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REVIEW ARTICLE

Nonpharmacological management of atopic

dermatitis
Sebastian Criton, Geethu Gangadharan
Department of Dermatology, Amala Institute of Medical Sciences, Thrisssur, Kerala, India

ABSTRACT

Atopic dermatitis is an immunologically mediated chronic inflammatory disease which cannot be controlled always with
topical agents. Systemic drugs play important role in these difficult to manage cases. Systemic agents are also important
in controlling the acute flare. Unfortunately these agents are very limited in number. Moreover none of them starting
from corticosteroid to azathioprine can provide complete cure. Continuous research is unfolding different aspects of AD
pathogenesis which was not known previously. Scientists are engaged in developing newer molecules targeting those novel
pathological pathways thus adding in the armamentarium of existing drugs. This article is dedicated to current systemic
treatment options available with their individual merit and demerit along with recent advances in this field.

Key words: Atopic dermatitis, azathioprine, cyclosporine, methotrexate, steroid, systemic therapy

INTRODUCTION determined epidermal and immune defects and

modified by environmental factors. The avenues for

A topic dermatitis is a chronic inflammatory dermatosis

affecting 7%–29% of the pediatric population
across the world.[1,2] The recent trend of an increase in
the prevalence of atopic dermatitis is attributed to the
changing gene–environment interactions. This has
resulted in an upsurge of research into the pathogenesis,
treatment, and prevention of atopic dermatitis. Even
with the development of newer drugs and treatment
modalities, nonpharmacological intervention remains an
integral part of the management of atopic dermatitis. The
success of management lies in a combined approach where
drug therapy is combined with a set of interventions,
apart from drugs, aimed at altering the factors involved
in initiation and progression of the pathogenic cascade of
atopic dermatitis in an individual patient.
NONPHARMACOLOGICAL
MANAGEMENT – THE RATIONALE
Atopic dermatitis is a chronic inflammatory disease
which is to a greater extent influenced by genetically
tackling it from outside should be fully understood
and harnessed. In atopic dermatitis, defects in
epidermal barrier lead to percutaneous penetration
of allergens, causing elaboration of thymic stromal
lymphopoietin by keratinocytes and activation
of Th2 and Th22 cells, leading to liberation of
cytokines, hence perpetuating the cascade.[3,4] Various
factors which contribute to this epidermal barrier
defect include filaggrin gene mutation, lipid defects,
proteases, irritants, pH changes, and influx of bacteria
and other pathogens [Figure 1]. This intricacy
of interaction between genetic defects, immune
system, and environment, resulting in dysfunction of
epidermal barrier integrity and elaboration of immune
dysfunction,[5,6] emphasizes that no single drug or
combination is effective in successful management
ADDRESS FOR CORRESPONDENCE:
Dr. Sebastian Criton,
Department of Dermatology, Amala Institute of Medical Sciences, Amala Nagar,
Thrisssur ‑ 680 555, Kerala, India.
E‑mail: amaladermatology@yahoo.co.in

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DOI:
10.4103/2319-7250.207605 How to cite this article: Criton S, Gangadharan G. Nonpharmacological
management of atopic dermatitis. Indian J Paediatr Dermatol 2017;18:166-73.

166 © 2017 Indian Journal of Paediatric Dermatology | Published by Wolters Kluwer ‑ Medknow

