Atopic Dermatitis

1
Atopic Dermatitis

• Adam Goldstein, MD
• Associate Professor
• UNC Department of Family Medicine
• Chapel Hill, NC
• aog_at_med.unc.edu

2
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

3
Atopic Dermatitis Definition

• 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.

4
Atopic Dermatitis Cause

• The exact cause is unknown.

5
Atopic Dermatitis Cause
(Charlesworth, Am J Med, 2002)
6
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)

7
Morphology
8
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.

9
Distribution
10
(No Transcript)
11
(No Transcript)
12
(No Transcript)
13
Hand Eczema
14
Foot Eczema
15
Atopic Derm Adults
16
Atopic Derm Adults
17
Atopic Dermatitis Associated features

• 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.

18
Associated Findings

• Pityriasis alba

19
Associated Findings

• Xerosis

20
Associated Findings

• Keratosis Pilaris

21
Associated Findings

• Ichthyosis

22
Hyperlinear Palmar Creases
23
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)

24
Differential Diagnosis

• Seborrheic dermatitis

25
Differential Diagnosis

• Seborrheic dermatitis
• Scabies

26
Differential Diagnosis

• Seborrheic dermatitis
• Scabies
• Drugs

27
Differential Diagnosis

• Seborrheic dermatitis
• Scabies
• Drugs
• Psoriasis

28
Differential Diagnosis

• Seborrheic dermatitis
• Scabies
• Drugs
• Psoriasis
• Allergic contact dermatitis

29
Differential Diagnosis

• Seborrheic dermatitis
• Scabies
• Drugs
• Psoriasis
• Allergic contact dermatitis
• Cutaneous T-cell lymphoma

30
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)

31
1. Reduce contact with irritants

• 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

32
Soap Substitutes

• 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.

33
2. Reduce exposure to allergens

• 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.

34
3. Emollients

• 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).

35
Emollients (contd)

• 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

36
Emollients Alpha-Hydroxy acid

• 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

37
Emollients Oils

• 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

38
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.

39
Corticosteroids

• 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.

40
Corticosteroids

• 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)

41
Steroids and Young Children

• Fluticasone proprionate cream 0.05
• Moderate- severe atopic derm gt 3 months
• Applied bid 3-4 weeks- mean 64 BSA
• No HPA suppression

(Friedlander, J Am Acad Dermatol, 2002)
42
Corticosteroids Pearls

• 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

43
5. Antibiotics

• Atopic eczema frequently secondarily colonized
  with a bacteria (up to 30).
• Use oral antibiotics in recalcitrant or
  widespread cases.

44
(No Transcript)
45
Keep it simple
46
(No Transcript)
47
6. Antihistamines

• Oral antihistamines can reduce urticaria itch
• Non-sedating antihistamines less side effects but
  more expensive
• Sedative effect of hydroxyzine diphenhydramine
  helpful

48
7. Steroid Sparing

• Topical calcineurin inhibitors
• 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)

49
Tacrolimus ointment (0.03, 0.1 Protopic)

• 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)

50
Pimecrolimus cream 1 (15, 30, 100 gm
Elidel)

• Approved Dec. 2001
• Blocks production/release cytokines T-cells
• Moderate eczema
• Steroid sparing
• Transient stinging 8 children, 26 adults
• Cost similar to high potency steroids (30gm/60)
• (Ruzicka, N Engl J Med, 1997)
• (Eichenfield, J Am Acad Dermatol, 2002)

51
Tacrolimus ointment pimecrolimus cream

• Licensed for patients gt 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
  

52
Ointments (Tacrolimus) better than cream
(Pimecrolimus)

53
Oral Cyclosporine and PUVA
54
Self Monitoring
The patient-oriented eczema measure
(Charman, Arch Dermatol, 2004)
55
Other

• Psychological support
• Alternative treatments
• Chinese herbal tea
• Variably effective-not very palatable
• Liver toxicity possible

56
(No Transcript)
57
Other

• Evening Primrose Oil / Star Flower Oil
• Contains gamma linolenic acid, fatty acid
  (deficient some atopic subjects)

58
Alternative medications some patients may use for
eczema

• Licorice
• Calendula
• Echinacea
• Golden Seal
• Nettle
• Oats

59
Probiotics in primary prevention of atopic
disease a randomized placebo-controlled trial.

• Lactobacillus
• prenatally to mothers (FH eczema, AR, asthma)
• postnatally for 6 months to infants
• Endpoint Chronic recurring eczema
• Eczema in probiotic 50 lt than placebo (23 vs
  46)
• Number needed to treat 4.5 (95 CI 2.6-15.6).
• (Kalliomaki, Lancet 2001)

60
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

61
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.

62
Soaps

• Mild or Hypoallergenic
• Dove (unscented) Contains lotion
• Keri
• Oil of Olay
• Basis
• Purpose
• Cetaphil Skin Cleanser (non-soap)
• Neutrogena bar
• Pure Ivory soap is very drying/irritating

63
Antibacterial Soaps

• Dial and Lever 2000
• Cetaphil antibacterial cleansing bar

64
Evidenced-based review 2002 (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

65
Systematic review 2000

• Insufficient evidence
• Ag avoidance pregnancy
• Antihistamines
• Dietary restriction
• Dust mite avoidance
• Hypnotherapy
• Emollients
• Massage
• Evening primrose oil
• Topical coal tar
• Topical doxepin
• Chinese herbs

• Positive evidence
• Topical steroids
• Oral cyclosporine
• UV light
• Psychological approaches

(Hoare, Health Technol Assess, 2000)
66
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)
67
Final Pearls

• 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.

68
Severe herpes infections in children with eczema
69
Atopic Derm and Smallpox Vaccine
(Ann Intern Med 2003139)
70
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
71
CASE 1

• 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?

72
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?

73
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

74
F/U 2 weeks later

• Only slightly improved- now what?

75
Now...

• Add oral antistaphylococcal agent for 7-14 days.
• REVIEW mild skin care regimen
• Follow-up in 2 weeks and SUCCESS!

76
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.

77
CASE 2

• 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

78
Case 3

• 75 YO male with chronic itchy spots-
• Using 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

79
Case 3

• 2.5 H/C too weak
• Fluocinonide (lidex) 0.05 ointment under
  occlusion causing atrophy
• Good case for topical tacrolimus

80
Patient Education

• National Eczema Association
• www.eczema-assn.org

81
Thank you.
82
References

• Drake LA, et al. Guidelines of Care For Atopic
  Dermatitis. J Am Acad Dermatol 199226485-8.
• 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 .

83
References

• 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.