Investigating the Research and Potential of Applying Osteopathic Manipulative treatments and Principles for Atopic Dermatitis

Introduction

Eczema, commonly known as atopic dermatitis (AD), affects approximately 101.27 million adults and 102.78 million children globally, and can have a significant impact on the lifestyle of those who experience it.⁶ Traditional allopathic treatments such as corticosteroids come with risk if instructions pertaining to usage are not followed diligently. There is a risk for steroid addiction and Topical steroid withdrawal.⁷ Other treatments such as injectable dupilumab (Dupixent) can be quite costly and unattainable for the majority of the population.⁸ Osteopathic treatments can offer an alternative that is more cost effective and safe.⁹ Such treatments do not require medication and are done with manual manipulative techniques such as craniosacral therapy, myofascial release and lymphatic drainage.¹⁰ The purpose of this review is to investigate the research and potential of applying osteopathic manipulative treatments (OMT) and principles for atopic dermatitis (AD).

Literature Review

Eczema, commonly referred to as AD, is a chronic and relapsing inflammatory disease that causes dry, itchy skin prone to infection.¹¹ It often begins in infancy and typically resolves before adolescence, though some individuals experience symptoms into their teenage years and adulthood, with many developing the condition for the first time as adults.¹² Known as the "itch that rashes," AD causes a rash when scratched or rubbed, leading to thickened skin and an impaired barrier susceptible to irritants and allergens.¹¹ This condition has profound and multifaceted impacts, deeply affecting children, teenagers, adults, and financial stability.¹³ Several factors can contribute to the development of AD, including an individual's lifestyle, diet, genetics, an overactive immune system, and environmental influences.^14,15 Despite its long history, dating back to 69-140 CE, there is still no known cure.¹⁶

Impact of AD on Children

Childhood chronic diseases like epilepsy and cerebral palsy can be as comparable as the effect that AD has on children.¹⁷ Data on 4,082 children with the condition was identified in a review by Olsen et al , concluding that on average, AD has a moderate effect on health-related Quality of Life (QOL ).¹⁸

Impact of AD on Teens and Adolescents

Adolescence and the teenage years can be challenging as it is an important developmental stage in life.¹⁹ Adding the burden of eczema during this time can make these years even more difficult. Among friends and at school, adolescents with AD are often more vulnerable to bullying and comments about their skin from peers.²⁰ This can lead to social isolation due to embarrassment, increasing their risk of depression and lowering self-esteem.²¹ The itching, pain, and stinging associated with AD can significantly impact daily activities, limiting clothing choices, participation in sports and hanging out with friends. ²²

Impact of AD on Adults

In a European study done by J Ring et al, participants experienced depressive symptoms and were emotionally burdened by feelings such as the need to "hide the eczema" and guilt about their condition. ²³ In severe cases, AD was noted to impair their ability to cope with life. Other issues related to AD include challenges with intimacy, choosing a partner, and making future decisions about having children. ⁵

Economic Burden

Due to the immense growing prevalence of AD, there is an economic burden. Amongst the adult population there is a greater burden due to the necessity of paying for their own healthcare. AD is estimated to cost over $5 billion annually, encompassing both direct and indirect expenses.²⁴ Direct costs include prescription medications, healthcare provider visits, transportation and hospitalization.²⁴ Indirect costs involve career adjustments missed days at work or school, and a diminished quality of life.²⁴

Costs for Families

AD entails substantial financial costs especially for out-of-pocket expenses.¹ Data on out-of- pocket expenses for AD management was obtained in a review done by Begolka et al. That review contained results from a 25-question voluntary online survey distributed to the National Eczema Association members plus other individuals with AD and non-affected family members worldwide.¹ Out of pocket expense were indicated in 3 categories, 1) nonprescription healthcare products: moisturizers (94.3%), hygiene products (85.0% ), allergy medications (75.1% ), itch relievers (68.25%), dietary supplements (52.2% ), and sleep aids (37.0%); 2) complementary approaches: cleaning products (74.7%), clothing/bedding (44.8%), alternative medications (19.0%), and adjunctive therapies (15.9%); 3)healthcare providers and prescriptions: healthcare providers and prescriptions, including visit deductibles (68.7%), prescription co-pays (64.3%), and prescriptions not covered by insurance (48.6%).¹