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Criton and Gangadharan: Nonpharmacological management of atopic dermatitisj
Figure 1: Pathogenesis of atopic dermatitis (adapted from essential
updates in atopic dermatitis: Pathophysiology, Prevalence, and Clinical
Manifestations, Anthony J Mancini, Medscape, August 2016)
of atopic dermatitis. Hence, a meaningful approach
to the management of atopic dermatitis should be
an all‑encompassing one with both drug therapy and
nonpharmacological intervention, each given its due
importance.
Nonpharmacological management includes the
treatment of atopic dermatitis using modalities other
than drugs for control of flare and maintenance of
remission of disease. It entails treatment modalities
which complement the pharmacological therapy
but not a substitute for drug therapy. The goals of
nonpharmacological management include reduction
in severity of illness and flare episodes, to maintain
remission and improvement in quality of life of patient
with atopic dermatitis. This can be achieved by patient
education, modification of atopic skin, its triggers, and
psychological interventions wherever needed.[7‑10] The
aim of this article is to give an update on the various
nonpharmacological approaches in atopic dermatitis.
Patient Education
The education of patient and family enables them
to have a realistic approach to the disease and
its outcome. Literature review has shown that
educational interventions can decrease the severity of
atopic dermatitis, improve patient adherence leading
to a positive long‑term outcome, and thus improve the
quality of life of patients.[11,12]
Recommendation
Educational intervention should be included in the
first visit of a patient to a dermatologists’ office. It
involves education of the family regarding the chronic
relapsing and remitting course of the disease, about the
triggering factors and importance of its modification.
The crucial role of intact skin and importance of its
maintenance should be given thrust. Instructions are to
be given regarding the drug therapy and the importance
Indian Journal of Paediatric Dermatology | Volume 18 | Issue 3 | July-September 2017
of adherence to treatment regimen. Initiative should
be taken to address any misconception regarding the
disease and its management. Furthermore, the role
of family as a support system for the child should be
emphasized.
Furthermore, the child should be encouraged to
attend school. Parents are advised to inform the
noninfectiousness of the condition to the school
authorities and the importance of school and peers
as a support system in a child with atopic dermatitis.
Educational interventions can be also done in group
workshops, using educational pamphlets and videos.[10]
Modification of Atopic Skin
One of the primary objectives of the management
of atopic dermatitis is modification of atopic skin.
This includes maintenance of barrier integrity and
modification of various factors which curtail the
integrity. It is achieved by the use of emollients, wet
wraps, bleach bath, and using various avoidance
strategies.
Use of Emollients
The remarkable ability of emollient in recovery of
barrier integrity and its maintenance makes it the
mainstay in treatment of atopic dermatitis. It has
been observed in number of clinical trials that they
lessen symptoms and signs of atopic dermatitis and
decrease the requirement of other anti‑inflammatory
treatments for disease control.[13‑16] An ideal emollient
would repair the skin barrier, maintain skin integrity
and appearance, reduce transepidermal water loss
(TEWL), and restore the lipid barrier’s ability to
attract, hold, and redistribute water.[13,16] However,
the market abundance of emollients ranging from
traditional to the designer ones makes the choice of
an ideal product confusing.
Recommendation
The choice of emollient should be according to the
preference of the patient. Ideally, the emollient of
choice should be dispensed with pump dispensers. If
the emollient is in a pot or jar, the required amount
should be removed with a clean spoon or spatula.
Fingers should not be inserted into pots, to prevent
contamination. Emollients should not be shared with
others. The patient is advised to use emollient liberally
and frequently as and when the child feels dry and
itchy. It is particularly important to use emollient
immediately following bathing and soft pat drying. The
products of choice have to be applied just sufficient
enough to smear the skin, in the general direction of
growth of body hair, to prevent folliculitis.[7]
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Criton and Gangadharan: Nonpharmacological management of atopic dermatitis
The cost of high‑quality emollient therapies often
restricts its use. Hence, in resource‑poor settings, the
use of any vegetable oil of patient preference can be
encouraged. The patient may be advised to apply
warmed vegetable oil for 10‑15 min before bathing
and frequently thereafter.[17]
Wet Wrap Therapy
Wet wrap therapy is a relatively safe and effective
