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Beautiful skin for Christmas with CBD

Beautiful skin for Christmas with CBD
Lina Mayorga
Diamond Hemp – The Best Holiday Gift
Hemp is among the most beneficial and versatile plants found in nature. Hemp oil is a powerful natural moisturizer and contains vitamins and other nutrients your skin uses to maintain strength and a youthful glow. Hemp seed oil comes from the seeds of the hemp plant.
I discovered Diamond Hemp recently and I noticed they conducted extensive testing to be certain that all our superior quality hemp-based products meet the highest standards for purity, potency, and freshness. Hemp seeds are used in beauty products to create a multitude of hemp-based skin care products, such as hemp oil soap, cream, lotion, and CBD oil for skin care. Hemp is non-toxic and contains a high level of CBD which makes hemp ideal as a base for beauty products.
Taking care of our skin today can prevent problems in the future such as wrinkles and skin cancer. However, we are often unsure of what products to use for skin protection. Many users have identified benefits of hemp oil for skin care. Hemp or cannabidiol oil is obtained from pressed hemp seeds taken from the hemp plant. Hemp oil has been dubbed asnatures most perfectly balanced oilbecause it contains Omega 3 and Omega 6 fatty acids, which are key ingredients in maintaining the health of your skin.
You deserve to have a beautiful skin for Christmas and your loved ones too. Why not start enjoying the best anti-aging skin care from Diamond Hemp for the Christmas season:
All Hemp products are Non-GMO, organically grown hemp plants are selected by hand. They harvest and dry their fresh picked hemp under optimal conditions taking into account environmental considerations. They work with sustainable hemp farms from Kentucky, Colorado, and Scandinavia. Their Hemp creams and hemp scrubs are a must for your daily routine.
Benefits of Hemp Products:
Hemp oil has numerous health benefits, including those that improve skin health. Its so beneficial for skin health thanks to its nourishing vitamins and moisturizing qualities.
1) Hemp can Slow Signs Of Aging
Hemp oil isn’t just an active ingredient that can be discovered in skin care items. It is high in omega fatty acids and loaded with essential amino acids that help make younger, smoother-looking skin and lower inflammation in the body. Hemp is also rich in antioxidants, hemp seed oil is a powerful anti-aging natural ingredient for smooth wrinkle-free skin. Hemp seed oil helps improves the skins elasticity and water retention in the skins tissues thereby keeping skin supple & youthful. The linoleic acid and oleic acids found in hemp oil cant be produced by the body but can play a crucial role in skin health and anti-aging and firm skin.
2) Hemp can Fight Acne
One of the most effective benefits of hemp seed oil for skin is it can be used to heal and calm acne-prone skin. Hemp has astringent properties balance sebum production of the skin thereby controlling greasy acne-prone skin.
As Hemp oil is Non-comedogenic (will not cause blocked pores), easily penetrating and highly emollient. Hemp oil can also bring down the redness and irritation of acne outbreaks. Over time, it can help eliminate acne by keeping the skin healthy and hydrated. It absorbs quickly and doesnt block the pores, but will actually help the skin balance oil production.
3) Hemp can be a Facial Cleanser
If you deep cleanse your skin with hemp seed oil, it dissolves stale sebum and drives out grime, dirt, and pollution from deep within the pores. To cleanse your face, simply massage a 1 tsp of hemp seed oil on your face for a minute. Next, soak and wring a microfiber washcloth in hot water and dab on your face. Repeat the process three more times, then finally use the washcloth to wipe off excess oil.
4) Hemp can Alleviate Dermatitis
The rich omega 3 & 6 fatty acids in hemp seed oil help alleviate and soothe dermatitis. Using Hemp seed oil for a period of 20 weeks can alleviate common symptoms of dermatitis including itchy skin and dryness.
5) Hemp can Prevent & Improve Psoriasis
Hemp seed oil is very rich in omega six fatty acids and other EHA’s which fight inflammatory skin conditions such as psoriasis. Psoriasis can be linked to the deficiency in omega 6 fatty acids and Hemp seed oil is super rich in omega 6 fatty acids and other EHAs which fight inflammatory skin conditions such as psoriasis. Topical application of hemp seed oil can also be used to moisturize, soothe and calm dried inflamed and itchy psoriasis patches.
6) Hemp can Naturally Moisturize
Hemp seed oil is high in omega acids 3, 6, and 9, all assist to hydrate the skin when used topically. It is likewise a humectant, so it draws moisture to the skin.
Hemp Seed Oil is full of elements that essentially act as food for your skin, leaving it nourished and healthy.
7) Hemp Creams can be Suitable for all skin types
Hemp seed oil is calming and soothing while providing just the right amount of moisture to all skin types.
Those with sensitive skin love how gentle Hemp oil iswidely tolerated by all skin typesand some even use it in their hair, because its so naturally conditioning.
Hemp oil is perfect for most skin types as it can moisturize without clogging your pores. It can even help to balance out oily skin, hydrating it and regulating the skins oil production.
Dryness can also cause your skin to overproduce oil, which in turn, can stimulate acne. Hemp oil can prevent dry skin without clogging pores. This helps reduce acne thats caused by excess oil.
Use of hemp oil
All hemp products raw ingredients meet stringent quality assurance and quality control protocols. Their products are batch tested and guaranteed for purity and potency. They offer label transparency to assure that what is in the product is clearly displayed on the label.
