Transcript PowerPoint Presentation - UNC School of Medicine

Atopic Dermatitis
Adam Goldstein, MD
Associate Professor
UNC Department of Family Medicine
Chapel Hill, NC
[email protected]
Objectives
Improve ability to accurately diagnose and
manage 90% of cases of atopic dermatitis
 Recognize differences in infant, childhood
and adult presentations of atopic dermatitis
 Improve ability to diagnose and manage
conditions associated with and sometimes
confused with atopic dermatitis

Atopic Dermatitis: Definition

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Atopic dermatitis = eczema = itchy skin
Greek- meaning
 (ec-) over
 (-ze) out
 (-ma) boiling
Infants & small children (affects 1 in 7)
Atopic dermatitis of childhood may reappear at
different site later in life.
Atopic Dermatitis: Cause

The exact cause is unknown.
Atopic Dermatitis: Cause
(Charlesworth, Am J Med, 2002)
Atopic Dermatitis: Cause


? Inborn skin defect that tends to run in families, e.g.
asthma or hay fever
85% with high serum IgE and + skin tests food & inhalant
(Jones, Clin Rev Allergy, 1993)
Morphology
Distribution
In infants, the face is often affected first,
then the hands and feet; dry red patches
may appear all over the body.
 In older children, the skin folds are most
often affected, especially the elbow creases
and behind the knees.
 In adults, the face and hands are more likely
to be involved.

Distribution
Hand Eczema
Foot Eczema
Atopic
Derm
Adults
Atopic Derm Adults
Atopic Dermatitis:
Associated features

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The skin is usually dry, itchy & easily irritated by:
 soap
 detergents
 wool clothing
May worsen in hot weather & emotional stress.
May worsen with exposure to dust & cats.
Associated Findings

Pityriasis alba
Associated Findings

Xerosis
Associated Findings

Keratosis Pilaris
Associated
Findings

Ichthyosis
Hyperlinear Palmar Creases
Diagnosis


Major characteristics
 Pruritus with or without excoriation
 Typical morphology and distribution
 Chronic relapsing dermatitis
 Personal or family history of atopy (asthma, allergy,
atopic derm, contact urticaria)
Other characteristics
 Xerosis/Ichthyosis/palmar hyper/kerat. pilaris
 Early age of onset
 Cutaneous colonization and/or overt infections
 Hand/foot/nipple/contact dermatitis, cheilitis,
conjunctivitis, Erythroderma, subcapsular cataracts
(Drake, JAAD, 1992)
Differential Diagnosis

Seborrheic
dermatitis
Differential Diagnosis
Seborrheic dermatitis
 Scabies

Differential Diagnosis
Seborrheic dermatitis
 Scabies
 Drugs

Differential Diagnosis
Seborrheic dermatitis
 Scabies
 Drugs
 Psoriasis

Differential Diagnosis
Seborrheic
dermatitis
 Scabies
 Drugs
 Psoriasis
 Allergic contact
dermatitis

Differential Diagnosis


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Seborrheic dermatitis
Scabies
Drugs
Psoriasis
Allergic contact
dermatitis
Cutaneous T-cell
lymphoma
Atopic Dermatitis: Treatment
1. Reduce contact with irritants (soap substitutes)
2. Reduce exposure to allergens
3. Emollients
4. Topical Steroids
5. Antihistamines
6. Antibiotics
7. Steroid sparing
8. Other (herbals, soaps)
1. Reduce contact with irritants
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Avoid overheating: lukewarm
baths, 100% cotton clothes, &
keep bedding to minimum
Avoid direct skin contact with
rough fibers, particularly wool,
& limit/eliminate detergents
Avoid dusty conditions & low
humidity
Avoid cosmetics (make-ups,
perfumes) as all can irritate
Avoid soap- use soap substitute
Use gloves to handle chemicals
and detergents
Soap Substitutes
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Cetaphil- soap substitute- far less drying and irritating
than soap
Cleansing & moisturizing formulations, all OTC
Lotion, bar, ‘soap’, cream, sunscreen
Costs about $8-9 for 16 oz.
2. Reduce exposure to
allergens
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Keep home, especially bedroom,
free of dust.
Allergic reactions include house
dust mite, molds, grass pollens &
animal dander.
Special diets will not help most
individuals b/c little evidence that
food is major culprit.
If food allergies exists, most likely
d/t dairy products, eggs, wheat, nuts,
shellfish, certain fruits or food
additives.
3. Emollients
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Emollients soften the skin soft and reduce itching.
Moisture Trapping effectiveness

