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Atopic Dermatitis. Adam Goldstein, MD Associate Professor UNC Department of Family Medicine Chapel Hill, NC aog@med.unc.edu . Objectives. Improve ability to accurately diagnose and manage 90% of cases of atopic dermatitis

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atopic dermatitis

Atopic Dermatitis

Adam Goldstein, MD

Associate Professor

UNC Department of Family Medicine

Chapel Hill, NC

aog@med.unc.edu

objectives
Objectives
  • Improve ability to accurately diagnose and manage 90% of cases of atopic dermatitis
  • Recognize differences in infant, childhood and adult presentations of atopic dermatitis
  • Improve ability to diagnose and manage conditions associated with and sometimes confused with atopic dermatitis
atopic dermatitis definition
Atopic Dermatitis: Definition
  • Atopic dermatitis = eczema = itchy skin
  • Greek- meaning
    • (ec-) over
    • (-ze) out
    • (-ma) boiling
  • Infants & small children (affects 1 in 7)
  • Atopic dermatitis of childhood may reappear at different site later in life.
atopic dermatitis cause
Atopic Dermatitis: Cause
  • The exact cause is unknown.
atopic dermatitis cause5
Atopic Dermatitis: Cause

(Charlesworth, Am J Med, 2002)

atopic dermatitis cause6
Atopic Dermatitis: Cause
  • ? Inborn skin defect that tends to run in families, e.g. asthma or hay fever
  • 85% with high serum IgE and + skin tests food & inhalant

(Jones, Clin Rev Allergy, 1993)

distribution
Distribution
  • In infants, the face is often affected first, then the hands and feet; dry red patches may appear all over the body.
  • In older children, the skin folds are most often affected, especially the elbow creases and behind the knees.
  • In adults, the face and hands are more likely to be involved.
atopic dermatitis associated features
Atopic Dermatitis: Associated features
  • The skin is usually dry, itchy & easily irritated by:
    • soap
    • detergents
    • wool clothing
  • May worsen in hot weather & emotional stress.
  • May worsen with exposure to dust & cats.
associated findings
Associated Findings
  • Pityriasis alba
associated findings20
Associated Findings
  • Keratosis Pilaris
diagnosis
Diagnosis
  • Major characteristics
    • Pruritus with or without excoriation
    • Typical morphology and distribution
    • Chronic relapsing dermatitis
    • Personal or family history of atopy (asthma, allergy, atopic derm, contact urticaria)
  • Other characteristics
    • Xerosis/Ichthyosis/palmar hyper/kerat. pilaris
    • Early age of onset
    • Cutaneous colonization and/or overt infections
    • Hand/foot/nipple/contact dermatitis, cheilitis, conjunctivitis, Erythroderma, subcapsular cataracts

(Drake, JAAD, 1992)

differential diagnosis
Differential Diagnosis
  • Seborrheic dermatitis
differential diagnosis25
Differential Diagnosis
  • Seborrheic dermatitis
  • Scabies
differential diagnosis26
Differential Diagnosis
  • Seborrheic dermatitis
  • Scabies
  • Drugs
differential diagnosis27
Differential Diagnosis
  • Seborrheic dermatitis
  • Scabies
  • Drugs
  • Psoriasis
differential diagnosis28
Differential Diagnosis
  • Seborrheic dermatitis
  • Scabies
  • Drugs
  • Psoriasis
  • Allergic contact dermatitis
differential diagnosis29
Differential Diagnosis
  • Seborrheic dermatitis
  • Scabies
  • Drugs
  • Psoriasis
  • Allergic contact dermatitis
  • Cutaneous T-cell lymphoma
atopic dermatitis treatment
Atopic Dermatitis: Treatment