Common Treatments

Although there is no cure for AD, there are several commonly used treatments available. Just to list a few are antihistamines, immunosuppressants and prescription injectables.²⁵ The most commonly prescribed medications for AD are topical corticosteroids/steroids.²⁴ When the skin is inflamed and itchy this topical cream “applied to the skin” can be effective in reducing inflammation as well as itching.²⁴ It is important to note that there are over thirty different topical steroids which come in a variety of potency (strength of their effect). Categorized into four groups from lowest potency to highest include the following: hydrocortisone and prednisolone; prednicarbate, triamcinolone and methylprednisolone; bethaspone and mometasone, and clobetaso. 26

The major issue with using topical steroids is the need to meticulously follow specific instructions and guidelines to ensure their effectiveness and safety.²⁶ Key factors include the method of application, the type of steroid product used, the area of skin being treated, and the dosage used.²⁶ Errors in dosage, in particular, can lead to reduced efficacy and increased risk of side effects.²⁶ If steroid medications are used in too high doses, too often and for too long the skin may thin, there will be changes in pigmentation of the skin and blisters.²⁶

Use in Pregnancy

The use of topical steroids in pregnancy is generally safe, however it is important to note that the baby does not come in contact with the medication. ²⁶

Topical Steroid Withdrawal (TSW)

TSW also referred to as topical steroid addiction or red skin syndrome is a condition resulting in burning, itching after abruptly discontinuing medium- to high -potency topical corticosteroids following extended use.² When patients are left unsupervised using topical corticosteroids for AD TSW can occur.²

Dupilumab (Dupixent)

Adult patients with moderate to severe AD that is not controlled with topical prescription therapies can use an FDA approved injectable dupilumab (Dupixent).²⁷ Despite this treatment's effectiveness in reducing skin lesions, alleviating pruritus, and mitigating other symptoms of AD, it still can have some drawbacks.²⁸

There is a risk for adverse reactions such as injection-site reactions, keratitis, conjunctivitis, blepharitis, oral herpes or other herpes simplex virus infections, eye pruritus, and dry eyes. To add there is a restriction of the use of live vaccines.²⁹ There is also limited knowledge about how pediatric and geriatric groups may respond.²⁹ The product may be out of reach for financially disadvantaged groups, as the average wholesale price is $3,517.85 for a pack of two prefilled syringes.²⁹ Depending on the patient's age and weight, the first recommended dose of dupilumab consists of two subcutaneous injections (SC) at various injection sites, followed by one injection at varied places every two weeks or every four weeks. ²⁷

Osteopathic Medicine

The Philosophy of Osteopathic Medicine was developed by Andrew Taylor Still in 1874.^30,31 It recognizes that the health of an individual should be looked at through physical, mental, and spiritual components. His belief strongly resided in the fact that musculoskeletal impediments, or somatic dysfunctions, can be treated through manual intervention “using the hands” and respond effectively to osteopathic manipulative treatments. This approach to medicine emphasizes that to deliver comprehensive care for an individual’s health, it is essential to delve deeper beneath the skin.³² The philosophy of osteopathic medicine is grounded in four fundamental tenets as outlined by the American Osteopathic Association (AOA). “1. The body is a unit; the person is a unit of body, mind, and spirit. 2. The body is capable of self-regulation, self-healing, and health maintenance. 3. Structure and function are reciprocally interrelated. 4. Rational treatment is based on understanding the basic principles of body unity, self-regulation, and the interrelationship of structure and function” (American Osteopathic Association, 2024).

AD is an inflammatory disease of the skin that stems from various reasons such as an overactive immune system, genetics and the environment.³³ Other reasons can include a poor diet, high stress, and inactive lifestyle. ^15,34 Osteopathic medicine can be used to promote homeostatic function in the body and alleviate skin symptoms of AD without the need for expensive systemic therapies that may come with risks and side effects.^{32, 35}Some potential osteopathic treatments that could be used for AD include release of cervical muscular tension, myofascial release, soft tissue technique and lymphatic technique.³⁵

This literature review is unique because it delves into osteopathic treatment for AD which has not been explored in sufficient detail to the best of the author’s knowledge and lack of literature found. The objective of the review is to advocate for increased clinical trials spanning diverse age groups and to promote the integration of holistic principles into treatments among non- osteopathic physicians. Because of the highly lacking experimental evidence of osteopathic medicine, two research questions will be answered:

Research Question 1a: Investigating the experimental evidence of osteopathic medicine for Atopic dermatitis

Research Question 1b: Investigating the theoretical evidence of osteopathic medicine for Atopic Dermatitis overall

The objective of these research questions is to gain a deeper understanding of the potential impacts of osteopathic care in an area with very limited existing research. This is why theoretical articles were included as a secondary focus in the research.

