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Defining Atopic Dermatitis

Atopic dermatitis is a chronic (long-lasting) disease that affects the skin. It is not contagious; it cannot be passed from one person to another. The word "dermatitis" means inflammation of the skin. "Atopic" refers to a group of diseases in which there is often an inherited tendency to develop other allergic conditions, such as asthma and hay fever. In atopic dermatitis, the skin becomes extremely itchy. Scratching leads to redness, swelling, cracking, "weeping" clear fluid, and finally, crusting and scaling. In most cases, there are periods of time when the disease is worse (called exacerbations or flares) followed by periods when the skin improves or clears up entirely (called remissions). As some children with atopic dermatitis grow older, their skin disease improves or disappears altogether, although their skin often remains dry and easily irritated. In others, atopic dermatitis continues to be a significant problem in adulthood.

Atopic dermatitis is often referred to as "eczema," which is a general term for the several types of inflammation of the skin. Atopic dermatitis is the most common of the many types of eczema. Several have very similar symptoms. Types of eczema are described below.

Incidence and Prevalence of Atopic Dermatitis

Atopic dermatitis is very common. It affects males and females at about the same rate. Although atopic dermatitis may occur at any age, it most often begins in infancy and childhood. Scientists estimate that 65 percent of patients develop symptoms in the first year of life, and 85 percent develop symptoms before the age of 5. Onset after age 30 is less common and is often caused by exposure of the skin to harsh or wet conditions. Atopic dermatitis is a common cause of workplace disability. People who live in cities and in dry climates appear more likely to develop this condition.

It is difficult to identify exactly how many people are affected by atopic dermatitis. Many people report that they have symptoms, but never have received a diagnosis from a doctor. An estimated 10 to 20 percent of infants and young children experience symptoms of the disease. Roughly 60 percent of these infants continue to have one or more symptoms of atopic dermatitis in adulthood. In adults, the prevalence is thought to be 1 to 3 percent, with an overall lifetime prevalance of about 7 percent.

Types of Eczema (Dermatitis)

Allergic Contact Eczema (dermatitis): A red, itchy, weepy reaction where the skin has come into contact with a substance that the immune system recognizes as foreign, such as poison ivy or certain preservatives in creams and lotions.Atopic Dermatitis: A chronic skin disease characterized by itchy, inflamed skin.

Contact Eczema: A localized reaction that includes redness, itching, and burning where the skin has come into contact with an allergen (an allergy-causing substance) or with an irritant such as an acid, a cleaning agent, or other chemical.

Dyshidrotic Eczema: Irritation of the skin on the palms of hands and soles of the feet characterized by clear, deep blisters that itch and burn.

Neurodermatitis: Scaly patches of the skin on the head, lower legs, wrists, or forearms caused by a localized itch (such as an insect bite) that become intensely irritated when scratched.

Nummular Eczema: Coin-shaped patches of irritated skin - most common on the arms, back, buttocks, and lower legs - that may be crusted, scaling, and extremely itchy.

Seborrheic Eczema: Yellowish, oily, scaly patches of skin on the scalp, face, and occasionally other parts of the body.

Stasis Dermatitis: A skin irritation on the lower legs, generally related to circulatory problems.
Cost of Atopic Dermatitis

In a recent analysis of the costs associated with atopic dermatitis in the United States, researchers reviewed studies evaluating both direct costs (doctor visits, hospitalizations, and medicine) and indirect costs (over-the-counter remedies, lubricants, and days lost from work). They found that direct costs totaled about 25 percent, and indirect costs totaled about 75 percent of costs. Per patient, the costs averaged about $600 per year. On the whole, direct costs alone may exceed $3 billion per year.

Causes of Atopic Dermatitis

The cause of atopic dermatitis is not known, but the disease seems to result from a combination of genetic (hereditary) and environmental factors.

Children are more likely to develop this disorder if a parent has had it or another atopic disease like asthma or hay fever. If both parents have an atopic disease, the likelihood increases. Although some people outgrow skin symptoms, approximately half of children with atopic dermatitis go on to develop hay fever or asthma. Environmental factors can bring on symptoms of atopic dermatitis at any time in individuals who have inherited the atopic disease trait.

Atopic dermatitis is also associated with malfunction of the body's immune system: the system that recognizes and helps fight bacteria and viruses that invade the body. Scientists have found that people with atopic dermatitis have a low level of a cytokine (a protein) that is essential to the healthy function of the body's immune system and a high level of other cytokines that lead to allergic reactions. The immune system can become misguided and create inflammation in the skin even in the absence of a major infection. This can be viewed as a form of autoimmunity, where a body reacts against its own tissues.

In the past, doctors thought that atopic dermatitis was caused by an emotional disorder. We now know that emotional factors, such as stress, can make the condition worse, but they do not cause the disease.

Atopic Pleat (Dennie-Morgan fold): An extra fold of skin that develops under the eye.

Cheilitis: Inflammation of the skin on and around the lips.

Hyperlinear Palms: Increased number of skin creases on the palms.

Hyperpigmented Eyelids: Eyelids that have become darker in color from inflammation or hay fever.

Ichthyosis: Dry, rectangular scales on the skin.

Keratosis Pilaris: Small, rough bumps, generally on the face, upper arms, and thighs.

Lichenification: Thick, leathery skin resulting from constant scratching and rubbing.

Papules: Small raised bumps that may open when scratched and become crusty and infected.

Urticaria: Hives (red, raised bumps) that may occur after exposure to an allergen, at the beginning of flares, or after exercise or a hot bath.

Symptoms of Atopic Dermatitis

Symptoms (signs) vary from person to person. The most common symptoms are dry, itchy skin and rashes on the face, inside the elbows and behind the knees, and on the hands and feet. Itching is the most important symptom of atopic dermatitis. Scratching and rubbing in response to itching irritates the skin, increases inflammation, and actually increases itchiness. Itching is a particular problem during sleep when conscious control of scratching is lost.

The appearance of the skin that is affected by atopic dermatitis depends on the amount of scratching and the presence of secondary skin infections. The skin may be red and scaly, be thick and leathery, contain small aised bumps, or leak fluid and become crusty and infected. The box above lists common skin features of the disease. These features can also be found in people who do not have atopic dermatitis or who have other types of skin disorders.

Atopic dermatitis may also affect the skin around the eyes, the eyelids, and the eyebrows and lashes. Scratching and rubbing the eye area can cause the skin to redden and swell. Some people with atopic dermatitis develop an extra fold of skin under their eyes. Patchy loss of eyebrows and eyelashes may also result from scratching or rubbing.

Researchers have noted differences in the skin of people with atopic dermatitis that may contribute to the symptoms of the disease. The outer layer of skin, called the epidermis, is divided into two parts: an inner part containing moist, living cells, and an outer part, known as the horny layer or stratum corneum, containing dry, flattened, dead cells. Under normal conditions the stratum corneum acts as a barrier, keeping the rest of the skin from drying out and protecting other layers of skin from damage caused by irritants and infections. When this barrier is damaged, irritants act more intensely on the skin.

The skin of a person with atopic dermatitis loses moisture from the epidermal layer, allowing the skin to become very dry and reducing its protective abilities. Thus, when combined with the abnormal skin immune system, the person's skin is more likely to become infected by bacteria (for example, Staphylococcus and Streptococcus) or viruses, such as those that cause warts and cold sores.

Stages of Atopic Dermatitis

When atopic dermatitis occurs during infancy and childhood, it affects each child differently in terms of both onset and severity of symptoms. In infants, atopic dermatitis typically begins around 6 to 12 weeks of age. It may first appear around the cheeks and chin as a patchy facial rash, which can progress to red, scaling, oozing skin. The skin may become infected. Once the infant becomes more mobile and begins crawling, exposed areas, such as the inner and outer parts of the arms and legs, may also be affected. An infant with atopic dermatitis may be restless and irritable because of the itching and discomfort of the disease.

In childhood, the rash tends to occur behind the knees and inside the elbows; on the sides of the neck; around the mouth; and on the wrists, ankles, and hands. Often, the rash begins with papules that become hard and scaly when scratched. The skin around the lips may be inflamed, and constant licking of the area may lead to small, painful cracks in the skin around the mouth.

In some children, the disease goes into remission for a long time, only to come back at the onset of puberty when hormones, stress, and the use of irritating skin care products or cosmetics may cause the disease to flare.

Although a number of people who developed atopic dermatitis as children also experience symptoms as adults, it is also possible for the disease to show up first in adulthood. The pattern in adults is similar to that seen in children; that is, the disease may be widespread or limited to only a few parts of the body. For example, only the hands or feet may be affected and become dry, itchy, red, and cracked. Sleep patterns and work performance may be affected, and long-term use of medications to treat the atopic dermatitis may cause complications. Adults with atopic dermatitis also have a predisposition toward irritant contact dermatitis, where the skin becomes red and inflamed from contact with detergents, wool, friction from clothing, or other potential irritants. It is more likely to occur in occupations involving frequent hand washing or exposure to chemicals. Some people develop a rash around their nipples. These localized symptoms are difficult to treat. Because adults may also develop cataracts, the doctor may recommend regular eye exams.

