Understanding the Role of Emollients in Atopic Dermatitis Management

8/17/2019 Understanding the Role of Emollients in Atopic Dermatitis Management

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ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

Understanding theRole of Emollients

in Atopic DermatitisManagement


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IFC


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Adelaide Ann Hebert

David Luk Chi Kang

Hardyanto Soebono

Hugo Van Bever

Inne Arline Diana

Kyu-Han Kim

Maria Victoria Dizon

Marysia Stella Recto

Yoke Chin Giam

Zakiudin Munasir

Understanding theRole of Emollientsin Atopic DermatitisManagement


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CONTENTSForeword 3

Introduction 4

What to consider when selecting moisturizers 7

Classification of moisturizers 9

Anti-inflammatory agents 10

Recommendations on moisturizer use 11

Moisturizer recommendations by specialty groups 12

Other factors to consider when choosing moisturizers 14

The Asian patient experience 17

Therapeutic patient education 18Patient education and counselling 19

SMART goals 20

Conclusions 21

References 23


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FOREWORDEffective treatment of atopic dermatitis (AD) involves treating the skin

barrier defect inherent in these patients. To do this, patients should be

advised to have adequate hydration and to use moisturizers regularly.

There are but a few available moisturizers supported by scientific evidence.

The booklet published by the Pediatric Dermatology Subspecialty Core

Group of the Philippine Dermatological Society entitled “A Guide toUnderstanding Moisturizers in Atopic Dermatitis” summarizes the most

commonly accessible moisturizing products and grades the quality of

evidence supporting the efficacy and safety of their active ingredients.

Among the factors that may be considered in the choice of treatment

options for any case are the overall benefits perceived by the clinician

on these products, and the patient’s profile. Through analysis of these

factors, one may be able to determine the rationale for choosing thebest moisturizer options for the appropriate patient.

Treatment adherence is vital in primary and secondary prevention of

the symptoms of AD. Different strategies may be on hand to help a

clinician in the effort to promote reduction of flares and to improve

overall quality of life.

This booklet gives an overview of the status of moisturizer use in Asians

with AD based on the consensus points discussed during the 2014 AsianAtopic Dermatitis Summit.


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Atopic dermatitis (AD) is a chronic pruritic inflammatory disorder characterized

as a defect in the skin barrier. This alteration in the barrier leads to increased

penetration by environmental allergens and infective organisms that cause

persistent inflammation in the skin. Although the barrier defect has been considered

in the past as an epiphenomenon, it is now believed to play a major role in the

pathophysiology of the disease.1 (Figure 1)2

FIGURE 1. Effect of barrier dysfunction on Th2 induction. Barrier dysfunction in line with filaggrindeficiency will lead to Th2 skewing conditions, which may play an important role in the developmentof AD

Legend: TSLP, thymic stromal lymphopoietin; Th2, T helper 2 cells; PAR-2, protease activated receptor-2

Reprinted from Journal of Dermatological Science, 70/1, Kabashima K, New concept of the pathogenesis of atopic dermatitis:Interplay among the barrier, allergy, and pruritus as a trinity, Page No. 4, Copyright (2013), with permission from Elsevier.

INTRODUCTION

External stimuli

Barrier disruption

Mechanical injury

TSLP upregulation

PAR-2 activation

Filaggrin mutation

Increased pH

Kallikrein activationProtease containing–

protein antigenexposure

Th2 induction


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As AD is chronic and relapsing, the most important treatment strategy is to treat

and prevent flares and repair the skin barrier in the long term. (Figure 2)

Among the available treatment modalities, moisturizers are the most fundamental

requirement for optimal treatment of AD regardless of the severity.3 These

moisturizers hydrate the skin and repair skin barrier function.4 Worldwide, in all theguidelines on management, moisturizer use is a key and basic step in the treatment

of AD. 3,5-11 (Figure 3)3

FIGURE 2. AD is described as a chronic and relapsing skin disorder

FIGURE 3. Stepwise management approach to AD

Adapted from Akdis CA, Akdis M, Bieber T, et al. Diagnosis and treatment of atopic dermatitis in children and adults: EuropeanAcademy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL ConsensusReport. J Allergy Clin Immunol 2006;118:152-69.

STEP 1 Basic Treatment: Skin hydration,emollients, avoidance of irritants,identification and addressing ofspecific trigger factors

I N T E

N S I T

Y O F

D I S

E A S ESTEP 2 Low-mid potency TCS and/or TCI*

TCS = Topical corticosteroidsTCI = Topical calcineurin inhibitors

CyA = Cyclosporine A*Over the age of 2 years

STEP 3 Mid-high potency TCS and/or TCI*

STEP 4 Systemic therapy (e.g. CyA) or UV therapy

Time

AD Severity

D r y s k i n

o n l y

M i l d

t o

m o d e r

a t e A D

M o d e r a

t e

t o s e v e r e A

D

R e c a l c i t r a

n t ,

s e v e r e

A D

FLARE FLARE FLARE


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The severity of chronic diseases, especially AD, has a definite impact on the quality

of life (QOL) of both the patient and the family. As a result, certain priority patientgroups with similar disease morphologies have been considered to benefit from

specific moisturizer types. However, there remains to be a clinical classification

system to objectively determine which types of moisturizers are best suited for these

AD phenotypes. Products may be chosen according to whether these contain the

necessary ingredients (i.e. occulsives, humectants, or emollients) to match specific

profiles.

