Cryotherapy? Cryotherapy?

Transcription

1 Non-Pharmacologic Therapies for Atopic Dermatitis Peter A. Lio, MD Assistant Professor Clinical Dermatology & Pediatrics Northwestern University Feinberg School of Medicine Cryotherapy? Cryotherapy? Very cold air may increase the body s antioxidative capacity Also has been shown to reduce the conduction velocity of peripheral nerves Cold may have local and systemic antiinflammatory effect relieve itch Whole-body cryotherapy in atopic dermatitis.klimenko T, Ahvenainen S, Karvonen SL.Arch Dermatol Jun;144(6): doi: /archderm. Cryotherapy? Whole-body cryotherapy has been used RA, pain, and inflammation since the 1970s The first 2 chambers are meant for precooling ( 30 C and 60 C), and the patient remains in these for a very short time. The third chamber temperature reaches 110 C, and the patient remains inside for 1 to 3 minutes wearing a bathing suit or trunks Cryotherapy? 18 adults (10 men and 8 women) with mild to moderate AD were enrolled Whole-body cryotherapy was given 3 times a week for 4 weeks Three patients had treatment-related adverse events, all mild acral frostbite! Whole-body cryotherapy in atopic dermatitis.klimenko T, Ahvenainen S, Karvonen SL.Arch Dermatol Jun;144(6): doi: /archderm. 1

2 Cryotherapy? Treatment Filaggrin filament-aggregating protein Filaggrin Mutations cause ichthyosis vulgaris (IV) 8% of eczema pts have features of IV Between 14 and 56% of eczema pts carry one or more filaggrin null mutations So: ~13% of eczema may be due to filaggrin mutations on a population scale Brown SJ, Irvine AD. Atopic eczema and the filaggrin story. Semin Cutan Med Surg Jun;27(2): Brown SJ, Irvine AD. Atopic eczema and the filaggrin story. Semin Cutan Med Surg Jun;27(2): Filaggrin IL-4 and IL-13 Irvine AD, McLean WH. Breaking the (un)sound barrier: filaggrin is a major gene for atopic dermatitis. J Invest Dermatol Jun;126(6): Keratinocytes differentiated in the presence of IL-4 and IL-13 exhibited significantly reduced filaggrin gene expression Howell MD, et al. Cytokine modulation of atopic dermatitis filaggrin skin expression. J Allergy Clin Immunol Jul;120(1):

3 Topical Steroids and Barrier Either Way Danby SG, Chittock J, Brown K, Albenali LH, Cork MJ. The effect of tacrolimus compared with betamethasone valerate on the skin barrier in volunteers with quiescent atopic dermatitis. Br J Dermatol Apr;170(4): The Barrier Problem is here to stay More Moisturizer = Less Eczema! Could moisturizers prevent eczema? Only 3/20 (15%) developed eczema Historic controls predict 6-10 should have (30-50%) Cork, et al. BJD 2003; 149: Simpson EL, Berry TM, Brown PA, Hanifin JM. A pilot study of emollient therapy for the primary prevention of atopic dermatitis. J Am Acad Dermatol Oct;63(4): The Golden Ratio Cholesterol, ceramides, and essential / nonessential free fatty acids (FFAs) in an equimolar ratio allows normal barrier recovery, whereas any 3:1:1:1 ratio of these four ingredients accelerates barrier recovery. Zettersten EM, Ghadially R, Feingold KR, Crumrine D, Elias PM. Optimal ratios of topical stratum corneum lipids improve barrier recovery in chronologically aged skin. J Am Acad Dermatol Sep;37(3 Pt 1):

4 Moisturizer or More?? Epiceram study Clinical trial of 121 patients with moderate AD (6 months to 18 years) No statistically significant difference in efficacy between EpiCeram and fluticasone cream at day 28 At days 14 and 28, EpiCeram had comparable efficacy to fluticasone in decreasing pruritus (P >.05) POSTER ABSTRACT Pediatric Dermatology. 25(6): , November/December Sugarman, Jeffrey L. ; Eichenfield, Larry ; Simpson, Eric Moisturizer or more? Alternatives?? as good as hc 1% 4

5 CONCLUSION Moisturize well... but save your (and your patients ) money! What about bathing? Water loss is fundamental, so bathing should be important Balneotherapy is ancient, but modern practices began in Europe in the 1800s Wait! What about bathtubs? As for actual baths, such as frequency, duration, and how soon to apply moisturizers afterwards... there really is no good data! Joint Task Force Practice Parameter Update 2012: we struggled with this... 5

