France — Atopic dermatitis is the focus of various mistaken beliefs held by patients or parents of children with this skin disorder. What’s more, this has a direct impact on the implementation and successful execution of effective treatment. Many treating physicians notice a gap between their medical knowledge and the common misconceptions of their patients. But sometimes it may be beneficial for specialists to question their own understanding of the disorder.
Medscape French Edition took stock of the situation with Isabelle Dreyfus, MD, clinical pharmacist at the Reference Center for Rare and Complex Genetic Skin Diseases and Syndromes in the Dermatology Department of Larrey Hospital in Toulouse, France, who addressed this topic of current interest at the 17th Francophone Congress of Allergology.
Medscape French Edition: Do patients’ common misconceptions and beliefs hinder the proper treatment of atopic dermatitis?
Dreyfus: There are, in fact, many mistaken representations and beliefs that interfere with proper execution of treatment, especially for mild and moderate forms in children. I would go so far as to say that there are few chronic childhood conditions that are surrounded by so many prejudices. Even the origin of the condition is the subject of a very frequently encountered misconception. Many parents actually believe that their child’s skin condition is associated with a food allergy. Sometimes they have changed the child’s milk two or three times before consulting a physician.
In medicine, atopic dermatitis is a chronic condition with a polygenic origin. It develops in a genetically predisposed individual and is brought on by a trigger or an aggravating factor, such as the use of soaps, detergents, or perfume, or an innate and adaptive immunodeficiency. This complex disorder is only very rarely associated with an allergy. But because parents are convinced of the food origin of eczema, they have trouble adhering to treatments based on local care, namely, application of anti-inflammatory topical corticosteroids on lesions and emollient creams to prevent dryness. Additionally, they consider the development of flare-ups proof that the treatments are ineffective, and this feeds their reluctance regarding the use of topical corticosteroids.
Medscape: How do you explain the persistent corticosteroid phobia?
Dreyfus: Several factors contribute to corticosteroid phobia: irrational fears and incorrect messages spread by the media, the internet, or close friends and family, but also ignorance regarding the side effects of the treatment. Topical corticosteroids are often confused with oral cortisone. Some parents fear potential side effects with topical corticosteroids, such as those possibly experienced with oral cortisone, like swelling of the face, impact on adrenal glands, or growth disorders. Ironically, they are often not reluctant to follow the prescribing instructions for 1 week of prednisolone for bronchitis. It should be noted that the impact of side effects is negligible with topical corticosteroids. For topical corticosteroids, 1 year of continuous treatment over the entire body is considered the equivalent of 1 week of treatment with oral corticosteroids. I also think the reluctance can be explained by uncertainty regarding the length of treatment and the amount of cream to apply. It is important for the prescribing physician to provide a demonstration.
Medscape: How might physicians themselves be feeding corticosteroid phobia?
Dreyfus: Surveys clearly show, quite logically, that medical studies reduce corticosteroid phobia. But physicians may need to question the way they present things, and especially to be aware that they sometimes use restrictive or negative terms that increase corticosteroid phobia in their patients. An example of a phrase to avoid is, “If absolutely necessary, place a tiny amount on highly inflamed lesions.” I have deliberately exaggerated, of course, but you can plainly see how each of the expressions “tiny amount,” “absolutely necessary,” and “highly inflamed lesions” might feed doubt. “Tiny amount” alone is troubling to a worried patient.
Medscape: Do patients tend to turn to do-it-yourself treatments?
Dreyfus: Absolutely. The search for alternative treatments stems from corticosteroid phobia. For example, we see patients turn to hypnotists or fire healers. The main risk is that effective management will be delayed. Essential oils, which are relatively allergenic, or home remedies, which are relatively eccentric, such as rubbing half a lemon over the lesions or keeping a green clay poultice on all night, can themselves exacerbate the situation. There is a risk of triggering contact eczema. It should be noted that patients with atopic dermatitis become hypersensitive very easily. The negative side of home remedies is that they can be quite harmful. As for vegetable oils, whether almond oil or olive oil, they are often mistakenly used in place of emollients. But although they do have an occlusive effect like emollients, they do not treat dry skin.
Medscape: What position should physicians take in the face of mistaken beliefs?
Dreyfus: The golden rule is to address the error with the patient without being curt or judgmental. Patients need to be able to state on their own the pitfalls of the “treatment” they have implemented. In other words, the patient will end up saying that it doesn’t work. Even in cities, nothing prevents physicians from adopting an educational approach. Physicians can use a board with hypothetical images to show their patients what is happening in their skin. They should explain their prescription clearly and show the amount of cream to be applied and where to apply it so that patients will be fully able to repeat the procedure at home. It can be reassuring to remind patients that topical corticosteroids work very quickly and provide rapid relief.
This article was translated from the Medscape French edition.
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