Diagnosing Atopic Dermatitis

Each person experiences a unique combination of symptoms, which may vary in severity over time. The doctor will base a diagnosis on the symptoms the patient experiences and may need to see the patient several times to make an accurate diagnosis and to rule out other diseases and conditions that might cause skin irritation. In some cases, the family doctor or pediatrician may refer the patient to a dermatologist (doctor specializing in skin disorders) or allergist (allergy specialist) for further evaluation.

A medical history may help the doctor better understand the nature of a patient's symptoms, when they occur, and their possible causes. The doctor may ask about family history of allergic disease; whether the patient also has diseases such as hay fever or asthma; and about exposure to irritants, sleep disturbances, any foods that seem to be related to skin flares, previous treatments for skin-related symptoms, and use of steroids or other medications. A preliminary diagnosis of atopic dermatitis can be made if the patient has three or more features from each of two categories: major features and minor features. Some of these features are listed in the box below.

Currently, there is no single test to diagnose atopic dermatitis. However, there are some tests that can give the doctor an indication of allergic sensitivity.

Pricking the skin with a needle that contains a small amount of a suspected allergen may be helpful in identifying factors that trigger flares of atopic dermatitis. Negative results on skin tests may help rule out the possibility that certain substances cause skin inflammation. Positive skin prick test results are difficult to interpret in people with atopic dermatitis because the skin is very sensitive to many substances, and there can be many positive test sites that are not meaningful to a person's disease at the time. Positive results simply indicate that the individual has IgE (allergic) antibodies to the substance tested. IgE (immunoglobulin E) controls the immune system's allergic response and is often high in atopic dermatitis.

Major Features

• Intense itching
• Characteristic rash in locations typical of the disease
• Chronic or repeatedly occurring symptoms
• Personal or family history of atopic disorders (eczema, hay fever, asthma)

Some Minor Features

• Early age of onset
• Dry skin that may also have patchy scales or rough bumps
• High levels of immunoglobulin E (IgE), an antibody, in the blood
• Numerous skin creases on the palms
• Hand or foot involvement
• Inflammation around the lips
• Nipple eczema
• Susceptibility to skin infection
• Positive allergy skin tests

If the quantity of IgE antibodies to a food in the blood is above a certain level, it is indicative of a food allergy. If a food allergy is suspected, a person might be asked to record everything eaten and note any reactions. Physician-supervised food challenges (that is, the introduction of a food) following a period of food elimination may be necessary to determine if symptomatic food allergy is present. Identifying the food allergen may be difficult when a person is also being exposed to other possible allergens at the same time or symptoms may be triggered by other factors, such as infection, heat, and humidity.

Factors That Make Atopic Dermatitis Worse

Many factors or conditions can make symptoms of atopic dermatitis worse, further triggering the already overactive immune system, aggravating the itch-scratch cycle, and increasing damage to the skin. These factors can be broken down into two main categories: irritants and allergens. Emotional factors and some infections and illnesses can also influence atopic dermatitis.

Irritants are substances that directly affect the skin and, when present in high enough concentrations with long enough contact, cause the skin to become red and itchy or to burn. Specific irritants affect people with atopic dermatitis to different degrees. Over time, many patients and their family members learn to identify the irritants causing the most trouble. For example, frequent wetting and drying of the skin may affect the skin barrier function. Also, wool or synthetic fibers and rough or poorly fitting clothing can rub the skin, trigger inflammation, and cause the itch-scratch cycle to begin. Soaps and detergents may have a drying effect and worsen itching, and some perfumes and cosmetics may irritate the skin. Exposure to certain substances, such as solvents, dust, or sand, may also make the condition worse. Cigarette smoke may irritate the eyelids. Because the effects of irritants vary from one person to another, each person can best determine what substances or circumstances cause the disease to flare.

Allergens are substances from foods, plants, animals, or the air that inflame the skin because the immune system overreacts to the substance. Inflammation occurs even when the person is exposed to small amounts of the substance for a limited time. Although it is known that allergens in the air, such as dust mites, pollens, molds, and dander from animal hair or skin, may worsen the symptoms of atopic dermatitis in some people, scientists aren't certain whether inhaling these allergens or their actual penetration of the skin causes the problems. When people with atopic dermatitis come into contact with an irritant or allergen they are sensitive to, inflammation producing cells become active. These cells release chemicals that cause itching and redness. As the person responds by scratching and rubbing the skin, further damage occurs.

• Wool or synthetic fibers
• Soaps and detergents
• Some perfumes and cosmetics
• Substances such as chlorine, mineral oil, or solvents
• Dust or sand
• Cigarette smoke

Children with atopic disease tend to have a higher prevalence of food allergy than those in the general population. An allergic reaction to food can cause skin inflammation (generally an itchy red rash), gastrointestinal symptoms (abdominal pain, vomiting, diarrhea), and/or upper respiratory tract symptoms (congestion, sneezing, and wheezing). The most common allergenic (allergy-causing) foods are eggs, milk, peanuts, wheat, soy, tree nuts, shellfish, and fish. A recent analysis of a large number of studies on allergies and breastfeeding indicated that breastfeeding an infant, although preferable for many reasons, has little effect on protecting the infant from developing atopic dermatitis.

In addition to irritants and allergens, emotional factors, skin infections, and temperature and climate play a role in atopic dermatitis. Although the disease itself is not caused by emotional factors, it can be made worse by stress, anger, and frustration. Interpersonal problems or major life changes, such as divorce, job changes, or the death of a loved one, can also make the disease worse.

Bathing without proper moisturizing afterward is a common factor that triggers a flare of atopic dermatitis. The low humidity of winter or the dry year-round climate of some geographic areas can make the disease worse, as can overheated indoor areas and long or hot baths and showers. Alternately sweating and chilling can trigger a flare in some people. Bacterial infections can also trigger or increase the severity of atopic dermatitis. If a patient experiences a sudden flare of illness, the doctor may check for infection.

Treatment of Atopic Dermatitis

Treatment is more effective when a partnership develops that includes the patient, family members, and doctor. The doctor will suggest a treatment plan based on the patient's age, symptoms, and general health. The patient or family member providing care plays a large role in the success of the treatment plan by carefully following the doctor's instructions and paying attention to what is or is not helpful. Most patients will notice improvement with proper skin care and lifestyle changes.

The doctor has two main goals in treating atopic dermatitis: healing the skin and preventing flares. These may be assisted by developing skin care routines and avoiding substances that lead to skin irritation and trigger the immune system and the itch-scratch cycle. It is important for the patient and family members to note any changes in the skin's condition in response to treatment, and to be persistent in identifying the treatment that seems to work best.

Medications

New medications known as immunomodulators have been developed that help control inflammation and reduce immune system reactions when applied to the skin. They can be used in patients older than 2 years of age and have few side effects (burning or itching the first few days of application). They not only reduce flares, but also maintain skin texture and reduce the need for long-term use of corticosteroids.

Corticosteroid creams and ointments have been used for many years to treat atopic dermatitis and other autoimmune diseases affecting the skin. Sometimes over-the-counter preparations are used, but in many cases the doctor will prescribe a stronger corticosteroid cream or ointment. When prescribing a medication, the doctor will take into account the patient's age, location of the skin to be treated, severity of the symptoms, and type of preparation (cream or ointment) that will be most effective. Sometimes the base used in certain brands of corticosteroid creams and ointments irritates the skin of a particular patient. Side effects of repeated or long-term use of topical corticosteroids can include thinning of the skin, infections, growth suppression (in children), and stretch marks on the skin.

When topical corticosteroids are not effective, the doctor may prescribe a systemic corticosteroid, which is taken by mouth or injected instead of being applied directly to the skin. Typically, these medications are used only in resistant cases and only given for short periods of time. The side effects of systemic corticosteroids can include skin damage, thinned or weakened bones, high blood pressure, high blood sugar, infections, and cataracts.

It can be dangerous to suddenly stop taking corticosteroids, so it is very important that the doctor and patient work together in changing the corticosteroid dose.

Antibiotics to treat skin infections may be applied directly to the skin in an ointment, but are usually more effective when taken by mouth. If viral or fungal infections are present, the doctor may also prescribe specific medications to treat those infections.

Certain antihistamines that cause drowsiness can reduce nighttime scratching and allow more restful sleep when taken at bedtime. This effect can be particularly helpful for patients whose nighttime scratching makes the disease worse.

In adults, drugs that suppress the immune system may be prescribed to treat severe cases of atopic dermatitis that have failed to respond to other forms of therapy. These drugs block the production of some immune cells and curb the action of others. The side effects of drugs like these can include high blood pressure, nausea, vomiting, kidney problems, headaches, tingling or numbness, and a possible increased risk of cancer and infections. There is also a risk of relapse after the drug is stopped. Because of their toxic side effects, systemic corticosteroids and immunosuppressive drugs are used only in severe cases and then for as short a period of time as possible. Patients requiring systemic corticosteroids should be referred to dermatologists or allergists specializing in the care of atopic dermatitis to help identify trigger factors and alternative therapies.