intervention in atopic dermatitis. It is a treatment
modality using a double layer of tubular bandages or
gauze, with a moist first layer and a dry second layer.[18]
Despite this general definition, there is considerable
variation in methodology across various centers, in
the topical products and bandages used, occlusion
time, and the treatment duration.[18‑23] Wet wrap
therapy increases the penetration of topical agent by
occlusion, decreases TEWL, has a soothing effect, and
provides a physical barrier against scratching. Except
for occasional adverse effects such as discomfort,
chills, folliculitis, and other minor skin infections,
wet wrap therapy can be considered a safe short‑term
intervention in atopic dermatitis.[22]
Recommendation
The conventional wet wrap therapy advocates the
use of topical products with double‑layer bandage
for 3–24 h a day with frequent wetting, claiming
the better efficacy with longer application, though
not proved.[20] However, this is often feasible only
in patient setting. In Amala Institute of Medical
Sciences, we use a modified regimen to circumvent the
disadvantages of this conventional regimen. According
to Amala modification of conventional wet wrap
therapy, we recommend a 2 h wet wrap therapy thrice
daily which includes twice wet wrap with a mid‑potent
topical steroid such as fluticasone propionate cream
and once daily with emollient, and the rest of the time
of the day, the patient is asked to leave the area open
with frequent application of emollient. We have found
this modified regimen to be efficacious in short‑term
management of moderate‑to‑severe atopic dermatitis
and also as a maintenance and proactive therapy. Both
objective and subjective improvement in severity of
atopic dermatitis was noted with minimal to nil side
effects (personal data).
Cleansing and Bathing Recommendations
The patients and family should be advised about
the importance of skin hygiene. Bathing with soap
and water helps to remove the dirt, scale, crust, and
irritants. Besides the primary aim of cleansing skin,
bathing also helps in reduction of the abnormal
bacterial colonization in atopic dermatitis. Moreover,
168 Indian Journal of Paediatric Dermatology | Volume 18 | Issue 3 | July-September 2017
there have been many studies showing improvement
in severity of atopic dermatitis with daily bathing.[23‑25]
Application of emollient after bathing, as a soak and
smear approach, has shown benefit when compared
to bathing without emollients.[18] However, there are
conflicting opinions about the frequency and duration
of bath and the type of cleansing agent to be used.[24,25]
Most soaps available in market are of high alkaline
pH.[26] They adversely affect the skin by increasing
skin pH, impairing the barrier function, altering
skin bacterial flora, desiccating the stratum
corneum, and inducing symptoms of subjective
irritation.[27] Instead, nonsoap‑based surfactants and
synthetic detergents (syndets) are often recommended
for better tolerance although this is based on only a
few supportive clinical studies.[26,27]
Recommendation
The patients should be advised to take bath once or
twice daily for maximum 10–15 min duration. The
recommended temperature of bath is 27°C–30°C,
which is usually the temperature of water which the
child enjoys to play in. Bathing should be a pleasurable
experience for the child. An ideal cleansing agent
is a low pH, hypoallergenic, fragrance‑free agent.
The patient may be advised to use syndet bars or
lipid‑free cleansers. However, based on our personal
observation, we suggest the use of any soap as per the
choice of patient, provided they remain in contact with
the skin for shorter period and produce less lather.
The patient may be advised to use warmed coconut
oil or any other vegetable oil 10–15 min before bath
and the application of the same or any emollient
of choice immediately after bathing and soft pat
drying (personal data). Caution must be taken while
using vegetable oils as these can cause the bathroom
floor to be slippery.
Bleach Bath
Adding sodium hypochlorite or bleach to bath water
has shown to reduce the Staphylococcus aureus counts
and hence the severity of atopic dermatitis and
frequency of its relapses.[28,29] The antimicrobial effect
of bleach is based on the property of hypochlorous
acid to aggregate the essential bacterial proteins.[30]
Recommendation
The patient may be advised to take bleach bath daily
when there is overt infection as evidenced by heavy
crusting and oozing, and then, the frequency may
be reduced to alternate day, twice a week, and once
a week as the condition improves, as a maintenance
treatment, to prolong the remission period. The bleach
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Criton and Gangadharan: Nonpharmacological management of atopic dermatitisj
solution is to be prepared by adding one tablespoon of
household bleaching powder to one liter of water, and
this should be diluted to a bucket of water (20 L).
Care should be taken to ensure that bleaching powder
has completely dissolved in water.