6 Bathtubs Although clinical trials on bathing frequency have shown mixed results, we believe that the weight of the evidence suggests that frequent soak and smear bathing is preferred to infrequent bathing in the management of AD. This simple, low-cost intervention could contribute to better AD control. Cardona ID, Stillman L, Jain N. Does bathing frequency matter in pediatric atopic dermatitis? Ann Allergy Asthma Immunol Jul;117(1):9-13. What about spa therapy? Data can be a bit messy since mineral water baths also involve: Warm weather (climatotherapy) Sunshine (heliotherapy) A vacation setting (relaxation) Balneotherapy There is solid data that children and adults with moderate-to-severe AD generally improve with balneotherapy/spa therapy But it s: Expensive Time-consuming Temporary Ahhhh... Treatment 6

7 Dilute Bleach baths Bleach: How does it work? Randomized placebo-controlled trial of 31 children with moderate-to-severe eczema All received oral antibiotics Half got intranasal mupirocin + dilute bleach bath; other half got vaseline nasally and placebo bleach bath Significant decrease in severity of eczema at 1 mo and 3 mo Huang JT, Abrams M, Tlougan B, Rademaker A, Paller AS. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics May;123(5):e It is probably anti-inflammatory 2. It probably has limited effect on the bacteria in the way that it is actually used: After TCS + bleach bath or TCS alone, bacterial compositions on lesional skin normalized (P <.0001), resembling nonlesional skin, with microbial diversity restored to control skin levels. HOCl attenuates acute radiation dermatitis Gonzalez ME et al. J Am Acad Dermatol Sep;75(3): e8 Leung TH, Zhang LF, Wang J, Ning S, Knox SJ, Kim SK. Topical hypochlorite ameliorates NF-κBmediated skin diseases in mice. J Clin Invest Dec;123(12):

8 3. It may be via TEWL and itch reduction: This study suggests that the benefit observed with bleach baths is likely mediated by improvement in skin barrier function (TEWL and SC cohesion) and reduction in itch intensity but not in normalization of the skin microbiome or systemic Th2 inflammation. Anti-bacterial Clothing? Specialized silk garments with antimicrobial properties have been studied in eczema Perez-Nazario N, et al. Bleach baths significantly reduce itch and severity of atopic dermatitis with no significant change in S. aureus colonization and only modest effects on skin barrier function. JOURNAL OF INVESTIGATIVE DERMATOLOGY. 2016, May. Vol. 135, pp. S37-S37. Anti-bacterial Clothing? 2007: 22 children with AD were divided into specialized silk clothing vs. cotton control At weeks 4, 8, and 12 significant decrease in SCORAD was found in the silk group Possibly works by aiding wound healing, enhancing collagen synthesis, and reducing inflammation and bacteria Koller DY, Halmerbauer G, Böck A, Engstler G. Action of a silk fabric treated with AEGIS in children with atopic dermatitis: a 3-month trial. Pediatr Allergy Immunol Off Publ Eur Soc Pediatr Allergy Immunol. 2007;18: Silky smooth? 15 pts with AD had split garments: cotton/silk On the cotton side they were allowed to use topical corticosteroids, but not on the silk side At day 7, no difference between the sides (suggesting that silk is as good as a topical steroid!) Senti G, Steinmann LS, Fischer B, Kurmann R, Storni T, Johansen P, et al. Antimicrobial silk clothing in the treatment of atopic dermatitis proves comparable to topical corticosteroid treatment. Dermatology (Basel, Switzerland). 2006;213: Silky smooth? Exciting! BUT... A 2009 review pointed out that all of the studies were underpowered to make such claims and cautioned skepticism... Silver Several silver-coated textiles have also been studied Do have true antibactieral effect on staph Several studies have found significant improvement in eczema and pruritus 8

9 Treatment Phototherapy PHOTOTHERAPY 1903 Nobel Prize in Medicine: Niels Ryberg Finsen, Danish pioneer of phototherapy Om Lysets Indvirkninger paa Huden (On the effects of light on the skin) Probably multiple mechanisms including increasing vitamin D which in turn enhances cathelicidin Phototherapy Works in about 60% of refractory cases NB-UVB (311 nm) seems fairly safe Problems: Time Money (co-pays, parking, etc) Home units? 9