In rare cases, when home-based treatments have been unsuccessful, a patient may need a few days in the hospital for intense treatment.

Phototherapy

Use of ultraviolet A or B light waves, alone or combined, can be an effective treatment for mild to moderate dermatitis in older children (over 12 years old) and adults. A combination of ultraviolet light therapy and a drug called psoralen can also be used in cases that are resistant to ultraviolet light alone. Possible long-term side effects of this treatment include premature skin aging and skin cancer. If the doctor thinks that phototherapy may be useful to treat the symptoms of atopic dermatitis, he or she will use the minimum exposure necessary and monitor the skin carefully.

Treating Atopic Dermatitis in Infants and Children

• Give lukewarm baths.
• Apply lubricant immediately following the bath.
• Keep child's fingernails filed short.
• Select soft cotton fabrics when choosing clothing.
• Consider using sedating antihistamines to promote sleep and reduce scratching at night.
• Keep the child cool; avoid situations where overheating occurs.
• Learn to recognize skin infections and seek treatment promptly.
• Attempt to distract the child with activities to keep him or her from scratching.
• Identify and remove irritants and allergens.

Skin Care

Healing the skin and keeping it healthy are important to prevent further damage and enhance quality of life. Developing and sticking with a daily skin care routine is critical to preventing flares.

A lukewarm bath helps to cleanse and moisturize the skin without drying it excessively. Because soaps can be drying to the skin, the doctor may recommend use of a mild bar soap or nonsoap cleanser. Bath oils are not usually helpful.

After bathing, a person should air-dry the skin, or pat it dry gently (avoiding rubbing or brisk drying), and then apply a lubricant to seal in the water that has been absorbed into the skin during bathing. A lubricant increases the rate of healing and establishes a barrier against further drying and irritation. Lotions that have a high water or alcohol content evaporate more quickly, and alcohol may cause stinging. Therefore, they generally are not the best choice. Creams and ointments work better at healing the skin.

Another key to protecting and restoring the skin is taking steps to avoid repeated skin infections. Signs of skin infection include tiny pustules (pus-filled bumps), oozing cracks or sores, or crusty yellow blisters. If symptoms of a skin infection develop, the doctor should be consulted and treatment should begin as soon as possible.

Protection from Allergen Exposure

The doctor may suggest reducing exposure to a suspected allergen. For example, the presence of the house dust mite can be limited by encasing mattresses and pillows in special dust-proof covers, frequently washing bedding in hot water, and removing carpeting. However, there is no way to completely rid the environment of airborne allergens.

Changing the diet may not always relieve symptoms of atopic dermatitis. A change may be helpful, however, when the medical history, laboratory studies, and specific symptoms strongly suggest a food allergy. It is up to the patient and his or her family and physician to decide whether the dietary restrictions are appropriate. Unless properly monitored by a physician or dietitian, diets with many restrictions can contribute to serious nutritional problems, especially in children.

Atopic Dermatitis and Quality of Life

Despite the symptoms caused by atopic dermatitis, it is possible for people with the disorder to maintain a good quality of life. The keys to quality of life lie in being well-informed; awareness of symptoms and their possible cause; and developing a partnership involving the patient or caregiving family member, medical doctor, and other health professionals. Good communication is essential.

When a child has atopic dermatitis, the entire family may be affected. It is helpful if families have additional support to help them cope with the stress and frustration associated with the disease. A child may be fussy and difficult and unable to keep from scratching and rubbing the skin. Distracting the child and providing activities that keep the hands busy are helpful but require much effort on the part of the parents or caregivers. Another issue families face is the social and emotional stress associated with changes in appearance caused by atopic dermatitis. The child may face difficulty in school or with social relationships and may need additional support and encouragement from family members.

Adults with atopic dermatitis can enhance their quality of life by caring regularly for their skin and being mindful of the effects of the disease and how to treat them. Adults should develop a skin care regimen as part of their daily routine, which can be adapted as circumstances and skin conditions change. Stress management and relaxation techniques may help decrease the likelihood of flares. Developing a network of support that includes family, friends, health professionals, and support groups or organizations can be beneficial. Chronic anxiety and depression may be relieved by short-term psychological therapy.

Recognizing the situations when scratching is most likely to occur may also help. For example, many patients find that they scratch more when they are idle, and they do better when engaged in activities that keep the hands occupied. Counseling also may be helpful to identify or change career goals if a job involves contact with irritants or involves frequent hand washing, such as work in a kitchen or auto machine shop.

Atopic Dermatitis and Vaccination Against Smallpox

Although scientists are working to develop safer vaccines, individuals diagnosed with atopic dermatitis (or eczema) should not receive the current smallpox vaccine. According to the Centers for Disease Control and Prevention (CDC), a U.S. Government organization, individuals who have ever been diagnosed with atopic dermatitis, even if the condition is mild or not presently active, are more likely to develop a serious complication if they are exposed to the virus from the smallpox vaccine.

People with atopic dermatitis should exercise caution when coming into close physical contact with a person who has been recently vaccinated, and make certain the vaccinated person has covered the vaccination site or taken other precautions until the scab falls off (about 3 weeks). Those who have had physical contact with a vaccinated person’s unhealed vaccination site or to their bedding or other items that might have touched that site should notify their doctor, particularly if they develop a new or unusual rash.

During a smallpox outbreak, these vaccination recommendations may change. People with atopic dermatitis who have been exposed to smallpox should consult their doctor about vaccination.

Tips for Working With Your Doctor

• Provide complete, accurate medical information.
• Make a list of your questions and concerns in advance.
• Be honest and share your point of view with the doctor.
• Ask for clarification or further explanation if you need it.
• Talk to other members of the health care team, such as nurses, therapists, or pharmacists.
• Don't hesitate to discuss sensitive subjects with your doctor.
• Discuss changes to any medical treatment or medications with your doctor.

Current Research

Researchers supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and other institutes of the National Institutes of Health are gaining a better understanding of what causes atopic dermatitis and how it can be managed, treated, and, ultimately, prevented. Some promising avenues of research are described below.

Genetics

Although atopic dermatitis runs in families, the role of genetics (inheritance) remains unclear. It does appear that more than one gene is involved in the disease.

Research has helped shed light on the way atopic dermatitis is inherited. Studies show that children are at increased risk for developing the disorder if there is a family history of other atopic disease, such as hay fever or asthma. The risk is significantly higher if both parents have an atopic disease. In addition, studies of identical twins (who have the same genes) show that a person whose identical twin has atopic dermatitis is seven times more likely to have atopic dermatitis than someone in the general population. A person whose fraternal (nonidentical) twin has atopic dermatitis is three times more likely to have atopic dermatitis than someone in the general population. These findings suggest that genes play an important role in determining who gets the disease.

Also, scientists have discovered mutations in a certain gene that plays a role in the production of a protein called filaggrin. The filaggrin protein is normally found in the outermost layer of the skin and functions as a component of the skin barrier. The gene mutation disrupts filaggrin’s ability to maintain a normal skin barrier and appears to be a genetic factor that predisposes people to develop atopic dermatitis and other diseases in which the skin barrier is compromised.

Biochemical Abnormalities

Scientists suspect that changes in the skin’s protective barrier make people with atopic dermatitis more sensitive to irritants. Such people have lower levels of fatty acids (substances that provide moisture and elasticity) in their skin, which causes dryness and reduces the skin’s ability to control inflammation. Researchers continue to search for treatments that help keep the skin intact and prevent flares.

Other research points to a possible defect in a type of white blood cell called a monocyte. In people with atopic dermatitis, monocytes appear to play a role in the decreased production of an immune system hormone called interferon gamma (IFN-y), which helps regulate allergic reactions. This defect may cause exaggerated immune and inflammatory responses in the blood and tissues of people with atopic dermatitis.

Faulty Regulation of Immunoglobulin E (IgE)

As already described in the section on diagnosis, IgE is a type of antibody that controls the immune system’s allergic response. An antibody is a special protein produced by the immune system that recognizes and helps fight and destroy viruses, bacteria, and other foreign substances that invade the body. Normally, IgE is present in very small amounts, but levels are high in about 80 percent of people with atopic dermatitis.

In allergic diseases, IgE antibodies are produced in response to different allergens. When an allergen comes into contact with IgE on specialized immune cells, the cells release various chemicals, including histamine. These chemicals cause the symptoms of an allergic reaction, such as wheezing, sneezing, runny eyes, and itching. The release of histamine and other chemicals alone cannot explain the typical long-term symptoms of the disease. Research is underway to identify factors that may explain why too much IgE is produced and how it plays a role in the disease.