Avoidance Strategies
The course of atopic dermatitis is characterized by
periods of acute worsening (flare) and periods of
quiescence. Identification and avoidance of triggers for
these flares is one of the crucial steps in the long‑term
management of atopic dermatitis, and their avoidance
leads to longer periods of remission. The common
triggers are summarized in Table 1.
Irritants
Numerous factors and substances in the environment
irritate the sensitive skin of atopic dermatitis patients
and can result in flares. They may be physical, such
as mechanic irritants (e.g., wool), chemical (acids,
bleaches, solvents, and water), or biological (microbes)
in nature. Other nonspecific provocative factors which
have been demonstrated to trigger atopic dermatitis
are tobacco smoke or volatile organic compounds
in indoor environments and traffic exhaust in the
outdoor air.[31] Irritability and irritant potential of
these substances differs among patients. Hence,
identification of possible triggers in a particular
patient is important in planning avoidance strategies.
Fabrics
Certain fabrics used as dressings or bedding may
produce worsening of atopic dermatitis. Acute and
cumulative irritation, allergic contact dermatitis,
exacerbation of atopic dermatitis, and contact urticaria
have been reported to have been caused by textile
fibers. Owing to their hygienic properties, fabrics
produced from natural fibers are preferred.
Wool intolerance due to spiky nature of its fibers
is considered characteristic of atopic dermatitis.
Loose‑fitting cotton clothing is the most suitable in
tropics, due to its wide availability, better conduction
of heat and excellent moisture absorption. However,
recent studies have suggested that damp absorption
and transfer occur by extension and contraction of the
single cotton fibers producing a movement that may
Table 1: Potential trigger factors in atopic dermatitis
Irritants, for example, soaps, detergents, and harsh fabrics
Skin infections
Aeroallergens
Contact allergens
Food allergens
Psychosocial stressors
Indian Journal of Paediatric Dermatology | Volume 18 | Issue 3 | July-September 2017
irritate and scratch the skin. Silk, on the other hand,
has a perfectly smooth fiber, does not cause friction
or irritate skin. Silk also helps to maintain the body
temperature, by reducing the excessive sweating and
moisture loss that can worsen xerosis.[32‑34] Special
type of fabrics such as anion textiles, modified silk
fabrics with elastic fibers and antibacterial properties,
and silver‑coated fabrics are also being investigated for
their suitability in atopic dermatitis. But so far, there
is no strong evidence to support its use.
Recommendation
Loose‑fitting cotton or silk fabrics are more suitable
for patients with atopic dermatitis. Too occlusive
clothing inducing heat sensations should be avoided.
[17,35]
 If patient wants to use wool, they may be advised
to use cotton inner clothes before wearing wool. There
is limited evidence to support the use of specialized
clothing fabrics in the treatment of atopic dermatitis.
Detergents and Other Chemicals
Detergents or washing powders are a frequently
attributed triggering factor by mothers. However, till
now, there is no conclusive evidence for the same.
Recommendation
The use of specific laundering techniques, such as
double rinsing, detergents, or other laundry products
such as fabric softeners is not recommended for atopic
dermatitis management because of the lack of clinical
studies. However, the mothers may be advised to
use enzyme‑free washing powders and also to ensure
that the detergent powder is rinsed off completely
from the clothing, for which double rinsing may be
useful. There is often a concern regarding the use of
chlorinated swimming pools. Children with atopic
dermatitis should not be discouraged from swimming.
The children may be advised to apply emollient before
entering pool, shower well after swimming and reapply
emollient to skin immediately.[35]
Aeroallergen
Aeroallergens are airborne proteins associated
predominantly with allergic reactions in the respiratory
tract associated with asthma and rhinoconjunctivitis.
The common aeroallergens include house dust mite,
animal dander (cat and dog), molds, and pollen
(allergens whose routes of exposure are primarily the
respiratory epithelia and skin). Inhalant allergy is
suspected in a child with atopic dermatitis associated
with asthma or allergic rhinitis, having seasonal
flares with lesions in the airborne distribution.
There will be characteristic improvement of eczema
when hospitalized or removed from the particular
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Criton and Gangadharan: Nonpharmacological management of atopic dermatitis
environment. Confirmation of diagnosis is by atopy
patch test along with skin prick test (SPT) and
radioallergosorbent assay.[36]
House Dust Mite
Most common airborne allergens eliciting eczema
are derived from house dust mites of the species
Dermatophagoides pteronyssinus and Dermatophagoides
farinae. Their principal habitat is fomites and their diet
