First-line therapy: Educate patients so that they understand that KP is not curable and that any therapeutic option only minimizes but does not eradicate the clinical lesions. Long-term management improves and maintains the cosmetic appearance of skin lesions and interventions to reduce inflammation are outlined below.
- A mild soap (e.g., Dove) or a soapless cleanser (e.g., Cetaphil, Cerave) should be used with a mild exfoliating scrub pad or washcloth. This treatment will gradually remove follicular plugs (over several weeks) and prevent new ones from emerging.
- Salicylic acid 6% lotion (e.g., Keralyt gel) should be applied q.h.s. or after bathing. This therapy is particularly effective when used in conjunction with mechanical exfoliation (see above).
- Urea creams or lotions in concentrations of 10 to 20% (e.g., Carmol) may be effective, and can be tolerated by many patients with atopic dermatitis.
- Ammonium lactate 12% lotion (e.g., LacHydrin or Amlactin) applied once daily after bathing is also effective for KP. It may be combined with urea.
- Individuals with atopic disease tend to tolerate high concentrations of lactic acid (>5%) without some adjunctive therapy to control their atopic condition. Alternatively, lower concentrations of lactic acid or combinations of lactic acid and urea may be considered.
- There is evidence that ointment-based emollients (such as petrolatum or Aquaphor ointment) may be sufficient to improve the cosmetic appearance of KP.
- Topical medium strength corticosteroids (e.g., triamcinolone 0.1% lotion, cream, or ointment) or tacrolimus 0.1% ointment (e.g., Protopic) may be effective in KP associated with atopic dermatitis, but are best utilized for flares of inflammatory KP and not for chronic use.
- If highly inflammatory lesions are present, an empiric trial of erythromycin or dicloxacillin 250 mg q.i.d. for 10 days may reduce erythema and pustule formation.
- After the keratinous plugs have been removed, use of an emollient cream containing 20% urea (Carmol) may prevent reappearance of lesions.
- Use of the abrasive scrub pad should be resumed at the first sign of reappearance of crops of new lesions.
- Patient education on gentle skin care, including discussion of bathing, mild soaps, and lubrication also should be taught; KP is almost invariably associated with xerosis, and xerosis may, in fact, predispose to exacerbations of KP. (See handout Skin Care in Atopic Dermatitis.)
When to refer to a dermatologist
- If the diagnosis of KP is not clear
- For severe facial involvement
- For widespread involvement of KP, or for management of generalized atopic dermatitis in the setting of KP