Management of atopic dermatitis

Management of Atopic dermatitis

Sasikarn Suesirisawad, M.D.

O AD is a chronic relapsing inflammatory skin disease

O AD associated with local infiltration of Th 2 that

secrete IL-4, IL-5, IL-13, IL-31

O More than 50% develop asthma

O 75% develop AR

O Complex interrelationship of genetic,

environmental, immunologic, and epidermal factor

Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1893-1999

EpidemiologyO Affects 15-30% of children, 2-10% of adult

O 60% begin during the first yr

O 45% begin within the first 6 mo

O 85% begin before 5 yrs

O Up to 70%: spontaneous remission before adolescence

O Predisposed to developing AR/asthma later in childhood .. “Atopic march”

NJEM 2008;358:1483-94

Epidemiology O E merges in 1st month of life, while its prevalen

ce decreases by age.

O Girls more often suffer from AD than boys ... but until age of 6, both sexes are affected equally.

O Increase exposure to allergen & decline in BF were reason for increasing of AD.

Williams H.C.: Is the prevalence of atopic dermatitis increasing?. Clin Exp Dermatol 1992; 17:385-391

O Childhood eczema found correlation with increased socioeconomic class

Williams H.C., Strachan D.P., Hay R.J.: Childhood eczema: disease of the advantaged?. Br Med J 1994; 308:1132-1135

Pediatr Allergy Immunol 2010:21:1028-1035

Risk factor in development of AD

Genetic host factors

O Gene encoding epidermal or other epithelial

structural proteins

Loss of function mutations of

epidermal barrier protein filaggrin (FLG)

Transepidermal water loss (hallmark)

& penetration of environmental allergens

N Engl J Med 2008;358:1483-94


Genetic host factors

• Gene encoding major elements of immune system:Gene encoding major elements of immune system:

3q21, 1q21, 16q, 17q25, 20p, 3p26 regulation of IgE synthesis

- Exaggerated T cell responses: imbalance between Th1 & Th2

- Reduced skin innate immune response:

human B defensins, cathelicidin, dermcidin

(antimicrobial peptide)

N Engl J Med 2008;358:1483-94


Environmental factorsO Food allergens (egg, milk, wheat, soy)

OAssociate to infantile AD

ORelated to disease severityO Aeroallergens (pets, mites, pollen)

OExacerbation AD in older children

N Engl J Med 2008;358:1483-94


Other factorsOther factorsO Weather conditions or humidityO Skin irritants : soap, detergentO Infections : S. aureus, M. furfur, HSVO Emotional stress

Persistent or worsening disease

N Engl J Med 2008;358:1483-94.

Acute ADO Intensely pruritic, erythematous papule

associated with excoriations, vesiculation, and serous exudate

Thomas Bieber. NEJM 2008; 358:1483-94

Histology: Spongiotic area within the epidermis

Chronic ADO May have all skin type, Dry skinO Lichenification … Thickening of skin with

accentuated surface markings and fibrotic papules

Thomas Bieber. NEJM 2008; 358:1483-94

Hyperplastic of epidermis with hyperkeratosis

Color Textbook of Pediatric Dermatology, 4th Edition.

Infantile type Childhood type Adult type

Face, scalp, trunk, extensor surfaces

of extremities

Flexural folds of ext(antecubital, popliteal fossa)

neck, ankles

Upper arms, back, wrists, hands,

fingers, feet, toes

Conventional TherapiesO Identification and elimination of

exacerbating factors (irritants, proven allergens)

OAddressing psychological aspectsOEducationOHydrationOMoisturizersOTopical corticosteroidsOTopical calcineurin inhibitorsOAnti-infective therapyOAnti-pruritic therapy

Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1 893-1999

Goal •Efficient short-term control of acute symptoms•Flare prevention•Avoidance side effects

Irritative substances

Allergens ( food and inhalant)

Infectious microorganisms Staphylococcus aureus Malassezia furfur

Exacerbating factor in AD

Irritants O A lowered threshold of irritant responsiveness.

O Detergents, soaps, chemicals, pollutants, abrasive

materials, extreme of temperature and humidity

O Cleansers with minimal defatting activity and

neural pH.

O New clothing should be laundered before it is worn

to reduce formaldehyde and chemicals.

Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition

Irritants O Changing detergent to a milder one, liquid are

morepreferred than a powder one, extra rinse cycle

O Occlusive clothing should be avoided, cotton should be used.

O Temperature should be temperate to minimize sweating.

O Swimming is well tolerated, shower and use mild soap to remove chlorine.

O Non-sensitizing sunscreen should be used to avoid sunburn.


Fabienne Rance. Ped AI 2008;19:279-84

Environmental risk factors for early infantile atopic dermatitis

O Purpose: To evaluate influence of various environmental risk factors for early infantile AD.

O Population: 2048 mother–child pairs from Taiwan in 2003.

O Method: Information on environmental risk factors for infant gathered by questionnaire were available from 1760 infants at 6 months of age.

O Result: 118 of 1760 (6.7%) were AD. After adjusting for confounding factor, fungi on walls [OR 2.14 (95% CI 1.41–3.22)] and frequent use of microwave oven at home [aOR 1.71 (95% CI 1.13–2.58)] increased risk of early infantile AD.

O Conclude: Fungi are especially important in humid climate as in Taiwan and The hazards of microwave use should be paid more attention.

Pediatr Allergy Immunol 2007: 18: 441–447

Pediatr Allergy Immunol 2007: 18: 441–447

AeroallergensO HDM, animal danders, pollens

O In 1940s, Tuft et al. demonstrated that AD patient who underwent bronchoprovocation of HDM extract developed cutaneous lesions after inhalation to dust mites

O Study with patch testing have shown that direct contact with inhalant allergens can also result in eczematous lesions

O Respiratory and direct contact may be important in the induction and exacerbation of AD


- Double blind controlled trial of effect o f

HDM allergen avoidance on AD

Tan et al. -1996 347 1518Lancet ; :

Patient 48 patients (24 adults; mean age 30, 24 children mean age 10) Positive skin test (>= 2mm than NSS) to aeroallergens

Intervention

Goretex bedcovers, benzyltannate spray for carpets and a high-filtration vacuum cleaner

(6 month)

Compare Cotton bedcovers, water spray, conventional domestic vacuum cleaner

Outcome -Der p1 concentration (ng/m2)

-Eczema severity score

-Surface area score

Tan et al. -1996 347 1518Lancet ; :

p=0.002

**

12.6 4.2

p=0.006

Psychosocial factorsO Relaxation, behavioural modification,

biofeedback may all be benefit

O Massage therapy can be adjunct treatment for AD


Hydration O Atopic dry skin and decreased ceramide

level enhanced transepidermal water loss and reduced water binding capacity

O Soak affected area or bath for 10 minutes in warm water and apply occlusive agent to retain absorbed water

O Bleach bath with dilute sodium hypochlorite recommended to reduce skin infection

Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th editionImokawa G.et al:J Invest Dermatol 1991; 96:523-526

HydrationO Hand and foot dermatitis treated by soaking limb

in basin.

O It is essential to use occlusive preparation within few minute after hydration skin to prevent evaporation.

O Bathing may remove allergens from skin and reduce colonization by S. aureus.

O Balneotherapy in acidic hot spring shown to help refractory AD

Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th editionKubota K.et al: Acta Derm Venereol 1997; 77:452-454.

“Soak and seal” MethodOSoak the affected area for

approximately 10 minutes in warm water

OSeal an occlusive agent to retain the absorbed water within a few minutes (for prevent evaporation which is damage to the epidermis)


An. Bras. Dermatol. vol.82 no.1 Rio de Janeiro Jan./Feb. 2007

Breaking the cycle: how I manage difficult ADBreaking the cycle: how I manage difficult AD

Wet wrapWet wrap

Pediatrics 2008;122;812-824

Wet dressing

O Wet-wrap dressings reduce pruritus and inflammation by cooling skin, act as barrier to trauma associated with scratching, improve penetration of steroid.

O Severe AD showed significant improvement after 1 week of treatment using tubular bandages applied over diluted topical steroid.

Wolkerstorfer A.: De Waard van der Spek FB, et al. Efficacy and safety of wet-wrap dressings in children with severe atopic dermatitis: influence of corticosteroid dilution. Br J Dermatol 2000; 143:999-1004. Boguniewicz M: Conventional therapy. Immunol Allergy Clinics North Am 2002; 22:107-124.

Moisturizers and occlusives

O Use of effective emollient combine with hydration help to preserve stratum corneum barrier and decrease need for topical steroid.