Controlling Atopic Dermatitis

• Prevent scratching or rubbing whenever possible.
• Protect skin from excessive moisture, irritants, and rough clothing.
• Maintain a cool, stable temperature and consistent humidity levels.
• Limit exposure to dust, cigarette smoke, pollens, and animal dander.
• Recognize and limit emotional stress.

Immune System Imbalance

Researchers also think that an imbalance in the immune system may contribute to the development of atopic dermatitis. It appears that the part of the immune system responsible for stimulating IgE is overactive, and the part that handles skin viral and fungal infections is underactive. Indeed, the skin of people with atopic dermatitis shows increased susceptibility to skin infections. This imbalance appears to result in the skin’s inability to prevent inflammation, even in areas of skin that appear normal. In one project, scientists are studying the role of the infectious bacterium Staphylococcus aureus (S. aureus) in atopic dermatitis.

Researchers believe that one type of immune cell in the skin, called a Langerhans cell, may be involved in atopic dermatitis. Langerhans cells pick up viruses, bacteria, allergens, and other foreign substances that invade the body and deliver them to other cells in the immune defense system. Langerhans cells appear to be hyperactive in the skin of people with atopic diseases. Certain Langerhans cells are particularly potent at activating white blood cells called T cells in atopic skin, which produce proteins that promote allergic response. This function results in an exaggerated response of the skin to tiny amounts of allergens.

Scientists have also developed mouse models to study step-by-step changes in the immune system in atopic dermatitis, which may eventually lead to a treatment that effectively targets the immune system.

Drug Research

Some researchers are focusing on new treatments for atopic dermatitis, including biologic agents, fatty acid supplements, and phototherapy. For example, they are studying how ultraviolet light affects the skin’s immune system in healthy and diseased skin. They are also investigating biologic response modifiers, or biologics, which are a new family of genetically engineered drugs that block specific molecular pathways of the immune system that are involved in the inflammatory process. A clinical trial is underway to test a drug to see if it can help control the itching associated with atopic dermatitis.

Researchers also continue to look for drugs that suppress the immune system. Also, anti-inflammatory drugs have been developed that affect multiple cells and cell functions, and may prove to be an effective alternative to corticosteroids in the treatment of atopic dermatitis.

Other research: Several experimental treatments are being evaluated that attempt to replace substances that are deficient in people with atopic dermatitis. Evening primrose oil is a substance rich in gamma-linolenic acid, one of the fatty acids that is decreased in the skin of people with atopic dermatitis. Studies to date using evening primrose oil have yielded contradictory results. In addition, dietary fatty acid supplements have not proven highly effective. There is also a great deal of interest in the use of herbs and plant extracts to treat the disease. Studies to date show some benefit, but not without concerns about toxicity and the risks involved in suppressing the immune system without close medical supervision.

Hope for the Future

Although the symptoms of atopic dermatitis can be difficult and uncomfortable, the disease can be successfully managed. People with atopic dermatitis can lead healthy, productive lives. As scientists learn more about atopic dermatitis and what causes it, they continue to move closer to effective treatments, and perhaps, ultimately, a cure.

Additional Resources

National Institute of Arthritis and Musculoskeletal and Skin Diseases
NIAMS/National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
(301) 495-4484 or toll free (877) 22-NIAMS (226-4267)
TTY: (301) 565-2966
Fax: (301) 718-6366
E-mail: [email protected]
Web Site: http://www.niams.nih.gov

Acknowledgments

NIAMS gratefully acknowledges the assistance of the following people in the preparation and review of this publication: Joanne Cono, M.D., Sc.M., Centers for Disease Control and Prevention, Atlanta; Kevin Cooper, M.D., Case Western Reserve University, University Hospitals of Cleveland; Jon Hanifin, M.D., Oregon Health & Science University, Portland, Oregon; Donald Leung, M.D., Ph.D., National Jewish Medical and Research Center, Denver; Alan Moshell, M.D., NIAMS, NIH; Amy Paller, M.D., Children’s Hospital of Chicago; Hugh Sampson, M.D., Mount Sinai School of Medicine, New York; Maria Turner, M.D., National Cancer Institute, NIH; and LaDonna Williams, Inflammatory Skin Disease Institute, Newport News, Virginia.

The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the U.S. Department of Health and Human Services’ National Institutes of Health (NIH), is to support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases; the training of basic and clinical scientists to carry out this research; and the dissemination of information on research progress in these diseases. The National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse is a public service sponsored by NIAMS that provides health information and information sources.

National Institute of Arthritis and Musculoskeletal and Skin Diseases
NIH Publication No. 09-4272

Page last modified or reviewed by athealth on January 29, 2014

Depression and Anxiety

Research suggests that regular physical activity:

• reduces feelings of mild to moderate depression and anxiety
• improves mood
• increases feelings of well-being

Physical activity is not a cure for depression or anxiety. But it may help you manage your symptoms by:

• giving you a sense of success, which can boost your confidence
• helping you meet other people
• taking your mind off your problems

Also, physical activity may help you feel better by:

• increasing the level of substances in the brain that improve your mood
• reducing levels of stress hormones

Research suggests that, for some people, physical activity can work as well as an antidepressant in treating major depression. But if you are now taking an antidepressant, do not stop taking it on your own. You should discuss with your doctor how physical activity might fit into your overall treatment plan before making any changes.

Quitting Smoking

As every smoker knows, quitting smoking can be hard to do. Every year, many smokers try to quit but only a few succeed. One research study suggests that vigorous physical activity can help women quit smoking, even women who have been heavy smokers for many years. As an added bonus, vigorous physical activity can also help you gain less weight after you quit.

It is not known for sure how vigorous physical activity might help you quit smoking. One way it might help is by reducing stress, which might reduce your urge to smoke.

Cognitive Decline During Aging

As we age, we sometimes forget things. Maybe we no longer think as quickly as we used to. Experts call this "cognitive decline," where "cognitive" refers to thinking, learning, and memory, as opposed to emotions.

It was once thought that cognitive decline was a normal part of aging. But research now suggests that staying physically active as you get older may slow cognitive decline, at least for a while. Some experts think that physical activity may slow cognitive decline in part by increasing blood flow to the brain. In addition, physical activity may even help new brain cells grow.

Source: Adapted from The Healthy Woman: A Complete Guide for All Ages
U.S. Department of Health and Human Services, Office on Women's Health - 2008

Page last modified or reviewed by athealth.com on February 3, 2014

When people find themselves suddenly in danger, sometimes they are overcome with feelings of fear, helplessness, or horror. These events are called traumatic experiences. Some common traumatic experiences include being physically attacked, being in a serious accident, being in combat, being sexually assaulted, and being in a fire or a disaster like a hurricane or a tornado. After traumatic experiences, people may have problems that they didn't have before the event. If these problems are severe and the survivor does not get help for them, they can begin to cause problems in the survivor's family. This fact sheet explains how traumas can affect those who experience them. This fact sheet also describes family members' reactions to the traumatic event and to the trauma survivor's symptoms and behaviors. Finally, suggestions are made about what a survivor and his or her family can do to get help for PTSD.

How do traumatic experiences affect people?

People who go through traumatic experiences often have symptoms and problems afterward. How serious the symptoms and problems are depends on many things including a person's life experiences before the trauma, a person's own natural ability to cope with stress, how serious the trauma was, and what kind of help and support a person gets from family, friends, and professionals immediately following the trauma.

Because most trauma survivors are not familiar with how trauma affects people, they often have trouble understanding what is happening to them. They may think the trauma is their fault, that they are going crazy, or that there is something wrong with them because other people who experienced the trauma don't appear to have the same problems. Survivors may turn to drugs or alcohol to make themselves feel better. They may turn away from friends and family who don't seem to understand. They may not know what to do to get better.

What do trauma survivors need to know?

• Traumas happen to many competent, healthy, strong, good people. No one can completely protect him- or herself from traumatic experiences.
• Many people have long-lasting problems following exposure to trauma. Up to 8% of individuals will have PTSD at some time in their lives.
• People who react to traumas are not going crazy. They are experiencing symptoms and problems that are connected with having been in a traumatic situation.
• Having symptoms after a traumatic event is not a sign of personal weakness. Many psychologically well-adjusted and physically healthy people develop PTSD. Probably everyone would develop PTSD if they were exposed to a severe enough trauma.
• When a person understands trauma symptoms better, he or she can become less fearful of them and better able to manage them.
• By recognizing the effects of trauma and knowing more about symptoms, a person is better able to decide about getting treatment.

What are the common effects of trauma?

During a trauma, survivors often become overwhelmed with fear. Soon after the traumatic experience, they may re-experience the trauma mentally and physically. Because this can be uncomfortable and sometimes painful, survivors tend to avoid reminders of the trauma. These symptoms create a problem that is called posttraumatic stress disorder (PTSD). PTSD is a specific set of problems resulting from a traumatic experience and is recognized by medical and mental-health professionals.