A testament to the purity of the Hemp processes, Supercritical CO2 Extraction is the most gentle approach to manufacturing that best retains the naturally occurring beneficial molecules in the hemp plant.
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Why CBD Massages Are the Best Way to Relax

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Have you heard of CBD?
Chances are that you have over the past year or so, but theres plenty of confusion around what CBD is and whether its actually marijuana. In short, it isnt.
Cannabidiols (CBD) are compounds extracted from the cannabis plant, often the hemp plant, which is part of the cannabis genus. Cannabidiols dont have hallucinogenic properties; its cannabiss other compound, THC, that creates ahigh.”
Instead of creating a high, CBD is packed with some pretty amazing health benefits. In fact, CBD researchers are continuing to uncover its ability to prevent seizures and fight cancer, chronic pain, and depressive illness, including anxiety and PTSD.
RELATED: Top 5 Ways to Reduce Chronic Joint Pain NaturallyCannabidiol (CBD)
The government is legalizing its use across the USA because studies show its valuable effect on the human body. As a result, CBD is rapidly increasing in popularity. Its not one of those flash-in-the-pan trends. CBD is here to stay in the medical and beauty world.
CBD is already extracted from cannabis plants and added to lots of products, from medications to your favorite lip balm. If you havent tried it yet, its worth giving it a goespecially if you have sore muscles, painful joints, or irritated skin.
CBD is available as a pill, tincture, vape, lotion, or oil. Its also being combined with facial care ingredients to produce skincare lines that offer medical benefits alongside beauty ones.
How you choose to use it is up to you, but one of the best ways to experience all its benefits is through skin contactnamely because you can combine it with massage!
Thats rightits time for a CBD-infused massage because you deserve it, and itll boost your well-being. The Benefits of Massage Therapy
Massage therapy is carried out in many forms, including Indian head massage, Swedish massage, sports massage, and reflexology.
Around paid for a massage in 20152016, and that kind of consumer power means something good is going on.
You may already know massage as a blissful way to de-stress and ease aching muscles, but did you know it also has these benefits? It improves blood circulation It stimulates your lymphatic system It can detox your body It boosts skin health It rejuvenates your mind and soul It promotes healing sleep
Whether you pay for a massage from a professional or prefer your own personal space and indulge in self-massage, its packed with feel-good boosters that actively improve your health as well as make you feel heavenly.
Adding CBD oil takes massage to the next levela two-for-one offer worth taking advantage of. Its difficult to massage without an oil or lotion, so why not make it a CBD product and get all the health benefits it offers?
RELATED: Try These 12 Self-Massage Tips to Boost Your Well-being How CBD Products Improve Your Massage Experience
CBD has medicinal benefits because it interacts with the bodys own endocannabinoid systema system we all have that helps regulate sleep, memory, appetite, and the immune system.
Boosting the endocannabinoid system means CBD is able to reduce pain, lower anxiety, and improve skin conditions.
People who play sports and those who have arthritis, anxiety, or eczema can potentially benefit from CBD in a big way.
Heres how: 1. Reduces inflammation
CBD is a natural anti-inflammatory, and using a massage oil or lotion means CBD is applied directly to the painful areas without gastric upsets sometimes caused by painkillers .
Inflammation is thought to triggerand be the result ofcommon diseases we suffer from in the modern world, such as skin disorders, stress, and bowel problems. 2. Reduces chronic pain
Lingering problems from a sports injury or an accident are a real drain on your pocket and spirits, and people with chronic pain, such as arthritis or fibromyalgia, suffer daily.
CBD massage can help manage pain in the long-term without side effects from medication, but make sure your therapist understands your disease first so they go steady with your joints. 3. Improves skin health
CBD oil helps heal up sore, inflamed skin, and it doesnt irritate conditions like psoriasis or eczema so long as the product is pure and doesnt contain chemicals and colorings.
Acne is worsened or even triggered by inflammation, and CBDs ability to dampen inflammation means its a useful acne and spot breakout treatment. It also contains linoleic acid to manage oil production.
Research into CBD has found it doesnt have the side effects that other medication can cause. Whether its skincare or treatment for seizures, CBD is almost side-effect-free, which makes it an attractive option for children and people who are struggling with their current products. 4. Alleviates anxiety and stress
We certainly all experience stress. Massage is a great way to reduce your blood pressure, but when CBD products are used, it boosts stress reduction effects even further.
Studies show that CBD promotes a calming effect on the brain and has a beneficial effect on PTSD, anxiety, and depression .
If your CBD product is infused with essential oilssuch as lavender or frankincense, for exampleits all the better for stress reduction. CBD can be combined with other oils to produce an individual product that suits your well-being needs. Dont Stop at Massage!
CBD brings immense benefits when its used during massage, but you dont have to stop therebecause its an excellent skincare ingredient for your face, too.
Substituting your normal skin cream or balm for one infused with CBD ensures moisturization to fight the signs of aging and delivers plenty of extra well-being benefits. Dry, flaking skin is moisturized and soothed Oily skin is regulated by linoleic acids Pain from acne or spot breakouts, bruising, or overuse is reduced Inflammation is reduced
RELATED: SOL*CBD BalmWhats in It and What Are Its Benefits
You can use CBD as a cleanser, a moisturizer, even a soothing balm-treat all over your body to take advantage of its relaxing, pain-relieving and calming properties. The best part is that there are fewif anyside effects from CBD.