Key Opinion Leaders (KOLs) composed of specialists and subspecialists from allergy

and immunology, dermatology (paediatric and adult), and paediatrics from the Asia

Pacific region convened to work on a set of recommendations for the selection of

treatment options in AD that may be applicable within the region. More importantly,

the importance of moisturizers in the management strategy was highlighted, both in

the active and proactive treatment to attain the goal of controlling and preventingthe disease.

Grade Dryness Scale

0 Healthy Skin

1 Feeling Dry but Healthy Skin

2 White Flaking Skin

3 Slight Scaling

4 Severe Scaling with Cracks

5 Severe Cracking

How dry is your skin?

Note: Used for visual representation. Not a validated scale.


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A basic principle of treatment of AD is optimal skin care that adequately addresses

the skin barrier defect. This skin barrier dysfunction manifests as an increase in

transepidermal water loss (TEWL) and increased penetration of allergens and

infectious agents, leading to inflammation and intense pruritus.3 (Figure 4)

Contributing to this abnormality is a disturbed epidermal terminal differentiation

leading to filaggrin deficiency and reduced natural skin lipids.

WHAT TO CONSIDER WHEN SELECTINGMOISTURIZERS

FIGURE 4. Immunologic pathways in AD

Th2 cells circulating in the peripheral blood of AD patients result in elevated serum IgE and eosinophils. These T cells express theskin homing receptor, CLA, and recirculate through unaffected AD skin where they can engage allergen-triggered IgE+ LCs andmast cells (MCs) that contribute to Th2 cell development. Skin injury by environmental allergens, scratching, or microbial toxinsactivates keratinocytes to release proinflammatory cytokines and chemokines that induce the expression of adhesion moleculeson vascular endothelium and facilitate the extravasation of inflammatory cells into the skin. Keratinocyte-derived thymic stromallymphopoietin (TSLP) and DC-derived IL-10 also enhance Th2 cell differentiation. AD inflammation is associated with increased Th2

cells in acute skin lesions, but chronic AD results in the infiltration of inflammatory IDECs, macrophages (Mφ ), and eosinophils. IL-12production by these various cell types results in the switch to a Th1-type cytokine milieu associated with increased IFN- expression.

Republished with permission of The Journal of Clinical Investigation, from New insights into atopic dermatitis, Leung DYM, et al, 113,5 and 2014; permission conveyed through Copyright Clearance Center, Inc.


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Moisturizers restore the intercellular lipid bilayers’ ability to absorb, retain and

redistribute water by maintaining the integrity of the barrier.14,15 These agents may

penetrate and contribute to the reorganization of the structure of the skin layers.16

(Figure 5)

The effects of moisturizers can be measured using subjective and objectiveparameters. However, the few trials that compare moisturizers have shown that it is

difficult to assess efficacy between products.17-19

There are several genes which contribute to skin types and mechanisms of repair

implying the presence of distinct atopic dermatitis phenotypes; however, is is

unknown which substrate (i.e. moisturizer ingredients) is necessary to address

the specific epidermal defect.20 The choice of moisturizers has therefore been

determined in clinical practice by individual preference, safety, efficacy, and absenceof fragrances, additives or other sensitizing agents.20

Rationale for moisturizer use

FIGURE 5. Reestablishment of the protective skin barrier with moisturizers

Humectantspass intocorneocyteswith trappedwater

Emollientmimicsepidermallipids

Occlusivetrapswater

Humectant

Water

H2O H

2O

H2O

H2OH2O

H2O

H2O

H2O

H2O H

2O

H2O

H2O

H2O

H2O

H2O

H2O


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9


There are several classes of moisturizers grouped according to their similar

characteristics and these are21:

(1) humectants, e.g. glycerine, 5 to 10% urea, lactic acid

(2a) occlusives, e.g. lipids, petrolatum, or liquid paraffin

(2b) emollients, e.g. fatty acids or cholesterol

These products are formulated in a variety of delivery systems including gels, oils,

creams, ointments, or lotions, and have different compositions and properties toenhance efficacy.22 The following table summarizes the modes of action, properties,

and some representative agents from each class. (Table 1)23,24

Class Mode of action Biologicalsimilarity

Some examples

Humectants Attract and bindwaterfrom deeper

epidermis to SC

NMF in corneocytes GlycerinAlpha hydroxy acids Hyaluronic acidPyrrolidone carboxylic acid