O Lotion contain more water than cream and may be more drying because of evaporation effect.

O Vaseline is effective occlusive when use to seal in water after bathing.


Process of moisturizers

O Repairing skin barrier

O Transiently increase water in stratum corneum

O Decrease transepidermal water loss

O Restoring lipid barriers’ ability to attract, hold and redistribute water

Lynde CW. Skin Therapy Lett 2001;6:3-6Kraft JN, et al Skin Therapy Lett 2005;10:1-8

Effect of a new moisturizing lotion on immediate and cumulative skin hydration:

Two randomized, intra-individual, vehicle and comparator-controlled studies

O Patient: Female ≥ 18 yr with very dry skin on legs. O Intervention: Cetaphil Daily Advance (CDA lotion),

Epidrat ultra hydrating lotion (E lotion), Physiogel lotion (P lotion), Physiogel AI cream (PAI cream)

O Compare: Non-treated control O Outcome: CDA lotion induced significantly greater

hydration than nontreated control (p < 0.001), induced skin hydration up to 3 days treatment cessation and improvement in skin dryness score up to 7 days after treatment cessation (p < 0.05)

Journal of Dermatological Treatment. 2011; 22: 221–225

Patient 173 infants, moderate to severe AD, SCORAD Index 20-70

Intervention

Exomega lotion (containing water, petrolatum, Shea butter, Evening primrose oil, glycerin, paraffin oil, niacinamide, butylene glycol, benzoic acid, carbomer oat extracts)

Compare Placebo

Outcome Primary Outcome: Amounts of use of high potency (0.1% Locatop) and moderate potency topical steroids cream (Locapred)

Secondary Outcome: SCORAD index

- The Steroid Sparing Effect of an Emollient Therapy in Infants with Atopic Dermatitis

G GGG GGG et al. 2 0 0 7 ;2 1 4 : 617

G GGG GGG et al. 2 0 0 7 ;2 1 4 : 617

P<0.05

P=0.722

* P<0.0005 **P<0.0001

Corticosteroid O Reduce inflammation and pruritus are

effective both acute and chronic AD.

O Side effect are thinning of skin, telangiectasia, bruising, hypopigmentation, acne, striae, secondary infection.

O Perioral dermatitis can occur with use of topical steroid on face.

O High-potency topical steroid may lead to atrophic changes and systemic side effect.


Stepwise management of patients with AD.Stepwise management of patients with AD.Akdis et al. J ALLERGY CLIN IMMUNOL JULY 2006

Current Medical Research & Opinion Vol. 26, No. 3, 2010, 633–640

Factors affecting systemic absorption

of Topical Steroids

Patient-relatedO AgeO Individual

response to drugO Presence or abse

nce of skin inflammation

David PariserAmerican Journal of Therapeutics 2009; 16: 264 73–

Drug-related

• Concentration • Potency• Extent of BSA involve

d• Duration• Location/ skin thickn

ess• Vehicle• Use of occlusive dres

sings

Pediatric patients: aware of age-appropriate indications

G GGGGG et al. -2006 54115J Am Acad Dermatol ; :GGGGGGG et al. 1 9 9 7 ; 60: -27980

Corticosteroid O Ointments are most occlusive and better

delivery of medication while preventing evaporative losses

O In humid environment, cream may better tolerated than ointments.

O Cream and lotions are less effective and lead to skin dryness and irritation.

O Solution used on scalp and hirsute area


Vehicle: Sequence of potency

Ointment

Cream

Lotion

Gel

Spray

Foam

Maximum

Minimum

Corticosteroid O Finger tip unit (FTU) proposed as applying

topical steroidO Amount of topical medication that extend from

tip to the first joint of index finger

O 1 FTU to cover hand and groinO 2 FTUs for face or footO 3 FTUs for armO 6 FTUs for legO 14 FTUs for trunk


CorticosteroidO Step care approach with mid range or high

potency preparation, followed by low potency preparation.

O Once daily treatment may help adherence to regimen, fluticasone propionate and mometasone.

O Fluticasone, once control of AD with once daily regimen was achieved, long term control could be maintained with twice-weekly, resulted in fewer relapses and less need for topical steroid.