Methods: Topical Review

For this review, articles that were included specifically collect data on the effectiveness of osteopathic treatments and theoretical papers that were not secondary reviews. For example, articles discussing how Osteopathic Manipulative Treatment (OMT) should help, and those that provide data to support their claims. The criteria or characteristics the articles had to possess to be included had to specifically mention OMT and inflammatory skin disease or atopic dermatitis. The articles collected were 2 theoretical papers, as well as and 2 case studies and 1 randomized control trial (RCT) that actually assessed the effectiveness of AD. The reason for the inclusion of the theoretical articles was for the lack of research in the field. There were only 3 primary studies found that fit the criteria and the theoretical papers helped provide additional research to why osteopathic medicine may help with atopic dermatitis. Articles selected from Google Scholar and PubMed from March to May of 2024 with no time limit on when published. Keywords used were Osteopathic treatments, Osteopathic Manipulative Medicine, cervical muscular tension, itch scratch cycle, atopic dermatitis, inflammatory skin disease, pruritus. Relevant results were selected to analyze the studies in a chart so the trends could be more clearly seen.

Results

Table 1. Summary of Osteopathic Research on AD

Osteopathic Manipulative Treatments (OMT), SCORing Atopic Dermatitis (SCORAD), Eczema Area and Severity Index (ESAI), Osteopathic Medicine (OM), Acupuncture (ACU), Topical Corticosteroids (TCS).

Of the three studies with data two out of the three studies (66%) suggested effectiveness while the third study indicated that there were no clinically relevant differences in disease severity. For the listed theoretical papers, the use of OMT can improve the imbalance in the body “atopic dermatitis.” Based on the information presented in the theoretical papers both suggest utilizing OMT will work.

Shusaku Hosono et al, 2020

Patient 1, a 24-year-old male, had suffered from AD since infancy. Although he had effectively managed eczema on his face, elbows, and knees with topical corticosteroids in the past, his condition exhibited a cycle of worsening and improvement over time. Throughout the study period, his skin issues became severe and worsened by the stress he experienced at work. Despite using topical corticosteroids, the itching did not get better, and he had trouble sleeping at night.

He showed up with eczema on his neck, which was intensely itchy. OMT helped alleviate his itching, improve his sleep quality, reduce the dermatitis on his neck, and led to better scores on various assessment scales for his condition. Certain biomarkers and physical assessments like TARC (Thymus and activation-regulated chemokine), AEC (Absolute Eosinophil Count), LDH (lactate dehydrogenase) levels, and cervical range of motion showed improvement, although his IgE (Immunoglobulin E) levels did not change.

Patient 2, aged 28, had suffered from widespread AD for over 25 years. By the age of 15, he had discontinued the use of topical treatments, including corticosteroids, due to inadequate relief from itching. He presented with severe itching on his face and oozing crusts on his face, neck, and ear. Following OMT his itching, sleep disturbances, and exudation from affected areas notably improved. Treatment also led to enhancements in his dermatitis, as well as improvements in EASI, sIGA, and DLQI scores, TARC and LDH levels, and cervical range of motion. However, there was no improvement in IgE and AEC levels.

Patient 3, a 46-year-old woman, had endured AD for over four decades. Eczema had affected various parts of her body, including her face, elbows, and the backs of her knees, prompting previous treatment with topical corticosteroids. However, at the age of 25, she was diagnosed with steroid addiction, leading her to discontinue corticosteroid use at age 41 due to persistent itching and eczema.Upon presentation, she exhibited widespread erythematous patches of eczema with intense itching on her back. Following OMT, improvements were observed in her itching, sleep patterns, AD symptoms, as well as scores on assessment scales like EASI, sIGA, and DLQI. Additionally, biomarkers such as TARC, AEC, and LDH levels, along with cervical range of motion, showed enhancement. However, her IgE levels remained unchanged.