Sodium pyrrolidonecarboxylic acid (Na PCA)Sodium and ammonium lactateSorbitolUrea

Occlusives Form a hydrophobicfilm to retard TEWLof SC

Intercellularlipid bilayers

- Ceramide- Cholesterol- Free fatty acids

Carnauba wax LanolinMineral oils Olive oilPetrolatum SiliconeCetyl/stearyl alcohol Propylene glycolSqualene Stearic acid

Emollients Smoothens skin

by filling thecracks betweendesquamatingcorneocytes

Natural lipids found on

skin and sebum

Collagen Colloidal oatmeal

Elastin Glyceryl stearateIsopropyl myristate/isostearateIsopropyl palmitateIsostearyl alcoholJojoba oil KeratinLauric acid Linoleic acidLinolenic acidOctyl octanoate/stearateOleic acid Propylene glycolShea butter Stearic acid

CLASSIFICATION OF MOISTURIZERS

TABLE 1. Moisturizer classification

Legend: SC, subcutaneous layer; NMF, natural moisturizing factor; TEWL, transepidermal water loss


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New anti-inflammatory agents are added into the formulation because of

their steroid-sparing effects.23 These agents include glycyrrhetinic acid, palmitoyl-

ethanolamine, telmesteine, Vitis vinifera , and ceramide-dominant barrier repair

lipids, and filaggrin breakdown products [e.g. ceramide precursor/pseudoceramide,

5-sphingosine derived sphingolipid, niacinamide, vitamin B3, pyrrolidone carboxylic

acid (PCA) and arginine].24

Of the available moisturizers with the above ingredients, a few have been

shown to provide effective control of xerosis and with rare adverse outcomes.24

MAS063DP (Atopiclair™) cream, a non-steroidal hydrolipidic combination of

glycyrrhetinic acid, telmesteine, Vitis vinifera or grape seed extract, combined

with hyaluronic acid and shea butter, has been documented in adults andchildren to have anti-inflammatory action on top of barrier repair features.25-27

FIGURE 6. Two-dimensional molecular representations of commonly used anti-inflammatory agentsfor moisturizers

ANTI-INFLAMMATORY AGENTS

Palmitoyl-ethanolamine

Ceramide

Telmesteine

Vitis viniferaextractGlycyrrhetinic

acid

HO

O

O

H3C

H3C CH

3

CH3 CH3

CH3

CH3

H

H

H

OH

OH

O

OH3C O

N

S

HO

NH

O

CH3

HO

HO

HO

HO

OH

OH

OH

OH

OH

O

O

H3C

O

HN

OH

OHHO

0


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RECOMMENDATIONS ON MOISTURIZERUSE

Guidelines have general recommendations on moisturizer use.3,13,24,43

These are:

FOR PATIENTS TO:

• Apply the product regularly evenwhen no actual inflammatory skin

lesions are seen.

• Use moisturizers two to three times

daily, or more as needed.

• Immediately use moisturizers after

washing/bathing to trap moisture in

the skin.

• First apply topical flare treatments

(i.e. topical steroids and

immunomodulators), left on for

at least 30 minutes (1 hour for

tacrolimus), and then followed by

the moisturizer.

• Avoid inserting hands or fingers

into the moisturizer canisters or

pots to avoid contamination of the

contents. They can pour out the

moisturizer into a clean container

with a clean spoon.

FOR DOCTORS TO:

• Inform patients of the cost ofmoisturizers and other treatments.

Prescribe the less expensive creams

if cost is an issue.

• Encourage patients to try a range

of appropriate moisturizers to

empower them.

• Advise patients in hot and humid

areas to cool the topical creams as

this may help provide a soothing

sensation when applied.

• Give ceramide dominant creams

or paraffin for xerosis and use

short term occlusion dressings for

extremely crusted lesions.

• Refer patients with recalcitrant and

severe conditions or when there

are co-existing conditions needing

higher level of treatment (e.g. AD,

asthma, allergic rhinitis, allergic

conjunctivitis, and food allergy).


