What s Topical About Topicals?

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1 What s Topical About Topicals? Megha M. Tollefson, MD Associate Professor of Dermatology and Pediatrics July 29, MFMER

2 Disclosures None 2015 MFMER

3 Outline Topical steroids Non-steroidal topicals Wet dressings Phosphodiesterase 4 inhibitors 2015 MFMER

4 2015 MFMER

5 Is it possible to prevent atopic dermatitis? 1. Yes 2. No 2015 MFMER

6 Can moisturization prevent atopic dermatitis? RCT of 124 neonates at high-risk for atopic dermatitis 1 st degree relative with AD, asthma, or allergic rhinitis Intervention: Fully body moisturizer at least once/day starting by 3 weeks of age Control: no moisturizer Outcome: prevalence of AD at 6 months of age Relative risk reduction of 50% in intervention group 43% vs 22% (p=0.17) Simpson et al. JACI 2014;134: MFMER

7 Can moisturization prevent atopic dermatitis? Simpson et al. JACI 2014;134: MFMER

8 Topical corticosteroids (TCS) They work!!! >100 RCTs Evidence level I Reduction of S. aureus burden Vehicle is important Oil/solution Cream Ointment Foam 2015 MFMER

9 TCS strength Eichenfield et al JAAD MFMER

10 Topical Steroid addiction Possible side effects when TCS withdrawn Systematic review of topical corticosteroid withdrawal 34 of 294 articles included Hajar et al. JAAD 2015;72: MFMER

11 Topical Steroid addiction Mostly involves face (97%) of women (81%) Only 7.1% kids With long-term, inappropriate potent TCS use Burning and stinging Erythematous and papulopustular types Hajar et al. JAAD 2015;72: MFMER

12 TCS cautions Allergic contact dermatitis Propylene glycol Preservatives Tachyphylaxis 2015 MFMER

13 Practical tips Dosing regimens Frequency of application Higher BSA to weight ratio in children Dispensed quantities Use of the fingertip unit 2015 MFMER

14 # FTU needed depends on age and area to be treated AGE OF PATIENT TREATED AREA 0-6 MO 6-24 MO 2-5 YR 5-10 YR 1 arm, face, chest leg, back MFMER

15 What is your treatment of choice? 1. Desonide 0.05% cream 2. Hydrocortisone 2.5% cream 3. Tacrolimus 0.03% oint 4. Tacrolimus 0.1% oint 5. Triamcinolone 0.1% ointment 2015 MFMER

16 Topical calcineurin Inhibitors (TCIs) Topical immunosuppressive agents that inhibit T cells Tacrolimus ointment 0.03% and 0.1% Pimecrolimus cream 1% Approved for treatment of AD in patients at least 2 years old (not tacrolimus 0.1%) 2015 MFMER

17 TCIs, cont. Common side effects: burning, stinging Do not cause atrophy, telangectasia Long-term side effects unknown Efficacy compared to topical steroids not well-studied 2015 MFMER

18 Pimecrolimus vs. vehicle Maged et al. J Dermatological Science MFMER

19 Pimecrolimus vs. TCS Maged et al. J Dermatological Science MFMER

20 Tacrolimus vs. vehicle Maged et al. J Dermatological Science MFMER

21 Tacrolimus vs. TCS Maged et al. J Dermatological Science MFMER

22 TCIs: Superior to steroids? Meta-analysis of RCTs studying Tacrolimus or Pimecrolimus for AD Both medications more effective than vehicle Tacrolimus 0.1% = moderately potent topical steroid Low potency TS < Tacrolimus 0.03% < potent TS Pimecrolimus 1% < potent TS; not compared to low potency TS Ashcroft DM et al. BMJ MFMER

23 TCIs: Superior to steroids? Conclusions of the meta-analysis Advantage of TCIs over TS unclear Tacrolimus may have a place in the long-term treatment of resistant AD at sites where TS side effects are more concerning (e.g. face) In the absence of key comparisons with mild corticosteroids, the clinical need for topical pimecrolimus is unclear MFMER

24 TCIs and the Black Box Mice, rats and monkeys exposed to high doses of TCIs have developed malignancies Cases of lymphoma and skin cancer in patients using TCIs reported Cause-effect relationship not proven Risk may be attributable to AD 2015 MFMER

