'Wet wrap' dressings for eczema: an effective treatment but not to be misused

Moisturizing effect of skin patches with hydrophobic and hydrophilic electrospun fibers for atopic dermatitis

Atopic dermatitis (eczema), one of the most common disease and also most difficult to treat, is seeking for novel development not only in medicine but also in bioengineering. Moisturization is the key in eczema treatment as dry skin triggers inflammation that damages the skin barrier. Thus, here we combine electrospun hydrophobic polystyrene (PS) and hydrophilic nylon 6 (PA6) with oils to create patches helping to moisturize atopic skin. The fibrous membranes manufactured using electrospinning: PS, PA6, composite PS - PA6 and sandwich system combining them were characterized by water vapor transmission rates (WVTR) and fluid uptake ability (FUA). To create the most effective moisturizing patches we use borage, black cumin seed and evening primrose oil and tested their spreading. We show a great potential of our designed patches, the oil release tests on a skin and their moisturizing effect were verified. Our results distinctly reveal that both fiber sizes and hydrophilicity/hydrophobicity of polymer influence oil spreading, release from membranes and WVTR measurements. Importantly, the direct skin test indicates the evident increase of hydration for both dry and normal skin after using the patches. The electrospun patches based on the hydrophobic and hydrophilic polymers have outstanding properties to be used as oil carriers for atopic dermatitis treatment.

Nano- and Microfiber PVB Patches as Natural Oil Carriers for Atopic Skin Treatment

Atopic dermatitis (eczema) is a widespread disorder, with researchers constantly looking for more efficacious treatments. Natural oils are reported to be an effective therapy for dry skin, and medical textiles can be used as an alternative or supporting therapy. In this study, fibrous membranes from poly(vinyl butyral-co-vinyl alcohol-co-vinyl acetate) (PVB) with low and high molecular weights were manufactured to obtain nano- and micrometer fibers via electrospinning for the designed patches used as oil carriers for atopic skin treatment. The biocompatibility of PVB patches was analyzed using proliferation tests and scanning electron microscopy (SEM), which combined with a focused ion beam (FIB) allowed for the 3D visualization of patches. The oil spreading tests with evening primrose, black cumin seed, and borage were verified with cryo-SEM, which showed the advantage nanofibers have over microfibers as carriers for low-viscosity oils. The skin tests expressed the usability and the enhanced oil delivery performance for electrospun patches. We demonstrate that through the material nano- and microstructure, commercially available polymers such as PVB have great potential to be deployed as a biomaterial in medical applications, such as topical treatments for chronic skin conditions.

Wet-wrap treatment in children with atopic dermatitis: a practical guideline

Treatment of children with severe atopic dermatitis (AD) can be especially challenging because several possible intervention treatments have (relative) contraindications in childhood. In recent years, wet-wrap treatment (WWT) has been advocated as a relatively safe and efficacious intervention in children with severe or refractory AD. The goal of this article is to provide a practical guideline as a starting point for clinicians who are interested in using WWT in their own clinical practice. We will address several practical issues surrounding the use of WWT by describing our own experiences, supplemented with data from the literature.

Management of itch in atopic dermatitis

Atopic dermatitis is a common, pruritic, inflammatory skin disorder. Chronic, localized, or even generalized pruritus is the diagnostic hallmark of atopic dermatitis, and its management remains a challenge for physicians. The threshold for itch and alloknesis is markedly reduced in these patients, and infections can promote exacerbation and thereby increase the itch. Modern management consists of anti-inflammatory, occasionally antiseptic, as well as antipruritic therapies to address the epidermal barrier as well as immunomodulation or infection. Mild forms of atopic dermatitis may be controlled with topical therapies, but moderate-to-severe forms often require a combination of systemic treatments consisting of antipruritic and immunosuppressive drugs, phototherapy, and topical compounds. In addition, patient education and a therapeutic regimen to help the patient cope with the itch and eczema are important adjuvant strategies for optimized long-term management. This review highlights various topical, systemic, and complementary and alternative therapies, as well as provide a therapeutic ladder for optimized long-term control of itch in atopic dermatitis.

Treatment of patients with atopic dermatitis using wet-wrap dressings with diluted steroids and/or emollients. An expert panel's opinion and review of the literature

BACKGROUND

The use of dampened bandages to reduce inflamed eczema (synonyme dermatitis) is an old remedy. In order to evaluate the current indications for so-called wet-wrap treatment (WWT) for atopic dermatitis (AD), and to compare the different currently recognized methods, a group of experts critically reviewed their own expertise on WWT in respect to the existing literature on the subject.

RESULTS

WWT is well tolerated in eczema due to the cooling effect on the skin and the rapid improvement in skin inflammation. It has been shown to be an extremely effective treatment for acute erythrodermic dermatitis, therapy-resistant AD and intolerable pruritus. Advantages of WWT include rapid response to therapy, reduction in itch and sleep disturbance, and potential for reduction in usage of topical corticosteroids (TCS). However, disadvantages include high cost, the necessity for special training in usage, potential for increased TCS absorption, increased cutaneous infections and folliculitis, and poor tolerability. Precautions to reduce the risks of long-term treatment should include education, monitoring of weight and height and, if necessary, serum cortisol levels. In adolescents the risk of striae from TCS absorption around puberty is high, and WWT with TCS in this age group should be used as a short-term therapy only and with extreme caution. To reduce risks, dilutions of steroids may be used ranging from 5 to 10%. In the maintenance phase this treatment can be rotated with the use of emollients only. Low potency TCS should be used on the face (with a mask).