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MOISTURIZER RECOMMENDATIONS BYSPECIALTY GROUPS

The Pediatric Dermatology Subspecialty Core Group of the Philippine Dermatological

Society published a review of the evidence on specific moisturizer ingredients.24

Below is an abridged adaptation of their appraisal:

Active ingredient Major category Notes Level ofevidence

Ceramide Emollient Repairs stratum corneum integrity & function IIIKernel oil Emollient Reduces water loss from the skin

Preserves the integrity of the stratum corneumbarrier

IIIb

Shea butter Emollient Provides a stable carrier of antioxidant substancesand supplies lipids to the skin

Ib

Filaggrin breakdownproduct

Emollient and humectant withanti-inflammatory properties

Enhances skin barrier integrityIncreases skin hydration and helps restore fissuredand dry skin

IIb

Palmitoyl-Ethanolamine

Emollient and humectant withanti-inflammatory properties

Cannabinoid receptor agonist with anti-inflammatory, analgesic and antioxidant effects

IIb

Sunflower oil Emollient and humectant with

anti-inflammatory properties

Reduces dryness, flaking, itching and redness

Improves lichenification and excoriations

Ib

Glycyrrhetinic acid Emollient with anti-inflammatoryproperties

Potentiates action of steroids on the skin due to itsstructural similarity with cortisone

Ib

Telmesteine Emollient with anti-inflammatoryproperties

Scavenging action on free radicals and may offerprotection against oxidizing agents responsible forepithelial damage

Ib

Vitis vinifera Emollient with anti-inflammatoryproperties

Reduces pro-inflammatory cytokines andsynergistically augments the inhibition ofmembrane peroxidation effects of antioxidants

Ib

Hyaluronic acid HumectantEmollient

Very hygroscopicHas a major organizational role within the collagenbundle

Ib

Lactic acid Humectant

Emollient

Decreases TEWL

Reduces dryness and scalingNo barrier function disruption

IIIb

Propylene glycol HumectantEmollient

Makes skin supple and smoothAbsorbs moisture into the skin

IIIb

Urea Humectant Moisturizes the skin by decreasing TEWL in adultAD patients

IIb

Mineral oil Occlusive Semi-occlusive layer that retards water evaporationPenetrates upper layers of stratum corneum

No reports

Olive oil Occlusive Semi-occlusive layer that retards water evaporation No reports

Petrolatum Occlusive Prevents TEWL IIIb

Virgin coconut oil Occlusive Decreases TEWLIncreases fibroblast proliferation and

neovascularisationAntioxidant, anti-inflammatory

IIIb

TABLE 2. Common moisturizer ingredients with mechanisms and evidence supporting their use24

Legend: Ib, Individual randomized controlled trials (RCTs) with narrow confidence interval; IIb, Individual cohort study and lowquality RCT; III/IIIb, Individual case-control study


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Some AD experts have developed consensus recommendations to address the need

for guidance in the decision to choose moisturizers. Moncrieff, Cork, and Lawson(2013) identified dry skin conditions and recommended moisturizers for use by

healthcare practitioners based on best clinical practice. (Figure 7)13

FIGURE 7. Dry skin groups and the recommended leave-on moisturizer types

Priority patientgroups Class Definition Usage

Mild to moderate AD Occlusive emollientcream

Oil-in-water emulsion toprevent water evaporationfrom the skin by providing afilm of lipid

Patient choice beconsidered regarding thethickness of barrier, variablelipid content, severity ofcondition, body site

More severe AD Occlusive emollientointment

Water-in-oil emulsionsintended to provide a thickerfilm of lipid on the skin.

Drier skin conditionsrequiring a thicker lipid film.Limited in use because ofpatient acceptability

Very severe AD Occlusive ointment,no water

White softParaffin (WSP), liquidparaffin (LP), 50:50 ratio ofthe WSP/LP

Very dry skin

Where simpleemollients areineffective orgreasier products areunacceptable

Humectantcontainingemollients

Emollient productcontaining humectants, ureaand glycerin, hold water inthe stratum corneum

Dry skin in cases whereotherproducts are not acceptableor effective

Pruritic variants Antipruritic emollient Emollient productscontainingantipruritic agents

Pruritus

Antipruritic emollients for pruritus

Humectant containing emollients for special cases

Mild tomoderate AD

More “severe” AD

Occlusiveemollient ointment

Occlusiveointment, no water

Occlusiveemollient cream “Very severe” AD


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T h i s i

s influe n c e d b y

:

OTHER FACTORS TO CONSIDER WHENCHOOSING MOISTURIZERS

Because personal preference plays a significant role

in the choice of moisturizers, it is necessary for

physicians to take the following factors into

consideration when prescribing

these products3,17:

Time of day that thepatient applies the

moisturizer

Cost of treatment

Cosmeticacceptability

Weather

conditions

PERSONALPREFERENCE

OR


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The Panel also discussed

that it is important to consider:

Availability of products

over-the-counter

Convenient packaging to carry

around in adequate quantities

CONVENIENCE


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The choice should not be based on

false economy, but on:

CLINICAL BASIS

PATIENT VALUES AND

PREFERENCES

CLINICAL

EXPERTISE

BEST

RESEARCH

EVIDENCE

Clinical

Best

Practice

Overall, until objective parameters identifying the best skin type for the choice of

moisturizers are developed, the decision to choose moisturizers will continue to

depend on the properties that physicians and their patients may find most beneficial

based on subjective considerations and outcomes.9,14


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In a two-year survey done in 1989

in Singapore, AD or eczema ranked

top among the most common skin

disorders amongst Chinese, Malay

and Indian patients.28 Despite the

differences in incidence among the

ethnic groups, the management of AD

was similar and standard moisturizer

was used in all patients.29

In a study cohort of childhood-onset

eczema paediatric patients in Hong

Kong, moisturizers were used on a

regular basis, 1.8 times per day in

mild cases as compared to 2.8 times

per day in moderate to severe cases.30 Patients preferred non-fragrant, non-

herbal, white or transparent cream.