Wolkerstorfer A. et al: Fluticasone propionate 0.05% cream once daily versus clobetasone butyrate 0.05% cream twice daily in children with atopic dermatitis. J Am Acad Dermatol 1998; 39:226-231. Lebwohl M.: A comparison of once-daily application of mometasone furoate 0.1% cream compared with twice-daily hydrocortisone valerate 0.2% cream in pediatric atopic dermatitis patients who failed to respond to hydrocortisone: Mometasone Furoate Study Group. Int J Dermatol 1999; 38:604-606.

V ariation in T opical Steroid P rescribing Habits

OStep-care approach O Mid-range or high potency to induce

remission followed by quick tapering down to low-potency preparations

OShort-burst treatmentO use short bursts of a potent preparation

followed by a steroid-free “holiday period” of emollient use only until relapse occurs

OMaintenance therapyO When once daily achieved, shifted to twice-

weekly applications to areas that had previously been involved but now appeared normal

GGGGGG GGG et al. GGGGGGGGGG 2008; 122 : -81224Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1 893-1999

CorticosteroidO Topical steroid can decrease S. aureus

colonization

O Allergen-induce immune activation can alter T cell response to glucocorticoid receptor binding affinity.

O Systemic steroid should be avoided in AD.

O Dramatic improvement with systemic steroid associated with flaring of AD after discontinuation.


Tacrolimus and Pimecrolimus are structurally similar

HO

H3COCH3

OH

O

CH3·H2O

CH3

H3CO OCH3

N

OO

O

O

H3C

H3CO

OH

H

H CI

H3COCH3

OH

O

CH3

CH3

H3CO OCH3

N

OO

O

O

H3C

H3C O

OH

H

H

CH3

Pimecrolimus810.48 Da

C43H68CINO11

Tacrolimus822.05 Da

C44H69NO12·H2O

Topical Calcineurin Inhibitors

1. Pimecrolimus cream 1% (≥ 2 yr) (Elidel)

O mild to moderate AD.

2. Tacrolimus ointment 0.1% (adult)

0.03% (≥ 2 yr) (Protopic)O moderate to severe AD.

Topical calcineurin inhibitors complexing with macrophilin-12 and calcium-calmodulin to block dephosphorylation of NF-AT by calcineurin, preventing translocation of NF-AT to the nucleus.CaN, Calcineurin; MP-12, macrophilin-12;NF-ATc, nuclear factor of activated T cells in the cytoplasm;NF-ATn, NF-AT in the nucleus; NF-κB,nuclear factor-kappa B; TCI, topical calcineurin inhibitor.

Topical calcineurin inhibitors complexing with macrophilin-12 and calcium-calmodulin to block dephosphorylation of NF-AT by calcineurin, preventing translocation of NF-AT to the nucleus.CaN, Calcineurin; MP-12, macrophilin-12;NF-ATc, nuclear factor of activated T cells in the cytoplasm;NF-ATn, NF-AT in the nucleus; NF-κB,nuclear factor-kappa B; TCI, topical calcineurin inhibitor.

Journal of the American Academy of Dermatology Volume 53, Issue 1 Suppl (July 2005)

Topical calcineurin inhibitors(TCIs)

O Useful for treatment face and intertriginous area.

O Inhibitory effect on cytokine production

O Application site : Stinging, burning, redness in 10-30% of patient esp in extensive excoriation but mostly transient < 1wk


O 6-week RCT O Compared twice daily Tx with pimecrolimus 1%

with tacrolimus 0.03% ointment O 141 children ( 2 – 17 yr ) with moderate AD O Pimecrolimus had better local tolerability. O No difference in efficacy Tx, after 6 wks O Pimecrolimus cream 1% had better formulation

attributes and local tolerability than tacrolimus ointment 0.03% while providing similar efficacy and overall safety in pediatric patients with moderate AD.

A randomized investigator-blinded study comparing pimecrolimus cream 1% with tacrolimus ointment 0.03% in the treatment of pediatric patients with

moderate atopic dermatitis

Kempers et a.lJ AM ACAD DERMATOL OCTOBER 2004

Tacrolimus ointment is more effective thanpimecrolimus cream with a similar safety

profile inthe treatment of atopic dermatitis: Results

from3 randomized, comparative studies

O 6-week RCT in 1065 patientsO Compared twice daily Tx with pimecrolimus 1%

cream with tacrolimus ointment 0.03% in 426 children with mild AD; 0.1% in 226 children with moderate to severe AD and in 413 adults with mild to very severe AD.

