Atopic Dermatitis Didactic Webinar

Thursday May 4, 2017

Bringing Basic Dermatology Care to the Pediatric Medical Home 1.2

A PPOC/CHICO Learning Community

& Integration Program

© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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We have no financial relationships with commercial entities producing, marketing, re-

selling, or distributing health care goods or services consumed by, or used on, patients

relevant to the content we are planning, developing, presenting, or evaluating.

Disclosure

© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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Glenn Focht, MDMedical Director

Pediatric Physicians’ Organization

at Children’s

Karen R. Barnett, MD, FAAPLC Medical Director

Pediatric Physicians’ Organization

at Children’s

© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

Madeleine Kuhn, MPHCHICO Program Manager

Faculty

Stephen E. Gellis, MDProgram Director, Dermatology

Boston Children’s Hospital

Sadaf Hussain, MDDermatology

Boston Children’s Hospital

Sophie Delano, MDDermatology

Boston Children’s Hospital

Tope Osineye, MBBS MPHPractice Consultant

Pediatric Physicians’ Organization

at Children’s

Alex LorenzoQI Program Coordinator

Pediatric Physicians’ Organization

at Children’s

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Graphs are only commercial payers and only

practices in the PPOC

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Learning Community Schedule

Date Content

Thursday, May 4, 2017 Atopic Dermatitis

Thursday, June 1, 2017 Acne

Thursday, June 29, 2017 Q&A (Optional and open to

past and current participants)

Thursday, August 24, 2017 Warts, Molluscum, Hives

Thursday, September 28,2017 Q&A (Optional and open to

past and current participants

Thursday, October 26, 2017 Wrap-up

Didactic Webinars: 7:30am – 9:00am

Q&A: 7:30am – 8:30am

© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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• Materials stored on Blackboard

childrens.blackboard.com and are

posted one day after each session.

• Materials on Blackboard include:

– Syllabus

– Schedule

– Slides

– Handout

– Videos

– Session recordings

– Surveys (MOC/CME)

• Questions email course director: Madeleine Kuhn at madeleine.kuhn@childrens.harvard.edu

Course Structure

© 2015 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

4 Didactic Webinars.

Didactic webinars are online sessions in which

a specialist in dermatology and primary care

lead is present to discuss anatomy and lead

case discussions.

Coursework:

• Qstream

• One Pre- and Post process map for one of

the areas of study (Acne, Atopic Dermatitis,

Warts/Molluscum/Hives) per practice

• Case reviews of past dermatology visits per

practice

• After every session you will receive a follow-

up email with the recording, course handouts

and CME/MOC Survey

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• Physician

o Boston Children’s Hospital designates this live activity for a maximum of 20.00 AMA PRA Category 1 Credits ™. Physicians should claim only credit commensurate with the extent of their participation in this activity.

o Boston Children’s Hospital approves this course for 20 ABP MOC Part IV credits

• Nurse

Boston Children’s Hospital designates this activity for 10.00 contact hours for nurses. Nurse should only claim credit commensurate with the extent of their participation in the activity.

Course Credits

© 2015 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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Atopic Dermatitis

Background

Definition

History

Physical Examination

Treatment

Cases

Special Circumstances

Common Questions

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Key Features of Atopic Dermatitis

• Pruritus

• Comes and goes

• Early age onset

• Characteristic locations

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Atopic Dermatitis Background

● Prevalence increasing with 15-29% children

affected

● Onset usually at 3-6 months of age; 90% develop

before age 5 years

● 1st manifestation of the “atopic march”

● Genetic and environmental factors

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Case Scenario One

Collecting the Patient’s History

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HistoryHPI:

● Onset

● Location

● Symptoms (itching/sleeping problems)

● Bathing Habits

o Frequency

o Duration

o Water temperature

o Soap

● Moisturizing

● Treatments tried

PMH: skin infections, seasonal allergies, asthma, food

allergies

FH: atopy

ROS: growing/feeding well, diarrhea, bloody stools

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Case Scenario 2

6 year old with

history of

intermittent, itchy

rash that began

around age 6

months. It is worse

in the winter.

She bathes once

daily for 20 minutes

with Johnson and

Johnson's cleanser

and moisturizes with

baby lotion.