Shusaku Hosono et al., 2022

Twenty patients who completed the treatment demonstrated improvement in the symptoms of AD: changes on the visual analog scale (VAS) for pruritus were 44.2%, EASI was 67.9%, thymus and activation-regulated chemokine (TARC) was 56.2%, Hospital Anxiety and Depression Scale (HADS) was 27.2%, sleep disturbance was 49.7%, and Dermatology Life Quality Index (DLQI) was 46.7%. Additionally, the cervical muscle tension improved significantly with changes in cervical ROM at 14.7%.

Gabriele Rotter et al., 2022

Overall, 121 patients (92 women, 29 men) with a mean age of 31.4 and SD of 10.5 years were randomized in various groups (ACU, OMT, and control. After 12 weeks, the adjusted means (95% CI) for ACU, OM and control were:, respectively, 22.3 (18.3–26.3), 26.4 (22.6–30.2) and 23.7 (19.9–27.5) for SCORAD (p= 0.32); 27.9 (19.5–36.4), 35.0 (26.9–43.0) and 42.3 (34.7–50.0) for VAS itching (p< 0.05); and 2.3 (0.8–3.9), 1.9 (0.4–3.5) and 4.3 (2.6–6.0), for TCS use (p = 0.10). ACU and OMT were not cost-effective compared with the control group.

Theoretical 

Alexa R. Leone et al., 2018

“Pediatric Atopic dermatitis: Utilizing OMT as an adjunct treatment,” suggests that atopic dermatitis in the pediatric population is caused due to somatic dysfunction, affecting the skin in conjunction with the immune system, surrounding fascia, lymphatic system and patients’ mental and emotional wellbeing. The paper implies that the following three OMT modalities can be useful in treating atopic dermatitis. Myofascial release can resolve palpable restrictive areas and tissue texture abnormalities in patients. Lymphatic pump release may improve AD as a result of decreasing immune congestion. Soft tissue techniques including effleurage, skin rolling, stretching and petrissage can improve scars, pruritus and pain in patients.

J. Hibler et al., 2003

According to, “Osteopathic Manipulative Medicine for Inflammatory skin diseases,” direct and indirect osteopathic manipulative techniques that alter the flow of lymph and inflammatory mediators can be used to treat inflammatory skin diseases such as eczema by resolving a pathological state. A specific example includes rib raising. Rib raising is a technique used to regulate or decrease autonomic output to blood and lymphatic vessels. This regulation can enhance blood and lymphatic flow to regions experiencing trauma, infection, or stress, thus promoting the healing process. For AD patients this may potentially help reduce inflammation, pruritus and promote healing of stressed skin.

Discussion

Empirical Data

Shusaku Hosono et al.,2020

In this study three patients with moderate to severe AD who did not cope well with the use of corticosteroids had an improvement in itching after 15 sessions of OMT. The patients underwent a treatment to reduce muscular stiffness around the cervical spine with the Spineliner SA201.

The technique was efficacious because it may have promoted lymphatic circulation, normalized blood and therefore aided in the restoration of the balance of autonomic nerves and the enhancement of the autoimmune function of the skin. The improvement is likely due to the reduction of stress and tension in the patient's body. This can be best explained through patient number 1’s situation. His symptoms were acute and exacerbated by work stress. This chronic stress from work likely caused an imbalance in his body promoting inflammation. By reducing tension in his neck muscles using OMT, it promotes better blood circulation and relaxation of the body. As a result, his symptoms of itching and sleep disturbance decreased. This reduction of itching may have promoted the healing of his skin barrier and stopped the itch scratch cycle.

Gabriele Rotter et al., 2022

In this randomized control explorative clinical trial, AD was treated by OMT in obligatory treatments including cervical column, thoracic column, ribs, diaphragm, lungs, intestines, cranial bones and cranial fascia. In the article there was no clear indication of why these techniques were used. To add there were no significant differences in AD severity according to SCORAD or EAsI after osteopathic manipulative treatment with routine care. The key takeaways were that ACU showed clinically relevant improvement in itching and OM resulted in less TCS.

Shusaku Hosono et al., 2022

This article was a case series with 20 patients with moderate to severe atopic dermatitis and done by the same author as the case study with three people above. The Spinliner A201 was used again to relieve cervical muscular tension, which assists in OMT. From the treatment 20 patients had clear improvement of symptoms of AD. Pruritus, a symptom of AD, is triggered by psychological stress and leads to a vicious cycle of scratching and worsening eczema. This scratching causes sleep disturbance and lowers HRQol, further exacerbating the AD. Stress and anxiety stimulate a type 2 helper T-cell immune response promoting the synthesis of IgE. Muscle tension in the neck results from that stress. Therefore, by reducing stress and inflammation in the body using OMT, pruritus reduces and allows the body to regenerate without constant scratching.