Its worth remembering you wont get high from CBD. THC is the only compound in cannabis thats hallucinogenic. CBD is packed with health benefits, and its bound to be the next big thing in massage, skincare, and health care.
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10 Best Moisturizers With SPF 2018, According to Dermatologists

1 EltaMD UV Clear Facial Sunscreen Broad-Spectrum SPF 46
Amazon amazon.com $33.00 SHOP NOW This oil-free facial sunscreen from EltaMD is a favorite of both Dr. Taub and Dr. Saedi. Ideal for those dealing with acne or rosacea , “it contains niacinamide [a form of vitamin B3], which is an anti-inflammatory that helps calm skin,” says Dr. Saedi. Whats more, it contains hyaluronic acid, an ingredient that acts like a tiny sponge to pull water to the skins surface for a boost in hydration.
2 La Roche-Posay Anthelios Ultra Light Sunscreen Fluid SPF 60
Amazon amazon.com $29.99 SHOP NOW This light, matte formula from La Roche-Posay absorbs into skin quickly, making it an ideal base to apply makeup on top, says Dr. Saedi. “It glides on easily, theres no white film, and it doesnt smell like sunscreen,” she says. Its also pumped with free radical-fighting antioxidants to fight the signs of skin aging, like fine lines and sun spots.
3 Neutrogena Clear Face Liquid Lotion Sunscreen SPF 55
Amazon amazon.com $7.19 Shop Now When you want a budget-friendly pick, Dr. Saedi recommends Neutrogena products for oily, acne-prone skin. This lightweight formula is oil-free, non-greasy, and noncomedogenic, so it wont cause further shine or make existing breakouts feel and look worse.
4 Olay Complete Daily Defense All Day Moisturizer with SPF 30
Amazon amazon.com $24.54 SHOP NOW This moisturizer with SPF from Olay deeply hydrates dull skin without leaving behind a sticky, greasy film. In fact, it feels pleasantly lightweight, doesnt smell of strong fragrances, and is noncomedogenic to prevent breakouts. Soothing aloe teams up with glycerin, niacinamide, and vitamins E, B3, and B5 to moisturize and protect the skin, while SPF 30 fights harmful UVA and UVB rays. Plus, it absorbs quickly, so you wont have to worry about your makeup sliding around.
5 Cetaphil Pro Oil Absorbing Moisturizer SPF 30
Amazon amazon.com $17.99 $14.36 (20% off) SHOP NOW Created specifically for oily skin types, this mattifying moisturizer with SPF from Cetaphil wont break you out or irritate existing acne, since its lightweight, non-greasy, and fragrance-free. Youll still receive broad-spectrum sun protection, as well as much-needed hydration via glycerin (which pulls and locks in moisture) and dimethicone (an ingredient that prevents water loss without clogging the pores).
6 Epionce Daily Shield Lotion Tinted SPF 50
Dermstore dermstore.com $38.00 SHOP NOW Dr. Taub recommends this moisturizer with SPF when youre looking for a sheer tint to even out the skin tone. Apply this water-resistant mineral sunscreen before using bronzer or blush to keep skin hydrated and glowing, thanks to moisturizing agents like argan oil, glycerin, and dimethicone. Free of fragrances, sulfates, and parabens, this is an ideal pick if your skin is easily irritated. Bonus: It also delivers a dose of antioxidants to fight free radical damage and the development of fine lines and wrinkles.
7 CeraVe AM Facial Moisturizing Lotion SPF 30
Amazon amazon.com $19.00 $12.99 (32% off) SHOP NOW Named one of our favorite moisturizers for oily, acne-prone skin , you can count on this as your go-to product when you need something gentle yet hydrating. Hyaluronic acid and ceramides work together to restore and moisturize the skin, niacinamide soothes, while zinc oxide provides broad-spectrum protection. Recommended by the National Skin Cancer Foundation, this noncomedogenic product is also oil- and fragrance-free, so you dont have to worry about irritation if you have sensitive skin.
8 NEOCUTIS Journée Bio-Restorative Day Cream SPF 30
Amazon amazon.com $151.00 SHOP NOW This fragrance-free, noncomedogenic moisturizer with SPF is a safe bet when youre looking to address signs of aging, like fine lines, says Dr. Taub. Antioxidants and minerals like vitamins C, E, and green tea extract provide free radical protection and help stimulate collagen growth, while hyaluronic acid offers max hydration.
9 bareMinerals Complexion Rescue Tinted Moisturizer
Nordstrom nordstrom.com $30.00 SHOP NOW If youre looking for an ideal tinted moisturizer with SPF, look no further than this gem from bareMinerals. The fragrance-free, noncomedogenic formula offers broad-spectrum sun protection to protect the skin, hydrates via glycerin, squalene, and botanical ingredients, and offers a sheer tint to even out the skin tone. The result? Fresh, glowing skin that doesnt look or feel heavy.
10 Colorescience Even Up Clinical Pigment Perfector SPF 50
Amazon amazon.com $125.00 SHOP NOW This tinted skin primer and lotion contains brighteners to add radiance and disguise dark spots. Titanium dioxide and zinc oxide provide the physical blockers that shield skin from the sun. Dr. Taub recommends this one particularly in pregnancy when you may be dealing with pigment problems like melasma.
Jessica Migala Jessica Migala is a health writer specializing in general wellness, fitness, nutrition, and skincare, with work published in Womens Health, Glamour, Health, Mens Health, and more.