Re-experiencing Symptoms:

Trauma survivors commonly re-experience their traumas. This means that the survivor experiences again the same mental, emotional, and physical experiences that occurred during or just after the trauma. These include thinking about the trauma, seeing images of the event, feeling agitated, and having physical sensations like those that occurred during the trauma. Trauma survivors find themselves feeling as if they are in danger, experiencing panic sensations, wanting to escape, getting angry, and thinking about attacking or harming someone else. Because they are anxious and physically agitated, they may have trouble sleeping and concentrating. The survivor usually can't control these symptoms or stop them from happening. Mentally re-experiencing the trauma can include:

• Upsetting memories such as images or thoughts about the trauma
• Feeling as if the trauma is happening again (flashbacks)
• Bad dreams and nightmares
• Getting upset when reminded about the trauma (by something the person sees, hears, feels, smells, or tastes)
• Anxiety or fear, feeling in danger again
• Anger or aggressive feelings and feeling the need to defend oneself
• Trouble controlling emotions because reminders lead to sudden anxiety, anger, or upset
• Trouble concentrating or thinking clearly

People also can have physical reactions to trauma reminders such as:

• Trouble falling or staying asleep
• Feeling agitated and constantly on the lookout for danger
• Getting very startled by loud noises or something or someone coming up on you from behind when you don't expect it
• Feeling shaky and sweaty
• Having your heart pound or having trouble breathing

Because trauma survivors have these upsetting feelings when they feel stress or are reminded of their trauma, they often act as if they are in danger again. They might get overly concerned about staying safe in situations that are not truly dangerous. For example, a person living in a safe neighborhood might still feel that he has to have an alarm system, double locks on the door, a locked fence, and a guard dog. Because traumatized people often feel like they are in danger even when they are not, they may be overly aggressive and lash out to protect themselves when there is no need. For example, a person who was attacked might be quick to yell at or hit someone who seems to be threatening.

Re-experiencing symptoms are a sign that the body and mind are actively struggling to cope with the traumatic experience. These symptoms are automatic, learned responses to trauma reminders. The trauma has become associated with many things so that when the person experiences these things, he or she is reminded of the trauma and feels that he or she is in danger again. It is also possible that re-experiencing symptoms are actually a part of the mind?s attempt to make sense of what has happened.

Avoidance Symptoms:

Because thinking about the trauma and feeling as if you are in danger is upsetting, people who have been through traumas often try to avoid reminders of the trauma. Sometimes survivors are aware that they are avoiding reminders, but other times survivors do not realize that their behavior is motivated by the need to avoid reminders of the trauma.

Ways of avoiding thoughts, feelings, and sensations associated with the trauma can include:

• Actively avoiding trauma-related thoughts and memories
• Avoiding conversations and staying away from places, activities, or people that might remind you of the trauma
• Trouble remembering important parts of what happened during the trauma
• Shutting down emotionally or feeling emotionally numb
• Trouble having loving feelings or feeling any strong emotions
• Finding that things around you seem strange or unreal
• Feeling strange
• Feeling disconnected from the world around you and things that happen to you
• Avoiding situations that might make you have a strong emotional reaction
• Feeling weird physical sensations
• Feeling physically numb
• Not feeling pain or other sensations
• Losing interest in things you used to enjoy doing

Trying to avoid thinking about the trauma and avoiding treatment for trauma-related problems may keep a person from feeling upset in the short term, but avoiding treatment means that in the long term, trauma symptoms will persist.

What are common secondary and associated posttraumatic symptoms?

Secondary symptoms are problems that arise because of the posttraumatic re-experiencing and avoidance symptoms. For example, because a person wants to avoid talking about a traumatic event, she might cut off from friends, which would eventually cause her to feel lonely and depressed. As time passes after a traumatic experience, more secondary symptoms may develop. Over time, secondary symptoms can become more troubling and disabling than the original re-experiencing and avoidance symptoms.

Associated symptoms don't come directly from being overwhelmed with fear; they occur because of other things that were going on at the time of the trauma. For example, a person who is psychologically traumatized in a car accident might also be physically injured and then get depressed because he can't work or leave the house.

All of these problems can be secondary or associated trauma symptoms:

Depression can develop when a person has losses connected with the trauma or when a person avoids other people and becomes isolated.

Despair and hopelessness can result when a person is afraid that he or she will never feel better again.

Survivors may lose important beliefs when a traumatic event makes them lose faith that the world is a good and safe place.

Aggressive behavior toward oneself or others can result from frustration over the inability to control PTSD symptoms (feeling that PTSD symptoms run your life). People may also become aggressive when other things that happened at the time of trauma make the person angry (the unfairness of the situation). Some people are aggressive because they grew up with people who lashed out and they were never taught other ways to cope with angry feelings. Because angry feelings may keep others at a distance, they may stop a person from having positive connections and getting help. Anger and aggression can cause job problems, marital and relationship problems, and loss of friendships.

Self-blame, guilt, and shame can arise when PTSD symptoms make it hard to fulfill current responsibilities. They can also occur when people fall into the common trap of second-guessing what they did or didn't do at the time of a trauma. Many people, in trying to make sense of their experience, blame themselves. This is usually completely unwarranted and fails to hold accountable those who may have actually been responsible for the event. Self-blame causes a lot of distress and can prevent a person from reaching out for help. Sometimes society also blames the victim of a trauma. Unfortunately, this may reinforce the survivor?s hesitation to seek help.

People who have experienced traumas may have problems in relationships with others because they often have a hard time feeling close to people or trusting people. This is especially likely to happen when the trauma was caused or worsened by other people (as opposed to an accident or natural disaster).

Trauma survivors may feel detached or disconnected from others because they have difficulty feeling or expressing positive feelings. After traumas, people can become overwhelmed by their problems or become numb and stop putting energy into their relationships with friends and family.

Survivors may get into arguments and fights with other people because of the angry or aggressive feelings that are common after a trauma. Also, a person's constant avoidance of social situations (such as family gatherings) may create hurt feelings or animosity in the survivor?s relationships.

Less interest or participation in things the person used to like to do may result from depression following a trauma. When a person spends less time doing fun things and being with people, he or she has fewer chances to feel good and have pleasant interactions.

Social isolation can happen because of social withdrawal and a lack of trust in others. This often leads to the loss of support, friendships, and intimacy, and it increases fears and worries.

Survivors may have problems with identity when PTSD symptoms change important aspects of a person's life such as relationships or whether the person can do his or her work well. A person may also question his or her identity because of the way he or she acted during a trauma. For instance, a person who thinks of himself as unselfish might think he acted selfishly by saving himself during a disaster. This might make him question whether he really is who he thought he was.

Feeling permanently damaged can result when trauma symptoms don't go away and a person doesn't believe they will get better.

Survivors may develop problems with self-esteem because PTSD symptoms make it hard for a person to feel good about him- or herself. Sometimes, because of how they behaved at the time of the trauma, survivors feel that they are bad, worthless, stupid, incompetent, evil, etc.

Physical health symptoms and problems can happen because of long periods of physical agitation or arousal from anxiety. Trauma survivors may also avoid medical care because it reminds them of their trauma and causes anxiety, and this may lead to poorer health. For example, a rape survivor may not visit a gynecologist and an injured motor vehicle accident survivor may avoid doctors because they remind him or her that a trauma occurred. Habits used to cope with posttraumatic stress, like alcohol use, can also cause health problems. In addition, other things that happened at the time of the trauma may cause health problems (for example, an injury).

Survivors may turn to alcohol and drug abuse when they want to avoid the bad feelings that come with PTSD symptoms. Many people use alcohol and drugs as a way to try to cope with upsetting trauma symptoms, but it actually leads to more problems.

Remember:

Although individuals with PTSD may feel overwhelmed by their symptoms, it is important for them to remember that there are other, positive aspects of their lives. There are helpful mental-health and medical resources available (see link below), and survivors have their strengths, interests, commitments, relationships with others, past experiences that were not traumatic, desires, and hopes for the future.

Treatments are available for individuals with PTSD and associated trauma-related symptoms.

Understanding the effects of trauma on relationships can also be an important step for family members or friends.

Source: National Center for PTSD
By Eve B. Carlson, PhD and Josef Ruzek, PhD

Updated September 2003

Page last modified or reviewed by athealth on February 4, 2014

Up to 70% of children under age five have sleep problems. Sleep issues are complicated and have many causes. They're hard to deal with because when children aren't sleeping, parents aren't sleeping, and that lack of sleep affects every minute of every day for every person in the family because lack of sleep isn't just about being tired. Sleep has a role in everything -- dawdling, temper tantrums, hyperactivity, growth, health, and even learning to tie his shoes and recite the ABCs. Sleep affects everything.

The following ideas are of value to almost any sleeper, of any age. These tips can bring improvement not only in your child's sleep, but also in her daytime mood and last, but not least - improvements in your own sleep and outlook as well.

# 1 Maintain a consistent bedtime and awaking time

Your child's biological clock has a strong influence on her wakefulness and sleepiness. When you establish a set time for bedtime and wake up time you "set" your child's clock so that it functions smoothly.