25 TCIs: FDA public health advisory Use (TCIs) as second-line agents for short-term and intermittent treatment of atopic dermatitis (eczema) in patients unresponsive to, or intolerant of other treatments. c.htm 2015 MFMER

26 What About the Malignancy Risk? PEER: longitudinal cohort study of children with atopic dermatitis and topical pimecrolimus use Outcomes: Reports of malignancy as compared to expected rates from SEER Mean 793g pimecrolimus 5 reported malignancies (2 leukemia, 1 osteosarcoma, 2 lymphomas) IR for malignancies 1.2 (95% CI, ) Unlikely to be associated with increased risk of malignancy Margolis et al. JAMA Dermatol MFMER

27 TCI practical tips When not to use Not directly to raw, open skin When I use Tacrolimus vs pimecrolimus No monitoring requirements 2015 MFMER

28 I employ proactive treatment as a strategy in my practice 1. Yes 2. No 2015 MFMER

29 Topical meds and QoL in AD 2015 MFMER

30 Proactive treatment Proactive, intermittent use of TCI as maintenance therapy (2-3 times per week) on areas that commonly flare is recommended to help prevent relapses while reducing the need for topical corticosteroids, and is more effective than the use of emollients alone Reduced exacerbations Increased time to flare Increased # flare-free days Eichenfield et al. JAAD 2014;71: MFMER

31 RR of disease flare with Proactive use Schmitt et al BJD MFMER

32 I use wet dressings in my practice 1. Yes 2. No 2015 MFMER

33 If you said no 1. I do not think they work 2. Patients do not like them 3. They are too cumbersome 4. They take too much time to explain 2015 MFMER

34 Wet dressings Useful for flares or recalcitrant disease Inpatient or outpatient setting Increased penetration of topicals Decrease in water loss Physical barrier to scratching 2015 MFMER

35 Wet Wrap Therapy Observational cohort study 72 children with moderate-to-severe AD 2-3 wet wraps per day, usually 5-10 days (2-16 days) Outcome: SCORAD Nicol et al. JACIP 2014;2: MFMER

36 Wet Wrap Therapy Nicol et al. JACIP 2014;2: MFMER

37 Inpatient wet dressing therapy Dabade et al JAAD MFMER

38 94% with improvement within one day Bingham et al. JAAD MFMER

39 Wet Dressing Steps 1. Warm solution is applied to dry dressings to make them wet 2. You will apply cream (either steroid or moisturizer) all over your body 3. Nurse will apply wet dressings over creams 2015 MFMER

40 Step 1: Warm Solution is Applied to Dressing Types of Solutions Used Tap Water Solution Moisturizes Reduces itching and redness Increases penetration of steroid Sweitzer s solution Antibacterial and antifungal Acetic Acid (Vinegar) solution Antibacterial Reduces itching 2015 MFMER

41 Step 2: Applying Cream The nurse will teach you how to apply creams over the entire body, with the nurse assisting with your back To achieve the best result, every area (including intimate areas) will need to be treated Privacy is provided to the extent possible 2015 MFMER

42 Step 3: Apply Dressing 2015 MFMER

43 Wet dressings- practical tips Modified wet dressings at home Cream vs ointment Dilute acetic acid may be helpful Dry pajamas, warm room Duration- 1 hour to overnight Wean wet dressings Intermittent use Give brochure and video 2015 MFMER

44 AD: wet dressings 1: Apply the steroid cream and cream-based moisturizer 2: Soak one set of sleepers in warm water (+/- acetic acid) 3: WRING OUT the sleepers until they are only very slightly damp 2015 MFMER

45 AD: wet dressings 4: Put the damp sleepers on your child and cover with a pair of dry sleepers. DO NOT cover with plastic. 5. Make certain the room is warm enough 6. Leave on for at least 1 hour, may leave on overnight 2015 MFMER

46 AD: wet dressings Your child may complain at first, but be firm 2015 MFMER

47 MFMER

48 Wet dressing cautions Systemic absorption and hypothalamic-pituitary-adrenal axis suppression Temporary serum cortisol level decrease 2015 MFMER

49 aad.org 2015 MFMER

50 2015 MFMER

51 2015 MFMER

52 Newest kid on the block Paller et al. JAAD MFMER

53 Crisaborole Paller et al. JAAD MFMER

54 Lots on the horizon! MFMER

55 The Dermatology Foundation has supported & advanced my career MFMER

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