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Physical Examination

● General: well-appearing,

appropriate size-for-age, non-

dysmorphic

● Full skin examination

● Rough, red

(hyperpigmented), plaques

● Classic distribution (varies

by age)

● Evidence of infection

(pustules, abscesses,

impetiginized areas, punched

out areas)

Pictures are placeholders for correct

imagery

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Distribution of AD by Age

Infant

(birth-2 years)

Face (cheeks),

scalp, ears

Extensor

extremities

Seborrheic

dermatitis

overlap

Childhood

(2 years-puberty)

Face (cheeks)

Flexural extremities

Teenager-Adult

Localized flexural

extremities

Hands, dorsum feet

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Physical Examination: Other Considerations

● Classic features/location-confirmation

● Evidence of infection

● Distribution that affects my management-topical strength (skin

thickness/site)

● Clues to exacerbators- airborne allergens, irritants (saliva, wet wipes)

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Case Scenario 3A 16 year-old with known atopic dermatitis presents with worsening skin

lesions in the popliteal fossae. He feels well but the areas are itchy and sore.

What would be your treatment plan?

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Atopic Dermatitis Treatment: Pathogenesis-Directed

● Primary problem in AD is an impaired skin barrier (e.g., filaggrin mutations)

o Water escapes the skin (dryness)

o Irritants, allergens and microbes easily enter the skin (inflammation-redness,

itchiness, serous drainage or impetiginization)

● Immune system “sees” more and reacts more

If the skin isn’t hydrated it isn’t able to block irritants and microbes

from “slipping through the cracks” and causing an infection.

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Treatment

2 Steps to Treat Effectively: Resolve existent inflammation (acute

flare) AND reinforce the skin barrier (maintenance)

1 2

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Skin Care

Bathe 5-10 minutes with warm, NOT hot, water once every other day

Sensitive skin soaps: Dove sensitive skin bar soap, Cetaphil cleanser, Vanicream soap

Moisturize twice daily every day Ointments: Hydrolatum, Vaseline, Aquaphor Creams: CeraVe cream, Cetaphil cream, Aveeno cream, Eucerin

cream, Vanicream

*do not use lotions as they are minimally effective (too thin) *avoid “organic” products or ones containing fragrance, plant derivatives

(calendula, cocamidylpropyl betaine)

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Treating the Inflammation

Topical steroids 1st line

*Systemic corticosteroids are not indicated

For itch: sedating antihistamines: diphenhydramine or

hydroxyzine po (0.5-2mg/kg/dose)

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Topical Steroids

Low Potency Cost / all are covered by

insurance and all are generic

Hydrocortisone 2.5% ointment $5.00 - $20.00

Desonide 0.05% ointment $13.00 -$25.00

Triamcinolone 0.025% ointment $4.00

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Topical Steroids

Very High-Potency: (if needed, consider derm eval)clobetasol, halobetasol, desoximetasone

Mid-Potency Cost / Coverage

FluocinoLONE 0.025% ointment $20 - $40 has a generic and brand

version and is covered by

insurance

Triamcinolone 0.1% ointment $4.00 Is generic and is covered by

insurance

High-Potency Cost / Coverage

Mometasone 0.1% ointment $6-$20 may be covered by

insurance

FluocinoNIDE 0.025% ointment may be covered by insurance

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Topical Steroid (Contd.)

Use ointments; don't burn and are more potent

Most are twice daily; use for 2-3 weeks during flares (stop treating once skin is completely smooth, flat, not red and not itchy)

If clearance doesn't happen, may need a higher potency topical steroid

Lower potency for thin-skinned areas (face, axillae, groin) and thin plaques

Higher potency for rest of skin, lichenified or thicker plaques

Try to use “less than half the days of the month”

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Topical Calcineurin Inhibitors

● Thin-skinned areas, periocular disease

● Maintenance therapy

● Safety data does not suggest any malignancy risk

● Prior authorization may be required

● Tend to be costly and not all are generic

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Eucrisa (Crisaborole 2%) Ointment