10 Vitamin D Vitamin D 11 children (mean age, 7 years) w/ AD that worsened in winter Randomly given 1000 IU of D2 or placebo qd x 1 mo Otherwise normal regimen Sidbury R, Sullivan AF, Thadhani RI, Camargo CA Jr. Randomized controlled trial of vitamin D supplementation for winter-related atopic dermatitis in Boston: a pilot study. Br J Dermatol Jul;159(1): Sidbury R, Sullivan AF, Thadhani RI, Camargo CA Jr. Randomized controlled trial of vitamin D supplementation for winter-related atopic dermatitis in Boston: a pilot study. Br J Dermatol Jul;159(1): Vitamin D Final Word? Corroborating study: 37 children 8 mo-12 yr with AD Serum 25(OH)D levels correlated significantly (inversely) with disease severity Higher D correlated with less severity Peroni DG, Piacentini GL, Cametti E, Chinellato I, Boner AL.Correlation between serum 25-hydroxyvitamin D levels and severity of atopic dermatitis in children. Br J Dermatol May;164 This meta-analysis showed that serum vitamin D level was lower in the AD patients and vitamin D supplementation could be a new therapeutic option for AD. Kim MJ, Kim SN, Lee YW, Choe YB, Ahn KJ. Vitamin D Status and Efficacy of Vitamin D Supplementation in Atopic Dermatitis: A Systematic Review and Meta-Analysis. Nutrients, 2016 Dec 3;8(12). pii: E789 FOOD ALLERGY AND AD: Is it a cause? Is it a trigger? Is it unrelated? Treatment -R. Sidbury, MD Moisturization 10

11 Antipruritics Very poor data for antihistamines (though we often use them, esp for sedation) Topicals are unsatisfying (camphor, menthol, pramoxine) Gabapentin, TCAs, SSRIs, even antipsychotics have been tried (olanzapine) ANTIPRURITICS 40 pts with refractory uremic pruritus randomized to: Unilateral Quchi (LI11) acupuncture 3x/wk x 1 mo Control was acupuncture to sham point 3x/wk x 1 mo Pruritus scores at baseline, 1 mo and 3 mo Significantly lower in acupuncture group at 1 and 3 months (P<0.001) Acupressure 15 adults, with moderate-severe eczema Half applied acupressure with small bead in LI11 point for 3 min 3x per week for 4 weeks Che-Yi C, Wen CY, Min-Tsung K, Chiu-Ching H. Acupuncture in haemodialysis patients at the Quchi (LI11) acupoint for refractory uraemic pruritus. Nephrol Dial Transplant Sep;20(9): Acupressure Hypnosis and Biofeedback Stress can worsen AD and directly slows healing skin barrier (Muizzuddin, 2003) Psychosocial stress and sleep deprivation disrupt skin barrier function in healthy patients (Altemus, 2001) Some forms of alt med may help AD by decreasing stress, something that we have limited options for in allopathic medicine 11

12 Hypnosis Study:18 adults and 20 children with severe, resistant atopic dermatitis treated with hypnotherapy Significant benefit found both subjectively and objectively, maintained up to 2 years in some patients 10/12 children at 18 months after the study reported continued improvement in itching and scratching, less sleep disturbance, and improvement in mood Hypnosis What is Eczema Boot Camp? An intensive daily regimen for patients with severe eczema to get their eczema back under control The regimen consists of the following treatments at least once daily: 10-minute bleach bath Topical therapy (application of a topical antiinflammatory agent, generally a mid-potency topical corticosteroid) Emollient application (applied on top of the antiinflammatory agent)** Wet wraps **Topical therapy followed by emollient application should be done twice daily. Wet Wraps 12

13 Study 37 adult patients or caregivers 19 in control group = Verbal Instruction (VI) only 18 in intervention group = written Eczema Action Plan (EAP) given Pre- and Post-education questionnaires given Results Find out more: The written EAP was better than the verbal instruction in terms of: Reducing anxiety about the plan (p<.01) Increasing understanding of: The treatment regimen (p=.02) The risks/benefits of the treatments (p=.02) Adjusting the medications based on disease severity and anatomic site (p<.01, p=.03) Shi VY, Nanda S, Lee K, Armstrong AW, Lio PA. Improving patient education with an eczema action plan: a randomized controlled trial. JAMA Dermatology (March). 13

14 Thank you! 14