Best: Oils (e.g. Petroleum Jelly)

Moderate: Creams

Least: Lotions
Apply emollients after bathing and times when the skin
is unusually dry (e.g. winter months).
Emollients (cont’d)
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Large variety (e.g. Vanicream, Eucerin, Lubriderm,
Moisturel, Curel, Neutrogena)
Inexpensive emollients include vegetable shortening
(Snowdrift by Martha White) and petroleum jelly
(Vaseline)
Urea creams
Oils
Emollients: Alpha-Hydroxy acid

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Creams are excellent for relieving dryness, but can
sting & sometimes aggravate eczema
Useful for maintenance when no longer inflamed
Forces epidermal cells to produce keratin that is softer,
more flexible and less likely to crack
Preparations
Glycolic Acid (8%)
Lactic Acid or Lac-Hydrin (5-12%)
Urea (3-6%)
Use 1X/ day
Emollients: Oils
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Consider using bath oil or mineral oil-based
lotions in lukewarm bath water
Add to tub 15 minutes into bath
Bath oil preparations:
 Alpha-Keri
 Aveeno bath
 Jeri-Bath
Colloidal oatmeal (Aveeno)
reduces itching
4. Corticosteroids
Topical steroids very effective
 Ointments for dry or lichenified skin
 Creams for weeping skin or body folds
 Lotions or scalp applications for hair-areas.

Corticosteroids
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Hydrocortisone 1-2.5% applied to all skin.
Quite safe used even for months
Use intermittently thin areas- (eg-face & genitals)
Stronger potency topical steroids for
nonfacial/genital regions.
Avoid potent/ultrapotent topical steroid preparations
on face, armpits, groins & bottom.
Corticosteroids

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Once under control, intermittent use of
topical corticosteroid may prevent relapse
Systemic steroids may bring under rapid
control, but may precipitate rebound
Once daily probably most cost effective
(Green, Br J Dermatol, 2005)
Steroids and Young Children
Fluticasone proprionate cream 0.05%
 Moderate- severe atopic derm > 3 months
 Applied bid 3-4 weeks- mean 64% BSA
 No HPA suppression

(Friedlander, J Am Acad Dermatol, 2002)
Corticosteroids: Pearls
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Different preparations prescribed for different
parts of body or for different situations
Educate on
 potencies & proper usage
 write down directions
Bring all topicals each appointment to clarify use
5. Antibiotics
Atopic eczema frequently secondarily
colonized with a bacteria (up to 30%).
 Use oral antibiotics in recalcitrant or
widespread cases.

Keep it simple
6. Antihistamines
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Oral antihistamines can
reduce urticaria & itch
Non-sedating antihistamines
less side effects but more
expensive
Sedative effect of
hydroxyzine &
diphenhydramine helpful
7. Steroid Sparing
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Topical calcineurin inhibitors
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Tacrolimus ointment & pimecrolimus cream
Oral Cyclosporine
Ultraviolet light therapy (phototherapy)
with PUVA (psoralens plus ultraviolet A
radiation) or combinations of UVA & UVB
(Jekler, J Am Acad Dermatol, 1990)
Tacrolimus ointment
(0.03%, 0.1% [Protopic])
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Mild to moderate eczema
Steroid dependent or signs of atrophy
Non-steroid responsive
BID x 2-4 weeks to evaluate response
Transient stinging possible
Longer disease-free intervals
Cost similar to high potency steroids
(30gm/$60)
(Ruzicka, N Engl J Med, 1997)
Pimecrolimus cream 1%
(15, 30, 100 gm [Elidel])

Approved Dec. 2001
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Blocks production/release cytokines T-cells
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Moderate eczema
Steroid sparing
Transient stinging 8% children, 26% adults
Cost similar to high potency steroids
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(30gm/$60)
(Ruzicka, N Engl J Med, 1997)
(Eichenfield, J Am Acad Dermatol, 2002)
Tacrolimus ointment & pimecrolimus
cream
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Licensed for patients > 2 years old mild-moderate eczema\
Safety?
In controlled trials appear safe in adults and children
 In 2005, FDA issued warnings about a possible link between the
topical calcineurin inhibitors and cancer (? increased risk of
lymphoma and skin cancers with topical exposure)
 However, no definite causal relationship established
FDA recommends that these agents are used only as second-line
therapy in patients unresponsive to or intolerant of other treatments
 Avoid in children younger than two years of age
 Use for short periods of time and minimum amount necessary
 Avoid continuous use
 Avoid in patients with compromised immune systems

