NEW YORK – To frustrated parents of children with severe atopic dermatitis, Dr. Sheilagh Maguiness offers a fast and effective remedy: a 2-week intensive treatment she calls Boot Camp. Instead of push-ups, however, this Boot Camp involves bleach baths, wet wraps, steroids, moisturizers, and sometimes oral antibiotics or antihistamines.
During the 2-week period, the treatment plan attempts to address all aspects of the disease – dry skin, itching, inflammation, and infection or colonization – simultaneously.
Dr. Sheilagh Maguiness
Dr. Maguiness’ instructions for the severe atopic dermatitis Boot Camp are as follows:
• For 2 weeks, bathe the child nightly in a dilute bleach bath of lukewarm water for 10 minutes. (No soap is needed, or use unscented Dove or Cetaphil for armpits, groin, hands, and feet.) After 2 weeks, use lukewarm water alone.
Data have shown that the baths are safe, said Dr. Maguiness of Harvard University, Boston, and Boston Children’s Hospital. In a recent randomized trial of 31 children, those who underwent regular, dilute bleach baths showed improvement in their atopic dermatitis with no increased susceptibility to infection (Pediatrics 2009;123:e808-14). The recipe for the bleach baths is ¼ to ½ cup of plain Clorox bleach in a full tub of bath water. (With more concentrated forms of Clorox, use 1/3 cup per full tub.) Comfort the worried parents by letting them know that the concentration is similar to that found in a swimming pool, and is safe for head and neck areas, she said in a presentation at the American Academy of Dermatology summer meeting.
• After bathing, pat the skin dry, and within 3 minutes apply triamcinolone (0.1% ointment) to affected areas on the body, and hydrocortisone (2.5% ointment) to the face.
• Follow the bath with a thick moisturizer (Vaseline, Aquaphor, or Hydrolatum ointment). Use the moisturizer on top of the medication twice daily, even if no bath is taken. Avoid lotions.
• Add wet pajama wraps nightly for 1-2 weeks as part of the Boot Camp and/or for acute flares, Dr. Maguiness noted. Studies have shown that wet wraps plus topical corticosteroids are effective, and can promote rapid improvement in the majority of patients, with very few side effects. In a recent retrospective study of 216 pediatric patients who underwent this combination, all of them showed at least 25% improvement, and 45% had 75-100% improvement (J. Am. Acad. Dermatol. 2012;67:100-6).
Advise parents to use long-sleeve cotton pajamas or Onesies for wet wraps, Dr. Maguiness added. Parents should soak the garment in warm water, wring it out until it’s slightly damp, then dress the child, and put on a dry outfit on top of the wet one. They should make sure the room is warm so the child can go to sleep.
In cases of obvious superinfection, prescribe an appropriate oral antibiotic such as cephalexin.
For itching at night, sedating antihistamines such as hydroxyzine 10 mg/5 mL, 30 minutes before bedtime can be helpful, Dr. Maguiness noted. For daytime itching, she suggested fexofenadine or cetirizine in the morning. Have a few "go-to" agents, she advised. For infants, consider fluocinolone oil or triamcinalone 0.025% ointment. For children, consider triamcinalone 0.1% ointment. For teenagers (or for use in more localized areas with younger children), consider stronger agents such as mometasone or fluocinonide ointment.
Limited studies support some systemic therapies for use in pediatric atopic dermatitis, including narrow-band ultraviolet B (nb UVB); cyclosporine and mycophenolate mofetil; and methotrexate and azathioprine, Dr. Maguiness said. Perhaps in the future, biologics such as tocilizumab may emerge as additional treatment options, she added. While cyclosporine can help with the rapid clearance of the disease, methotrexate and mycophenolate mofetil may represent longer-term options, she said.
Meanwhile, don’t be surprised if families resist the Boot Camp at first, Dr. Maguiness said.
"You have to get the families on your side," she said. "They’re terrified of bleach baths, wet pajamas, and topical steroids. Let them know there’s no faster or safer way to improve their child’s condition in 2 weeks or less."
So invest time in the first visit, educate your patients and parents about the treatment plan, and give them printed instructions and handouts, Dr. Maguiness said.
Finally, don’t forget to obtain cultures to rule out possible superinfection, as well as schedule a prompt follow-up visit in about 2 weeks.
At this visit, after following the Boot Camp regimen, the eczematous areas should be mostly cleared, with possible residual hot spots, she said. Begin to taper the topical steroids, bleach baths, and wet wraps at night.