Letters to the Editor: June 2025

J Clin Aesthet Dermatol. 2025;18(6):6–8.

Systemic Cryotherapy: A Potential Therapeutic Option for Mild to Moderate Atopic Dermatitis

Dear Editor:

Atopic dermatitis (AD), a chronic inflammatory skin disease affecting up to 10 percent of the population, often remains inadequately controlled despite numerous treatment options.1 Itch, skin redness, and poor sleep are among the most bothersome symptoms affecting quality of life.1 Limited effective treatments for AD has prompted some to investigate alternative treatment methods. Skin cooling is believed to have anti-inflammatory effects and can also reduce peripheral nerve conduction velocity, decrease acetylcholine synthesis in nerve ganglia, and lower the levels of inflammatory cytokines, contributing to reduced itch severity.2,3 Piao et al3 demonstrated that cold thermal therapy significantly decreased inflammatory cytokines like IL-4 and IL-5.3 Furthermore, localized application of cryotherapy has shown promise in reducing itch severity in AD, and whole-body cryotherapy may also confer similar benefits.4 The exact mechanism by which cryotherapy alleviates symptoms of AD is unclear, but it may involve anti-inflammatory effects through improved anti-oxidative capacity and higher blood concentrations of anti-inflammatory cytokines.2,5

Systemic/whole-body cryotherapy uses a cryotherapy chamber to expose the whole body to temperatures between -100° and -180° C for short durations.2 To date, there are two scientific published studies that have investigated the effects of whole-body cryotherapy in patients with AD.2,5

In a 2008 study by Klimenko et al,2 18 patients with mild to moderate AD underwent whole-body cryotherapy (3 times a week for 4 weeks) (Table 1). Without topical anti-inflammatories (corticosteroids or calcineurin inhibitors) or antihistamines, treatment significantly improved Scoring of Atopic Dermatitis (SCORAD) index, transepidermal water loss, sleep, and pruritus (all P<0.05). Patients tolerated treatment well and expressed willingness for further sessions.2

A subsequent study of 14 participants with mild to moderate AD was performed by Kepinska-Szyszkowska et al5 in 2020 where patients received whole-body cryotherapy three times a week for one month (15 treatments total). Local anti-inflammatories and systemic antihistamines were also held for the duration of this study. Average overall disease severity measured by the SCORAD index was decreased significantly in this study (p=0.011) after treatment and transepidermal water loss also decreased (p<0.05).5 Improvements were noted immediately after the treatment period and were sustained at three weeks after the last treatment.5

Adverse events related to treatment were minimal across the two studies, with only a few participants reporting mild acral frostbite and dry skin.2,5 Thermal glass and intrachamber monitoring allow an operator to safely monitor patients, and audio communication can be used to notify patients of the length of therapy. Clinicians can enhance safety by installing an alarm button and an internal evacuation system within the chamber.5

A significant limitation of these studies is the lack of adequate follow-up, which makes it challenging to assess the long-term effects and durability of treatment outcomes. Although whole-body cryotherapy shows promise as a treatment option, further research involving larger patient cohorts, extended treatment durations, and control groups is necessary to better understand its impact on AD.

With regard,

Aileen Park, BS; Leo Wan, BA; and Peter Lio, MD

Keywords. Atopic dermatitis, cryotherapy, itch, cooling, therapy, non-pharmacologic

Affiliations. Ms. Park is with the University of Colorado Anschutz School of Medicine in Aurora, Colorado. Mr. Wan is with the West Virginia School of Osteopathic Medicine in Lewisburg, West Virginia. Dr. Lio is with Medical Dermatology Associates of Chicago and the Feinberg School of Medicine at Northwestern University in Chicago, Illinois.

Funding. No funding was provided for this article.

Disclosures. Dr. Lio reports being on the speaker’s bureau for AbbVie, Arcutis, Eli Lilly, Galderma, Hyphens Pharma, Incyte, La Roche-Posay/L’Oreal, Pfizer, Pierre-Fabre Dermatologie, Regeneron/Sanofi Genzyme, Verrica; reports consulting/advisory boards for Alphyn Biologics (stock options), AbbVie, Almirall, Amyris, Arcutis, ASLAN, Astria Therapeutics, Bristol-Myers Squibb, Burt’s Bees, Castle Biosciences, Codex Labs (stock options), Concerto Biosci (stock options), Dermavant, Eli Lilly, Galderma, Janssen, LEO Pharma, Lipidor, L’Oreal, Merck, Micreos, MyOR Diagnostics, Pelthos Therapeutics, Regeneron/Sanofi Genzyme, Sibel Health, Skinfix, Stratum Biosciences (stock options), Soteri Skin (stock options), Theraplex, UCB, Unilever, Verdant Scientific (stock options), Verrica, Yobee Care (stock options). In addition, Dr. Lio has a patent pending for a Theraplex product with royalties paid and is a Board member and Scientific Advisory Committee Member emeritus of the National Eczema Association.

