Friday, September 18, 2009

Atopic Dermatitis - update on treatment

Pediatrics. 2008;122:812-824.

Clinical Context

AD affects 10% to 20% of children, according to Larsen and Hanifin in the February 2002 issue of Immunology and Allergy Clinics of North America. The primary factors in AD are epidermal barrier function defects and skin inflammation. The diagnosis of AD is based on combined essential, important, and associated nonspecific features. Essential features include pruritus, eczematous dermatitis, typical morphologic features with age-specific patterns, and chronic or relapsing nature.

This review of AD describes the management of AD, including topical corticosteroids, topical calcineurin inhibitors, and new treatments.

Study Highlights

Education is a crucial part of management:
A 6-week education program for parents resulted in improved quality of life and eczema severity for their children older than 12 months.
Comprehensive centers can provide care in dermatology, allergy, infectious disease, and behavioral psychology.

Trigger avoidance measures include mattress covers, low-pile carpet, pets that do not produce dander, and avoidance of known food allergens.
The American Academy of Pediatrics 2008 breast-feeding guidelines recommend exclusive breast-feeding for at least 4 months to decrease AD incidence in the first 2 years of life in children at high risk for AD.
There is no evidence that delaying solid food, including cow's milk, fish, eggs, and peanut-containing foods, after ages 4 to 6 months protects against AD.
Studies on probiotic effects on risk for AD had conflicting results.
Skin care recommendations include dye-free, fragrance-free emollients and moisturizers applied at least twice a day, ointments, and ceramide-rich products.
"510(k) medical devices" are approved by the US Food and Drug Administration as new barrier products.
Bathing in lukewarm water with moisturizing cleanser for several minutes once or twice a day should be followed by use of a towel to pat dry and emollients.
Avoid fragrance soaps or bubble baths.
First-line treatment of AD flares is topical corticosteroids:
Class I are most potent and class VII, least potent.
Adverse effects are skin atrophy, striae, telangiectasias, hypopigmentation, rosacea, perioral dermatitis, acne, cataracts, glaucoma, hypothalamic-pituitary-adrenal axis suppression, growth retardation, and bone density reduction.
Twice-a-day use has the same effect as once-a-day use.
The topical calcineurin inhibitors tacrolimus and pimecrolimus are second-line treatment for short-term and noncontinuous long-term use in immunocompetent patients at least 2 years old with moderate to severe AD:
Long-term safety is not known, according to 2006 US Food and Drug Administration boxed warning.
Indications include AD persistence or frequent flares requiring almost continuous topical corticosteroids and involvement of sensitive skin areas.
Sedating antihistamines hydroxyzine and diphenhydramine might improve sleep but do not directly affect AD-related pruritus.
Possible complications include overgrowth of S aureus, Molluscum contagiosum, eczema herpeticum, eczema vaccinatum, and fungal infections.
If bacterial superinfection occurs, culture for methicillin-resistant S aureus should be considered.
Diluted bleach baths can decrease local skin infections and need for systemic antibiotics.
Wet wraps and once-daily topical corticosteroids are effective for severe or refractory AD, but close supervision is needed because of risk for skin maceration or secondary infection.
Systemic immunomodulatory therapies can be used for refractory AD:
Multiple phototherapy sessions
Short-term cyclosporine; long-term use can be linked with hypertension and renal toxicity
Azathioprine monotherapy; monitor blood cell counts and liver function tests
Mycophenolate mofetil appears safe; prospective controlled studies are needed.
Dermatology referral indications include moderate or severe AD, poor response to moderate-potency topical corticosteroids, persistent AD, frequent flares, AD-related hospitalization, and systemic therapy.
Other specialty referrals include allergy referral for suspected specific triggers and gastroenterology or immunology referral for possible eosinophilic gastroenteritis or esophagitis with failure to thrive or frequent systemic infections.

Pearls for Practice

In children with atopic dermatitis, the first-line treatment is topical corticosteroids, with potency ranging from the least potent class VII to the most potent class I. Second-line treatment of frequent flares or sensitive skin areas is a topical calcineurin inhibitor, for use in children 2 years or older.
New treatment modalities for children with atopic dermatitis include education models; bleach bath; wet wraps; and systemic immunomodulatory therapies, including phototherapy, cyclosporine, azathioprine, and mycophenolate mofetil.

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