Atopic dermatitis: Chronic and relapsing disorder

Nestor Cisneros MD FRCPC

Assistant professor Allergy and Clinical immunology

Training Program Director Allergy and Clinical Immunology

Conflict of interest

• Shires: speaker

Objectives

➢At the end of this session,

➢ participants will be able to recognize the prevalence of atopic dermatitis.

➢ Review the current management of atopic dermatitis

➢ Recognize the psychosocial impact of atopic dermatitis.

Atopic Dermatitis: Epidemiology.• Chronic and relapsing disorder

• AD is the most common skin condition. • Affect 20 % children.

• 20-33% of AD patients have moderate to severe disease

• AD first manifestation with allergic disorder.

• Impact QoL to patients & their families

Burden of AD.

Infants with Eczema, sleeping problems and mental health at 10 yrs of age

Variable Odds ratio (95 CI)

• Emotional problemsInfant eczema with

sleep problems 2.63 (1.20-5.78)

• Conduct problemsInfant eczema with sleep problems 3.03 (1.01-9.2)

• Hyperactivity -Infant eczema 1.78 (1.02-3.09)- ever eczema 2.12 (1.34-3.37) Schmitt et al Allergy 2011Schmitt et al Allergy 2011

InfectionURI/OMBacterial, fungalViral infection

AllergensFood (egg)Environmental (mites)Contact dermatitis (Nickel)

Heat, drynessAnxiety

Triggers for atopic dermatitis

Itch-scratch cycle AD flares

How to treat Atopic Dermatitis

Education

Maintenance and repair of skin barrier

managing infectious triggers

Minimizing triggersSkin directed TXAntihistamines ( caution)

TCSTCI

/Bleach bath

Maintenance skin care

• Foundation of the AD management ( soaking bath)• Bathe daily

• Soak 10-15 minutes in lukewarm water

• Use moisturizing cleanser where needed

• Apply medication &moisturizing after bath

• Lubrication/moisturization:• Reduce the needs for topical steroids.

• Help to repair the skin barrier

Nicol NH, Boguniewicz M .Dematology Nursing Oct 2008

Topical therapy: emollient

Clark A et al J Drugs Dermatol 2011;10(5):531-7

Day 7

Day 21

N:392-17 year with mild to moderate AD

Topical Treatment of inflammation: TCS and TCI• Goal of therapy to treat inflammation

• Topical steroids: effective and extremely safe when use correctly

• Topical Calcineurin inhibitor: ( second line)• Acute therapy for inflammation and proactive therapy

• Key-give skin break.

Use of anti-inflammatory therapy to "put out the fire”

Topical corticosteroids

• First line treatment

• Potency classification• Class I –most potent

• Class VII – least potent

• Potency differ and can be confusing

• Address the steroid phobia.

Topical Corticosteroids

Vehicle or form of the products

TCI: topical calcineurin inhibitor

• Do not cause the side effects of TCS

• Beneficial to treat AD • Concern about long term use of TCS

• In areas on the face, eyelids

• Side effect: burning and stinging

• Higher cost

• FDA:• Black box warning (2006) due to the theoretical risk of lymphoma.

• Pediatric eczema elective registry :no increase in the risk of eczema (2014)

Black warming

Topical steroids-pearl

For patient saying

“As soon as I stop , it comes RIGHT BACK”

OR

“I HAVE TO USE IT EVERY DAY”

Then steroids potency is probably too low

Provided that all other areas of the treatment are being maximized

Management of the AD exacerbation

Zubierbier et al JACI 2006

Anti-inflammatory treatment

AD flare

Topical steroids application

Day 7-14;Low potency _faceMid high potency

Daily useEOD Emollients

Recovery

Aim for rare flares up

Proactive therapy for AD

Preventing eczema flare up William HC BJD 2011

How much to dispense

Area treated* Once BID x 1 week

Hands, head, face 2 g 88 g

Leg 4 g 56 g

Entire body 30 g 420 g

* 70 kg adult

Bleach bath

• Randomized• 31 patients ( 6 m-17 year with

moderated to severe eczema and bacteria infection)

• All treated with cephalexin 14 days prior.

Mean EASI score at one month and 3 month.

Huang J et al Pediatrics Vol. 123 No. 5 May 1, 2009

Mupirocin oint.Bleach bath

Intranasal petroleum ointPlain water bath

EASI: Eczema area and severity index score

Step care management.