O Significantly more patients treated with tacrolimus had almost or completely cleared AD (43 vs 31 %)

O Tacrolimus ointment is more effective and has a faster onset of action than pimecrolimus cream; their safety profiles are similar.

Paller et alJ AM ACAD DERMATOL MAY 2005.

Paller et alJ AM ACAD DERMATOL MAY 2005.

O Patient: Adult and pediatric (n = 347) with ADO Intervention: Tacrolimus ointment 0.03%O Compare: Pimecrolimus cream 1%; O Control: -O Outcome: EASI at the end of study, tacrolimus

ointment was significantly more effective than pimecrolimus cream (p = 0.0002). Frequency of adverse events was comparable between treatment groups (24.0% for tacrolimus ointment vs. 25.6% for pimecrolimus cream)

Safety and Efficacy of Tacrolimus Ointment Versus Pimecrolimus Cream in the

Treatment of Patients with AD Previously Treated with Corticosteroids

Robert S.et al. Acta Derm Venereol 2010; 90: 58–64

Robert S.et al. Acta Derm Venereol 2010; 90: 58–64

In a Public Health Advisory issued March 10, 2005, FDA recommended physicians

to consider:

O Use TCIs only as second-line therapy in unresponsive to or intolerant of other Tx

O Avoid use of TCIs in < 2 yrs ; found higher rates of URI in < 2 yrs treated with pimecrolimus

O Use TCIs only for short periods of time and use minimum amount necessary to control symptoms; avoid continuous use

O Avoid use TCIs in compromised immune systems

FDA issued warnings about possible link between TCIs and cancer 2006 placed "black box"

O Animal studies in mice, rats, monkeys have increased risk of lymphoma and skin cancers with TCIs

O 2004, FDA received 29 reports of cancers in adults and children treated with TCIs; half were lymphomas and other half were cutaneous tumors

Current Medical Research & Opinion Vol. 26, No. 3, 2010, 633–640

Tar preparationsO Tar inhibit influx of proinflammatory cells

and in expression od adhesion molecules in response to epicutaneous allergen challenge.

O Tar preparation used with topical steroid in chronic AD may reduce need for more potent steroid preparation.

O Tar shampoos are often beneficial for scalp involvement.


Paghdal KV - J Am Acad Dermatol - 01-AUG-2009; 61(2): 294-302

Adverse effects of Tar Adverse effects of Tar Preparations.Preparations.

O Avoid using Tar in inflamed skin because it may result in skin irritation.

O photosensitivity reactionsO pustular folliculitis.

Rare

Microbial agentO Lipophilic yeast M. sympodialis and

superficial dermatophyte T. rebrum associated with elevated with specific IgE levels in AD, clinical improvement after antifungal therapy

Boguniewicz M., SchmiGrendelmeier P., Leung D.Y.M.: Atopic dermatitis. J Allergy Clin Immunol 2006; 118:40-43.

O S. aureus are superantigen result in persistent inflammation or exacerbation of AD

Leung: Presence of IgE antibodies to staphylococcal exotoxins on the skin of patients with atopic dermatitis: evidence

for a new group of allergens. J Clin Invest 1993; 92:1374 O More than half of AD had S. aureus culture

from skin.

Antiinfective therapyO Systemic ATB may necessary to treat AD

when secondary infection with S. aureus is present.

O Penicillin or first or second generation cephalosporins for 7-10 days are usually effective.

O Maintenance ATB therapy should be avoided, because it may result in colonization by methicillin-resistant organisms.


Antiinfective therapyO Topical ATB mupirocin (Bactroban) may be

effective for treating localized involvement.

O Twice-daily treatment for 5 days with nasal preparation of mupirocin may reduce nasal carriage of S. aureus.

O Daily bathing with antimicrobial soap 1.5% triclocarban reduces in S. aureus colonization and greater improvement than placebo soap.


Bleach baths O Sodium hypochlorite 6% solution (liquid

chlorine bleach) has activity against S. aureus

including MRSA.

O Lukewarm water, soak in the bath for 5 to 10

min.

O Rinse with fresh water, pat themselves dry

O Immediately apply an emollient and/or

prescribed medications.