Two out of the three data papers clearly support OMT. The case series with 20 patients was promising as it showed that a reduction of cervical muscle tension reduced itching and other atopic symptoms and allergy related markers without the use of treatments such as topical corticosteroids and molecular- targeted drugs. Although they provide an amount of evidence there is still a lack of empirical evidence to strongly support these claims.

Theoretical Papers

Alexa R. Leone et al., 2018 

When AD is assessed through an osteopathic lens, the impact of the chronic illness on a patient's quality of life and overall well-being becomes more apparent. In this paper, AD is looked at as a source of somatic dysfunction in children. This affects not only a child's skin but their immune system, lymphatic system, surrounding fascia and their mental and emotional wellbeing. There is knowledge known about the immunology behind AD but the biomarker for diagnosis of AD is unclear. Usually, IgE levels tend to be elevated, there are reduced T-cell-mediated immunity and T-Lymphocyte subsets, and cytokines and chemokines are altered in AD patients. Direct and indirect techniques done by Osteopathic physicians can be used to restore homeostasis and treat somatic dysfunction. The three OMT modalities that are useful in treating AD include myofascial release, lymphatic pump technique and soft tissue technique. Indicated below are how each technique may work to aid AD patients.

Myofascial release (MFR) disengages the restrictive barrier and places fascial tension in a state of ease, decongesting the lymphatic area. To perform this technique, firstly an area of myofascial strain must be located, and secondly compression or distraction forces should be applied to the somatic dysfunction until the fascia releases and the strain is resolved. It is important to note that there are many palpable restrictive areas and tissue-texture abnormalities in patients with AD. By doing MFR the lymphatic and immune systems of a patient are enhanced and inflammatory mediators are modulated contributing to decreased symptoms of AD theoretically.

The location of an AD flare can be helpful to determine which out of the four physiological diaphragms in the human body should be treated. For example, pediatric patients with AD on the face could benefit from the treatment of thoracic inlet, one of the diaphragms. This would in turn relax tissue restrictions and enhance lymphatic drainage from the head and neck.

Soft tissue techniques like effleurage, used on superficial eczematous plaques or patches, and petrissage, which is more invasive and has been shown to improve itching, pain and anxiety in patients, can relax the surrounding fascia and boost lymphatic flow toward the lymphatic ducts. These methods can improve circulation to local fascial structures, enhance tissue elasticity, increase local nutrition and oxygenation, and improve the local immune response.

Because the skin inflammation from AD is thought to be caused due to a misdirected immune reaction “somatic dysfunction in the body” against harmless antigens. Theoretically, utilizing these techniques for an improved immune response could help AD patients.

J. Hibler et al., 2003

OMT that involves the treatment of inflammatory skin conditions like AD can help resolve a pathological state. These manual treatments have been shown to change the flow of lymph and inflammatory mediators that could be worsening the skin disease. A primary principle of osteopathy states that the body has the capability to self-heal and is capable of homeostasis and health maintenance. OMT such as rib raising can be used to promote the self-healing process of the body. More specifically it can be used to normalize or reduce autonomic output to blood and lymphatic vessels, enhancing blood and lymphatic flow to areas of stress and support the healing process of inflammatory skin diseases.

Based on these findings it could be recommended practitioners use OMT and osteopathic principles to reduce discomfort in patients with AD. Especially for dermatology because based on the theoretical articles it seems reasonable that OMT can alleviate symptoms of AD and other inflammatory skin conditions. However, more research and clinical trials are needed to be done throughout various age groups and amongst patients with varying AD severity to see how efficacious and consistent the results are.

There is very minimal research pertaining to OMT and its impact on AD. This is likely the first literature review on this topic and there is a high probability that this is most of the research about this specific area to the best knowledge of the author.