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‘Tis The Season Beauty Giveaway Worth Over $300! | Story of My Dress

What You’ll Win:
European Wax Center $60 Gift Card European Wax Center Smooth Me Ingrown Hair Serum 1.7 fl oz European Wax Center Restoring Serum 0.5 fl oz Julep Love Your Bare Face Hydrating Cleansing Oil 1.5 fl oz Julep Your Lip Addiction Tinted Lip Oil Treatment in Crave 0.15 oz DevaCurls How to Quit Shampoo Kit for Hydrated Natural Curls , Kit Includes: No-Poo Decadence 8oz, One Condition Decadence 8oz & SuperCream 3oz HUM Nutrition Collagen POP Sebamed Moisturizing Body Lotion 6.8 fl oz Dessange Paris Top Coat Serum for Color-treated Hair 3.4 fl oz Indigo Wild Zum Face Rosemary-Mint & Walnut Sugar Facial Scrub 4 oz Bang Beauty Dolce Pink Cream Color Redken Color Extend Travel Size Shampoo 1.7 fl oz Redken Color Extend Travel Size Conditioner 1 fl oz NYX Professional Makeup Suede Matte Lip Liner in Brooklyn Thorn NYC Liquid Lipshine Lip Gloss in Nude York City Jesse’s Girl Lipstick in Victoria Vital Proteins Beauty Collagen Lavender Lemon 1 Stick Pack Free 20-Minute Facial at Aveda $1 off any service at Brow Arc Colleen Rothschild Dual Enzyme Polish , travel size Colleen Rothschild Radiant Cleansing Balm , travel size Dermalogica Precleanse travel size Real Chemistry Luminous 3-Minute Peel , Travel Size Samples x3 Caviar Anti-Aging Miracle Multiplying Volume Mist , Travel Size Sample x2 Nomaterra Malibu honeysuckle Fragrance Wipe Nomaterra Oahu gardenia Fragrance Wipe Fresh Sugar Lip Treatment Perfecting Wand Sample Yves Saint Laurent Forever Youth Liberator Water-in-Oil Sample Charlotte Tilbury K.I.S.S.I.N.G Lipstick Samples Charlotte Tilbury Matte Revolution Lipstick Sample and more! Total Beauty Giveaway Value Over $300!
Also, don’t miss my gift guides this year! Whether friends, family, co-workers or loved ones or yourself(!), I’ve done my best to find those fewer, better things this season that are sure to delight the gift receiver.
Gift Guide: Hygge & Home
Gift Guide: Jetset & Wanderlust
Gift Guide: Beauty Lover
Gift Guide: Host & Entertain
Gift Guide: Fashion Lover Bohème
Stay tuned for more giveaways this holiday season, because I’m all about gifting love this festive season!
Happy Holidays and Best of Luck!
xoxo
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*Please Note: This Giveaway is open to U.S. Residents only. This giveaway is in no way affiliated with any brand included in this giveaway. Thank you for entering and best of luck!

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Diagnosis and Management of Atopic Dermatitis: A Review

Sibbald, Cathryn MD, BScPhm, ACPR, FRCPC Pope, Elena MD, MSc, FRCPC Gary Sibbald, R. DSc (Hons), MD, MEd, BSc, FRCPC (Med Derm), ABIM, FAAD, MAPWCA Abstract GENERAL PURPOSE: The purpose of this learning activity is to provide information about the diagnosis and management of atopic dermatitis (AD). TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After completing this continuing education activity, you should be able to: 1. Recall the diagnostic process of AD. 2. Identify nonpharmacologic therapies for skin care in patients with AD. 3. Explain the pharmacologic management of AD. ABSTRACT: Atopic dermatitis is a chronic, relapsing, intensely pruritic inflammatory skin disease that affects both children and adults. This article provides an overview of the epidemiology, clinical features, pathophysiology, complications, and specific investigations of atopic dermatitis. The current and novel therapies for the treatment of atopic dermatitis will be discussed. Article Content CASE STUDY
A 3-month old boy was referred to dermatology for uncontrolled eczema. His parents described dry erythematous patches of skin that began when he was 4 weeks old. They had been using 1% hydrocortisone cream on the body and betamethasone 0.1% lotion on the scalp. Three weeks prior to presentation, the child had been prescribed a 2-week course of systemic cephalexin and topical mupirocin cream 2% for impetiginized eczema, but it had not improved.
His medical history was otherwise unremarkable, being born full term by vaginal delivery with an uncomplicated postnatal course. There were no concerns with his height, weight, or developmental milestones to date, and immunizations were up to date. There was a history of rhinitis in the father and mild dermatitis in his 2-year-old brother, but no other history of atopy in the family.
On examination at presentation, there were scattered nummular patches of dermatitis with some erosions and crusting over the torso and extremities ( Figure ). He had scattered erythematous papules on his face and thick adherent yellow scale on greater than 40% of the scalp. He was afebrile. Figure. NUMMULAR LESIONS ON THE POSTERIOR LEGS OF AN INFANT WITH ATOPIC DERMATITIS
At the first visit, education was provided on the natural history and management of atopic dermatitis (AD), and handouts provided with links to eczema information websites. The family was instructed to bathe the child one or two times daily in lukewarm water for 5 to 10 minutes using a mild, unscented cleanser. After drying gently, they were advised to apply prescription ointments to eczema patches and a bland emollient to the rest of the body.