•FDA Approval December 2016

•PDE-4 inhibitor

•Ages 2+ mild-to-moderate atopic dermatitis

•Side effects: hypersensitivity, stinging/burning/pain

•1522 participants from 2-79 years

•Clear/almost clear: 32.8% vs. 25.4% (placebo); 31% vs. 18% (placebo)

•Utility-yet to be determined

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Complications

Infections

Bacterial

● Perform a bacterial culture for identification and sensitivities

● Cephalexin po or clindamycin po

● Bleach baths 2-3 times per week for maintenance (also helps with

Inflammation)

Herpes Simplex Virus

Coxsackie Virus

Molluscum

Eczema herpeticum requires emergent dermatologic treatment

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http://www.wider.es/casosclinicos/index.php/eczema-coxsackium-

causado-por-coxsackievirus-a6-caso-600/

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Treatment Cases

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Algorithm

Adapted from Perman M, Yan A. Getting 'ADEPT' at Atopic Dermatitis. Dermped.org. 1:1 (2012)

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Algorithm Continued

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How would you treat?Questions Based on the Algorithm

Is this atopic dermatitis?

Infection?

Mild/Mod/Severe (thick or thin plaques)?

Thin skinned area?

Affecting sleep?

Triggers?

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WebEx Questions

• You will get the first 4 questions of each case. They are multiple choice and most are yes or no. You will have a total of 30 seconds to answer the 4 questions on each case. Once you have submitted your answers, the speaker will go over the right answers and see how the group did.

• If you don't have the question feature you can write your answers in the chat box or listen along.

• If you have technical issues during this portion, email the course directors after the course.

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Case 1

● Is this atopic dermatitis?

● Infection?

● Mild/Mod/Severe?

● Thin Skin?

● Affecting Sleep?

● Triggers?

YES

NO

MILD

YES

YES; SALIVA,FOOD, WIPES

NO

How would you treat?

Plan: Sensitive skin careLow potency-desonide 0.05% ointment BID x1-2 weeksThick layer of vaseline, hydrolatum, aquaphor before meals, before naps, before bedtimeAntibiotics and antihistamines are not necessary

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Case 2

● Is this atopic dermatitis?

● Infection?

Mild/Mod Severe?

● Thin Skin?

● Affecting Sleep?

● Triggers?

YES

NO

MOD

NO

?

YES

How would you treat?Plan: Sensitive skin care

Mid-potency-fluocinolone 0.025 ointment BID x2-3 weeksAvoid fragrances and chemicalsAntibiotics are not necessaryHydroxyzine 0.5mg/kg/dose at bedtime

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Case 3:

● Is this atopic dermatitis?

● Infection?

● Mild/Mod/Severe?

● Thin Skin?

● Affecting Sleep?

● Triggers?

YES

NO; culture if not sure

Mild-Mod

NO

NONE APPARENT

YES

Patient has history of skin infection. How would you treat?Plan: Sensitive skin care

Mid-potency-triamcinolone 0.1 ointment BID x2 weeksBleach baths 2-3 times per weekHydroxyzine 0.5mg/kg/dose at bedtime

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Case 4:

● Is this atopic dermatitis? NO! This is Scabies!!!

How would you treat?Plan: Permethrin 5% cream

aad.org

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Case 5:

● Is this atopic dermatitis?

● Infection?

● Mild/Mod/Severe?

● Thin Skin?

● Affecting sleep?

● Triggers?

YES

YES

MOD-SEV

NO

NO

How would you treat?(With evidence of infection, do we treat infection and inflammation at the same time?)Plan: Sensitive skin care

Bacterial culture; po cephalexin(Maintenance-bleach bath)Med-potency-triamcinolone 0.1 ointment daily x2 weeks (wrap with plastic wrap)

NO

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Case 6:

● Is this atopic dermatitis?

● Infection?

● Mild/Mod/Severe?

● Thin Skin?

● Affecting sleep?

● Triggers?

YES

NO

MILD

YES

NO

Plan: Sensitive skin careAvoid fragrancesLow-potency-hydrocortisone 2.5 ointment daily x3-5 days, then switch to protopic ointment BID x2-3 weeksApply a thick layer of moisturizer to act as a protective layer against contactant

YES; FRAGRANCES, AIRBORNE

Picture courtesy of Dr. Gellis

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Case 7:

● Is this atopic dermatitis?