In the guidelines created by the Asia-

Pacific group, they recommended

regular use of moisturizers as

maintenance therapy and as an adjunct to other existing therapies such as topical

steroids.31 Greasy moisturizers were considered best for dry skin and those withcreamier textures for red and inflamed eczema.31 Fragrances and preservatives

should be avoided due to their potential irritant properties.31

The Panel recognizes the potential existence of well-defined clinical phenotypes

of AD in Asians that would optimally benefit from specific moisturizer types. The

moisturizers that will correspond to these phenotypes should ideally be able to

treat both lesional or non lesional skin, and both. A categorization system based

on objective measures (e.g. filaggrin mutation subtypes, confocal microscopicevaluation, pH, TEWL levels, presence of allergy specific IgE in oriental versus non-

oriental skin) can be used to determine these clinical phenotypes in the future.

THE ASIAN PATIENT EXPERIENCE


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Educational programs as shown in clinical guidelines are necessary to improve

awareness in AD patients. These are effective tools to improve treatment compliance

as they include psychological support to the patients and their caregivers.32

Therapeutic patient education (TPE) is a comprehensive program that helps patients

with chronic diseases acquire or maintain the skills they need to manage their life in

the best possible way. This has already been in use in the treatment of many chronic

diseases.33

The aim of this program is to improve the patient’s therapeutic adherence, general

health, and QOL. This resource addresses the patient’s or their caregiver’s refusal to

listen.

This will usually include information on32:

THERAPEUTIC PATIENT EDUCATION

The effects of these patient and caregiver education programs have been evaluated

in randomized controlled trials. Intervention groups in these studies were shown

to have positive improvement in the patient’s coping behaviour, sleeplessness

symptoms, anxiety about corticosteroid usage, and other psychological variables.

Hence, clinical outcomes may be improved by providing educational initiatives ontop of conventional treatments for AD.34-36

The cause ortrigger of AD

The laboratoryexaminations necessary

for diagnosis

Treatment options,skin care, andenvironmental

management

The clinicalmanifestations

and features of AD


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Treatment adherence is important in AD management to aid in primary prevention

of relapses. Different non-pharmacological strategies are now available to help the

clinicians reduce AD flares.

In addition to physician-led patient education, intervention by dermatology nurses

has been shown to provide additional benefits to patients in their care and control

of symptoms.37 Nurses may achieve this by38:

PATIENT EDUCATION AND COUNSELLING

Educating patients about their skin

condition and its management

Educating about specific medications,

instructions for use and side effects

Treating with anti-inflammatory agents and

maintaining comfort of the patient by tackling

how to self-manage distressing symptoms

Tailoring all skin care regimens to suit

individual patients and their families

Supporting patients by support groups, coping

strategies, stress management, counselling,

listening and talking

Providing time for the patient and providingcontinuity of care


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Overall management points that were outlined by the Panel include:

• Compliance is of utmost importance and patient factors and

preference should always be taken into consideration when choosing

treatment for AD.

• It is important to avoid cleansers with sodium lauryl sulphate, cetyl

alcohol, or strong sensitizers (e.g. bacitracin, neomycin, and polymyxin

B, lavender, etc).• Therapeutic patient education should be carried out.

• Define goals that are patient-specific, measurable, achievable,

agreeable to patient, relevant, result-oriented, and time-limited

(SMART).

• Promote activities to help build a good patient and doctor relationship,

eliciting concerns, requests, showing empathy and caring (e.g.

workshops).• Education of patients and their caregivers on the patient’s skin

condition and management is a key component of the strategies

(e.g. re-enforced nurse counselling, written action plan, patient

information leaflets, finger unit chart, written care instructions).

• Treatment of AD should entail collaboration among the specialists

(e.g. dermatologists, paediatricians, allergists/immunologists,

pulmonologists, ENT, ophthalmologists) to address all interrelatedconditions of the patient (e.g. AD, asthma, allergic rhinitis, allergic

conjunctivitis, food allergy).

CONCLUSIONS


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24. Paediatric Dermatology Subspecialty Core Group and Philippine

Dermatological Society. A Guide to Understanding Moisturizers inAtopic Dermatitis. 2014.

25. Abramovits W, Perlmutter A. Atopiclair™: its position within a topicalparadigm for the treatment of atopic dermatitis. Expert Rev. Dermatol 2007; 2: 115-9.