consists of human epidermal scale, animal dander, and
micronutrients.[37] They are found in carpets, fabric,
pillows, and mattresses.
Recommendation
Removal of dust reservoirs such as heavy curtains,
carpets, and soft toys is advised. Regular vacuuming
and/or wet mopping with special attention to corners
and crevices should be done accordingly. The bed
clothes and soft toys should be washed in hot water
(>55°C) and left in sun for drying. A reduced ambient
humidity (<50%) should also be advised.[37]
Allergen‑specific immunotherapy with house dust
mite allergens has shown positive effects in highly
sensitized atopic dermatitis patients.[38] It aims to
induce allergen‑specific tolerance otherwise known
as allergen vaccination through acquiring immune
tolerance with induction of allergen‑specific regulatory
T‑cells (Tregs). The effectiveness of allergen‑specific
immunotherapy has been proved in several trials, but
a consensus protocol and its application in clinical
setting are not clear.[38,39]
Molds and Fungi
Mold exposure in damp indoor environment with poor
air circulation has been found to be associated with
increased eczema risk. Alternaria alternata, Aspergillus
fumigatus, and Cladosporium herbarum are the common
molds implicated as aeroallergens.
Recommendation
Avoidance of damp environment, repair of leaks,
and removal sources of damp should be advised. Use
heating in the winter and air conditioning in summer,
ensuring good air circulation. Any contaminated area
should be cleaned with bleach solution to prevent
growth of mold.[39]
Animal Dander
Many patients are already aware that contact with
animals is leading to a deterioration of the skin
symptoms. Once a patient is sensitized and allergic to
a pet, avoidance is absolutely necessary. Pet removal,
pet washing, and usage of high‑efficiency particulate
170 Indian Journal of Paediatric Dermatology | Volume 18 | Issue 3 | July-September 2017
filters are the recommended avoidance strategies. Cat
epithelia exposure is regarded by most authors as a risk
factor, so it should be avoided. There is no evidence
that dogs increase the risk of atopic dermatitis in
children.[8,37]
Pollen
Pollen in the outdoor air can elicit flares of atopic
dermatitis. Seasonality of disease severity is often a
clue to pollen allergy.[37,40] However, pollen avoidance
is difficult under everyday conditions in most parts
of India except when air conditioning with pollen
filters is used in the indoor. However, we may advise
such patients to use mask and nose plugs when going
outdoors.
Food Allergy
A commonly implicated and misunderstood concept
in atopic dermatitis is food allergy, often resulting
in improper elimination diets and thus leading to
malnutrition. Avoidance of a particular food should
be advised only based on a clear history and diagnosis
of food allergy. The common food allergens are cow’s
milk, egg, wheat, soy, and peanut.
A diagnosis of food allergy should be considered
in children with atopic eczema who have reacted
previously to a food with immediate symptoms such
as urticaria and anaphylaxis or in infants and young
children with moderate or severe atopic eczema that
has not been controlled by optimum management,
particularly if associated with gut dysmotility or failure
to thrive. Sensitizations to food can be identified by
means of in vivo tests (SPT and atopy patch test) and
in vitro tests (serum‑specific IgE). The double‑blind
placebo‑controlled food challenge is considered the
gold standard for diagnosing food allergy.[7,35]
Recommendation
If there is consistent correlation of symptoms, a
diagnostic elimination diet for up to 4–6 weeks with
the suspected food item may be initiated. If the
individual’s atopic dermatitis remains stable or even
increases in severity, it is unlikely that the food is
a relevant atopic dermatitis trigger and additional
testing is not necessary. If there is an improvement
of the symptoms during a diagnostic elimination diet,
an oral food challenge should be considered ideally.
Children <5 years of age with moderate‑to‑severe
atopic dermatitis should be considered for food allergy
evaluation if they have persistent atopic dermatitis in
spite of optimized treatment or they have a reliable
history of immediate reaction after ingestion of a
specific food.[41]
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Criton and Gangadharan: Nonpharmacological management of atopic dermatitisj
In a setting where the food allergy testing is not
available, if there is a reliable history of food allergy,
it is advisable to avoid that particular food and
rechallenge may be done with all necessary precautions
2 weeks after complete recovery. If there is recurrence
of symptoms, that particular food is to be avoided.
Furthermore, any misconception about food allergy
should be addressed and diet may be planned with the
help of a dietician wherever necessary.
Contact Allergens
The most common contact allergens in patients with
atopic dermatitis include nickel, neomycin, fragrance,
formaldehyde and other preservatives, lanolin,
