Chapter 4. Avoidance of Irritants
Patients with atopic dermatitis have a lowered threshold of responsiveness to irritants which can act as non-specific triggers contributing to chronic inflammation. Thus, avoidance of irritants is part of fundamental skin care. Loose fitting, non-coarse clothing can soothing, as even air on open skin can be a precipitant of pruritus in atopic individuals. Cotton gloves or socks can be used as a barrier against a number of irritants and are also useful in decreasing trauma to the skin due to scratching.
Although soaps and detergents can be significant irritants, total avoidance may be impractical and unnecessary. In fact, cleansers may be useful, especially in patients with frequent skin infections. Current recommendations include using cleansers with minimal defatting activity and a neutral pH. Commercial soaps may contain, in addition to surfactant, a number of additives including optical whiteners, suds-controlling agents, germicidal agents, perfumes, abrasive agents and dyes. Of these, perfumes and dyes frequently contribute to skin irritation. Perfume- and dye-free products are often identified as "sensitive skin formulations" and may be better tolerated by patients with atopic dermatitis. In a comparative study of 18 soaps and cleansers using a chamber test, Dove® was found to be the mildest with respect to erythema, scaling, and fissuring. Alcohol and astringents in skin care products can be drying and their use should be minimized. Use of a liquid, rather than powder detergent can result in more complete rinsing or adding a second rinse cycle may facilitate removal of residual detergent. Caregivers should be instructed to wash any new clothing prior to use to remove formaldehyde or other chemicals.
While caregivers and patients are often told to avoid swimming in pools, such activity can in fact be beneficial to some patients. It is important, however, to point out the need to shower using a gentle cleanser afterwards to effectively remove the chlorine or bromine rather than simply rinsing off and then apply a moisturizer. Although ultraviolet rays in sunlight have some beneficial activity in atopic dermatitis, they can cause photodamage and sunburn.
Caregivers and older patients need to be educated regarding the risks and benefits of natural sunlight and proper use of sunscreens. Sunscreens made specifically for the face are often the ones best tolerated by patients with atopic dermatitis.
Environmental factors that can contribute to skin irritation include temperature, humidity and texture of fabrics. Patients tend to do better in air- conditioned or temperate environments that minimize sweating. Sun exposure can lead to overheating, evaporation and perspiration, all of which can contribute to skin irritation. Loose-fitting cotton or cotton blend clothing should be used to prevent overheating. The two most important qualities of fabrics may be non-abrasiveness and breathability, and many blended fabrics are well-tolerated.