Skin Deep: Or is It? Practical Pearls from a Pediatric Dermatologist

Transcription

1 Skin Deep: Or is It? Practical Pearls from a Pediatric Dermatologist I have no conflicts of interest 6 yo boy referred for AD. On topical HC and food elimination diet s/p topical triamcinolone to body and desonide to face x 1 month 1

2 4 months later: mom stopped medicines at neighbor s advice Consistent topical therapy Advances and Controversies in Management of Atopic Dermatitis What I Have Learned from Referred Patients with Atopic Dermatitis (ie: Knowledge Gaps) 2

3 Rationale for Treatment Which is worse: treatment or disease? skin barrier dysfunction Filaggrin mutation water loss = dehydration protection against infection immune dysregulation Atopic Dermatitis Itch Scratch Management? 3

4 Approach to the Patient: applies to all ages #1: Repair the Skin Barrier #2: Control the Itch #3: Look for and treat/prevent triggers Infection, allergies, environment #4: Educate & Follow-Up #5: Maintain Barrier Integrity 4 year-old boy with diffuse, infected eczema 4

5 Approach to the Patient #1: Repair the Skin Barrier PITFALLS #2: Control the Itch #3: Look for and treat/prevent triggers: Infection, allergies, environment #4: Educate & Follow-Up #5: Maintain Barrier Integrity Pitfall #1 Not incorporating water Water avoidance is out, rehydration is in Soak and seal minute soak in warm water Use non-soap cleansers: cetaphil, aveeno, cerave Immediate application of emollients and medications 5

6 Pitfall #2. Not using topical corticosteroids when indicated First line therapy (still) Anti-inflammatory, decrease Staph density Side effects rare when used appropriately Key: used within a multi-modality care plan Derms often fear NOT using rather than using Children with severe AD suffer recurrent infections, failure to thrive and poor QOL Atopic Derm Action Plan best way to avoid AE Get comfortable with a topical steroid from each potency class Low potency: face, folds, thin patches Hydrocortisone, desonide, fluocinolone oil Mid-high potency: scalp, trunk, extremities, palm/ sole, medium or thick plaques Triamcinolone (mid) Fluocinonide (high) Clobetasol (very high) Improve the skin, taper and maintain or withdraw 6

7 ARS: This picture depicts: A. Vitiligo B. Post-inflammatory hypopigmentation C. Loa loa disease D. Hypopigmentation from topical steroids Pitfall #3: Misdiagnosing atopic dermatitis sequelae as steroid side effects Pityriasis alba: scaly white skin 7

8 Is it all about steroids? NO! Approach to the Patient #1: Repair the Skin Barrier #2: Control the Itch PITFALLS #3: Look for and treat/prevent triggers: Infection, allergies, environment #4: Educate & Follow-Up #5: Maintain barrier integrity 100% of kids with AD itch. 8

9 Pitfalls: Inadequate control of itch (underprescribing sedating anti-histamines or giving them prn) Approach to the Patient #1: Repair the Skin Barrier #2: Control the Itch #3: Look for and treat/prevent triggers: Infection, allergies, environment PITFALLS #4: Educate & Follow-Up #5: Maintain barrier integrity Pitfalls #1: Treating blindly with oral antibiotics without culturing #2: Depending on oral antibiotics as monotherapy for treatment of atopic dermatitis flares #3: Inadequately treating the AD in the first place 9

10 Impetiginized (Staph) Atopic Dermatitis Eczema herpeticum + impetigo (herpes simplex + staph) Bullous Impetigo in AD Pt Look for and treat infection 10

11 Pitfall: Over-evaluating/diagnosing/treating food allergy at the expense of standard treatments for atopic dermatitis Test if standard therapies fail or known food triggers exist Clinical Correlation is Key 11

12 Maintain Skin Integrity Putting it all together: 4 year-old boy with diffuse, impetiginized eczema 12

13 ARS: The best next step for this child is? Management 13

14 Culture for infection Desonide face BID fluocinolone oil body BID Hydroxyzine 2mg/kg divided q6 hours Liberal aquaphor or petrolatum When to refer? Anytime you are not comfortable. Take Home Points: 14

15 Thank you Which is worse: treatment or disease? 15