Aim for an early bedtime. Young children respond best with a bedtime between 6:30 and 7:30 P.M. Most children will sleep better and longer when they go to bed early.

# 2 Encourage regular daily naps

Daily naps are important. An energetic child can find it difficult to go through the day without a rest break. A nap-less child will often wake up cheerful and become progressively fussier or hyper-alert as the day goes on. Also, the length and quality of naps affects night sleep - good naps equal better night sleep.

# 3 Set your child's biological clock

Take advantage of your child's biology so that he's actually tired when bedtime arrives. Darkness causes an increase in the release of the body's sleep hormone -- the biological "stop" button. You can align your child's sleepiness with bedtime by dimming the lights during the hour before bedtime.

Exposing your child to morning light is pushing the "go" button in her brain - one that says, "Time to wake up and be active." So keep your mornings bright!

# 4 Develop a consistent bedtime routine

Routines create security. A consistent, peaceful bedtime routine allows your child to transition from the motion of the day to the tranquil state of sleep.

An organized routine helps you coordinate the specifics: bath, pajamas, tooth-brushing. It helps you to function on auto-pilot at the time when you are most tired and least creative.

# 5 Create a cozy sleep environment

Where your child sleeps can be a key to quality sleep. Make certain the mattress is comfortable, the blankets are warm, the room temperature is right, pajamas are comfy, and the bedroom is welcoming.

# 6 Provide the right nutrition

Foods can affect energy level and sleepiness. Carbohydrates can have a calming effect on the body, while foods high in protein or sugar generate alertness, particularly when eaten alone. A few ideas for pre-bed snacks are: whole wheat toast and cheese, bagel and peanut butter, oatmeal with bananas, or yogurt and low-sugar granola.

Vitamin deficiencies due to unhealthy food choices can affect a child's sleep. Provide your child with a daily assortment of healthy foods.

# 7 Help your child to be healthy and fit

Many children don't get enough daily physical activity. Too much TV watching and a lack of activity prevents good sleep. Children who get ample daily exercise fall asleep more quickly, sleep better, stay asleep longer, and wake up feeling refreshed.

Avoid activity in the hour before bedtime though, since exercise is stimulating - they'll be jumping on the bed instead of sleeping in it!

# 8 Teach your child how to relax

Many children get in bed but aren't sure what to do when they get there! It can help to follow a soothing pre-bed routine that creates sleepiness. A good pre-bed ritual is story time. A child who is listening to a parent read a book or tell a tale will tend to lie still and listen. This quiet stillness allows him to become sleepy.

Used with permission from Elizabeth Pantley, author of The No-Cry Sleep Solution for Toddlers and Preschoolers (McGraw-Hill 2005)

Page last modified or reviewed by athealth on February 4, 2014.

In our society food is a part of almost every activity: watching TV, sports events, weddings, funerals, parties, holidays, business meetings, play dates, basically any social get together has become an excuse to wheel out the food.

Emotional eating happens any time you eat not because you are physically hungry but because you have feelings of boredom, depression, loneliness, fear, anger or frustration. Eating takes your mind off the feelings. Eating comforts you. Eating in response to emotions and not hunger can result in overeating, unwanted weight gain, health problems and even greater stress. Be aware of what triggers your eating, and if you reach for food when stressed, consider the following:

• Keep a food diary. In your diary record data under these column headings: time, place, food eaten, amount, and your feelings. Identifying any stress, negative thoughts or emotions you're having at the time will help you determine why you are eating.
• Identify patterns of emotional eating. Many people find that overeating tends to occur at specific times and in specific places. For instance, you may overeat in front of the TV in the evening after a stressful day.
• Plan alternatives and change routines. Instead of sitting down in front of the TV with a bag of chips after a stressful day you could take a walk, take a long bath, call a friend, write in a journal, or read a book. Do something that removes you from the situation that results in overeating.
• Remove tempting foods. Don't buy the foods you crave when stressed! Having them in your house or desk is a disaster waiting to happen. If you really want to watch a favorite TV show in the evening, have nutritious low-calorie foods on hand. Better yet, find something to occupy your hands while you watch: give yourself a manicure, iron clothes or exercise.
• Know when and how to give in. It's all right to occasionally give in to cravings. When you really do want to eat chips, buy a single serving instead of a whole bag, or take a small portion out of the bag, put in a small cup, and put the bag away before you eat.
• When you eat, focus on the task at hand. Do not watch TV or read. Sit down at the table and leave when you are finished. Consciously eat slowly to give your stomach time to tell your brain when it's full. If you're still hungry after finishing your meal, wait 20 minutes before having a second helping or dessert.
• Plan nutritious meals and snacks. If you wait until you are ravenous, you're more likely to reach for the wrong foods and to overeat. You may also find yourself nibbling all the way through meal preparation.
• Reward yourself when you eat in a healthy way. Buy yourself a novel or a new journal, go see a movie or get a massage. Rewarding yourself will increase the likelihood that you will maintain your new healthy habits.
• Make "The Healthy Refrigerator," otherwise known as you can't eat the wrong food if you don't stock it. One of the easiest ways to ensure healthier eating is to periodically clean out the refrigerator and get rid of all the junk... the junk food, that is.

Making dietary changes, and especially those centered on emotional eating, is tough. Changing eating habits that have been ingrained for years takes time. Take it one meal and one day at a time. You will be successful in combating overweight, obesity, and stress when you combine both diet and exercise. Treat the whole you and you will feel better about yourself.

Adapted from The Stress Owner's Manual: Meaning, Balance & Health in Your Life (2nd Ed.), by Ed Boenisch, Ph.D., and C. Michele Haney, Ph.D. Available at online and local bookstores or directly from Impact Publishers, PO Box 6016, Atascadero, CA 93423-6016, by phone at 1-800-246-7228, or www.bibliotherapy.com.

Page last modified or reviewed by athealth on January 29, 2014

How do you define intimacy?

Intimacy is the feeling that your partner and you really get each other. It is a closeness that breeds security, understanding, and romance. Think of it as "real love" rather than "in love" (which is temporary insanity).

Remember that sex is only a small part of an intimate relationship. Couples can learn to reverse the negative effects of too little intimacy by finding ways to eliminate bad behaviors and by creating new behaviors with an open-to-intimacy attitude. Ask each other exactly what intimacy means to you and what you need from your mate to feel more of it. From a gentle caress to an overflowing heart, the art of intimacy always begins with the desire to be as close as humanly possible.

What is the difference between interdependence and codependence?

Codependence is most easily described and "neediness". Interdependence is how you relate when you love someone enough to let him or her be who they really are and don't feel threatened by it.

Focusing on integrating continuous positive behaviors into your overall lifestyle is paramount to maintaining a good and loving connection. Codependents find it difficult to cope with major but common challenges, like finances, kids, and even illness. Once you incorporate relationship enhancing techniques, and move closer to interdependence, your issues will become more manageable and your connection deeper.

How can interdependence increase intimacy in a relationship?

When you are loved because you are wanted versus needed, it is empowering rather than burdensome. We all need emotional support, but generally we are more attracted to someone who has good self-esteem and enjoys his or her life than to a person who needs to be emotionally taken care of.

Keeping a relationship balanced is also key to keeping it on track. Once couples begin to get back on course romantically, they need to remember that maintaining a satisfying relationship requires regular attention and upkeep in all areas. Truth is that all it really takes is ten minutes a day to check in with your partner. Just as a successful physical fitness program requires a lifelong commitment, when it comes to emotional fitness, it's impossible to overstate the importance of regular relationship maintenance.

Can you explain what you mean by saying that there are cat people and bunny people?

Cat people like to take naps and lounge in the sun while bunny people are happiest when they are out and about going, going, and going. The interesting thing is that the two combined can make for a great relationship because they balance each other out.

Although love is the bedrock of romantic relationships, it is only a part of what makes a relationship great. What most couples don't understand about love is that it doesn't exist in a vacuum, nor does it stay alive simply because we say the words "I love you." Love requires that you take action and do things for and with your partner that show you care. Having differences makes a relationship interesting and it gives you more to talk about. Even if you don't agree, as long as you're not disagreeable, a little razor-sharp repartee can be fun and even sexy.

Do you have any recommendations in your book for couples with children?

You mean in addition to putting a dead-bolt lock on the bedroom door? Yes, of course. Many couples begin to experience a loss of intimacy as soon as they start having children, so the importance of keeping the closeness is even more profound.

Flowers and dinners out are commonplace at the beginning of a relationship, but it is surprising to learn how few couples recognize the importance of keeping romance alive throughout their lives, even when the novelty or the desire to impress is long gone. Truth be told, a relationship done right is romantic. Just follow your heart and don't ignore your feelings or needs.

How can people whose partners have lost their jobs in the recent economic downturn be supportive?

