BLAINE, WASH. — Skin disorders such as dermatitis can be vexing to parents and children alike, often out of proportion to their seriousness, Marvin J. Scotvold, M.D., said at a conference sponsored by the North Pacific Pediatric Society.
In other instances, “I've had pediatric patients and adult patients with severe internal medical problems, but they're really concerned about that spot on their skin, which is pretty benign,” said Dr. Scotvold of the University of Washington in Seattle.
He offered a number of pearls for diagnosing and treating dermatitis:
▸ Acute dermatitis is wet, and chronic dermatitis is dry. In both cases, the skin will be red, it will itch or burn, and it's often infected. In acute dermatitis, the primary pathology in acute dermatitis is in the epidermis, and you'll see vesicles, bullae, edema, oozing, and weeping. In chronic dermatitis, the primary pathology is located in deeper skin layers. The skin will be lichenified, scaled, excoriated, and thickened, and may have accentuated skin markings.
▸ Healing from acute or chronic dermatitis usually takes a minimum of 2–8 weeks, depending on the severity and how long it has been present. Most physicians and patients fail in treating dermatitis by treating only until the skin heals. Despite being healed, that skin remains quite sensitive, and it takes very little to irritate it again. The skin takes a minimum of 6–24 months to lose that irritation, to toughen up, and to become resistant, and it should be protected for at least that long.
▸ Treat the redness, treat the burning and itching, eliminate the infection, remove the wetness, prevent the dryness, and keep the skin covered when treating dermatitis.
▸ None of that will help much unless the patient avoids continued irritation. As dermatitis is healing, the physician should give patients a list of don'ts, including: don't expose the skin, don't scratch, don't use hot water, don't use soap with harsh chemicals, and avoid dirt, grime, salt, friction, rubbing, and chafing near the affected area.
▸ Intermittent compresses work well for acute dermatitis. Use a porous material, such as a worn-out cotton T-shirt. Apply it to the skin, and leave it open to the air. That produces evaporation, which dries the wetness, cuts down on edema, and also cools, relieving the itchiness.
▸ Apply topical corticosteroids very sparingly but very frequently, four to six times a day. Since the epidermis maintains a certain reservoir of drug, it is not necessary to set the alarm clock for midnight and 4 a.m. “I find that if I tell patients to put it on six times a day, they'll probably get it on three or four,” Dr. Scotvold said. “If I tell them to put it on four times a day, they're going to get it on two or maybe three. If I tell them to put it on morning and night, they may get it on in the morning.”
▸ Tell patients to keep the topical corticosteroid in the refrigerator and apply it cold. When you put something cold on the skin it's more soothing.
▸ Continue topical corticosteroids until the redness is gone, not just the itchiness.
▸ Often, patients don't use their medication long enough, then return to the office saying it doesn't work, because every time they quit using it the dermatitis comes back. Dr. Scotvold's reply? “Well I guess my razor doesn't work, because every time I stop using it my whiskers return.”
▸ The greasier an emollient, the better it is at softening and keeping the skin moisturized. A similar principle applies when choosing what form of a topical corticosteroid to use. A lotion of 0.1% triamcinolone is at the lower end of the potency scale. A cream of 0.1% triamcinolone is a level of potency higher than the lotion, and in an ointment it is still more potent.
▸ Tell patients to treat their skin like they treat the dishes. You put dirty dishes into hot soapy water; you don't put clean dishes in the dishwasher. The same thing goes for people. Have you been rolling in the mud or yanking out transmissions? Probably not. People who wear clothing generally need soap regularly only on the scalp, in the armpits, and in the groin.