INTRODUCTION
Atopic dermatitis (AD) is the most common inflammatory skin disease in childhood and affects about 20% of children in the industrialized world. Our current understanding of the pathophysiology has shown that the disease represents a complex interplay of genetic, immunologic, metabolic, infectious, and environmental factors. Over the past decade, research has particularly focused on the defective skin barrier due to a genetic mutation in fillagrin, an integral structural protein of the epidermis. Affected individuals are more prone to increased transepidermal water loss (TEWL) via the epidermis, increased penetration of sensitizing agents resulting in inappropriate stimulation of the immune system, and increased loss of natural moisturizing factor. In addition, the resulting T-helper 1 (Th1)/T-helper 2 (Th2) imbalance of the immune system promotes a hyperreactivity of the skin that is clinically manifest in various forms of dermatitis, and the lack of defensins as major players of their innate immunity leaves patients more susceptible to skin infections. It is increasingly evident that our treatment efforts need to focus on the correction and reversal of these pathophysiologic mechanisms. New studies to support this claim are underway and this article will present some of the latest data.
Numerous moisturizers and so-called barrier creams aim at the restoration of the compromised skin barrier function. This has been identified as key to minimizing progression of the “atopic march†and evolution into further atopic disorders such as asthma, allergic rhinitis, and eosinophilic esophagitis. The search for safe and efficacious agents has led to renewed interest in natural ingredients that have been known and trusted as “home remedies†for centuries. From among these ingredients, oatmeal, feverfew, chamomile, aloe vera, licorice, and dexpanthenol deserve particular citation because they have recently been researched more thoroughly and are considered safe and effective for various skin conditions. However, in contrast to previous experience based solely on observation and heresay, our current knowledge of these agents and their pharmacologic mechanism is based on sound scientific research and clinical studies. Based on controlled clinical data and reproducible pharmacologic compounding, these agents have been catapulted from their traditional use into modern medicine.
While topical corticosteroids remain the mainstay of anti-inflammatory treatment, and their judicious use has been shown to be both efficacious and safe, their continuous, sometimes daily, use over months raises concerns, particularly in the pediatric age group. Caregivers often shy away from the appropriate duration and intensity of required treatment due to widespread fear of side effects of topical steroids and widespread steroid phobia. Topical calcineurin inhibitors offer a second line treatment approach, but are not US Food and Drug Administration (FDA)-approved for children under 2 years of age. Their use raises concerns in parents, given the “black box†warning that remains active even after the recent FDA review of use data over the past 10 years.
The search for alternative options has rekindled the interest in natural ingredients as adjunct treatment for AD. Recent data have further corroborated that the properties of these “new naturals†reach well beyond their moisturizing effects. They are increasingly valued in modern dermatology for their additional anti-inflammatory, anti-pruritic, and skin-protectant properties.
