Atopic Dermatitis (1 of 13)

ACUTE FLARE UP TREATMENT

A
Non-pharmacological therapy
•
Patient/caregiver education
•
Avoidance of trigger factors
•
Skin care
-
Bathing
-
Moisturizers
B
Pharmacological therapy
Any
one
of the following agents:
•
Corticosteroids (topical)
•
Calcineurin inhibitors (topical)
If skin infection is present:
•
Appropriate antibiotics, antifungals,
antivirals (oral &/or topical)
Symptomatic relief of pruritus:
•
Antihistamines (oral)
1
Patient presents w/ skin manifestations
suggestive of atopic dermatitis
MAINTENANCE TREATMENT
A
Non-pharmacological therapy
•
Same as acute fl are-up
•
Investigate precipitating factors of each fl are-up
B
Pharmacological therapy
Start at earliest sign of local recurrence:
•
Corticosteroids (topical), intermittent use
or
Long-term:
•
Corticosteroids (topical), intermittent use
•
Calcineurin inhibitors (topical), combined w/
If skin infection is present:
•
Appropriate antibiotics, antifungals, antivirals
(oral &/or topical)
Symptomatic relief of pruritus:
•
Antihistamines (oral)
ALTERNATIVE
DIAGNOSIS
TREATMENT
See next page
•
Continue non-pharmacological
therapy
•
Patient/caregiver education
•
Avoidance of trigger factors
•
Skin care
•
Discontinue topical corticosteroid
&/or calcineurin inhibitor
EVALUATION
Disease remission
2
DIAGNOSIS
Do history & physical
exam confirm atopic
dermatitis?
Patient suff ers from
acute flare-up of
pruritus & inflammation
Patient suff ers from
disease persistence or
frequent recurrences
No
No
Ye s
Ye s
Not all products are available or approved for above use in all countries.
Specifi c prescribing information may be found in the latest MIMS.
ATOPIC DERMATITIS
B16
Atopic Dermatitis (2 of 13)
Not all products are available or approved for above use in all countries.
Specifi c prescribing information may be found in the latest MIMS.
TREATMENT OF SEVERE
REFRACTORY ATOPIC DERMATITIS
•
Expert referral is recommended
•
Psychotherapeutic/psychopharmacological options
may be combined w/ the therapies listed below
A
Non-pharmacological therapy
•
Continue as previous page
•
Wet wrap therapy
•
Phototherapy
B
Pharmacological therapy
•
Potent corticosteroids (topical)
•
Systemic corticosteroids
•
Immunosuppressants
•
Other dermatologicals (eg Alitretinoin)
•
If skin infection is present:
-
Appropriate antibiotics, antifungals, antivirals
(oral &/or topical)
1
ATOPIC DERMATITIS
•
A familial, chronic, relapsing, infl ammatory skin disease characterized by intense itching, dry skin, w/ infl ammation
& exudation that commonly presents during early infancy & childhood, but can persist or start in adulthood
•
Also referred to as “atopic eczema”
•
One of the most common skin diseases affl icting both children & adults
Pathophysiologic Features:
•
Heredity (80% in monozygous twins, 20% in heterozygous twins)
•
Increased IgE production in some individuals
•
Lack of skin barrier producing dry skin due to abnormalities in lipid metabolism & protein formation
•
Susceptibility to infections caused by
Staphylococcus aureus/epidermidis
&
Malassezia furfur
•
Common causes include allergens such as food, soaps, detergents, inhalant allergens & skin infections
•
Presence of FLG gene defects increase the risk of developing atopic dermatitis
2
DIAGNOSIS
•
Diagnosis is based on patient’s history, cutaneous fi ndings (atopic stigmata), & physical exam
•
Investigate exacerbating factors
- Eg Aeroallergens, foods, irritating chemicals, emotional stress, extreme temperature
- Not very useful clinically
Criteria for Diagnosis (Based on criteria developed by Hanifi n 1991)
Major Features
(must have ≥3)
•
Pruritus
•
Typical morphology & distribution
•
Facial & extensor involvement in infants & children
•
Flexural lichenifi cation & linearity in adults
•
Dermatitis - chronic or chronically relapsing
•
Personal or family history of atopy - asthma, allergic rhinitis, atopic dermatitis
Minor/Less Specifi c Features
•
Cheilitis
•
Hand/foot dermatitis
•
Scalp (cradle cap) dermatitis
•
Ichthyosis, hyperlinearity, keratosis pilaris
•
Periauricular fi ssures
•
Eczema - perifollicular accentuation
•
Xerosis
•
Recurrent conjunctivitis
•
Keratoconus
•
Anterior subcapsular cataract
•
Pityriasis alba
•
White dermographism
•
IgE reactivity (increased serum IgE, radioallergosorbent, or prick test reactivity)
•
Cutaneous infections (
Staphylococcus aureus
, Herpes simplex)
ATOPIC DERMATITIS
B17
Atopic Dermatitis (3 of 13)
Not all products are available or approved for above use in all countries.
