Regular follow up is always important to keep reassuring and reaffirming that parents are doing the right thing, modifying treatment according to response and complications, and praising positive results. There are so many negative influences on these families that it becomes imperative to keep repeating that of all the treatments available, by and large Western medicine still works best and is safe.
Environmental modification is an essential part of AD management, and one that parents readily accept, in theory at least. It is always important when telling parents what to take out of the child’s environment that you suggest what they should put in instead. Soap, shampoo and bubble bath do need to be eliminated. There are numerous soap substitutes that can be used (Box 1). Skin contact with woollen or acrylic clothes, blankets and toys should also be avoided, substituting pure cotton or at least 70% cotton blends.
When dust and other aeroallergens such as animal dander, pollen, grasses and moulds are a genuine problem, children often have an accentuation of their rash in exposed areas such as the periocular area or the thighs where their skin contacts dust on the floor when sitting cross-legged at school. There is a history of exacerbation on exposure, and these children are more likely to have asthma and hayfever.5 Dust is difficult to minimise; however, using mattress and pillow covers, washing bedding and other fabric that comes in contact with the child’s skin in hot water, eliminating dust-catching objects (e.g. fluffy toys) and vacuuming thoroughly can help. If the child has to sit on the floor at school, a washable bathmat should be used. Before taking steps to reduce aeroallergens it is important to confirm with allergy testing that there genuinely is a very significant reaction present.
Many households, preschools and primary kindergartens have a sandpit. Sand is a major problem for children with AD. It is easy to get rid of the sandpit at home, but parents need to talk to carers about trying to keep the child out of sand elsewhere. Sand tends to accumulate in socks and shoes and is mostly a problem for hands and feet.
In summer, or year-round for the child who is swimming training, chlorinated pools can be a problem. It can be helpful to apply a greasy emollient before swimming and to shower and apply emollient immediately afterwards.
Control of skin dryness
Dispersible bath oil should be used daily in the bath. It is a common belief that baths should be taken infrequently and kept cool, but a normal daily bath helps to reduce bacteria and airborne allergens and irritants on skin without causing dryness as long as such an additive is used (Box 1).
After bathing, an emollient should be applied over the whole body. The frequency of use will depend on the child’s degree of skin dryness. For mild cases, application of emollient after bathing is sufficient. For more severe xerosis, application two or three times daily is often necessary. Emollients are easiest to apply when the skin is still damp after bathing.