Limitations 

The current study was conducted to the fullest extent possible given significant challenges, including limited literature and restricted access to comprehensive databases, which narrowed the scope of available research. Due to the lack of evidence supporting research question 1a, an additional research question, 1b, was introduced. The overall scarcity of experimental research made it difficult to establish cause-and-effect relationships. Moreover, the study's small sample size limits its applicability to broader populations and countries. There are also studies on acupuncture, massage, and chiropractic care that are theoretically similar to osteopathy and OMT and the role it may play in helping manage AD. The specific overlaps between these alternative treatments and osteopathy are still unclear. More detailed exploration and examples of these overlaps are needed to better understand the similarities and distinctions, providing a clearer resource for future studies.

Future Directions

More empirical studies are needed as only three empirical studies were found when searched on PubMed and Google Scholar, with two being case studies. When more extensive evidence-based research is performed on how OMT helps AD symptoms, this could incline practitioners and patients to consider OMT as a potentially more cost effective treatment with less side effects due to its noninvasive nature and lack of need for prescriptions.

It is important to note that when researching this area there were various articles on alternative treatments. That is why there is a need for discussion on how alternative medicine and osteopathic medicine overlap. For example, when the current research was being performed on various search platforms such as PubMed and Google Scholar, articles such as “Treatment of Acute Atopic Eczema by Chiropractic Care,” “Influence of Acupuncture on Type I Hypersensitivity Itch and the Wheal and Flare Response in Adults with Atopic Eczema – a blinded, randomized, placebo-controlled, crossover trial”, “Complementary and Alternative Medicine (CAM ) and Atopic Eczema” appeared.

Future research should investigate the role of stress in triggering AD symptoms such as pruritus. Throughout the course of AD patients often endure psychological stress stemming from financial, familial, occupational, academic, and unforeseen challenges. Stress can manifest physically as muscle tension, particularly in the neck area. In the “Release of cervical muscular tension improved severe pruritus in moderate- to- severe atopic dermatitis” case series, one patient reported significant work-related stress, which OMT alleviated by reducing neck tension, subsequently reducing inflammation and itching.³⁶ Combining stress reduction strategies with OMT could potentially benefit future patients, although further research is necessary to support these findings.

Conclusion

Two out of the three empirical studies demonstrated that OMT, specifically targeting cervical muscular tension, reduces AD symptoms in patients. Theoretical articles support these findings by outlining various techniques that could be beneficial. For instance, myofascial release is suggested to enhance the lymphatic and immune systems, modulate inflammatory mediators, and promote the body's self-healing processes.

Given that OMT poses little to no side effects and can be more affordable compared to the constant use of conventional treatments, it should be considered by Doctors of Osteopathic Medicine (DOs) for dermatological issues. Although the amount of research is limited, the findings are promising. Utilizing OMT may carry less risk compared to some traditional allopathic treatments, and further research and clinical trials could strengthen the trust and credibility in its use for treating dermatological conditions.

References

1. Smith Begolka W, Chovatiya R, Thibau IJ, Silverberg JI. Financial Burden of Atopic Dermatitis Out- of-Pocket Health Care Expenses in the United States. Dermatitis. 2021;32(1 Suppl):S62-S70. doi:10.1097/DER.0000000000000715

2.  Mohta A, Sathe NC. Topical Steroid Withdrawal (Red Skin Syndrome). In: StatPearls. StatPearls Publishing; 2024. Accessed July 17, 2024. http://www.ncbi.nlm.nih.gov/books/NBK603718/

3.  Tan SY, Chandran NS, Choi ECE. Steroid Phobia: Is There a Basis? A Review of Topical Steroid Safety, Addiction and Withdrawal. Clin Drug Investig. 2021;41(10):835-842. doi:10.1007/s40261- 021-01072-z

4.  Chovatiya R, Begolka WS, Thibau IJ, Silverberg JI. Impact and Associations of Atopic Dermatitis Out-of-Pocket Health Care Expenses in the United States. Dermatitis. 2022;33(6 Suppl):S43-S51. doi:10.1097/DER.0000000000000795

5.  Misery L, Seneschal J, Corgibet F, et al. Impact of Atopic Dermatitis on Patients and their Partners. Acta Derm Venereol. 2023;103. doi:10.2340/actadv.v103.5285

6.  Tian J, Zhang D, Yang Y, et al. Global epidemiology of atopic dermatitis: a comprehensive systematic analysis and modelling study. Br J Dermatol. 2023;190(1):55-61. doi:10.1093/bjd/ljad339