Specifi c prescribing information may be found in the latest MIMS.
A
NON-PHARMACOLOGICAL THERAPY
Patient/Caregiver Education
•
Discuss the chronic nature of atopic dermatitis, exacerbating factors & appropriate treatment options
- Emphasize that atopic dermatitis tends to decrease w/ increase in age
•
Convey the goal of treatment is control rather than “cure”
•
Discuss that many factors probably contribute to fl are-ups & usually a specifi c cause cannot be found
•
Educate the patient about proper skin care (eg bathing, hydration & use of moisturizers)
- Patient/caregiver should be instructed to apply emollients liberally 3 minutes after taking a bath 2-3 times
daily or frequently as the skin gets dry even in the absence of symptoms
- Studies showed that correct & adequate instructions for use & application of moisturizers when done properly
reduces disease severity & overall topical corticosteroids use
•
Explain potential side eff ects of medications when used over extended periods of time
- Apply topical steroid 10-15 minutes after application of emollients
•
Keep fi ngernails trimmed short
•
Use of cotton gloves at night to limit scratching
2
DIAGNOSIS (CONT’D)
Signs & Symptoms
Infants <2 years usually present w/:
•
Signs of infl ammation usually develop during the 3rd month of life
•
Patient commonly presents w/ dry skin
- Lesions (red papules w/ oozing, crusting & scaling) usually found on the facial cheeks &/or chin
- Lip licking may result in scaling, oozing & crusting on the lips & perioral skin, eventually leading to secondary
infections
•
Continued scratching or washing will create scaling, oozing, red plaques on cheeks
- Infant may be restless or agitated during sleep
•
A small number of infants may present w/ generalized eruptions
- Papules, redness, & scaling
- Diaper area is usually not aff ected
Children 2-12 years usually present w/:
•
Infl ammation in the fl exural areas (eg neck, wrists, ankles, antecubital fossae)
•
Rash may be contained to 1 or 2 areas
- May progress to involve more areas eg neck, antecubital & popliteal fossae, wrists & ankles
•
Papules that quickly change to plaques then lichenifi ed when scratched
•
Scratching & chronic infl ammation may lead to areas of hypo- or hyperpigmentation
12 years-adults usually present w/:
•
Resurgence of infl ammation that recurs near puberty onset
•
It is unusual for adults w/ no history of dermatitis in earlier years, to present w/ new onset dermatitis
•
Pattern of infl ammation is similar as in a child 2-12 years w/ additional lesions on nape & hands
•
Hand dermatitis may be present in the adult due to exposure to irritating chemicals
•
Dry, erythematous papules & plaques, scaling & lichenifi cation
Disease Severity
•
Severity is assessed using diff erent scoring methods [eg SCORing Atopic Dermatitis (SCORAD), Eczema Area
and Severity Index (EASI), Patient Oriented Eczema Measure (POEM), ree Items Severity Score (TISS)]
•
SCORAD is the scoring method developed by the European Task Force of Atopic Dermatitis (ETFAD), which
uses area/extent aff ected, intensity & subjective symptoms to score the severity of patient’s atopic dermatitis
- Mild disease: <25
- Moderate disease: 25-50
- Severe disease: >50
•
TISS is a simplifi ed scoring system based on 3 symptoms of the disease: Erythema, edema/papulation, &
excoriation
•
POEM measures severity by depending on the patient’s answers to 7 questions based on symptoms & its
frequency
•
Other scoring systems based on the impact on the quality of life are also used [eg Children’s Dermatology Life
Quality Index (CDLQI), the Dermatitis Family Impact (DFI), the Dermatology Life Quality Index (DLQI), &
the Infant’s Dermatology Life Quality Index (IDQOL)]
•
Ocular or infectious complications may also be present in severe atopic dermatitis
•
May require hospitalization for severe eczema or skin infections
ATOPIC DERMATITIS
B18
Atopic Dermatitis (4 of 13)
Not all products are available or approved for above use in all countries.