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Ointments (Tacrolimus) better than cream (Pimecrolimus)
Oral Cyclosporine and PUVA
Self
Monitoring
The patientoriented eczema
measure
(Charman, Arch Dermatol,
2004)
Other
Psychological support
 Alternative treatments
 Chinese herbal tea
 Variably effective-not very palatable
 Liver toxicity possible

Other
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Evening Primrose Oil / Star Flower
Oil
 Contains gamma linolenic acid, fatty
acid (deficient some atopic subjects)
Alternative medications some
patients may use for eczema
Licorice
 Calendula
 Echinacea
 Golden Seal
 Nettle
 Oats
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Probiotics in primary prevention of atopic
disease: a randomized placebo-controlled trial.
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Lactobacillus

prenatally to mothers – (FH eczema, AR, asthma)

postnatally for 6 months to infants
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Endpoint: Chronic recurring eczema
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Eczema in probiotic 50% < than placebo (23% vs 46%)
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Number needed to treat = 4.5 (95% CI 2.6-15.6).
(Kalliomaki, Lancet 2001)
Other
Laughter May Be Best Medicine...For Allergies
NEW YORK, NY - Although few would consider allergies to be
funny, results of a new study suggest that laughing them off
might actually work. Dr. Hajime Kimata, of Unitika Central
Hospital in Japan, induced allergic responses on the skin of 26
people with allergic dermatitis by exposing them to house dust
mites, cedar pollen and cat hair, and then had them watch
``Modern Times'', featuring Charlie Chaplin. The participants
exhibited a significant reduction in their allergic responses after
watching the classic comedy, according to the report in the
February 14th issue of The Journal of the American Medical
Association. The effect lasted for 4 hours after the viewing
Other

Coal tar or less messy preps (liquid carbonis
detergent 5-10%) in Eucerin or Aquaphor
 Chronic lichenified eczema patches
 Coal tar smells & stains clothes so apply
qhs using old clothes and old linens
 Coal tar can provoke a folliculitis.
Soaps
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Mild or Hypoallergenic
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Dove (unscented): Contains lotion
Keri
Oil of Olay
Basis
Purpose
Cetaphil Skin Cleanser (non-soap)
Neutrogena bar
Pure Ivory soap is very drying/irritating
Antibacterial Soaps
Dial and Lever 2000
 Cetaphil antibacterial cleansing bar
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Evidenced-based review 2002
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(BMJ Clinical Evidence)
Positive evidence that:
 topical corticosteroids relieve symptoms and are safe
 emollients & steroids better than steroids alone
 excellent control of house dust mite reduces symptoms if
positive mite RAST scores & children
 bedding covers most effective
Little to no evidence that:
 dietary change reduces symptoms
 breast feeding or mother's diet prevents infant eczema
Systematic review 2000

Positive evidence:
 Topical steroids
 Oral cyclosporine
 UV light
 Psychological
approaches

Insufficient evidence
 Ag avoidance pregnancy
 Antihistamines
 Dietary restriction
 Dust mite avoidance
 Hypnotherapy
 Emollients
 Massage
 Evening primrose oil
 Topical coal tar
 Topical doxepin
 Chinese herbs
(Hoare, Health Technol Assess, 2000)
Systematic review

Not beneficial:
 Cotton clothing
 Biofeedback
 Bid vs qd topical steroids
 Bath additives
 Topical antibiotic/steroids vs steroids
alone
(Hoare, Health Technol Assess, 2000)
Final Pearls

