2/25/17. Translating the Evidence: Allergy vs. Dermatology. How can they disagree?! Bias: It doesn t come out in the wash. wash. Precision Medicine

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1 Translating the Evidence: Allergy vs. Dermatology Peter A. Lio, MD, FAAD Assistant Professor Clinical Dermatology & Pediatrics Northwestern University Feinberg School of Medicine How can they disagree?! A good meditation on: Limits of knowledge Limits of evidence based medicine Practical limits of research Bias: It doesn t come out in the wash We emphasize disclosures all the time But what do we do with that information? Not much, right? Bias: It doesn t come out in the wash This is potentiated by meta-analyses and reviews: Most bias information is ignored and most of the data is treated equally This is sloppy but really hard to fix Precision Medicine There is probably something better than EBM as we know it: Precision Medicine Precision medicine: Mechanism-based diagnosis and treatment with highly reproducible results and highly predictable outcome Clayton Christensen and Jerome H. Grossman, M.D., of Harvard Kennedy School of Government From: 1

2 Allergy May focus more on allergic triggers than other physicians Evidence that allergists more likely to use diet changes for AD Thompson MM, Tofte SJ, Simpson EL, Hanifin JM. Patterns of care and referral in children with atopic dermatitis and concern for food allergy. Dermatologic therapy 2006;19:91-6. Saavedra JM, Boguniewicz M, Chamlin S, Lake A, Nedorost S, Czerkies LA et al. Patterns of clinical management of atopic dermatitis in infants and toddlers: a survey of three physician specialties in the United States. The Journal of pediatrics 2013;163: JTF Joint Task Force represents the American College of Asthma, Allergy and Immunology (ACAAI) and the American Academy of Asthma, Allergy and Immunology (AAAAI) Strategy Systematic literature review of PubMed and the Cochrane Database Classification of recommendations to grade the evidence Consensus expert opinion was obtained on each section 2

3 Similarities Differences Overall, many similarities between the guidelines: Use of moisturizers and TCS/TCI as mainstays Lack of evidence on specialty emollients/barrier Maintenance therapy (proactive) to prevent flares There are interesting differences Wet wraps or dressings during disease flares No role for topical antihistamines True or False Selected Differences I There is general consensus about the efficacy of supplementation in Atopic Dermatitis A. True TOPIC AAD JTF TCS + TCI combination May be more effective than either alone Not discussed TCS phobia Counsel patients Not discussed Systemic agents Detailed guidelines Data reviewed, no specifics Not enough evidence Supports use B. False Sidbury R, Tom WL, Bergman JN, Cooper KD, Silverman RA, Berger TG et al. Guidelines of care for the management of atopic dermatitis: Part 4. Prevention of Disease Flares and Use of Adjunctive Therapies and Approaches. Journal of the American Academy of Dermatology might: Improve barrier function Reduce inflammation Boost cathelicidin and thus antimicrobial immunity Oh JW. Allergy Asthma Immunol Res Jul;5(4): doi: /aair Epub 2013 Jun 26. The clinical impact of vitamin d in children with atopic dermatitis. 3

4 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): Lee SA, Hong S, Kim HJ, Lee SH, Yum HY. Correlation between serum vitamin d level and the severity of atopic dermatitis associated with food sensitization. Allergy Asthma Immunol Res Jul;5(4): Chiu YE, Havens PL, Siegel DH, Ali O, Wang T, Holland KE, Galbraith SS, Lyon VB, Drolet BA. Serum 25-hydroxyvitamin D concentration does not correlate with atopic dermatitis severity. J Am Acad Dermatol Jul;69(1):40-6. doi: /j.jaad Epub 2013 Feb 14. But, does it work? Akan A, Azkur D, Ginis T, Toyran M, Kaya A, Vezir E, Ozcan C, Ginis Z, Kocabas CN. Vitamin d level in children is correlated with severity of atopic dermatitis but only in patients with allergic sensitizations. Pediatr Dermatol May-Jun;30(3): doi: /pde Epub 2013 Jan 7. 4

5 95 patients with AD and 58 controls Mean serum D3 similar in AD and controls 20 pts with lowest vit D levels rec d 2000 IU of cholecalciferol daily for 3 months After 3 mo: significant increase in D3 level in exp group significant decrease in SCORAD 18/20 reported improvement after vit D supplementation Samochocki Z, Bogaczewicz J, Jeziorkowska R, Sysa-Jędrzejowska A, Glińska O, Karczmarewicz E, McCauliffe DP, Woźniacka A. effects in atopic dermatitis. J Am Acad Dermatol Aug;69(2): doi: /j.jaad Epub 2013 May 2. Multi-center, placebo-controlled, double-blind study in 30 pts with AD and 30 non-atopics, plus 16 with psoriasis Randomized to: 4,000 IU of D3 or placebo for 21 days After day 21: 25OHD increased No significant change in skin cathelicidin or EASI scores Hata TR, Audish D, Kotol P, Coda A, et al. A randomized controlled double-blind investigation of the effects of vitamin D dietary supplementation in subjects with atopic dermatitis. J Eur Acad Dermatol Venereol May 3. doi: /jdv [Epub ahead of print]? True or False There is general consensus about the helpfulness of environmental modifications such as double-rinsing laundry. A. True B. False Selected Differences II Environmental Modifications TOPIC AAD JTF Not enough evidence Temp/humidity control/heat/sweating + laundry modifications Silver/silk clothing Unclear evidence May be helpful Sidbury R, Tom WL, Bergman JN, Cooper KD, Silverman RA, Berger TG et al. Guidelines of care for the management of atopic dermatitis: Part 4. Prevention of Disease Flares and Use of Adjunctive Therapies and Approaches. Journal of the American Academy of Dermatology Aeroallergens Allergen-specific Immunotherapy Testing needed before acting; dust mite covers Insufficient evidence Minimizing exposure to aeroallergens w/o testing; weekly bedding washes/remove carpeting Testing needed before using immunotherapy 5

6 Selected Differences III Sidbury R, Tom WL, Bergman JN, Cooper KD, Silverman RA, Berger TG et al. Guidelines of care for the management of atopic dermatitis: Part 4. Prevention of Disease Flares and Use of Adjunctive Therapies and Approaches. Journal of the American Academy of Dermatology TOPIC AAD JTF Food allergy testing Diagnostic elimination diet or controlled oral food challenge if specific food allergy suspected IgE testing if clinically suspected; oral food challenge only if IgE testing negative Bath additives Not enough evidence May be antipruritic Psychological Care Not discussed Recommends psychological eval + tx True or False Sidbury R, Davis DM, Cohen DE, et al.; American Academy of Dermatology. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol Aug;71(2): There is general consensus about the efficacy antihistamines in AD management. A. True B. False a practice parameter update The Journal of allergy and clinical immunology 2013;131:295-9.e1-27. Summary Mostly good agreement on all of the basics Some slight differences at the edges Sidbury R, Davis DM, Cohen DE, et al.; American Academy of Dermatology. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol Aug;71(2): Perhaps some room for each group to learn Therapeutic alliance: Everybody wins! a practice parameter update The Journal of allergy and clinical immunology 2013;131:295-9.e

7 Thank you! 7