Specifi c prescribing information may be found in the latest MIMS.
1
Various products are available. Please see prescribing information for specifi c formulations in the latest MIMS.
A
NON-PHARMACOLOGICAL THERAPY (CONT’D)
Avoidance of Trigger Factors
Identify & Eliminate Trigger Factors
•
Identify potential allergens by careful history & selective allergy tests
- Skin prick tests & serum tests for allergen-specifi c IgE are only useful if there is a suspected allergen
- Negative results are useful for ruling out suspected allergens
-
In vitro
allergy tests or positive skin prick tests do not always correlate w/ clinical symptoms (especially
foods) & controlled food challenges, atopy patch tests or elimination diets may be needed
- Limited food allergy testing may be considered in children <5 years w/ moderate-severe or refractory disease
&/or a history of an allergic reaction after a particular food exposure
- Most children will outgrow food hypersensitivity within the fi rst few years of life
•
Avoid foods identifi ed as allergens in controlled food challenges
•
Avoidance of aeroallergens, eg house dust mites, may result in improved symptoms
- Use dust mite-proof encasings on pillows, mattresses & box springs
- Wash bedding weekly in hot water (>58°C)
- Remove bedroom carpeting & curtains
- Decrease indoor humidity to levels below 60%
- Evidence suggests that allergen-specifi c immunotherapy may be an option in treating select patients w/
sensitivity to aeroallergens
•
In most cases, trigger factors cannot be specifi cally identifi ed
- Apply holistic approach to avoidance since trigger factors are usually multiple
Common Trigger Factors
•
Wool clothing, pollen, extreme temperature, sweat, products w/ perfumes or preservatives, foods, cigarette
smoke & animal dander
Other Factors
•
Psychological factors
- Emotional factors (eg anxiety, stress & anger) cause disease exacerbation, induce immune activation &
increase pruritus & scratching
- Psychological evaluation & counseling should be considered in patients who have diffi culty w/ emotional
triggers or who have psychological problems
Skin Care
•
Hydration of skin w/ emollients is essential to treatment of atopic dermatitis
Bathing
1
•
Soap substitutes w/ minimal defatting activity, moisturizer-containing, fragrance-free, hypoallergenic, & a
neutral to low pH are preferred
•
If possible, limit soap use to hands, feet, genitalia, axillae
•
Limit bathing to once daily for 5-10 minutes using warm water
•
Pat dry after bath & apply moisturizer or bath oils within 2 minutes of bath
•
Studies have shown a decrease in bacterial infection (eg staphylococcal, MRSA), disease severity, & fl are-ups
in patients taking regular bleach baths (1:1200 dilution of 6% hypochlorite bleach; 10-minute soak, 3x/week)
-
Bleach baths w/ intranasal Mupirocin are highly recommended for patients w/ moderate-severe disease w/
recurrent secondary bacterial infection
•
Salt baths may also be used to help shed dead keratin materials from the skin
•
Oatmeal products added to bath may be soothing but do not increase water absorption by the skin
•
Topical medications are best applied after bathing because of greater penetration of hydrated skin
Moisturizers
1
•
Water-in-oil emollients are preferred; occlusive agents & humectants also used
- Useful for the treatment of active disease & both prevention & maintenance therapy
- Helps reestablish & preserve the stratum corneum
•
Eff ects:
- Emollients (eg Glycerol stearate, Lanolin, Soy sterols) provide lubrication & helps soften skin surface
- Occlusive (eg Dimethicone, Mineral oil, Petrolatum) agents provide a physical barrier against water evaporation
- Humectants (eg Urea, Glycerol, Lactic acid) help retain moisture in
•
A comparative review of diff erent clinical studies on moisturizers revealed that proper use reduces pruritus,
reduces topical corticosteroid use, & prevents fl ares & recurrences
- Clinically signifi cant reduction in disease severity w/ moisturizer use compared to no moisturizers was seen
- Moisturizer combined w/ Fluticasone propionate applied 2x/week was more eff ective in preventing fl ares
compared to moisturizers alone
- Better effi cacy was noted in patients who used topical active treatment combined w/ moisturizers compared
to using topical active treatment alone

ATOPIC DERMATITIS
B19
Atopic Dermatitis (5 of 13)
Not all products are available or approved for above use in all countries.
