Skin Conditions in Patients Experiencing Homelessness: Atopic Dermatitis

Patients who are unhoused or experiencing housing insecurity are at increased risk for skin conditions caused or exacerbated by exposure to the cold or sun, overcrowding, malnutrition, and lack of access to clean water and privacy.

This series will highlight skin diseases that may disproportionately affect individuals experiencing homelessness, including common disorders, infections, foot problems, sexually transmitted diseases, and nonmelanoma skin cancers.

Atopic dermatitis (AD), a type of eczema, is a common, chronic, pruritic skin condition caused by an overreactive immune system. Cold exposure and stress can cause disease flare-ups or worsening symptoms.

• Redness, scaling, and thickening of the skin is a direct result of increased inflammation.
• Barrier dysfunction, changes in normal skin bacteria, and intense pruritus (leading to scratching) result in skin dryness (xerosis), fissures, and an increased risk for skin infections such as impetigo.
• Dyschromia may be more prominent in darker skin colors, including postinflammatory hyperpigmentation and postinflammatory hypopigmentation or depigmentation.

Managing atopic dermatitis

This can be challenging for individuals experiencing homelessness. Tenets of treatment include the following:

Moisturizing with liberal use of bland emollients

• Remember: ointments >> creams >> lotions for hydration.
• Avoid hot showers.

Treating flares with intermittent topical corticosteroids

• Class 6-7 topical steroids can be used on the face.
• Mid- to high-potency preparations can be used on the trunk and extremities.
• Ointments without preservatives are preferred.
• Application to damp skin or under occlusion can enhance penetration.

Treating and preventing infection

• If evidence of impetiginization (honey-colored crust, denuded skin, or oozing), treat with oral antibiotics; mupirocin 2% topical ointment can be used as a topical adjunct.
• For patients with multiple excoriations or a history of multiple infections, chlorhexidine washes or bleach baths (weekly, if possible) can help. For bleach baths, dilute 1/4 to 1/2 cup household bleach in a full bathtub of water and soak for 10 minutes.