For the patient’s current flare, betamethasone valerate 0.1% ointment was prescribed for application twice daily to dermatitic patches on the body, and hydrocortisone valerate 0.2% ointment was prescribed for the boy’s face. Betamethasone valerate 0.1% lotion was continued for use on the scalp. Swabs were taken of the crusted patches on the body to assess for methicillin-resistant Staphylococcus aureus . Sulfamethoxazole-trimethoprim was prescribed twice daily for antistaphylococcal coverage as well as anti-inflammatory action. Hydroxyzine syrup was prescribed as needed for sleep and itch.
Adjunctive measures were reviewed with the family; cotton clothing and bed sheets were recommended, as well as using mild detergents or plain vinegar for washing without fabric softeners or dryer sheets. Follow-up was booked for 4 weeks, and the family was advised to call if there were any signs of infection. INTRODUCTION
Atopic dermatitis is a chronic, relapsing, intensely pruritic inflammatory skin disease. This skin disease is commonly associated with allergic rhinitis (hay fever or seasonal allergies) and asthma. This triad of conditions is collectively known as atopy , with affected individuals having a personal or family history of one or more of the three conditions. This word was first used in 1923 to define a domain of inherited hypersensitivity to environmental allergens, disparate from hypersensitivity and anaphylaxis to infection. 1 It is commonly referred to by dermatologists as either AD or atopic eczema, and the terms can be used interchangeably.
In 1979, Hanifin and Rajka 2 advanced major criteria for the diagnosis of atopic eczema. Spearheaded by Williams et al 3 in 1993, a team of dermatologists and pediatricians formulated and validated diagnostic criteria for AD that closely paralleled the major criteria advanced by Hanifin and Rajka 2 with a further slight modification in 2005 by Williams 4 ( Table 1 ). Table 1. DIAGNOSTIC GUIDELINES FOR ATOPIC DERMATITIS EPIDEMIOLOGY
The lifetime prevalence of AD is estimated to be 10% to 30% in children and 2% to 10% in adults, with a two- or threefold increase over the past 3 decades in industrialized nations. 5 The International Study of Asthma and Allergies of Childhood (ISAAC) has provided the most salient trends of AD across the world; AD in general is not increasing or has leveled off in countries with the highest prevalence (eg, the United Kingdom). The younger children subpopulations (aged 6-7 and 13-14 years) and individuals in low-income countries are still experiencing an increased incidence of AD. 6,7 Research studies documented that a higher risk of AD development is associated with areas of industrialization, urbanization, and higher affluent class, 8-10 whereas living in more tropical latitudes and rural areas are associated with lower risk of AD. 11 CLINICAL FEATURES
As documented in Table 2 , pruritus, dry skin, and a compromised barrier function are characteristic of all stages of AD. Fish-like polygonal scales may appear on the skin, particularly the legs. These scales often spare the palms and soles and may be indistinguishable from ichthyosis vulgaris. Table 2. CLINICAL SIGNS AND SYMPTOMS OF ATOPIC DERMATITIS
A decreased skin barrier can also facilitate microorganism overgrowth with bacteria, viruses, and yeasts. There is an increased susceptibility to secondary bacterial colonization and infection with staphylococcus more frequently than streptococcus, often presenting with crusting of involved skin with secondary impetiginization.
Hair follicles are often prominent on the extensor aspect of the upper arms and anterior thighs with a surface scale and underlying follicular prominence (keratosis pilaris), occasionally involving the cheeks. Pigmented skin (black or brown) may have a predominant follicular pattern that can also be present on the trunk as well as the rest of the body.
The area around the eyes may also offer clues for atopy. Allergic sensitivity often causes swelling of the periorbital skin that can leave shiners or dark skin with resolution. There is also often a double crease around the eye (Dennie-Morgan lines) or loss of the lateral third of the eyebrows from constant scratching. Increased skin markings may also be present on the neck and palms of the hands.
Atopic eczema may have a slight hypopigmented characteristic (pityriasis alba) that is common on the face of children. External stroking of the skin can produce white dermatographism especially over the scapular area where prestored mediators including histamine are not depleted.
There are three stages of AD based on the age of affected individuals ( Table 3 ). The infantile stage is often acute, with papules (raised lesions <1 cm) that develop after the second week of life up to age 2 years. It is classically located on the head and neck with involvement of the extensor skin on the elbows and knees related to the trauma from the crawling posture. The infantile stage from age 2 years to puberty is most likely to present with subacute lesions on the trunk and extremities and prominent flexural involvement of the elbows and knees. The adult stage may be limited to the hands but can be involved elsewhere on the skin surface. Table 3. CLINICAL FEATURES BY AGE
There are myriad regional expressions of AD that can be observed in patients because of dry skin and susceptibility to contact irritant or allergic dermatitis on the lips, ears, and eyelids. Changes in skin color may also reflect involvement of the skin with a yeast, Malassezia furfur . The yeast is a normal colonizing organism on the skin. When it overgrows and stimulates tyrosinase, an enzyme in melanocytes, it causes hyperpigmentation. Inhibition of tyrosinase leads to hypopigmentation and irritation of the skin can cause involved skin to be red. The hands and feet are often involved with acute, subacute, or chronic signs of eczema.