26. Abramovitz W, et al. A Multicenter, Randomized Vehicle-ControlledClinical Study to Examine the Efficacy and Safety of MAS063DP(AtopiclairTM) in the Management of Mild to Moderate AtopicDermatitis in Adults. J Drugs Dermatol 2006;5: 236-44.

27. Patrizi A, et al. A double blind, randomized, vehicle-controlled clinicalstudy to evaluate the efficacy and safety of MAS063DP (AtopiclairTM)in the management of atopic dermatitis in paediatric patients.Paediatric Allergy and Immunology 2008;19:619-25.

28. Chua-Ty G, Goh CL, Koh SL. Pattern of skin diseases at the National

Skin Centre (Singapore) from 1989-1990. Int J Dermatol 1992;31:555-9.

29. Ho SGY, Chan HHL. The Asian Dermatologic Patient: Review ofCommon Pigmentary Disorders and Cutaneous Diseases. Am J ClinDermatol 2009;10:153-68.

30. Hon KL, Wang SS, Pong NH, Leung TF. The ideal moisturizer: a surveyof parental expectations and practice in childhood-onset eczema. JDermatolog Treat 2013;24:7-12.

31. Rubel D, Thirumoorthy T, Soebaryo RW, et al. Consensus guidelines forthe management of atopic dermatitis: an Asia-Pacific perspective. JDermatol 2013;40:160-71.

32. Shin JY, Kim do W, Park CW, et al. An educational program thatcontributes to improved patient and parental understanding ofatopic dermatitis. Ann Dermatol 2014;26:66-72.

33. Weingarten SR, Henning JM, Badamgarav E, et al. Interventionsused in disease management programmes for patients with chronicillness-which ones work? Meta-analysis of published reports. BMJ2002;325:925.

34. Staab D, von Rueden U, Kehrt R, et al. Evaluation of a parentaltraining program for the management of childhood atopic dermatitis.Pediatr Allergy Immunol 2002;13:84-90.

35. Futamura M, Masuko I, Hayashi K, et al. Effects of a short-termparental education program on childhood atopic dermatitis: arandomized controlled trial. Pediatr Dermatol 2013;30:438-43.

36. Kupfer J, Gieler U, Diepgen TL, et al. Structured education programimproves the coping with atopic dermatitis in children and theirparents-a multicenter, randomized controlled trial. J Psychosom Res2010;68:353-8.

37. Lawton S. Atopic Eczema and Evidence-Based Care. J Dermatol NursesAssoc 2011;4:131-9.

38. Lawton S. Assessing the patient with a skin condition. J TissueViability 2001;11:113-5.

39. Morrison M. History of SMART Objectives. Available at https://rapidbi.com/history-of-smart-objectives. Accessed 13/10/2014.

40. Oakland Southfield Physicians, PC Administrative Network, Inc.SMART Goals: a patient self-management tool. Available at https://www.bcbsm.com/pdf/OSP-SMART_Goals.pdf. Accessed 13/10/2014.

41. Substance Abuse and Mental Health Services Administration.S.M.A.R.T. Treatment Planning. Available at http://www.samhsa.gov/samhsa_news/volumexiv_5/article2.htm. Accessed 13/10/2014.

42. Saint Vincent Catholic Medical Centers. Treatment Plans Using theS.M.A.R.T. Model. Available at https://www.decisionhealth.com/

content/articles/Facilities/SMART_Train_the_trainer.pdf. Accessed13/10/2014.

43. Holden C, English J, Hoare C, et al. Advised best practice for the useof emollients in eczema and other dry skin conditions. J DermatologTreat 2002;13:103-6.


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Faculty

Profiles


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Professor Adelaide Ann HebertDepartments of Dermatology and Paediatrics University of Texas-Houston Medical School Texas, Unites States of America

Professor Adelaide Ann Hebert is a Professor of Dermatology and Paediatrics atthe University of Texas-Houston Medical School. She is also Chief of Paediatric

Dermatology at the Memorial Hermann Children’s Hospital. Prof. Hebert earned her

medical degree from Tulane University School of Medicine in New Orleans, Louisiana,

and went on to complete an internship in internal medicine at the University of Texas

Medical Branch, Galveston, Texas, where she subsequently completed her residency

in Dermatology. Prof. Hebert was the only paediatric dermatology Fellow in the

United States when she completed her advanced training at Children’s Memorial

Hospital of Northwestern University in Chicago, Illinois.

Her areas of clinical interest and research include atopic dermatitis, psoriasis,

hyperhidrosis, skin and soft tissue infections, tinea capitis, and disorders of the

mucous membranes.

Prof. Hebert is on the Board of Directors of the Society for Paediatric Dermatology

and the Women’s Dermatological Society and is Chair of the Society for Paediatric

Dermatology Foundation.