● Infection?

● Mild/Mod/Severe?

● Triggers?

YES but hmmm

YES

SEVERE

HSV

How would you treat? Plan: Emergent referral (eczema herpeticum)

Abrupt rash in child with history of

eczema and cold sores.

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When to Refer to Dermatology?

EMERGENT:

• Fevers

• Eczema herpeticum

• Widespread redness with peeling of the skin (erythroderma)

Widespread atopic dermatitis, especially with other types of atopy (food allergy, etc.) or complicated history (immunosuppression, nutritional issues)

Limited response to topical steroid therapy

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Common Questions

How can I tell the difference between atopic dermatitis and

psoriasis?

But I've seen the diaper area involved in children with

atopic dermatitis. What is going on?

Is it safe to use topical steroids on eczema that looks

infected?

When should I test for food allergies?

Should I be worried about systemic absorption of topical

steroids? What about the side effects?

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Psoriasis

Medicinenet.com

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Common Questions

How can I tell the difference between atopic dermatitis and

psoriasis?

But I've seen the diaper area involved in children with

atopic dermatitis. What is going on?

Is it safe to use topical steroids on eczema that looks

infected?

When should I test for food allergies?

Should I be worried about systemic absorption of topical

steroids? What about the side effects?

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Seborrheic Diaper Dermatitis

Skinsight.org

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Baby Wipe Contact Dermatitis (Methylchloroisothiazinolone)

http://pediatrics.aappublications.org/content/133/2/e434

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Blue Dye Diaper Dermatitis

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Common Questions

How can I tell the difference between atopic dermatitis and

psoriasis?

But I've seen the diaper area involved in children with

atopic dermatitis. What is going on?

Is it safe to use topical steroids on eczema that looks

infected?

When should I test for food allergies?

Should I be worried about systemic absorption of topical

steroids? What about the side effects?

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Common Questions

How can I tell the difference between atopic dermatitis and

psoriasis?

But I've seen the diaper area involved in children with

atopic dermatitis. What is going on?

Is it safe to use topical steroids on eczema that looks

infected?

When should I test for food allergies?

Should I be worried about systemic absorption of topical

steroids? What about the side effects?

57

Common Questions

How can I tell the difference between atopic dermatitis and

psoriasis?

But I've seen the diaper area involved in children with

atopic dermatitis. What is going on?

Is it safe to use topical steroids on eczema that looks

infected?

When should I test for food allergies?

Should I be worried about systemic absorption of topical

steroids? What about the side effects?

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Postinflammatory PityriasisHypopigmentation Alba

Pediatricsconsultant360.com Dermnetz.org

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Algorithm

© 2015 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

On Blackboard and in follow-up email after this session

60© 2015 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

Coursework

• You are assigned a team and will receive an email from Qstream to answer 12 questions over 4 weeks. If you get the question right twice the question will retire and you will get a new question.

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Key Terms

“atopic march”

Hyperpigmented

Evidence of infection (pustules, abscesses, impetiginized areas, punched

out areas)

Seborrheic dermatitis overlap

Xerosis

lichenification

filaggrin mutations

Impetiginization

Eczema Herpeticum

Eczema coxsackium

Molluscum dermatitis

Red Flags

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Learning Community Schedule

Date Content

Thursday, May 4, 2017 Atopic Dermatitis

Thursday, June 1, 2017 Acne

Thursday, June 29, 2017 Q&A (Optional and open to

past and current participants)

Thursday, August 24, 2017 Warts, Molluscum, Hives

Thursday, September 28,2017 Q&A (Optional and open to

past and current participants

Thursday, October 26, 2017 Wrap-up

Didactic Webinars: 7:30am – 9:00am

Q&A: 7:30am – 8:30am

© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

Recordings will be sent out in follow-up email

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Your Feedback Helps Us Succeed!

Please take a moment to fill out the session evaluation survey you will receive via email and

provide us with your feedback so that we can continue to improve and meet your expectations!

Survey is also a CME / MOC requirement

© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

Thank you!

Appendix

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Atopic Dermatitis: Definition