Nummular eczema (coin-shaped lesions) is most common on the arms and legs. This form of eczema is common in children with atopy and may be associated with contact allergic dermatitis, especially in adults. Not all persons with nummular eczema have atopy. PATHOPHYSIOLOGY
The pathophysiology of AD is complex and multifactorial; AD is the product of the interaction between skin barrier dysfunction, immunologic factors, and environmental factors. Abnormal gene(s) that encode defective skin barrier components (eg, filaggrin, ceramides) lead to increased transepidermal water loss and associated dry skin and surface pH changes. The pathogenesis of AD is also orchestrated through a biphasic inflammatory response typified by a helper T-cell type 2 (T H 2) lymphocyte-dominant response with overproduction of T H 2 cytokines interleukin 4 (IL-4), IL-5, and IL-13 prior to converting to a T1 response.
Finally, the interplay of psychological stress and environmental factors has a salient role in causing AD. The dysregulation of the skin barrier predisposes individuals to colonization of microbial pathogens. Well-established triggers for atopic eczema include environmental aeroallergens (eg, animal dander), along with environmental stressors such as reduced humidity and lower outdoor temperatures. Further, the use of harsh alkaline detergents and soaps over the skin is known to alter the skin's acidic pH. When the skin becomes more alkaline, this dysregulates downstream enzyme activity and triggers AD. A proper understanding of how the genetic, immunologic, and environmental factors interact with one another can help healthcare providers develop effective therapeutic management plans. Microbial Colonization in Atopic Dermatitis
Patients with AD and their associated epidermal barrier dysregulation are at risk of skin infections with S aureus and Streptococcus pyogenes . 13-15 Approximately 90% of AD lesions have S aureus with methicillin-resistant S aureus colonization occurring in up to 12% of patients. 14
Eczema herpeticum (widespread cutaneous herpes simplex virus infection) is a serious comorbidity occasionally seen in patients with AD. 16 Fungal infections also are commonly seen in patients with AD. In particular, the yeast M furfur commonly affects the head neck and trunk 17 with red, hypopigmented (white), or hyperpigmented (light to medium brown) patches that may have a fine surface scale. COMPLICATIONS
The patient burden of AD is significant. Itch and pain are the most commonly reported symptoms and can lead to detrimental effects on quality of life in both children and adults. 18 Itch can impact the ability to fall asleep and lead to frequent awakenings, resulting in decreased amount and quality of sleep. Children may be teased or bullied and feel self-conscious about their skin. This may also result in decreased participation in sports or leisure activities. Effective treatments often result in objective improvements in quality of life. 18 DIAGNOSIS
A punch skin biopsy may be necessary for patients with atypical presentations to rule out other skin conditions that may resemble AD. These conditions include other inflammatory dermatoses (seborrheic dermatitis, psoriasis, allergic or irritant contact dermatitis, and pityriasis lichenoides), primary ichthyosis, infestations (scabies), infections (fungal, human immunodeficiency virus [HIV]), malignancies (most commonly cutaneous T-cell lymphoma), and metabolic disorders. 19 One needs to consider mycosis fungoides in patients with a skin eruption that may resemble AD presenting much later in life or that is completely resistant to therapy. Serial biopsies may need to be performed for a definitive diagnosis if there is a high index of suspicion. If HIV is suspected, a serum enzyme-linked immunosorbent assay for HIV should be performed.
Patients with extensive skin disease or recurrent staphylococcal infections may have very high levels of immunoglobulin E (IgE), and this should be measured in these patients. Bacterial skin swabs should be performed on crusted and persistent skin lesions and tested for culture and sensitivity. Chronic staphylococcal carriage in the nostrils or perianal skin may also be a source of recurrent staphylococcal infections.
There may also be a history of IgE-mediated food allergies. Food allergy testing for moderate to severe AD patients younger than 5 years of age should be performed with a reliable history of immediate reaction after ingestion of a specific food. Testing is most commonly performed with a skin-prick test on the forearm. A positive test results when a raised red skin flare from histamine or other mediator release occurs within minutes as a reaction to the test substance. Alternately, allergen-specific IgE levels can be determined from serum samples that are tested with common food and environmental trigger antigens. Food allergies may be documented with a confirmatory oral food challenge. These challenges should be performed in a controlled environment with resuscitation equipment if anaphylaxis or a severe reaction to the food is suspected.
Allergic contact dermatitis is a differential diagnosis to AD, but both conditions can coexist. These two conditions can be challenging for physicians to distinguish. Patch testing that can detect delayed hypersensitivity (48 and 72 hours) to common allergens (eg, nickel, cobalt, neomycin, and so on) should be performed with a history or examination suggestive of allergic contact dermatitis. The patches are applied to the back of patients with suspected contact allergies. The patches are then removed at 48 hours, the sites marked, and a final reading for allergic sensitivity should be made at 72 hours. FIRST-LINE THERAPIES Interventional Education
Patient education about their skin condition is a crucial component of providing effective healthcare delivery. The treatment of AD can be exceedingly demanding, resulting in poor adherence to therapy. Educational programs including nurse-led eczema workshops can reduce AD severity and improve the quality of life of pediatric AD patients when compared with standard of care. 20,21 Often, AD is more effectively managed through an interprofessional team of AD specialists (dermatologist or allergist, nurses, psychologists, and dietitians) to address the patients' medical management, psychological, and behavioral factors. 22
Consider how information will be delivered to the patient. Video-based educational formats have improved patient AD education when compared with a written pamphlet. 23 Support groups have also reported significant psychosocial improvements to AD-related pruritus symptoms, mood, and quality of life. 24 There are four prominent organizations in North America from which patients can obtain further AD information: The National Eczema Association ( http://www.nationaleczema.org ), American Academy of Dermatology ( http://www.aad.org ), Eczema Society of Canada ( http://www.eczemahelp.ca ), and the Canadian Skin Alliance ( http://www.canadianskin.ca ). Topical Moisturizers and Bathing
The most important therapy patients with AD of all severity levels should consider is the use of moisturizers. The continued use of moisturizers for cutaneous hydration will abate associated xerosis and pruritus and reduce the number of flare-ups and the necessity of topical steroid preparations. 25,26 Moreover, there is some evidence that the habitual use of moisturizers from birth is an efficacious approach to prevent AD in infants considered to be high risk. 27
Moisturizing has several key roles in treating the skin, including assisting in repair of the damaged skin barrier, lessening transepidermal water loss, maintaining skin hydration, alleviating dry skin, and reducing the need for topical corticosteroids (TCSs). 28 The stratum corneum's primary function is to prevent transcutaneous evaporation of water. 28 A minimum of 10% moisture content is necessary for the stratum corneum to function.