7.  Ghosh A, Sengupta S, Coondoo A, Jana AK. Topical Corticosteroid Addiction and Phobia. Indian J Dermatol. 2014;59(5):465-468. doi:10.4103/0019-5154.139876

8. Dupilumab (Dupixent): CADTH Reimbursement Recommendation: Indication: For the Treatment of Patients Aged 12 Years and Older with Moderate-to-Severe Atopic Dermatitis Whose Disease Is Not Adequately Controlled with Topical Prescription Therapies or When Those Therapies Are Not Advisable. Canadian Agency for Drugs and Technologies in Health; 2023. Accessed July 17, 2024. http://www.ncbi.nlm.nih.gov/books/NBK601818/

9.  Osteopathic Manipulative Medicine Explained. Default. Accessed July 17, 2024. https://www.aacom.org/become-a-doctor/about-osteopathic-medicine/omm-explained

10.  Campbell SM, Winkelmann RR, Walkowski S. Osteopathic Manipulative Treatment. J Clin Aesthetic Dermatol. 2012;5(10):24-32.

11.  Nemeth V, Syed HA, Evans J. Eczema. In: StatPearls. StatPearls Publishing; 2024. Accessed July 17, 2024. http://www.ncbi.nlm.nih.gov/books/NBK538209/

12.  Abuabara K, Ye M, McCulloch CE, et al. Clinical onset of atopic eczema: Results from 2 nationally representative British birth cohorts followed through midlife. J Allergy Clin Immunol. 2019;144(3):710-719. doi:10.1016/j.jaci.2019.05.040

13.  Campos ALB, de Araújo FM, dos Santos MAL, dos Santos A de AS, Pires CAA. IMPACT OF ATOPIC DERMATITIS ON THE QUALITY OF LIFE OF PEDIATRIC PATIENTS AND THEIR GUARDIANS. Rev Paul Pediatr. 2017;35(1):5-10. doi:10.1590/1984-0462/;2017;35;1;00006

14.  David Boothe W, Tarbox JA, Tarbox MB. Atopic Dermatitis: Pathophysiology. Adv Exp Med Biol. 2017;1027:21-37. doi:10.1007/978-3-319-64804-0_3

15.  Ilaria P, Ersilia T, Nicoletta B, et al. The Role of the Western Diet on Atopic Dermatitis: Our Experience and Review of the Current Literature. Nutrients. 2023;15(18):3896. doi:10.3390/nu15183896

16.  Kramer ON, Strom MA, Ladizinski B, Lio PA. The history of atopic dermatitis. Clin Dermatol. 2017;35(4):344-348. doi:10.1016/j.clindermatol.2017.03.005

17.  ALI F, VYAS J, FINLAY AY. Counting the Burden: Atopic Dermatitis and Health-related Quality of Life. Acta Derm Venereol. 2020;100(12):5766. doi:10.2340/00015555-3511

18.  Olsen JR, Gallacher J, Finlay AY, Piguet V, Francis NA. Quality of life impact of childhood skin conditions measured using the Children’s Dermatology Life Quality Index (CDLQI): a meta-analysis. Br J Dermatol. 2016;174(4):853-861. doi:10.1111/bjd.14361

19.  Christie D, Viner R. Adolescent development. BMJ. 2005;330(7486):301-304.

20.  Neri I, Galli E, Baiardini I, et al. Implications of Atopic Dermatitis on the Quality of Life of 6–11 Years Old Children and Caregivers (PEDI-BURDEN). J Asthma Allergy. 2023;16:383-396. doi:10.2147/JAA.S404350

21.  Rivara F, Menestrel SL, Prevention C on the B and PE of PVL for B, et al. Consequences of Bullying Behavior. In: Preventing Bullying Through Science, Policy, and Practice. National Academies Press (US); 2016. Accessed July 17, 2024. https://www.ncbi.nlm.nih.gov/books/NBK390414/

22.  Snyder AM, Taliercio VL, Brandenberger AU, et al. Atopic Dermatitis: A Qualitative Study on the Burdens of Living with Itchiness. J Clin Aesthetic Dermatol. 2023;16(7):22-25.