and rubber chemicals.[42,43] Patch testing should be
considered in cases suggestive of allergic contact
dermatitis, such as disease aggravated by topical
medications or emollients or patterns that reflect
application of, or exposure to, a consistent item, such
as marked facial and/or eyelid involvement, increased
severity at the flexures of the neck, and vesicular lesions
on the dorsal surfaces of the hands and fingertips.
Testing may also be considered where there is an
unusual and atypical distribution of lesions of atopic
dermatitis (e.g., on the sides of the feet), if there is
later onset of disease or new significant worsening, if
there is no family history of atopy, and in patients with
persistent/recalcitrant disease that has not responded
to standard atopic dermatitis therapies.[42]
Psychological Interventions
There is no other disease which exemplifies the psyche
skin interaction, better than atopic dermatitis. The
finding that psychological stress can alter permeability
barrier homeostasis and stratum corneum integrity,
justifies the reported exacerbation of atopic dermatitis
in 30% patients following stressful situations.[44‑46]
The initiation or exacerbation of atopic dermatitis is
manifested by its characteristic symptom of itch, which
is rewarded by the conscious subjective response of
scratch. The initial relief of itch by scratching later on
leads to lowering of itch threshold and perpetuation
of the itch‑scratch cycle resulting in maintenance
of skin lesions. In due course of time, the conscious
response of scratch becomes an unconscious act or a
habit of scratching without genuine stimulus of itch.
Thus, in a patient with atopic dermatitis, scratching
may be due to true itching sensation or out of habit.
The psychological intervention and behavioral
therapy in atopic dermatitis are aimed at breaking this
itch‑scratch cycle.[47,48] Hence, successful management
of atopic dermatitis requires a team effort including a
dermatologist and sensitized psychiatrist or a trained
child psychologist.
Indian Journal of Paediatric Dermatology | Volume 18 | Issue 3 | July-September 2017
Furthermore, atopic dermatitis is found to be
associated with attention deficit hyperactivity
disorder, depression, anxiety, and sleep disturbances.
The impact of atopic dermatitis on the quality of life
of patient and caregiver is also well documented.[49]
Recommendation
The basic step in habit reversal behavioral therapy is
counseling of the patient to make the unconscious
habitual act of scratch conscious, by guiding the patient
to register each act of scratch. Once this is achieved,
the patient is trained on steps to avert scratching such
as clenching the fist and counting to 10 or pinching
the area of itch. This can only be achieved by regular
visits, encouragement, and counseling. For younger
children, their parents are to be actively involved
in habit reversal therapy, and the child should be
under supervision day and night. Parents are advised
not to reprimand the child from scratching, but
instead, a positive approach is undertaken to avoid
the circumstances when the child usually scratches.
The child should not be allowed to watch television
alone. While dressing, undressing, and bathing,
the child’s hands should be kept busy and the child
should be talked to in order to divert attention from
scratching. Once this routine is accomplished for a
few days, the habitual itch gets under control, thus
breaking the itch‑scratch cycle.[49]
Depending on need as assessed by a trained psychiatrist,
various other techniques such as stress management,
role play, and relaxation techniques can also be
implemented. Stress management psychotherapy
includes a counseling intervention focusing on atopic
dermatitis perception and related conflicts such
as disfigurement, feelings of rejection from others,
anxiety, and aggression related to itch‑scratch patterns.
These psychotherapies aided patients or their parents
in realizing atopic dermatitis‑related problems and
restructuring their thinking patterns, thereby reducing
the intensity of stress. Thus, the most effective
psychological intervention will be a combination of all
these techniques catered to the need of a particular
patient.[48,49] Hence, a close liaison with a psychologist
or psychiatrist well versed in psychotherapeutic
procedures will aid in control of atopic dermatitis and
maintenance of its remission.
CONCLUSION
As a caregiver for a chronic relapsing condition affecting
the formative years of childhood, dermatologist is in a
unique position to help the child fulfill their social and
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Criton and Gangadharan: Nonpharmacological management of atopic dermatitis
developmental potential. This can only be attained
by expanding our care to holistic proportions. The
nonpharmacological management of atopic dermatitis
is distinctly relevant in this regard.
Financial Support and Sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
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