Moisturizer choice is based on factors such as the site of application, season, patient preference, and degree of dryness of the skin. Moisturizers can be formulated in a variety of delivery systems including creams, ointments, lotions, and gels. Creams are an emulsion of continuous water with suspended oil that are often well tolerated and not greasy. Ointments have the highest moisturizing ability of all the formulations because of a very high lipid composition (continuous oil phase with a potential suspended water component). Ointments are more occlusive and tend to cause less stinging than gels (powder suspended in a lattice), but patients may find ointments uncomfortable, itchy, or sticky. Gels facilitate transport down hair follicles and may be drying. Lotions (powder in water) contain a higher percentage of water relative to oil, and because they evaporate, they tend to be used on areas where drying effects are not as troublesome (eg, the scalp and chin).
No study to date has demonstrated one moisturizer preparation to be superior to another. Topical preparations with known allergens including perfumes and lanolin should be avoided. There are three classes of moisturizers patients with AD can be treated with. Refer to Table 4 for a classification of moisturizers (humectant, emollient, occlusive types), along with their properties. Table 4. MOISTURIZERS
Patients should not overbathe. One suggestion is to take warm water baths or showers for no more than 5 to 10 minutes. The water may prepare the skin for more permanent hydration treatments of the stratum corneum and helps to eliminate scales, crust, sweat, irritants, and allergens. 29 Patients should avoid taking bubble baths or bathing with scented oils and fragrances. Whereas taking warm water baths in conjunction with nonirritating, mild acid soaps is encouraged, scrubbing the skin is highly discouraged and should be avoided. Moisturizers should be introduced within 3 minutes after exiting the shower or lukewarm bath because the skin can become very dry without it. 30
It is imperative that patients become educated on proper use of moisturizers to improve skin function and appearance. Refer to Table 5 for evidence of interventional education and moisturizing in improving outcomes in patients with AD. The study by Chiang and Eichenfield 33 documented the best results when moisturizers were used without routine bathing. Table 5. EVIDENCE FOR MOISTURIZING IN PATIENTS WITH ATOPIC DERMATITIS (AD) Topical Corticosteroids
Topical corticosteroids are used as a first-line prescription therapy for both adults and children to treat inflammatory symptoms and signs of AD including acute flares and itchiness. Thei use is well validated, with more than 100 randomized controlled trials performed 35 demonstrating that they reduce the acute and chronic signs of AD. 37
The most preferable TCSs are those that are formulated with low systemic bioavailability and a favorable therapeutic index matched to the area of the involved skin ( Table 6 ) particularly for infants and young children with widespread involvement. 37,38 When selecting the potency of the TCS, be cognizant of the patient's age, disease severity, and thickness of the involved skin region/relative absorption ( Table 7 ). Table 6. CLASSIFICATION OF TOPICAL CORTICOSTEROIDS Table 7. TOPICAL STEROID PERCUTANEOUS RELATIVE ABSORPTION
Potential adverse risks associated with TCSs include skin atrophy, perioral dermatitis, adrenal suppression, acne rosacea, and the development of striae. After the lesion appears to have resolved, patients should taper their use to every other day before beginning maintenance therapy. Long-term use of medium-potency TCSs with proactive twice-weekly application in conjunction with emollient use can reduce the risk of relapse for adults and children with moderate to severe forms of AD. 39-41
High-potency TCSs (more than three times 1% hydrocortisone) should not be routinely used on thin skin such as the face, body folds, and groin because of the risk of cutaneous atrophy. The appropriate amount of cream or ointment that should be dispensed often for 2 weeks of use is measured in adult fingertip units, or approximately 0.5 g applied over an area the size of two adult palms. Clinicians often underestimate or overestimate the quantity of topical steroids to order. Table 8 provides a guide to appropriate quantities depending on the extent of involvement in each area. 42 Table 8. QUANTITY OF TOPICAL CORTICOSTEROID TO APPLY BY ANATOMICAL REGION Topical Calcineurin Inhibitors
There are two nonsteroidal topical calcineurin inhibitors (TCIs): tacrolimus and pimecrolimus. Tacrolimus 0.1% is approved for adults only. Although tacrolimus 0.03% ointment and pimecrolimus 1% cream are officially indicated only for patients with AD older than 2 years, the recent American Academy of Dermatology guidelines recommend their off-label use in patients younger than 2 years with mild or severe disease. 29 The major adverse reactions to TCI use are transient, local burning or itching sensations at the site of application (keeping the topical cream/ointment in the refrigerator may partly alleviate this). That said, long-term use of TCIs is not associated with skin atrophy, and they can preserve the epidermal barrier further weakened by topical steroid application. 43 One study illustrated that tacrolimus ointment 0.1% has shown efficacy and safety for long-term treatment of up to 12 months in children with AD. 44 Similarly, one open-label clinical study reported that tacrolimus 0.1% has been shown to be safe and effective in adult patients with AD. 45 Moreover, a 6-month controlled clinical trial observed that 1% pimecrolimus cream was well tolerated and effective in patients (infants and adults) with AD. 46