23.  Ring J, Zink A, Arents BWM, et al. Atopic eczema: burden of disease and individual suffering - results from a large EU study in adults. J Eur Acad Dermatol Venereol JEADV. 2019;33(7):1331- 1340. doi:10.1111/jdv.15634

24.  Adamson AS. The Economics Burden of Atopic Dermatitis. Adv Exp Med Biol. 2017;1027:79-92. doi:10.1007/978-3-319-64804-0_8

25.  Ross G. Treatments for atopic dermatitis. Aust Prescr. 46(1):9-12. doi:10.18773/austprescr.2023.002

26.  Eczema: Learn More – Steroids and other topical medications. In: InformedHealth.Org [Internet]. Institute for Quality and Efficiency in Health Care (IQWiG); 2021. Accessed July 17, 2024. https://www.ncbi.nlm.nih.gov/books/NBK424899/

27.  Gade A, Ghani H, Patel P, Rubenstein R. Dupilumab. In: StatPearls. StatPearls Publishing; 2024. Accessed July 17, 2024. http://www.ncbi.nlm.nih.gov/books/NBK585114/

28.  Parmar NV, Abdula MA, Al Falasi A, Krishna CV. Long-term real-world experience of the side effects of dupilumab in 128 patients with atopic dermatitis and related conditions aged 6 years and above: Retrospective chart analysis from a single tertiary care center. Dermatol Ther. 2022;35(5):e15415. doi:10.1111/dth.15415

29.  D’Ippolito D, Pisano M. Dupilumab (Dupixent). Pharm Ther. 2018;43(9):532-535.

30.  Hamonet C. Andrew Taylor Still and the birth of osteopathy (Baldwin, Kansas, USA, 1855). Joint Bone Spine. 2003;70(1):80-84. doi:10.1016/s1297-319x(02)00019-2

31.  Tuscano SC, Haxton J, Ciardo A, Ciullo L, Zegarra-Parodi R. The Revisions of the First Autobiography of AT Still, the Founder of Osteopathy, as a Step towards Integration in the American Healthcare System: A Comparative and Historiographic Review. Healthcare. 2024;12(2):130. doi:10.3390/healthcare12020130

32.  Ventura N, Soti V. Integrating Osteopathic Principles for Enhanced Dermatological Outcomes: A Literature Review. Cureus. 16(1):e52665. doi:10.7759/cureus.52665

33.  Branch NSC and O. Atopic Dermatitis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Published April 10, 2017. Accessed July 17, 2024. https://www.niams.nih.gov/health- topics/atopic-dermatitis

34.  Lönndahl L, Abdelhadi S, Holst M, Lonne-Rahm SB, Nordlind K, Johansson B. Psychological Stress and Atopic Dermatitis: A Focus Group Study. Ann Dermatol. 2023;35(5):342-347. doi:10.5021/ad.22.035

35.  Roberts A, Harris K, Outen B, et al. Osteopathic Manipulative Medicine: A Brief Review of the Hands-On Treatment Approaches and Their Therapeutic Uses. Medicines. 2022;9(5):33. doi:10.3390/medicines9050033

36.  Hosono S, Fujita K, Nimura A, Akita K. Release of cervical muscular tension improved severe pruritus in moderate-to-severe atopic dermatitis: A case series. JAAD Case Rep. 2020;6(6):510-513. doi:10.1016/j.jdcr.2020.03.018

37.  Rotter G, Ahnert MW, Geue AV, et al. Acupuncture and osteopathic medicine for atopic dermatitis: a three‐armed, randomized controlled explorative clinical trial. Clin Exp Dermatol. 2022;47(12):2166- 2175. doi:10.1111/ced.15340

38.  Hosono S, Fujita K, Nimura A, Akita K. Release of Cervical Muscle Tension Improves Psychological Stress and Symptoms of Moderate-to-Severe Atopic Dermatitis: a Case Series with 20 Patients. Dermatol Ther. 2022;12(10):2383-2395. doi:10.1007/s13555-022-00814-x

39.  Hibler J, Perkins J, Eland D, Sammons D. Osteopathic Manipulative Medicine for Inflammatory Skin Diseases.

40.  Leone AR, Rowane MP, Lloyd JR. Pediatric Atopic Dermatitis: Utilizing OMT as an Adjunct Treatment.

41.  About osteopathic medicine. Default. (n.d.). https://www.aacom.org/become-a-doctor/about- osteopathic-medicine

42. Leone, Alexa, et al. Pediatric Atopic Dermatitis: Utilizing OMT as an Adjunct Treatment.

43. Hibler, et al. Osteopathic Manipulative Medicine for Inflammatory Skin Diseases.