Specifi c prescribing information may be found in the latest MIMS.
A
NON-PHARMACOLOGICAL THERAPY (CONT’D)
Moisturizers
1
(Cont’d)
•
Patient preference & treatment area will determine formula used in moisturizers [eg Ceramides,
Hydroxypalmitoyl sphinganine, Palmitoylethanolamide (PEA), Liquid paraffi n, Mineral oils, Glycerin,
Hyaluronic acid, Shea (
Butyrospermum parkii
) butter, Telmesteine, Glycyrrhetinic acid, Lactic acid]
- Glycyrrhetinic acid has anti-infl ammatory properties that helps reduce pruritus
- Urea-containing moisturizers reduce rate of fl ares but may cause transient burning & stinging after application
- Oat- & Glycerol-containing moisturizers also reduces rate of fl ares but w/ lesser side eff ects & lessens the
use of topical corticosteroids
- e anti-infl ammatory & antibacterial properties of Licochalcone contained in some moisturizers are
comparable to the effi cacy of combination therapy of moisturizers & 1% Hydrocortisone acetate cream
•
Should be applied all over at least twice daily regardless of the presence of active dermatitis
•
Avoid products w/ preservatives or fragrances; if product stings &/or burns, seek expert advice
•
Reports of studies suggest that the use of emollients in infants might prevent atopic dermatitis development
in high-risk patients
Wet Wrap erapy
•
May be used for chronic & refractory lesions or for moderate-severe weeping lesions
- Cools infl amed skin, maintains hydration, & decreases scratching
- Can help reduce water loss & disease severity in patients w/ moderate-severe atopic dermatitis
•
Combined w/ topical corticosteroids can be eff ective in treating refractory cases
Phototherapy
•
Considered in patients w/ recalcitrant disease or when 1st-line therapy w/ topical agents has been unsuccessful
•
Broad-band UVB & UVA, narrow-band UVB & UVA-1 or combined UVA & UVB can be useful
- Treats chronic lichenifi ed forms of moderate-severe disease
- Eff ectively reduces colonization of
S aureus
&
Malassezia
sp & mediate cytokine production
•
Photochemotherapy w/ Psoralens & UVA should be restricted to patients w/ widespread severe atopic dermatitis
•
May be combined w/ corticosteroids & emollients in phases of acute fl ares & to prevent future fl are-ups
•
Relapse after therapy cessation frequently occurs
•
Adverse reactions:
- Short-term: Erythema, skin pain, pigmentation, itching
- Long-term: Premature skin aging & potential cutaneous malignant diseases
Prevention
•
Identifi cation & elimination of triggering factors are the mainstay for prevention of fl ares as well as for the
long-term treatment of atopic dermatitis
•
Breastfeeding or feeding w/ hypoallergenic hydrolyzed formula milk was shown to be benefi cial
- If the patient w/ atopic dermatitis is also diagnosed w/ food allergy, the mother should be advised to eliminate
all identifi ed food allergen from her diet
•
Probiotics may also reduce the incidence or severity of atopic dermatitis, however, more studies are needed
to prove this benefi t
B
PHARMACOLOGICAL THERAPY
Topical Corticosteroids
•
Used as 1st-line treatment for mild to severe atopic dermatitis & when non-pharmacological interventions
have been unsuccessful
•
Rapid symptomatic relief for acute fl are-ups; also used for prevention of relapses
•
Choice of product will depend on severity of fl are-up, distribution & site of lesions, patient’s age & preference,
& other factors eg humidity
•
Anti-infl ammatory & antipruritic activity through several mechanisms
- Alteration in leukocyte number & activity
- Suppression of mediator release (histamine, prostaglandins)
- Enhanced response to agents that increase cyclic adenosine monophosphate (prostaglandin E
2
& histamine
via the histamine-2 receptor)
•
Follow the recommended restrictions regarding intensity & duration of use especially in children on delicate
skin areas (eg face, neck & skin folds)
- Intermittent use in combination w/ moisturizers is historically the standard therapy for atopic dermatitis
- Continuous use can lead to adverse eff ect
•
Available in diff erent potencies from mildly potent to very potent
- Potency is also aff ected by the vehicle the product is formulated in (eg ointment, cream, lotion in decreasing
order of effi cacy)
1
Various products are available. Please see prescribing information for specifi c formulations in the latest MIMS.