Occasionally, patients may develop an allergy to these agents, and the cost may be a deterrent for individuals who do not have coverage for these topical agents. There is a black box warning about the use of these agents and the theoretical risk of lymphoma, which was based on lymphomas noticed in mice exposed to extreme doses of the drug. 47 However, there does not appear to be any increased risk of this cancer in humans using TCIs. 47
Tacrolimus ointment 0.1% is indicated for moderate to severe AD, often used in combination with TCSs, while pimecrolimus cream 1% is indicated for mild to moderate AD. Topical calcineurin inhibitors are particularly recommended for the treatment of AD that manifests on the eyelid, facial regions, and intertriginous areas. Moreover, they are suitable in patients with frequent flares or persistent AD who otherwise would require the prolonged use of TCSs. Even though there are concerns of the development of malignancies with chronic use of TCIs, there is currently no short- or medium-term (<10 years) evidence of increased risk of lymphoma in patients who used TCIs for a long period relative to the general population. 48,49 Recent studies have reported that patients using tacrolimus three times weekly for maintenance therapy experience greater flare prevention and longer times until first disease relapse. 50 Preventive Therapy
Because AD is a chronic, relapsing inflammatory disease, it is now recommended that patients follow a long-term maintenance therapy rather than following the traditional "reactive" approach to flare-ups ( Table 9 ). The preventive approach recognizes that previously involved lesional skin is far from normal. In actuality, the skin of AD patients has subclinical signs of inflammation, epidermal barrier defects, and damage. Always recommend the daily application of emollients or moisturizers to unaffected areas. They should be applied in the following scenarios: after bathing while the skin is still damp, after handwashing, anytime the skin is dry, and in the chronic stage to prevent recurrences of flares. Table 9. OPTIMAL TREATMENT BY ECZEMA STAGE
Comprehensive treatment and preventive therapy consist of three components. 51
* Intensive TCSs twice daily for moderate to severe AD severity until remission flares and lesions have mostly cleared often in a week or slightly longer.
* Subacute eczema often has the appropriate TCS cream in the morning and TCI at night.
* Long-term low-dose intermittent application of TCI twice a week. SECOND-LINE THERAPIES Antimicrobial Therapy
Patients with bacterial infection should use topical and/or oral antibiotic therapy but should generally be restricted to short-term use in order to prevent the development of antibacterial resistance. Some evidence points to the use of first-generation cephalosporins for the treatment of S aureus that colonizes and causes superinfection in patients with AD. 52 Other clinicians will order antibiotics with effects against staphylococcus that also have anti-inflammatory action (eg, doxycycline, cotrimoxazole).
Bleach (sodium hypochlorite) baths may also be recommended as an adjuvant therapy in patients with AD and frequent or extensive secondary bacterial infections. It is suggested that the antiseptic effects of bleach can reduce the colonization of the skin by S aureus . 52 Patients should soak for 5 to 10 minutes in a bathtub full of lukewarm water mixed with one-quarter to one-half cup of 6% bleach solution.
Eczema herpeticum is characterized by numerous painful, monomorphic, "punched-out" lesions with hemorrhagic crusting. Patients with facial lesions should be referred to ophthalmology for assessment of possible retinal involvement. Cutaneous lesions should be swabbed for polymerase chain reaction identification of herpes simplex virus or varicella zoster virus. If results cannot be obtained within hours of testing if the morphology of lesions is consistent with herpes simplex virus, empiric treatment should be started. Treatment includes the antivirals acyclovir or its derivatives famciclovir and valacyclovir. Oral formulations are indicated for patients with a primary infection or severe involvement, including fever, malaise, and lymphadenopathy. Intravenous acyclovir is usually reserved for patients who cannot eat or drink, are immunocompromised, or have ocular or systemic involvement.
Patients with a dermatophyte (fungal) infection from M furfur (microscopic examination of involved skin scraping of the scale is best) should be treated with topical or systemic antifungal therapy (eg, topical "azole" agents). Some evidence suggests that the onset of AD can be delayed or prevented by 20% in the first 3 years of life when mothers are supplemented during pregnancy or during the infancy stage with probiotics. 53,54 One recent meta-analysis of the role of probiotics in AD occurrence indicated that both Lactobacillus alone and Lactobacillus with Bifidobacterium are protective against AD. 55 Antihistamine Therapy
Scratching will induce histamine and other mediator release, thereby exacerbating the pruritus. This can become frustrating because patients may have difficulty sleeping. Both sedating and nonsedating oral antihistamines are often prescribed, with the nonsedating antihistamines less useful in managing AD for control of the pruritus. Sedating oral antihistamines (eg, hydroxyzine, diphenhydramine, doxepin) have been shown to improve patient sleep quality. 56 However, there