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A/Professor Giam Yoke ChinNational Skin Centre Singapore

Associate Professor Giam Yoke Chin is a Senior Consultant at the National SkinCentre (NSC), Singapore and is the Advisor to the Paediatric Dermatology Division

at the NSC. A/Prof. Giam is also a clinical teacher at the National University of

Singapore and is a visiting consultant to the Paediatric Dermatology clinic at the

National University Hospital. Singapore. A/Prof. Giam received her medical and

doctoral degrees from the National University of Singapore. She underwent training

in various subspecialties of Dermatology and Paediatric Dermatology in the United

Kingdom at the University of Edinburgh (Royal Infirmary Edinburgh) and at St

John’s Institute of Dermatology. In the United States, she trained at the University

of Chicago (Illinois), Children’s Memorial Hospital (New York) and the University of

California, San Francisco (UCSF).

Her clinical and research interests include paediatric dermatology and skin health.

She is an Advisor to the Paediatric Dermatology Division, Education Committee at the

National Skin Centre in Singapore and sits on the Review Committee of Journal of

Philippines Dermatological Society . She is a reviewer for Annals Academy of Medicine

Singapore (AMS) , the Singapore Medical Journal and Paediatric Dermatology (US) .

FACULTY PROFILES


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Professor Hardyanto SoebonoFaculty of Medicine Gadjah Mada University Yogyakarta, Indonesia

Professor Hardyanto Soebono was Dean of the Faculty of Medicine at GadjahMada University, Yogyakarta, Indonesia from 2000 - 2008. He earned his medical

degree and completed his training in dermatology and venereology at the Faculty

of Medicine, Gadjah Mada University. Thereafter, he conducted further training in

immunodermatopathology, photobiology, immunogenetics and the serology of

leprosy. His doctoral degree focused on the immunoepidemiology of leprosy.

Prof. Soebono is currently the Chairman of the Indonesian Medical Council, a

Fellow of the Asian Academy of Dermatology and Venereology, a member of theInternational Society of Dermatology and International Leprosy Association and

also an honorary member of the Dutch Society of Dermatology and Venereology.

FACULTY PROFILES


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Dr Inne Arline DianaDivision of Paediatric Dermatology Hospital Dr Hasan SadikinBandung, Indonesia

Dr Inne Arline Diana is Head of the Division of Paediatric Dermatology at the Dr HasanSadikin Hospital, Bandung, Indonesia. She earned her medical degree and trained

as a dermato-venereologist at the Faculty of Medicine, University of Padjadjaran,

Bandung, Indonesia. Dr Diana underwent further training in paediatric dermatology

at the Academic Medical Center, University of Amsterdam, the Netherlands and in

pigmentary disorders at the Netherlands Institute for Pigmentary Disorders. She

also underwent training in phototherapy at the National Skin Centre, Singapore.

Dr Diana is a member of the Indonesian Medical Association, Indonesian Societyof Dermatology and Venereology, International Society of Dermatologic Surgery,

American Society of Dermatologic Surgery, Dermatology and Aesthetic Surgery

International League and is the Chairman of Indonesian Paediatric Dermatology

Study Group.

FACULTY PROFILES


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Professor Kyu-Han KimDepartment of Dermatology,Seoul National University Hospital,Seoul, Korea

Professor Kyu-Han Kim is Chairman of the Department of Dermatology at SeoulNational University Hospital, Seoul, Korea. He graduated from Seoul National

University College of Medicine and completed his residency in dermatology at Seoul

National University Hospital. He furthered his training and research by completing

his doctoral degree in Dermatology at his alma mater. He subsequently undertook a

research fellowship at the Department of Dermatology, Emory University School of

Medicine, Atlanta, Georgia, USA.

Prof. Kim is former President of Korean Atopic Dermatitis Association and a Boardmember in charge of scientific affairs at both the Korean Society of Investigative

Dermatology and the Korean Society of Atopic Dermatitis. Prof. Kim is on the

editorial board of the Korean Journal of Dermatology and the Korean Journal of

Medical Science , and also on the Advisory Board of Acta Dermato-Venereologica .

FACULTY PROFILES


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Dr David Luk Chi KangDepartment of Paediatrics and Adolescent Medicine United Christian Hospital Hong Kong

Dr David Luk is an Associate Consultant in the Department of Paediatrics andAdolescent Medicine at United Christian Hospital, Hong Kong. He is also an Honorary

Clinical Assistant Professor at The University of Hong Kong and The Chinese University

of Hong Kong. Dr Luk earned his medical degree from The Chinese University of

Hong Kong and subsequently obtained his Membership of the Royal Colleges of

Physicians (UK) and Membership of the Royal College of Paediatric and Child Health

(UK). Dr Luk completed his postgraduate diploma in Dermatological Sciences at

University of Wales, UK and a Master of Science in dermatology at Cardiff University,

UK. He undertook further training in dermatology at the Birmingham Skin Centre,

United Kingdom.