ATOPIC DERMATITIS
B20
Atopic Dermatitis (6 of 13)
B
PHARMACOLOGICAL THERAPY (CONT’D)
Topical Corticosteroids (Cont’d)
- Potency of topical corticosteroid does not relate to percentage stated (eg Hydrocortisone 2.5% versus
Betamethasone dipropionate 0.05%)
- Least potent but eff ective product should be used, especially if for long-term use
- May use mid- & high-potency preparations (except when lesions are on face, groin or axillae) to control
acute fl ares & then follow w/ lower potency preparations after clinical improvement is seen
- Rebound fl aring can occur if higher potency preparations are discontinued abruptly
- A gradual decrease in potency should follow use of higher potency preparations
- erapy-resistant lesions may require potent topical corticosteroid used under occlusion
Solutions
•
Useful for the scalp or other hirsute areas
•
Alcohol content may be irritating when used on infl amed lesions
Lotions
•
Useful for minimal application to a large area or on hirsute areas
•
May also be used on exudative lesions & in hairy areas
Creams
•
Usually preferred for moist/weeping lesions
•
May be preferred during periods of excessive heat or humidity
•
Easier to apply but may be less eff ective
Ointments
•
Generally used for dry, scaly or lichenifi ed lesions or if a more occlusive eff ect is needed (most occlusive vehicle)
•
Usually less additives are used
•
Evaporative losses are decreased
Systemic Corticosteroids
1
•
Should only be considered in treatment-resistant atopic dermatitis, acute severe exacerbations & as a bridge
therapy to other steroid-sparing systemic treatments
•
Improve lesions but rebound fl are-up usually occurs upon discontinuation
•
Use short-term & decrease chance of rebound eff ect by tapering oral form slowly while increasing topical
corticosteroid treatment & continuously hydrating the skin
Calcineurin Inhibitors - Topical Immunomodulators
•
Steroid-sparing agents for acute & maintenance therapy, topical calcineurin inhibitors inhibit infl ammatory
cytokine transcription in activated T cells & other infl ammatory cells through inhibition of calcineurin
•
May be used on all body locations for extended periods of time, especially the face, hands & feet
•
All preparations are of a standard potency
•
ere is no evidence of causal link between the use of calcineurin inhibitors & cancer
•
Preferred over topical corticosteroids when atopic dermatitis is unresponsive to steroid therapy, w/ presence
of atrophy or telangiectasia secondary to steroid use, when aff ected areas are either the face, anogenital area,
&/or skin folds, & for long-term treatments
•
Also used in patients w/ inadequate response or contraindication to other topical therapeutic agents
Pimecrolimus
•
Safety & effi cacy have been shown in children >2 years of age & adults w/ mild-moderate atopic dermatitis
- Pruritus relief has been seen as early as day 3 of use; does not cause atrophy
- Prevents fl are-ups & results in signifi cant steroid-sparing eff ect when used for up to 12 months
•
When used in early stages of disease, it has shown to be therapeutically advantageous over typical moisturizers
plus topical corticosteroids in long-term use
Tacrolimus
•
Rapidly decreases the signs & symptoms of atopic dermatitis in adults & children >2 years of age
- Improvement is seen within 3-7 days of therapy & sustained for at least 12 months
- Well-tolerated w/ transient skin burning/irritation; less incidence of atrophy compared to steroids
•
Studies have confi rmed the effi cacy of Tacrolimus 0.03% compared to low-potency topical corticosteroids in
children & the effi cacy of Tacrolimus 0.1% compared to mid-potency topical corticosteroids in adults
Biologic erapy
Dupilumab
•
A human immunoglobulin G4 monoclonal antibody approved for use in patients ≥18 years of age w/ moderate
to severe atopic dermatitis
•
Binds to the interleukin-4Ra subunit thereby inhibiting interleukin-4 & interleukin-13 cytokine-induced
responses which includes proinfl ammatory cytokine, chemokines & IgE release
Other Biologicals
•
Further studies are needed to prove the effi cacy of Nemolizumab, Rituximab, Mepolizumab, Omalizumab, &
Ustekinumab for atopic dermatitis
Not all products are available or approved for above use in all countries.
Specifi c prescribing information may be found in the latest MIMS.
1
Various oral corticosteroids are available. Please see prescribing information for specifi c formulations in the latest MIMS.