O The baths are taken two times per week.Krakowski AC et al. Management of atopic dermatitis in the pediatric population. Pediatrics 2008; 122:812.

Mechanism of PruritusO Neuropeptides, proteases, kinins, cytokines induce

itching.

O IL-31 (produced by T cells) : - strongly pruritogen - up-regulated by exposure to staphylococcal exotoxins in vitro.

N Engl J Med 2008;358:1483-94.

Antipruritic agentsO Systemic antihistamine and anxiolytics may

be most useful through their tranquilizing and sedative effects

O TCA doxeptin: both H1 and H2 receptor binding affinity as well as long half life.

O Second-generation antihistamine: effective in treating pruritus, modest clinical benefit

O Cyclosporin A: decrease transcription of proinflammatory cytokines


HospitalizationO Erythroderma

O Toxic

O Remove Pts from environmental allergen or stressor


Systemic immunomodulatory therapies

O CyclosporineO Recombinant human Interferon-gammaO AzathioprineO Mycophenolate mofetilO Phototherapy

Cyclosporin AO Cyclosprin A (5MKD) using either intermittent

or continuous treatment show no significant differences between two approaches.

O Severe AD treated with cyclosporin A, 5MKD for 6 wks, monitored until relapse and treated with second 6 wks course. Subset of Pts get clinical benefit.

Harper J.I.et al: Br J Dermatol 2000; 142:52-58.

Phototherapy and photochemotherapy

O UV light: modality for chronic AD.

O High dose UVA1: decrease dermal IgE-binding cells, down regulating proinflammatory cytokines or inducing apoptosis in skin-infiltrating CD4+ T cells.

O Photochemotherapy with oral methoxypsoralen therapy followed by UVA may be indicated in severe AD.

Hanifin J.M., Cooper K.D., Ho V.C., et al: J Am Acad Dermatol 2004; 50:391-404.

Clinical Efficacy of Blue Light Full Body Irradiation as

Treatment Option for Severe Atopic Dermatitis

O Patient: 36 pts with severe, chronic AD resisting long term disease control with local corticosteroids

O Intervention: 1 cycle of 5 consecutive blue light-irradiations (28.9 J/cm2).Patients were instructed to ask for treatment upon disease exacerbation despite interval therapy with topical corticosteroids

O Compare: -

O Outcome: The majority of pts noted first improvements after 2–3 cycles. EASI score was improved by 41% and 54% after 3 and 6 months

. Becker.D et al. Plos One.2011;6(6):e20566. Epub 2011 Jun 8.

*=p≤0.05***=p≤0.02

**p≤0.005

***p≤0.002

Recombinant human IFN-ɣ

O IFN-ɣ suppresses IgE synthesis and inhibit Th2 cell function.

O rhIFN-ɣ reduced severity and decrease total circulating eosinophil in AD.


AzathioprineO Affect purine nucleotide synthesis and

metabolism.

O Side effect: myelosuppression, hepatotoxicity, GI disturbance, susceptible for infection, skin cancer.

O Onset of action is slow, benefit may not be apparent for several month after treatment.


O Allergen desensitizationO Intravenous gammaglobulinO Omalizumab O Antifungal therapyO Traditional Chinese herbal therapyO ProbioticsO Essential fatty acidsO Leukotriene receptor antagonists

• Prevention– Delayed solid food introduction

• No protective effect was seen by delaying the introduction of solid food after 4 month.

• Avoidance of soybean, nuts, and cocoa in first 6 months , did have protective effect in the nonintervention cohort.

• AAP recommend for delayed beyond 4 month of life– Probiotics

• The evidence for the use of probiotics for treatment of AD is lacking, however, there does appear to be benefit to the use of prenatal probiotics for prevention of AD.

OEnvironmental and behavioral modificationO Unfavorable indoor climate, HDM exposureO Zinc : decrease plasma level found in ADO Vitamin D : induces expression of protective

antimicrobial peptidesO Contact allergiesO Food –induced eczemaO Education O Skin care and emollient

Conventional TherapiesO Identification and elimination of

exacerbating factors (irritants, proven allergens)

OAddressing psychological aspectsOEducationOHydrationOMoisturizersOTopical corticosteroidsOTopical calcineurin inhibitorsOAnti-infective therapyOAnti-pruritic therapy


Management of atopic dermatitis

Health & Medicine

Transcript of Management of atopic dermatitis