CONCLUSION

WWT using diluted steroids is a relatively safe addition to the therapeutic treatment options for children and adults with severe and/or refractory AD. Explanation and education is extremely important in the treatment of AD and WWT should only be employed by practitioners trained in its use. Specialized nursing care is essential, especially when using WWT for prolonged periods.

Efficacy and safety of ‘wet-wrap’ dressings as an intervention treatment in children with severe and/or refractory atopic dermatitis: a critical review of the literature

BACKGROUND

During the last two decades wet-wrap treatment (WWT) has been advocated as a relatively safe and effective treatment modality in children with severe and/or refractory atopic dermatitis (AD). Unfortunately, there are still many unsolved issues concerning the use of wet-wrap dressings in patients with AD.

OBJECTIVES

To make an inventory of the different methodologies and to evaluate the currently available evidence for the use of WWT as an intervention treatment in children with severe and/or refractory AD.

METHODS

We performed a search of the literature via the online PubMed database. Reference lists from relevant articles were scanned for additional publications. Publications describing a treatment modality for children with severe and/or refractory AD, which included the application of wet dressings, were collected and evaluated using the guidelines of the NHS Centre for Reviews and Dissemination, University of York.

RESULTS

Twenty-four publications were included for evaluation. Eleven of the publications detailed original clinical studies (study design level 2-4), while 13 revealed expert opinions (study design level 5). Evidence levels did not exceed level 4.

CONCLUSIONS

Large prospective studies evaluating the efficacy and safety profile of WWT are lacking. We were able to formulate the following conclusions with a grade C of recommendation. (i) WWT using cream or ointment and a double layer of cotton bandages, with a moist first layer and a dry second layer, is an efficacious short-term intervention treatment in children with severe and/or refractory AD. (ii) The use of wet-wrap dressings with diluted topical corticosteroids is a more efficacious short-term intervention treatment in children with severe and/or refractory AD than wet-wrap dressings with emollients only. (iii) The use of wet-wrap dressings with diluted topical corticosteroids for up to 14 days is a safe intervention treatment in children with severe and/or refractory AD, with temporary systemic bioactivity of the corticosteroids as the only reported serious side-effect. (iv) Lowering the absolute amount of applied topical corticosteroid to once daily application and further dilution of the product can reduce the risk of systemic bioactivity.

A randomised study of "wet wraps" versus conventional treatment for atopic eczema

AIMS

To compare two treatments in common usage for children with atopic eczema: "wet wrap" bandages versus conventional topically applied ointments.

METHODS

A total of 50 children (age 4-27 months) with moderate to severe eczema were randomised to one or other treatment. Two research nurses supervised the study. The first gave advice and support, and the second, blinded to the treatment modality being used, scored the change in eczema severity over a period of four weeks using the SCORAD eczema severity scale.

RESULTS

Both treatments gave a benefit in overall SCORAD scores (mean change for wet wrap group was 53 to 24; for the conventional group, 41 to 17). There was no significant difference between the two groups in terms of overall improvement at four weeks or in the timescale of improvements. The amount of topical of topical steroid used was similar in both groups. The wet wrap group suffered significantly more skin infections requiring antibiotics. Carers reported that wet wraps were less easy to apply than conventional treatment.

A pilot study on the use of wet wraps in infants with moderate atopic eczema

Wet wrap therapy (WWT) is a well-established treatment for severe atopic dermatitis (AD). However little evidence exists to justify widespread use in the community for less severe eczema. We compared the efficacy of WWT with a standard regime of hydrocortisone, to control moderate AD in children. We carried out a single-observer, randomized, controlled pilot study in 19 children under 5 years of age, with AD of 30% or more body surface area, using only 1% hydrocortisone (HC) prior to the study. Group one applied HC once in the morning for 2 weeks, with wet wraps twice daily for week 1, but only at night for week 2. Group two applied HC twice daily without wet wraps. Both applied emollient twice daily and as necessary. The primary outcome measure was the Six Area, Six Sign Atopic Dermatitis (SASSAD) severity score, and the secondary outcome measures were the Infants Dermatology Quality of Life Index (IDQOL), the Dermatitis Family Impact (DFI) score and the weight of topical steroids and emollients used. Over the 2-week active therapy period the mean fall in SASSAD was 8 [95% confidence interval (CI), -18 to +2; P = 0.11] more in the non-WWT group, the median change in the IDQOL was 2 for Group one and 7 for Group two (95% CI for difference, -10 to +3; P = 0.24) and the median change in DFI score was 2 for Group one and 5 for Group two (95% CI for difference, -14 to +2; P = 0.42). This small study has shown that conventional therapy with HC and emollients alone is as effective as WWT for infants with moderately severe, widespread AD, and provides weak evidence to suggest that it may be more effective. We would not advocate routine use of WWT for moderate eczema without further evaluation.

[Topical corticosteroids]

Therapeutics in dermatology underwent complete change after the introduction of topical hydrocortisone in the Fifties. At the time, stronger derivatives than hydrocortisone were synthetised and the indications for topical corticosteroids were expanded. Around twenty different molecules, classified according to their strength, are currently available for prescription in France. Many inflammatory or tumoral skin diseases respond to these products. The choice of a topical corticosteroid (strength, vehicle.) and of its mode of application (technique, rhythm of application) is oriented by the context (dermatitis treated, localization) and must respect "Good clinical practice" guidelines so as to select the best benefit/risk ratio.