First, refrain for blaming, shaming or complaining; your partner feels bad enough right now. Spend your energy working together to make a plan. As your partner is looking for a new job, you can also look at what expenses you can cut and perhaps how to bring in a little extra money with something part-time or together creating a small, home-based business.

While talking through problems doesn't always take away the pain, communicating gently and effectively can help couples avoid the pitfalls that cause unnecessary issues from surfacing in the first place. Most successful couples share certain behaviors, skills, and practices, and the most essential of these is good communication. Couples must learn that communicating with each other is the most important thing in their relationship. If you don't take the risk to speak what's in your heart, it will become too heavy; your true feelings will leak out, and this usually happens in inappropriate ways.

You recommend that couples discuss their finances together - what can this do to deepen intimacy?

Actually, dealing with adversity as a couple is a bonding experience. Money issues are the number one reason couples break up, so learning how to talk about them and deal with finances as a team is paramount to maintaining an emotionally fit relationship.

Fulfillment comes from building the life you have dreamed of. To create a great and loving relationship, you first need a strong foundation. Making sure that the cornerstones of your life are solid will give you the ability to weather the storms of real life. When money stress surfaces people can't be as intimate as they would like, so getting those financial issues handled or at least out of the closet is very important to maintaining a close relationship.

One of your chapters is called "Relationships are about Running Errands." What do you mean by that, and why is it important for couples to do little things together?

Most of our time is not spent at The Ritz; it's spent at Target. Having someone take on the task of living along with you makes it easier and even a little fun. If you feel that you are doing all the legwork in your relationship, it's going to cause some resentment, and it certainly won't make you feel intimate. Sharing in the daily grind makes your life a little sweeter because you know you are not alone or being taken for granted.

The key is that seemingly little things can make an astonishingly big difference. A cup of coffee, a text message, or a spontaneous romantic kiss will work. Follow your heart (and your partner's lead) and commit to making intimacy a part of your daily life.

Reprinted with permission by New Harbinger Publications, Inc.
Emotional Fitness for Intimacy by Barton Goldsmith

PhD Page last modified or reviewed by athealth on February 4, 2014.

How Shielding an Addict Can Harm You

Enabling is shielding an addicted individual from the costs of addiction. This shielding changes the cost-benefit analysis by lowering the costs and thereby lowering the addict's motivation to change.

Ironically, enabling is typically a well-intentioned effort to be helpful to the addicted individual. These well-intentioned efforts can take many forms, including making excuses for the individual to others, performing the individual's responsibilities, financially supporting the individual, staying around and accepting abuse or neglect so as not to let the individual be lonely, and similar activities.

In an ideal world, partners and families and friends might immediately distance themselves from addictive behavior. However, many times the addicted individual is still relied on, and distancing is not easy. A classic example is the woman with children who has not been previously employed outside the home, and who relies for financial support solely on her addicted and abusive but still employed husband. In this case shielding him from the consequences of his actions (like getting fired) is also shielding herself. We can understand why she might call the boss to say his Monday morning hangover is a cold!

If you are involved with an addicted individual, become as independent of the individual as you can, develop new support systems for yourself, and to the extent feasible let the costs of addiction fall on the individual, not yourself. If distancing yourself (or even departing) from the relationship becomes desirable and feasible, recognize that this cost may or may not be motivating to the individual. Decide to distance yourself or not by what it will do for you, not what it might do for the individual.

Adapted from Sex, Drugs, Gambling, & Chocolate: A Workbook for Overcoming Addictions (2nd Ed.), by Dr. A. Thomas Horvath. Available at online and local bookstores or directly from Impact Publishers, PO Box 6016 , Atascadero , CA 93423-6016 , www.bibliotherapy.com or phone 1-800-246-7228.

Page last modified or reviewed by athealth on January 29, 2014

Planning for End-of-Life Care Decisions

Because of advances in medicine, each of us, as well as our families and friends, may face many decisions about the dying process. As hard as it might be to face the idea of your own death, you might take time to consider how your individual values relate to your idea of a good death. By deciding what end-of-life care best suits your needs when you are healthy, you can help those close to you make the right choices when the time comes. This not only respects your values, but also allows those closest to you the comfort of feeling as though they can be helpful.

There are several ways to make sure others know the kind of care you want when dying.

TALKING ABOUT END-OF-LIFE WISHES

The simplest, but not always the easiest, way is to talk about end-of-life care before an illness. Discussing your thoughts, values, and desires will help people who are close to you to know what end-of-life care you want. For example, you could discuss how you feel about using life-prolonging measures or where you would like to be cared for. For some people, it makes sense to bring this up at a small family gathering. Others may find that telling their family they have made a will (or updated an existing one) provides an opportunity to bring up this subject with other family members. Doctors should be told about these wishes as well. As hard as it might be to talk about your end-of-life wishes, knowing your preferences ahead of time can make decision making easier for your family. You may also have some comfort knowing that your family can choose what you want.

On the other hand, if your parents are aging and you are concerned about what they want, you might introduce the subject. You can try to explain that having this conversation will help you care for them and do what they want. You might start by talking about what you think their values are, instead of talking about specific treatments. Try saying something like, "when Uncle Walt had a stroke and died, I thought you seemed upset that his kids wanted to put him on a respirator." Or, "I've always wondered why Grandpa didn't die at home. Do you know?" Encourage your parents to share the type of care they would choose to have at the end of life, rather than what they don't want. There is no right or wrong plan, only what they would like. If they are reluctant to have this conversation, don't force it, but try to bring it up again at a later time.

ADVANCE DIRECTIVES AND OTHER DOCUMENTS

Written instructions letting others know the type of care you want if you are seriously ill or dying are called advance directives. These include a living will and health care power of attorney. A living willrecords your end-of-life care wishes in case you are no longer able to speak for yourself. You might want to talk with your doctor or other health care provider before preparing a living will. That way you will have a better understanding of what types of decisions might need to be made. Make sure your doctor and family have seen your living will and understand your instructions.

Because a living will cannot give guidance for every possible situation, you probably want to name someone to make care decisions for you if you are unable to do so for yourself. You might choose a family member, friend, lawyer, or someone in your religious community. You can do this either in the advance directives or through a durable power of attorney for health care that names ahealth care proxy, who is also called a representative, surrogate, agent, or attorney-in-fact. "Durable" means it remains in effect even if you are unable to make decisions. A durable power of attorney for health care is useful if you don't want to be specific—if you would rather let the health care proxy evaluate each situation or treatment option independently. A durable power of attorney for health care is also important if your health care proxy, the person you want to make choices for you, is not a legal member of your family. Of course, you should make sure the person and alternate(s) you have named understand your views about end-of-life care. If you don't name someone, the state you live in probably has an order of priority based on family relationships to determine who decides for you. A few states let people name a health care proxy by telling their doctor, without paperwork.

Don't confuse a durable power of attorney for health care with adurable power of attorney. The first is limited to decisions related to health care, while the latter covers decisions regarding property or financial matters.

A lawyer can prepare these papers, or you can do them yourself. Forms are available from your local or State government, from private groups, or on the Internet. (See To Learn More below.) Often these forms need to be witnessed. That means that people who are not related to you watch as you sign and date the paperwork and then sign and date it themselves as proof that the signature is indeed yours. Make sure you give copies to your primary doctor and your health care proxy. Have copies in your files as well. Hospitals might ask for a copy when you are admitted, even if you are not seriously ill.

Sometimes people change their mind as they get older or after they become ill. Review the decisions in your advance directives from time to time and make changes if your views or your health needs have changed. Be sure to discuss these changes with your health care proxy and your doctor. Replace all copies of the older version with the updated ones, witnessed and signed if appropriate.

You should also give permission to your doctors and insurance companies to share your personal information with your health care proxy. This lets that person discuss your case with your doctor and handle insurance issues that may come up.

Do you live in one state, but spend a lot of time in another? Maybe you live in the north and spend winter months in a southern state. Or possibly your children and grandchildren live in a different state and you visit them often. Because states' rules and regulations may differ, make sure your forms are legal in both your home state and the state you travel to often. If not, make an advance directive with copies for that state also. And make sure your family there has a copy.

To Learn More

About Advance Directives and Living Wills:

• American Bar Association
  www.americanbar.org
  1-800-285-2221 (toll-free)
• Caring Connections
  (National Hospice and Palliative Care Organization)
  www.caringinfo.org
  1-800-658-8898 (toll-free)
• MedlinePlus.gov
  www.medlineplus.gov, go to: Advance Directives
• National Cancer Institute
  www.cancer.gov
  1-800-422-6237 (toll-free)

Publication Date: September 2012
Page Last Updated: June 26, 2013

Reviewed by athealth.com on February 4, 2014

When a patient's health care team determines that the cancer can no longer be controlled, medical testing and cancer treatment often stop. But the patient's care continues. The care focuses on making the patient comfortable. The patient receives medications and treatments to control pain and other symptoms, such as constipation, nausea, and shortness of breath. Some patients remain at home during this time, while others enter a hospital or other facility. Either way, services are available to help patients and their families with the medical, psychological, and spiritual issues surrounding dying. A hospice often provides such services.