Dr Luk is President of the Hong Kong Paediatric and Adolescent Dermatology Society.

He is a Fellow of the Hong Kong Academy of Medicine and the Hong Kong College

of Paediatricians. Dr Luk has published in areas of dermatology and paediatrics with

a particular interest in paediatric dermatology.

FACULTY PROFILES


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Dr Zakiudin MunasirDepartment of Allergy and Clinical Immunology University of Indonesia Jakarta, Indonesia

Dr Zakiudin Munasir is Head of the Division of Allergy and Immunology, Departmentof Child Health in the Faculty of Medicine, University of Indonesia - Cipto

Mangunkusumo Hospital. He completed his medical degree at the University of

Indonesia, Jakarta, Indonesia and residency in paediatrics. Dr Munasir subsequently

became a paediatric consultant in allergy and immunology for the Indonesian

Paediatric Society.

Dr Munasir is a member of the working group on allergy and immunology for

the Indonesian Paediatric Society and also a member of the Indonesian Allergyand Immunology Association. He is a member of the European Paediatric Allergy

Rheumatology, World Allergy Organization, European Academy of Allergy and

Clinical Immunology and board member of Asia Pacific Association of Paediatric

Allergy, Respirology and Immunology (APAPARI). He is also an editor for the Asia

Pacific Allergy Journal .

FACULTY PROFILES


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A/Professor Marysia Tiongco-RectoSection of Allergy and Immunology Department of Paediatrics University of the Philippines Manila, Philippines

Associate Professor Marysia Tiongco-Recto is Head of the Section of Allergyand Immunology, Department of Paediatrics, Asian Hospital and Medical Centre,

Associate Professor at the Section of Allergy and Immunology in the Department

of Paediatrics, University of the Philippines, Manila, Philippines and associate active

staff at the Department of Paediatrics, Makati Medical Centre.

She earned her medical degree from the University of the Philippines, College of

Medicine. She subsequently completed her residency training in paediatrics and a

post-residency fellowship at the Section of Allergology and Clinical Immunologyat University of the Philippines, Philippine General Hospital Medical Centre.

A/Prof. Tiongco-Recto furthered her training in paediatric allergy and immunology

at the University of Padova, Italy.

A/Prof. Tiongco-Recto is a member of the Philippine Paediatric Society. She is a

Fellow and Advisory Board member of the Philippine Society of Allergy, Asthma and

Immunology and has published widely in the fields of paediatric allergology and

clinical immunology.

FACULTY PROFILES


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Professor Hugo Van BeverDivision of Paediatric Allergy, Immunology and Rheumatology Khoo Teck Puat-National University Children’s Medical Institute Singapore

Professor Hugo van Bever is Professor and Senior Consultant at the Division ofPaediatric Allergy, Immunology and Rheumatology, Khoo Teck Puat-NationalUniversity Children’s Medical Institute, Singapore. He obtained his medical degreeat the State University of Ghent, Belgium where he also completed his paediatricstraining at the Children’s Hospital. He continued his training in paediatric allergy andpulmonology at the University of Antwerp, Belgium, where he eventually becameProfessor in Paediatric Allergy and Pulmonology and Head of the Department ofPaediatrics before moving to Singapore.

His areas of clinical research and interest include paediatric allergy, asthma andrespiratory infections. His current research is focused on eczema, allergic rhinitis,sublingual immunotherapy, primary prevention of allergy and food allergy.

Prof. van Bever is a member of various national and international societies, includingthe European Academy of Allergy and Clinical Immunology (EAACI), the AmericanAcademy of Allergy, Asthma and Immunology (AAAAI), the European Society ofPaediatric Allergy and Clinical Immunology (ESPACI), and the European RespiratorySociety (ERS). He is Past Secretary of the Group Paediatric Asthma and Allergy of

the ERS, Past Secretary of The Belgian Society of Allergy and Clinical Immunology(BELSACI) and Board Member of The Flemish Group of Allergologists. He is a long-standing member of the Asian Pacific Association of Paediatric Allergy, Respirologyand Immunology (APAPARI).

Prof. van Bever has published more than 300 papers in national and international journals. He is a member of the Editorial Board of Paediatric Allergy , Asian PacificJournal of Allergy and Immunology and is Editor in Chief of the Journal of Allergy .Prof. van Bever is a reviewer for the European Journal of Paediatrics, Paediatrics,

Paediatric Allergy and Immunology , Allergy , Paediatric Pulmonology , the EuropeanRespiratory Journal , Paediatric Research, British Medical Journal , the AmericanJournal of Respiratory and Critical Care Medicine and Archives of Diseases inChildhood .

FACULTY PROFILES


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Understanding the Role of Emollients in Atopic Dermatitis Management

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