Itchy babies: Current treatment guidelines for atopic dermatitis Rachel Laarman, MD Helen DeVos Children s Hospital Grand Rapids, MI Photo cred: www.dermatologytimes.modernmedicine.com I have no disclosures to report. Objectives Recognize the clinical presentation of atopic dermatitis in infancy, childhood, and adolescence Grade atopic dermatitis as mild, moderate and severe Apply skin care guidelines for atopic dermatitis in clinical practice Discuss new therapies with parents and patients; including non-steroidal topical and systemic medications
Atopic dermatitis Clinical findings Onset between 0-6 months 60% before age one 90% by 5 years of age Infancy: scalp & cheeks; lateral arms and legs Childhood: flexural surfaces Adults: hands/feet, face, back, wrists Clinical presentation 6
8 Clinical diagnostic features Essential features Pruritis Eczematous skin lesions Typical morphology and age-specific pattern Chronic or relapsing hx Important features Early age at onset Atopy (personal and family hx) Xerosis Associated features KP, hyperlinear palms, ichthyosis, perioral changes, ocular changes, perifollicular accentuation, prurigo lesions
Atopic dermatitis - Epidemiology Prevalence is increasing ~15-29% Associated with loss of function mutations in Filaggrin (FLG) gene Increase expression of IL-4, IL-5, IL-13 and IgE Thymic stromal lymphopoeitin (TSLP) Positive family hx of atopy Atopic dermatitis -- Treatment Emollients & Moisturizers Bleach baths Topical corticosteroids Topical calcineurin inhibitors Antibiotics Systemic therapies Translating Atopic Dermatitis Management Guidelines Into Practice for Primary Care Providers. Eichenfield LF, Boguniewicz M, Simpson EL, Russell JJ, Block JK, Feldman SR, Clark AR, Tofte S, Dunn JD, Paller AS. Pediatrics. 2015 Sep;136(3):554-65.
Moisturizers Twice daily Consistent use Dye-free and fragrance-free Atopic dermatitis Bleach baths ¼ - ½ c. per full tub Research is showing decreased inflammation as well as reducing bacterial colonization, without damage to keratinocytes Topical Steroids These typically are the first line therapies covered by most insurances Be aware of potency Discuss length of use Review side effects: skin atrophy Translating 15Atopic Dermatitis Management Guidelines Into Practice for PrimaryCare Providers. Eichenfield LF, Boguniewicz M, Simpson EL, Russell JJ, BlockJK, Feldman SR, Clark AR, Tofte S, Dunn JD, Paller AS.Pediatrics. 2015 Sep;136(3):554-65.
Topical Calcineurin inhibitors Elidel (pimecrolimus) 1% cream Protopic (tacrolimus) 0.1% or 0.03% ointments Do not cause skin atrophy useful at thin or sensitive sites Face, axilla, groin Can be as efficacious as topical steroids (more evidence for tacrolimus as compared to pimecrolimus) 16 Topical phosphodiesterase inhibitor Eucrisa (crisaborole) 2% ointment Boron-based benzoxaborole PDE4 inhibitor Prevents activation of pro-inflammatory cytokines Main issues: burning or stinging at application sites Sleep disturbance 47-60% of children with AD Management strategies: Disease controlling therapies First generation antihistamines (diphenhydramine and hydroxyzine) Melatonin Tricyclic anti-depressants Behavior modification
On the horizon: new therapies Dupilumab FDA approved for adults >18 yo with moderate to severe atopic dermatitis Human monoclonal Ab to IL-4 Rα Inhibits signaling of IL-4, IL-13 (Th2 cytokines) Subcutaneous injection given every two weeks Peanut allergy and Atopic dermatitis Learning Early about Peanut allergy LEAP Trial Enrolled patients with Severe eczema Required application of corticosteroid or calcineurin inhibitor 12 out of 30 days on two occasions in the last 6 months Graded 40 on the modified SCORAD Parental description of very bad rash in joints and creases or a very bad itchy, dry, oozing or crusted rash Early introduction of peanut decreased development of peanut allergy: 14% absolute risk reduction, 81% relative risk reduction Du Toit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S, Santos AF, Brough HA, Phippard D, Basting M, Feeney M, Turcanu V, Sever ML, Gomez Lorenzo M, Plaut M, Lack G; Randomized trial of peanut consumption in infants at risk forpeanut allergy. N Engl J Med. 2015 Feb 26;372(9):803-13 References Bolognia,Jean,ed. Dermatology: [ExpertConsult].3rd ed. Edinburgh:Elsevier,Saunders,2012 Eichenfield, Lawrence F., Mark Boguniewicz, Eric L. Simpson, John J. Russell, Julie K. Block, Steven R. Feldman, Adele R. Clark, Susan Tofte, JeffreyD. Dunn,andAmyS. Paller. TranslatingAtopicDermatitisManagementGuidelinesIntoPracticefor PrimaryCareProviders. Pediatrics 136,no.3 (September1, 2015):554.doi:10.1542/peds.2014-3678. Eichenfield,LawrenceF, IlonaJ Frieden, ErinFMathes,andAndreaL Zaenglein. Neonatal and Infant Dermatology, 2015. https://www.clinicalkey.com/dura/browse/bookchapter/3-s2.0-c20110000753. Fleischer, David M., Scott Sicherer, Matthew Greenhawt, Dianne Campbell, Edmond Chan, Antonella Muraro, Susanne Halken, et al. ConsensusCommunicationonEarlyPeanutIntroductionandPreventionofPeanutAllergyin High-RiskInfants. PediatricDermatology 33, no. 1 (January1, 2016):103 6.doi:10.1111/pde.12685. IerodiakonouD,Garcia-LarsenV, LoganA, andetal. Timing ofallergenicfoodintroductiontotheinfantdietandriskofallergicor AutoimmuneDisease:ASystematicReviewandMeta-Analysis. JAMA 316,no. 11 (September20, 2016):1181 92. doi:10.1001/jama.2016.12623. Maarouf,Melody,VivianY. Shi. Bleachfor atopicdermatitis:beyondantimicrobials. Dermatitis 00, No. 00: 1-7. Paller, Amy, Anthony J. Mancini,and Sidney Hurwitz. Hurwitz Clinical Pediatric Dermatology.4th ed. Edinburgh ;New York:Elsevier Saunders, 2011. Patel, Devika,Melissa Levoska,Tor Shwayder. Managing sleep disturbances in children with atopic dermatitis. Pediatric Dermatology. 2018:00: 1-6.https://doi.org/10.1111/pde.13444. Simpson,Eric L., Thomas Bieber,Emma Guttman-Yassky,Lisa A. Beck,Andrew Blauvelt,Michael J. Cork,Jonathan I.Silverberg,et al. Two Phase3 Trialsof DupilumabversusPlaceboin AtopicDermatitis. NewEnglandJournalofMedicine 375, no. 24 (September30,2016): 2335 48. doi:10.1056/nejmoa1610020. Waldman Andrea R,Jusleen Ahluwalia,Jeremy Udkoff, Jenna F. Borok,Lawrence F.Eichenfield. Atopic dermatitis. Pediatrics in Review 39, 2018:180-193.doi:10.1542/pir.2016-0169.