Beacon Hospital Annual Study Morning Treatment of Atopic Dermatitis (Eczema) in Primary Care Alan D. Irvine MD DSc
Lecture overview What causes AD How to get optimise results in primary care Eczema and food allergy
AD Impacts both Adults and Children AD affects: [a] 3-10% Adults Up to 20% Children The prevalence of AD is increasing, particularly in lowincome countries [b] Most new cases develop in infancy and childhood, and are mild-to-moderate in severity [c,d] a. Bieber T. N Engl J Med. 2008; 358: 1483 94. b. Shaw TE, et al. J Invest Dermatol. 2011; 131: 67 73. c. Lyons JJ. Immunol Allergy Clin North Am. 2015 Feb; 35(1): 161 183. d. Silverberg JI, et al. Dermatitis. 2014; 25: 107 14.
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Impact of AD on Quality of Life in Children Child Symptoms of itching and soreness impair sleep Sleeplessness affects mood and psychosocial functioning Embarrassment and teasing can lead to isolation, depression, and school avoidance Lifestyle is limited (activity, sport, clothing choice) Family Members Patient sleeplessness also affects family members Parents report feeling overwhelmed, tired, hopeless, guilty, angry, and depressed Siblings may receive less attention and/or need to serve an auxillary caregiver Lewis-Jones S. Int J Clin Pract. 2006;60:984-992.
Comorbidity Allergic conditions Asthma Food allergy Bacterial Infection Rhinitis Viral Conjunctivit is AD Neuropsychiatric Eosinophilic Esophagitis Cardiovascular Cancer Overweigh t/ obesity (US) Other disorders Brunner PM, et al. J Invest Dermatol. 2017;137:18-25.
Psychiatric Comorbidity Associated with AD Autistic spectrum disorder Anxiety Depression Conduct disorder Attention Deficit Hyperactivity Disorder Suicide Substance misuse a. Yaghmaie P, et al. J Allergy Clin Immunol. 2013:131:428-433; b. Yu SH, Silverberg JI. J Invest Dermatol. 2015;135:3183-3184; c. Silverberg JI, Greenland P. J Allergy Clin Immunol. 2015;135:721-728.
What causes it doctor? S Aureus Barrier Th2
Successful treatment of childhood eczema Manage inflammation Treat infection if present Avoid allergens if relevant
Managing inflammation-topical steroid failure Too little Too low potency Too short duration Regimen is too complex Steroid phobia Pharmacists
How much?? The Finger Tip Unit 1 finger tip unit (ftu) = 0.5g
36 FTUs for an adult/20 grams
Work out how much each patient needs per week and per month WRITE ACTUAL VOLUMES ON RX EXPLAIN HOW MUCH YOU EXPECT THE PATIENT TO USE
What strength? If no infection pick one strength for the face and one for the body 1% hydrocortisone to face Betnovate RD or Locoid Ointment to body
Relative Potency of Topical Steroids Hydrocortisone 1% 1 Eumovate (clobetasone) 5-20 Betnovate RD 50 Betnovate 200 Elocon 200 Dermovate 1000
How long? Non infected Betnovate RD OINTMENT OD for 2 weeks Then weekends only (F/S/S) for 4 consecutive weekends
Managing inflammation-topical steroid failure Too little Too low potency Too short duration Regimen is too complex Steroid phobia Pharmacists
KISS in eczema management One or max two creams Don t worry much about bathing Don t worry much about moisturizing, at least initially Use steroids just once per day Review in 6 weeks
Patient/Parent comprehension The OECD Adult Skills Survey 17.9% or about 1 in 6, Irish adults are at or below level 1 on a five level literacy scale. At this level a person may be unable to understand basic written information. Problem Solving in Technology-Rich Environments (PS-TRE) (42% - 1,283,467) of Irish adults score at or below Level 1 (29.5% at Level 1, 12.6% below Level 1) on the problem solving scale
Recognise infection
Eczema Herpecticum
Advancing Therapy for Children With Moderate-to- Severe AD Optimize topical therapy before considering systemic medications for AD [a] Consider disease severity, impact on QoL, and risks/ benefits of systemic therapies [a] Evaluate triggers or concomitant diagnosis such as cutaneous infection or allergic contact dermatitis a. Simpson EL, et al. J Am Acad Dermatol. 2017;77:623-633; b. Drucker AM, et al. Br J Dermatol. 2018;178:768-775
An obsession with food
Food has little effect on eczema but eczema has big effect on food
Food allergy in 1158 Irish Children with moderate-severe atopic dermatitis Lizalet Oosthuizen None: 64% Peanut: 7% Egg: 17% Milk: 5% Multiple: 7%
Other way around: Prevalence of AD in FA Hill DJ, et al. Confirmation of the association between high levels of immunoglobulin E food sensitization and eczema in infancy: an international study Clin Exp Allergy. 2008 Jan;38(1):161-8. Epub 2007 Nov 19
Food Allergy No Food Allergy
Food Allergy No Food Allergy
Food Allergy No Food Allergy Epicutaneous exposure to Food protein Good GI exposure Leaky Barrier in infancy Robust Infant Skin Barrier Low GI exposure Low epicutaneous exposure
Translational Benefits
Urticaria (hives) Angioedema -swelling of face, eyes,lips Wheezing Vomiting How does Food Allergy present? Symptoms usually within mins to 2 hours of exposure
RAST Testing Know what you are ordering and how to interpret
https://www.nice.org.uk/guidance/cg57 https://irishskin.ie/eczema/ Resources