This is a 4 post series centered on ‘The Combined Approach’ that is explained in the ‘Atopic Skin Disease’, a manual for practitioners authored by Christopher Bridgett, Peter Noren and Richard Staughton (copy of book viewable by joining here). The Combined Approach uses habit reversal to stop habitual scratching in atopic eczema. Dr Christopher Bridgett has previously helped in Friday Doctor Q&A from November 2011 to February 2012 and MarcieMom has invited him to share more about the Combined Approach.
Explaining Topical Treatment – Moisturizer
As we understand last week, The Combined Approach includes topical treatment using emollient and steroid. Moisturizing is a HUGE part of topical treatment, as emollients both lubricate and moisturize. Dr Bridgett’s advice on moisturizing is Thinly, Gently, Quickly and Often. There are a few other points mentioned in the ‘Atopic Skin Disease’:
- Thinnest possible application without ‘rubbing it in’
- More on exposed areas such as the head, neck and hands
- Pump dispensers preferable to open tubs due to bacteria infection
- Applying topical steroid first, then emollient over both the skin and the steroid
- Cream preferred over lotion
Can you explain why thinnest possible application is preferable for emollient? (I’d usually slather on my child as I find applying a thin layer leads to more rubbing to spread the emollient)
Also, can you explain why topical steroid first? (I’d written on this here and it does generate some discussion!)
Can you explain why cream is preferable over lotion?
Your three questions answered:
- Thin applications of moisturizer allows heat to escape, but insulates against water loss.
- If moisturizer is applied often enough, when the steroid is applied directly onto the eczema, it is applied to skin that has been recently moisturized. We get then the best results by putting moisturizer on over topical steroid, and moisturizing all the skin, not just that which has the eczema.
- The thicker the moisturizer, the better the moisturizing effect. Also, often there are less additives in thicker moisturizers, as thicker moisturizers “keep” longer. There is less chance that a sensitivity reaction will occur with an ointment, compared with a cream. See http://atopicskindisease.com/articles/20110801
Explaining Topical Treatment – Steroid
It is stated in ‘Atopic Skin Disease’ manual that steroid cream work by inhibiting protein synthesis, secretion of products, cell division and migration of cells. The epidermis can benefit from reduced cell division, and the dermis from reduced cellular and lymphokine activity. Can you explain what this means, and why it is important to continue steroid treatment after epidermis healing (‘2-stage in steroid effect’)?
It seems the steroid anti-inflammatory effect is partly achieved by reducing over-activity in the skin, allowing natural healing then to lay down healthy skin again. By the time the seems good to look at, the healing is not complete through and through – there is more that is needed under the surface, so we recommend continuing with the topical steroid, beyond The Look Good Point: do not stop too soon. See http://atopicskindisease.com/articles/TT7
Many parents are very concerned with the skin-thinning side effects of steroid and also the ‘withdrawal’ symptoms once steroid treatment is discontinued. I read in your manual that side-effects are associated with inappropriate use of topical steroid and the risk is usually inadequate treatment (i.e. stopping steroid cream too early or using one of too low strength). How do you normally convince parents that steroid cream is safe? And what guidelines would you give them to gauge if the steroid cream of correct potency, frequency and amount is used?
Steroid side-effects come especially from using topical steroids long-term and in an unsupervised way. The method we use in The Combined Approach includes more supervision than is usually given, with a programme of several clinic visits, involving careful discussion of all anxieties and concerns. Using The Combined Approach, including therefore habit reversal, which allows natural healing alongside the good steroid effect. Then less topical steroid is used overall, for good effects, not side effects!
We offer information about the potency groups of the topical steroids, and how they are usually used. The thicker the skin, the stronger the topical steroid to be used. See http://atopicskindisease.com/categories/20110423_11
Each application of any cream needs to be sparingly applied – whether it is an emollient or a topical steroid: only a shine is required.
MarcieMom: Thank you Dr Christopher Bridgett for explaining the topical treatment that is part of The Combined Approach. In our next post, we will understand more on habit reversal techniques.