Long-term Management Strategies for AD, Melasma, and More

Protecting the Barrier in Adult Atopic Dermatitis

“I still think it’s so important to remember topical fundamentals,” says Peter Lio, MD. Skin barrier dysfunction is a feature of AD, whether genetically mediated or secondary to inflammation. “We have to protect, and moisturizing is the best way to do that.”

In an interview for DermTube Journal Club, he notes, “One of the hottest topics topically right now is thinking about the role of microbiome on the skin and what is happening in atopic dermatitis before a flare, during a flare, and after a flare. Can we rebalance that bacteria to get things back in harmony?”

He advocates for the use of eczema action plans for both acute and long-term management.

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Caution After Hyperpigmentation

Be conservative when it comes to treating hyperpigmentation, warns Heather Woolery-Lloyd, MD. “It’s better to have to do two or three extra procedures to get the desired benefit than to be too aggressive at the beginning and get unwanted side effects,” she says.

Patients with darker skin types, and especially those with a history of hyperpigmentation, need not avoid cosmetic interventions. “We actually have now a lot of options for darker skin types and patients with skin of color. The things we want to stay away from are the ablative lasers and really anything at aggressive settings,” Dr. Woolery-Lloyd says. Microneedling is an “excellent option with a good safety profile,” for acne scarring in darker skin types, she adds.

When it comes to melasma, patients should think of it as a chronic condition. “There is no ‘quick-fix’ that gets rid of melasma forever,” Dr. Woolery-Lloyd says. Sunblock and sun avoidance are foundational, she notes, indicating that patients with near-clear skin can reverse treatment benefits with just a brief period of sun exposure.

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Getting Beyond Delusions of Parasitosis

When patients present with delusions of parasitosis, it’s important to try to understand the patient’s concerns. “They’ve often been mocked, rejected, dismissed,” by other clinicians, says Richard G. Fried, MD. “The first thing is to accept their complaint.”

“If we can say to them in a compassionate, non-judgmental way, we understand it, we know how to fix it, and we have no difficulty whatsoever in working with you, often at that point they are engaged enough that you can move forward.”

Pimozide has many benefits for delusions of parasitosis. It’s not indicated for psychosis—beneficial if patients research it, Dr. Fried says. It has a stabilizing effect on nerve endings, antipruritic effects, and antimicrobial effects, all of which may be beneficial for delusions of parasitosis, he notes. He also recommends 15mg or 18mg of ivermectin, in case there is a true mite infestation.

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Assess Allergic Comorbidities for Long-term AD Control

Adult atopic dermatitis can differ from pediatric AD in terms of morphology, observes Jonathan Silverberg, MD. Head and neck and hand involvement seems to be more common in older patients, leading to suspicion for contact dermatitis.

Increasing attention is focusing on comorbidities associated with atopic dermatitis. “These can be very important from a therapeutic decision-making standpoint. Allergic comorbidities are not only more common in atopic dermatitis but can also feed directly in to the atopic dermatitis and flare it up,” Dr. Silverberg says. Attention to the management of comorbidities in the acute phase and long-term may help to keep eczema under control.

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High SPF is Essential to Reduce Hyperpigmentation

Patients prone to uneven pigment will always be at risk, says Jeanine Downie, MD. She urges patients to use high SPF daily and to reapply often. Patients need protection from solar radiation and indoor light sources, she says. “Once you wash your face in the morning, you should be putting sunscreen on—just to walk around your house,” she says. SPF help prevent new pigmentary changes and protects against skin cancer.

Growth factors, “are wonderful for brightening and evening out the skin tone and decreasing fine lines and wrinkles and increasing the luminosity of the skin.” She also recommends retinoids.

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