The time at the end of life is different for each person. Each individual has unique needs for information and support. The patient's and family's questions and concerns about the end of life should be discussed with the health care team as they arise.

The following information can help answer some of the questions that many patients, their family members, and caregivers have about the end of life.

• How long is the patient expected to live?

Patients and their family members often want to know how long a person is expected to live. This is a hard question to answer. Factors such as where the cancer is located and whether the patient has other illnesses can affect what will happen. Although doctors may be able to make an estimate based on what they know about the patient, they might be hesitant to do so. Doctors may be concerned about over- or under-estimating the patient's life span. They also might be fearful of instilling false hope or destroying a person's hope.

• When caring for the patient at home, when should the caregiver call for professional help?

When caring for a patient at home, there may be times when the caregiver needs assistance from the patient's health care team. A caregiver can contact the patient's doctor or nurse for help in any of the following situations:

• The patient is in pain that is not relieved by the prescribed dose of pain medication;
• The patient shows discomfort, such as grimacing or moaning;
• The patient is having trouble breathing and seems upset;
• The patient is unable to urinate or empty the bowels;
• The patient has fallen;
• The patient is very depressed or talking about committing suicide;
• The caregiver has difficulty giving medication to the patient;
• The caregiver is overwhelmed by caring for the patient, or is too grieved or afraid to be with the patient; or
• At any time the caregiver does not know how to handle a situation.

• What are some ways that caregivers can provide emotional comfort to the patient?

Everyone has different needs, but some emotions are common to most dying patients. These include fear of abandonment and fear of being a burden. They also have concerns about loss of dignity and loss of control. Some ways caregivers can provide comfort are as follows:

• Keep the person company - talk, watch movies, read, or just be with the person.
• Allow the person to express fears and concerns about dying, such as leaving family and friends behind. Be prepared to listen.
• Be willing to reminisce about the person's life.
• Avoid withholding difficult information. Most patients prefer to be included in discussions about issues that concern them.
• Reassure the patient that you will honor advance directives, such as living wills.
• Ask if there is anything you can do.
• Respect the person's need for privacy.

• What are the signs that death is approaching? What can the caregiver do to make the patient comfortable?

Certain signs and symptoms can help a caregiver anticipate when death is near. They are described below, along with suggestions for managing them. It is important to remember that not every patient experiences each of the signs and symptoms. In addition, the presence of one or more of these symptoms does not necessarily indicate that the patient is close to death. A member of the patient's health care team can give family members and caregivers more information about what to expect.

• Drowsiness, increased sleep, and/or unresponsiveness.

The caregiver and family members can plan visits and activities for times when the patient is alert. It is important to speak directly to the patient and talk as if the person can hear, even if there is no response. Most patients are still able to hear after they are no longer able to speak. Patients should not be shaken if they do not respond.

• Confusion about time, place, and/or identity of loved ones; restlessness; visions of people and places that are not present; pulling at bed linens or clothing (caused in part by changes in the patient's metabolism). Gently remind the patient of the time, date, and people who are with them. If the patient is agitated, do not attempt to restrain the patient. Be calm and reassuring. Speaking calmly may help to re-orient the patient.
• Decreased socialization and withdrawal (caused by decreased oxygen to the brain, decreased blood flow, and mental preparation for dying).

Speak to the patient directly. Let the patient know you are there for them. The patient may be aware and able to hear, but unable to respond. Professionals advise that giving the patient permission to "let go" can be helpful.

• Decreased need for food and fluids, and loss of appetite (caused by the body's need to conserve energy and its decreasing ability to use food and fluids properly).

Allow the patient to choose if and when to eat or drink. Ice chips, water, or juice may be refreshing if the patient can swallow. Keep the patient's mouth and lips moist with products such as glycerin swabs and lip balm.

• Loss of bladder or bowel control (caused by the relaxing of muscles in the pelvic area).

Caregivers can consult a member of the patient's health care team about the need to insert a catheter to avoid blockage. A member of the health care team can teach the caregiver how to take care of the catheter if one is needed.

• Skin becomes cool to the touch, particularly the hands and feet; skin may become bluish in color, especially on the underside of the body (caused by decreased circulation to the extremities).

Blankets can be used to warm the patient. Although the skin may be cool, patients are usually not aware of feeling cold. Caregivers should avoid warming the patient with electric blankets or heating pads, which can cause burns.

• Rattling or gurgling sounds while breathing, which may be loud; breathing that is irregular and shallow; decreased number of breaths per minute; breathing that alternates between rapid and slow (caused by congestion from decreased fluid consumption, a buildup of waste products in the body, and/or a decrease in circulation to the organs).

Breathing may be easier if the patient's body is turned to the side and pillows are placed beneath the head and behind the back. Although labored breathing can sound very distressing to the caregiver, gurgling and rattling sounds do not cause discomfort to the patient. An external source of oxygen may benefit some patients. If the patient is able to swallow, ice chips also may help. In addition, a cool mist humidifier may help make the patient's breathing more comfortable.

• Turning the head toward a light source (caused by decreasing vision).

Leave soft, indirect lights on in the room.

• Increased difficulty controlling pain(caused by progression of the disease).

It is important to provide pain medications as the patient's doctor has prescribed. The caregiver should contact the doctor if the prescribed dose does not seem adequate. With the help of the health care team, caregivers can also explore methods such as massage and relaxation techniques to help with pain.

• Involuntary movements (called myoclonus), changes in heart rate, and loss of reflexes in the legs and arms are additional signs that the end of life is near.
• What are the signs that the patient has died?

• There is no breathing or pulse.
• The eyes do not move or blink, and the pupils are dilated (enlarged). The eyelids may be slightly open.
• The jaw is relaxed and the mouth is slightly open.
• The body releases the bowel and bladder contents.
• The patient does not respond to being touched or spoken to.

• What needs to be done after the patient has died?

After the patient has passed away, there is no need to hurry with arrangements. Family members and caregivers may wish to sit with the patient, talk, or pray. When the family is ready, the following steps can be taken.

• Place the body on its back with one pillow under the head. If necessary, caregivers or family members may wish to put the patient's dentures or other artificial parts in place.
• If the patient is in a hospice program, follow the guidelines provided by the program. A caregiver or family member can request a hospice nurse to verify the patient's death.
• Contact the appropriate authorities in accordance with local regulations. If the patient has requested not to be resuscitated through a Do-Not-Resuscitate (DNR) order or other mechanism, do not call 911.
• Contact the patient's doctor and funeral home.
• When the patient's family is ready, call other family members, friends, and clergy.
• Provide or obtain emotional support for family members and friends to cope with their loss.

• What additional resources offer information about end-of-life issues?

The following National Cancer Institute (NCI) resources are available by calling the Cancer Information Service (CIS) (see below) at 1-800-4-CANCER (1-800-422-6237). They can also be accessed on the NCI's Web site at http://www.cancer.gov/cancer_information/coping/ by clicking on the title under "End-of-Life Issues."

• The NCI fact sheet Hospice provides information about hospice care and includes contact information for hospice organizations.
• Advance Directives is an NCI fact sheet that discusses a patient's rights regarding medical treatment.
• The NCI fact sheet Home Care for Cancer Patients provides information and resources related to home care services.
• The NCI booklet Advanced Cancer: Living Each Day provides practical support to cancer patients, families, and friends.
• PDQ® supportive care summaries on loss, grief, and bereavement.

National Cancer Institute
Date reviewed: 10/30/2002

Reviewed by athealth on February 4, 2014.

The 2005 Dietary Guidelines recommend finding your balance between food and physical activity. Consuming more calories than you expend leads to weight gain. More than half of all Americans don't get the recommended amount of physical activity. To reduce the risk of chronic disease in adulthood, engage in at least 30 minutes of moderate activity a day on most days of the week. Children and adolescents should engage in at least 60 minutes a day on most, and preferably all, days of the week.

To manage body weight and prevent gradual weight gain, people should exercise about 60 minutes at a moderate to vigorous intensity on most days of the week, while not exceeding recommendations for caloric intake. Sixty to 90 minutes may be needed to maintain weight loss.

The more vigorous the activity and the longer the duration, the more health benefits you'll get. But every little bit counts. Here are some examples of easy ways to work exercise into your day:

• Take a 10-minute walk after breakfast, lunch, and dinner to reach the goal of 30 minutes per day.
• Park your car in the farthest spot when you run errands.
• Take a family walk after dinner.
• Walk your dog.
• Do yard work.
• Wash your car by hand.
• Pace the sidelines at kids' athletic games.
• Ask a friend to exercise with you.
• Run around and play with your children for 30 minutes a day.
• Walk briskly at the mall.
• Take the stairs instead of the elevator.
• Do sit-ups or lift weights in front of the TV.

Source: FDA Consumer Magazine
Adapted from HHS Small Steps program
Date: May-June 2005 Issue

Reviewed by athealth on February 4, 2014.