References

  1. National Eczema Association. Eczema stats. 2024. Accessed 14 Aug 2024. https://nationaleczema.org/research/eczema-facts/.
  2. Klimenko T, Ahvenainen S, Karvonen S. Whole-body cryotherapy in atopic dermatitis. Arch Dermatol. 2008;144(6):806–808.
  3. Piao CH, Kim M, Bui TT, et al. Anti-Inflammatory Effects of Cold Thermal Therapy on Allergic Skin Inflammation Induced by Trimellitic Anhydride in BALB/c Mice. Mediators Inflamm. 2019;2019:1936769.
  4. Lee EH, Lee HJ, Park KD, et al. Effect of a new cryotherapy device on an itchy sensation in patients with mild atopic dermatitis. J Cosmet Dermatol. 2021;20(9):2906–2910.
  5. Kepinska-Szyszkowska M, Misiorek A, Kapinska-Mrowiecka M, et al. Assessment of the influence systemic cryotherapy exerts on chosen skin scores of patients with atopic dermatitis: pilot study. Biomed Res Int. 2020;2020:5279642.

The Colorimetric Scale for Skin of Color Should Replace the Fitzpatrick Skin Type Scale for Classifying Individuals with Darker Skin

In their excellent single-center, survey-based study Bhanot et al1 recommended that the Fitzpatrick classification system “needs to be… replaced with methods that more accurately, appropriately, and reliably describe skin tones…” The investigators attribute the “…use of the Fitzpatrick skin type scale as a surrogate for skin color is largely because to date, no globally adopted, objective, consistent, and practical method for stratifying and describing skin color exists.”1 The researchers alert the readers that “until better methods for stratifying skin color and sun exposure are developed, extreme caution must be used to prevent the misuse and overgeneralization of the Fitzpatrick skin type scale.”1

The Fitzpatrick classification of sun-reactive skin types was originally developed in 1975 for a psoriasis study to determine the initial ultraviolet A dose.2 Individuals with white skin were assigned to skin types I to IV (based on sunburn tendency and tanning ability following sunlight exposure); skin type V for brown skin and skin type VI for black skin were added the following year.2 The Fitzpatrick skin type scale was never intended to be used to categorize patients with skin of color;2 according to Bhanot et al,1 the Fitzpatrick skin type scale creates “…a potential gap in equitable dermatologic care—one that can lead to false assumptions about patient risk for adverse dermatologic outcomes.”

Alternative classification schemes to replace the Fitzpatrick skin type scale for individuals with dark skin have previously been suggested. However, the new classification schemes have fundamental issues; they either have between 10 and 36 possible categories for selection or include white and black (which are not colors) or both. Therefore, none of the alternative schemes have been deemed suitable to be universally applied for classifying patients with skin of color.3

Bhanot et al1 observed that “the patient’s race played an important factor in a discrepancy between provider and patient described Fitzpatrick skin type.” Indeed, the persistence of racial disparities in dermatology has been attributed to the lack of an objective scoring system to categorize patients with skin of color.4 The colorimetric scale for skin of color is a recently described practical approach for classifying skin color in patients with dark skin;3 it eliminates racial disparities since it is not based on the ethnicity of the individual.5

The colorimetric scale for skin of color fulfills all the necessary criteria that Bhanot et al1 have identified for a scale to successfully categorize skin tones in individuals with darker skin. The colorimetric scale for skin of color is easy for the clinician to use and evaluation of the patient can be quickly performed; an assessment of the individual using the colorimetric scale for skin of color can be readily incorporated during the cutaneous examination.3 The colorimetric scale for skin of color (Figure 1) has five color categories that range from very light beige (type 1) to very dark brown (type 5).2

In conclusion, when Bhanot et al1 evaluated the significance of their investigation, they stated that “the results of such a study may be used to adjust our clinical practice with the ultimate goal of providing patient care that is more effective and more equitable.” They also wanted “…improved accuracy of patient skin-type reporting and better clinical outcomes.”1 The colorimetric scale for skin of color fulfills both dictums; it is a simple technique for clinicians to rapidly categorize patients with dark skin in a non-racial and non-ethnic manner that can be used for assessing skin cancer risk and providing dermatology management.3

With regard,

Philip R. Cohen, MD

Keywords. Color, colorimetric, Fitzpatrick, ethnic, racial, scale, skin

Affiliations. Dr. Cohen is with the Department of Dermatology at the University of California, Davis in Sacramento, California; the Touro University California College of Osteopathic Medicine in Vallejo, California; and the Maples Center for Forensic Medicine at the University of Florida College of Medicine in Gainesville, Florida.

Funding. No funding was provided for this article.

Disclosures. The author declares no conflicts of interest relevant to the content of this article.

References

  1. Bhanot A, Bassue J, Ademola S, et al. Fitzpatrick skin typing self reporting versus provider reporting: a single-center, survey-based study. J Clin Aesthet Dermatol. 2024;17(12):18–22.
  2. Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. 1988;124(6):869–871.
  3. Cohen PR, DiMarco MA, Geller RL, et al. Colorimetric scale for skin of color: a practical classification scale for the clinical assessment, dermatology management, and forensic evaluation for individuals with skin of color. Cureus. 2023;15(11):e48132.
  4. Narla S, Heath CR, Alexis A, et al. Racial disparities in dermatology. Arch Dermatol Res. 2022;315(5):1215–1223.
  5. Cohen PR, DiMarco MA, Geller RL, et al. Comments on: racial disparities in dermatology. Arch Dermatol Res. 2023;316(1):48.

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