Avoidance as a Basic Element in Atopic Dermatitis Management Posted By:
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Atopic dermatitis (AD) is a chronic inflammatory disorder affecting millions of pediatric patients and, oftentimes, continuing into adulthood. When not adequately controlled, moderate to severe AD is associated with significant morbidity and a wide range of comorbid conditions. Here, I discuss the role of trigger avoidance in the management of AD. To learn about new and emerging therapies approved for the use of moderate to severe AD, visit practicingclinicians.com.

Reducing Allergen Exposure in the Management of AD
Avoiding exacerbating triggers is a key component of basic AD management recommendations, along with warm daily bathing using nonsoap cleansers and frequent application of emollients. These practices are recommended throughout the disease course and for all severity levels. Healthcare professionals (HCPs) treating AD should be able to identify agents known to be triggering and work with patients to develop plans to decrease their exposure. Two clinical approaches are used to identify and reduce exposure to triggering agents.

The first strategy involves performing patch testing, which detects the specific allergens that may be impacting a patient. On patch testing, positivity to allergens is common in patients with AD, most of whom are unfamiliar with the agents and unaware of their impact on them. This tool is invaluable in designing a patient-specific and data-oriented plan.

However, patch testing is not feasible for all patients; common barriers may include access to specialists, limited time, lack of transportation, or financial constraints. In these cases, an empiric approach of eliminating common triggers can be used, whereby HCPs can guide patients to choose products that don’t contain common AD triggering allergens or those including minimal ingredients.

Identifying Key Allergens
Although there are many commonly recognized allergens known to exacerbate AD, some key allergens may go overlooked. One to consider is cocamidopropyl betaine (CAPB), a surfactant found in a variety of skin care products, including shampoos, conditioners, body washes, shaving creams, liquid soaps, contact lens solution, and more. It was originally developed to replace surfactants like sodium laurel sulfate (SLS), which tends to cause irritation, like burning of the eyes when put in a shampoo. As a result, companies aimed to develop products that were better tolerated. Although CAPB is less irritating than SLS, it is itself an allergen that can have its own degree of irritancy. Oftentimes, the shampoos marketed as “no-tear” or “better for sensitive skin” expose patients to CAPB.

Other allergens that are important to call out are methylisothiazolinone (MI) and its sister allergen methylchloroisothiazolinone (MCI). These are preservatives that serve to reduce microbial growth and delay chemical changes within the product. They are used almost ubiquitously in personal care products and even in things like acrylic paints. MI and MCI were designed as alternatives to things like parabens, a group of preservatives that are also allergenic. In the world of contact dermatitis, we refer to MI as the “epidemic” because it has become particularly problematic for patients with AD.

Patients with uncontrolled AD may grow frustrated by unsuccessful attempts to choose products they tolerate if they are not informed about the role of these allergens. A common misconception is that each product has unique ingredients and that changing from one to another will be helpful; in actuality, they may have pretty similar ingredients. Perhaps one includes MI as a preservative, where the other contains MCI. Another misconception is that “all natural” or “fragrance-free” products will not contain triggering ingredients, but a lot of them contain these chemicals. HCPs should discuss the role preservatives play in skin care products and AD with patients, as most available skin care products will contain them.

Additional Clinical Considerations
HCPs should not overlook the potential for a patient to have overlapping AD and contact dermatitis, which can confound the clinical picture. If eczema is particularly localized to a limited area of the body, (eg, hands, head, or neck), this may be a sign of overlap as it deviates from the traditional presentation of AD. Diagnostic accuracy is necessary to achieve beneficial outcomes for both AD and contact dermatitis.

In some cases, AD is refractory to therapy, not responding in the expected way. The symptoms seem to come back with a vengeance despite treatment. Patients may report using a certain over-the-counter or prescription medication on their skin, like a topical steroid, which initially helps to improve symptoms, but worsens them shortly thereafter. This could be a sign the patient has an allergy to the medication—initially the medication’s anti-inflammatory effects work, but as they fade away, the allergy triggers a reaction.

Collaboration in the Management of AD
Actively engaging patients in shared decision-making about their AD treatment plan can help to align patient and care team goals, improve the quality of the patient-HCP relationship, and reduce patient fears and misconceptions. When efforts to identify and eliminate AD triggers empirically are unsuccessful in the primary care setting, HCPs are encouraged to refer patients for specialty care and allergy patch testing.


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Filed under: Dermatology , NPs & PAs , Allergy/Immunology

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