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Atopic dermatitis (AD) is an extremely challenging condition for many patients and their families. While its cause is not fully understood, it is now known to be intimately related to at least 5 key aspects: the skin barrier, the immune system, the microbiome, the nerve endings that send the itch signal, and finally the mind-body connection.
Fittingly for such a complex disease, there are many medications–pharmacologic treatments–for AD. Anti-inflammatory agents, antibacterials, anti-itch agents, and many others are available both with and without a prescription. However, there is another world of non-pharmacologic treatments, that although less well known, can play an important role for some patients. The best part about these is that they tend to be both safe and inexpensive, and can often be used along with other treatments without issue. I’d like to highlight some of my favorite non-pharmacologic approaches that are worth thinking about and, in some cases, have made an outsized difference.
It has long been known that for patients with AD, the feeling of wool on the skin can be very itchy and unpleasant. While it is true that some of the modern wool clothing is now so soft that it can be okay for those with eczema, it does raise an interesting question: if there are fabrics that make the skin feel worse, are there some that could make it feel better? Silk is a fabric that is thought to aid wound healing and even has some anti-bacterial properties which makes it a very interesting material. Several small studies have actually found that silk clothing, even when compared to soft cotton, actually seems to be very soothing to the skin. Sometimes even silk bedding can be helpful at night as it is so soft and so cooling to the skin.
There are also some textiles that have silver impregnated or woven into them. These also have some small studies that suggest the anti-bacterial aspects of silver may be helpful for those with AD. Although these can be expensive, it could be worth trying for certain situations.
In a similar vein, the concept of “wet-wrap therapy” utilizes a fabric, or sometimes gauze, to help intensify topical treatments. The idea here is that the patient can take a bath or shower, and then while the skin is still damp, a medication or moisturizer can be applied to the skin. Immediately after, a damp–not wet, just a bit damp–layer of clothing (such as long underwear or a onesie for a baby, or perhaps just soft cotton gloves for the hands) can be applied, followed by a nice warm dry layer of clothing, such as sweat pants and a sweatshirt. This can be left in place for several hours or even overnight, so long as it is comfortable and the room is kept toasty warm. This is a very intensive way to protect the skin, push the medication or moisturizer into the skin, and also cool it down. There have been several studies that show that this technique is very powerful, though it can be uncomfortable and can, on some occasions, increase the risk of bacterial infection.
Finally, we understand the importance of the mind-body connection in many diseases and AD is no exception. Stress, anxiety, depression, sleep deprivation: all of these can both cause flare ups as well as be triggered by flare ups, creating a terrible, vicious cycle. A study in 1993 examined biofeedback and hypnotherapy on eczema in 44 children. They found that those receiving hypnotherapy or biofeedback had significant improvement compared to the control group. Similarly, a technique called progressive muscle relaxation therapy (PMR) was found to help with itch, sleep, and anxiety in 25 patients with AD. Habit reversal therapy (HRT) also was found to be superior to a control group for scratching in AD patients. Finally, coping with stress through support groups also seems to help both patients and families with AD.
There are so many aspects to this condition and everyone is truly unique: what works great for one person might not work at all for another. Because of this, having a big tool box of ideas is critical and sometimes trying something new can be very insightful, especially when it is done under the guidance of an experienced clinician.