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Educate parents that the goal is
CONTROL not CURE
Atopics exposed to herpes virus or smallpox
vaccination may get severe infection with
widespread involvement d/t altered skin
barrier.
Severe herpes infections in children with eczema
Atopic Derm and Smallpox Vaccine
(Ann Intern Med 2003;139)
Costs
H/C 1%
Bid-tid
30 gm
$3.00
TAC 0.1%
Bid
30 gm
$8.00
Fluticasone
propionate 0.05%
Qd-bid
30 gm
$42.00
Mometasone
furoate 0.1%
Qd
30 gm
$45.00
Betamethasone
dipropionate
0.05%
Bid
30 gm
$20.00
Clobetasol
propionate 0.05%
Bid
30 gm
$15.00
Halobetasol
propionate 0.05%
Qd-bid
30 gm
$72.00
Pimecrolimus 1%
Bid
30 gm
$56.00
Tacrolimus 0.1%
Bid
30 gm
$60.00
Drugstore.com 2004
CASE 1
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3 year old female with h/o eczema since 4 months old.
Had done well on hydrocortisone 2.5% ointment when
flared last winter. Parents ran out of the ointment and have
been using vaseline and OTC hydrocortisone 0.5% without
improvement. Child is now waking at night and constantly
scratching.
What do you want to do?
Case Treatment strategy:
Review mild skin care regimen
 Confirm use of
• mild cleanser
• daily moisturizers &
• mild laundry detergent
 Prescribe sufficient potency & quantity of
topical corticosteroids
 Which steroid class(es) would you px?

Case- topical steroid choices
TAC 0.1% oint. bid worse areas x 7-14 days
 Switch to H/C 2.5% ointment BID
 Taper over 4 weeks to emollients if possible
 Confirm parents understand dangers of
prolonged steroid use and not to use potent
steroids on face

F/U 2 weeks later:

Only slightly improved- now what?
Now...
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Add oral antistaphylococcal agent for 7-14 days.
REVIEW mild skin care regimen
Follow-up in 2 weeks and SUCCESS!
CASE 2
34 yo female with h/o hand eczema diagnosed by former MD for 6 years.
Seems to get worse in winter, but never goes away entirely. A friend
told her it could be a fungus. She was given fluocinonide (lidex)
0.05% cream and it helps some. She wants a refill.
CASE 2
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Not likely fungus given chronicity
May have secondary staph infection
May need more potent Class I steroid initially, e.g.
clobetasol propionate (temovate) ointment
Class II Fluocinonide (lidex) 0.05% cream ok less severe
Case 3
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75 YO male with chronic itchy spotsUsing hydrocortisone cream 2.5% bid to ankle- minimal
improvement
Using Class II Fluocinonide (lidex) 0.05% ointment under
occlusion to hip area- “only thing that works”
Case 3
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2.5% H/C too weak
Fluocinonide (lidex) 0.05% ointment under
occlusion causing atrophy
Good case for topical tacrolimus
Patient Education

National Eczema Association
 www.eczema-assn.org
Thank you.
References
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Drake LA, et al. Guidelines of Care For Atopic Dermatitis. J Am Acad
Dermatol 1992;26:485-8.
Atopic eczema. In Clinical Evidence British Medical Journal 2001.
Available online at www.clinicalevidence.org
Correale CE, Walker C, Murphy L, Craig TJ. Atopic Dermatitis: A
Review of Diagnosis and Treatment. J Fam Pract 1999; available at
http://www.aafp.org/afp/990915ap/1191.html
Ruzicka T, Bieber T, Schopf E, et al. A short-term trial of tacrolimus
ointment for atopic dermatitis. European Tacrolimus Multicenter
Atopic Dermatitis Study Group. N Engl J Med 1997; 337(12): 816-21.
Eichenfield LF, LuckyAW, Boguniewicz M, et al. Safety and efficacy
of pimecrolimus cream 1% in the treatment of mild and moderate
atopic dermatitis in children and adolescents. J A Acad Dermatol 2002;
46; 495-504 .
References
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Charlesworth EN . Pruritic dermatoses: overview of etiology and therapy. Am
J Med 2002; 113S, 9A: 25S-33S.
Wahn U, et al. Efficacy and safety of pimecrolimus cream in the long-term
management of atopic dermatitis in children. Pediatrics 2002; 110 (1 Pt 1): e2.
Friedlander SF, et al. Safety of fluticasone proprionate cream 0.05% for the
treatment of severe and extensive atopic dermatitis in children as young as 3
months. J Am Acad Dermatol 2002; 46: 387-394.
Hoare C, et al. Systematic review of treatments for atopic eczema. Health
Technol Assess 2000; 2: 1-191.
Green C, Colquitt JL, Kirby J, Davidson P. Topical corticosteroids for atopic
eczema: clinical and cost effectiveness of once-daily vs. more frequent use. Br
J Dermatol 2005; 152: 130-41.
Charman CR, Venn AJ, Williams HC. The patient-oriented eczema measure:
development and initial validation of a new tool for measuring atopic eczema
severity from the patients' perspective. Arch Dermatol 2004; 140: 1513-9.