1. Reduce contact with irritants (soap substitutes)

2. Reduce exposure to allergens

3. Emollients

4. Topical Steroids

5. Antihistamines

6. Antibiotics

7. Steroid sparing

8. Other (herbals, soaps)

1 reduce contact with irritants
1. Reduce contact with irritants
  • Avoid overheating: lukewarm baths, 100% cotton clothes, & keep bedding to minimum
  • Avoid direct skin contact with rough fibers, particularly wool, & limit/eliminate detergents
  • Avoid dusty conditions & low humidity
  • Avoid cosmetics (make-ups, perfumes) as all can irritate
  • Avoid soap- use soap substitute
  • Use gloves to handle chemicals and detergents
soap substitutes
Soap Substitutes
  • Cetaphil- soap substitute- far less drying and irritating than soap
  • Cleansing & moisturizing formulations, all OTC
  • Lotion, bar, ‘soap’, cream, sunscreen
  • Costs about $8-9 for 16 oz.
2 reduce exposure to allergens
2. Reduce exposure to allergens
  • Keep home, especially bedroom, free of dust.
  • Allergic reactions include house dust mite, molds, grass pollens & animal dander.
  • Special diets will not help most individuals b/c little evidence that food is major culprit.
  • If food allergies exists, most likely d/t dairy products, eggs, wheat, nuts, shellfish, certain fruits or food additives.
3 emollients
3. Emollients
  • Emollients soften the skin soft and reduce itching.
  • Moisture Trapping effectiveness
    • Best:Oils (e.g. Petroleum Jelly)
    • Moderate: Creams
    • Least: Lotions
  • Apply emollients after bathing and times when the skin is unusually dry (e.g. winter months).
emollients cont d
Emollients (cont’d)
  • Large variety (e.g. Vanicream, Eucerin, Lubriderm, Moisturel, Curel, Neutrogena)
  • Inexpensive emollients include vegetable shortening (Snowdrift by Martha White) and petroleum jelly (Vaseline)
  • Urea creams
  • Oils
emollients alpha hydroxy acid
Emollients: Alpha-Hydroxy acid
  • Creams are excellent for relieving dryness, but cansting & sometimes aggravate eczema
  • Useful for maintenance when no longer inflamed
  • Forces epidermal cells to produce keratin that is softer, more flexible and less likely to crack
  • Preparations
    • Glycolic Acid (8%)
    • Lactic Acid or Lac-Hydrin (5-12%)
    • Urea (3-6%)
  • Use 1X/ day
emollients oils
Emollients: Oils
  • Consider using bath oil or mineral oil-based lotions in lukewarm bath water
  • Add to tub 15 minutes into bath
  • Bath oil preparations:
    • Alpha-Keri
    • Aveeno bath
    • Jeri-Bath
  • Colloidal oatmeal (Aveeno) reduces itching
4 corticosteroids
4. Corticosteroids
  • Topical steroids very effective
  • Ointments for dry or lichenified skin
  • Creams for weeping skin or body folds
  • Lotions or scalp applications for hair-areas.
corticosteroids
Corticosteroids
  • Hydrocortisone 1-2.5% applied to all skin.
  • Quite safe used even for months
  • Use intermittently thin areas- (eg-face & genitals)
  • Stronger potency topical steroids for nonfacial/genital regions.
  • Avoid potent/ultrapotent topical steroid preparations on face, armpits, groins & bottom.
corticosteroids40
Corticosteroids
  • Once under control, intermittent use of topical corticosteroid may prevent relapse
  • Systemic steroids may bring under rapid control, but may precipitate rebound
  • Once daily probably most cost effective

(Green, Br J Dermatol, 2005)

steroids and young children
Steroids and Young Children
  • Fluticasone proprionate cream 0.05%
  • Moderate- severe atopic derm > 3 months
  • Applied bid 3-4 weeks- mean 64% BSA
  • No HPA suppression

(Friedlander, J Am Acad Dermatol, 2002)

corticosteroids pearls
Corticosteroids: Pearls
  • Different preparations prescribed for different parts of body or for different situations
  • Educate on
    • potencies & proper usage
    • write down directions
  • Bring all topicals each appointment to clarify use
5 antibiotics
5. Antibiotics
  • Atopic eczema frequently secondarily colonized with a bacteria (up to 30%).
  • Use oral antibiotics in recalcitrant or widespread cases.
6 antihistamines
6. Antihistamines
  • Oral antihistamines can reduce urticaria & itch
  • Non-sedating antihistamines less side effects but more expensive
  • Sedative effect of hydroxyzine & diphenhydramine helpful
7 steroid sparing
7. Steroid Sparing
  • Topical calcineurin inhibitors
    • Tacrolimus ointment & pimecrolimus cream
  • Oral Cyclosporine
  • Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation) or combinations of UVA & UVB

(Jekler, J Am Acad Dermatol, 1990)

tacrolimus ointment 0 03 0 1 protopic
Tacrolimus ointment (0.03%, 0.1% [Protopic])
  • Mild to moderate eczema
  • Steroid dependent or signs of atrophy
  • Non-steroid responsive
  • BID x 2-4 weeks to evaluate response
  • Transient stinging possible
  • Longer disease-free intervals
  • Cost similar to high potency steroids (30gm/$60)

(Ruzicka, N Engl J Med, 1997)

pimecrolimus cream 1 15 30 100 gm elidel
Pimecrolimus cream 1%(15, 30, 100 gm [Elidel])
  • Approved Dec. 2001
  • Blocks production/release cytokines T-cells
  • Moderate eczema
  • Steroid sparing
  • Transient stinging 8% children, 26% adults
  • Cost similar to high potency steroids (30gm/$60)

(Ruzicka, N Engl J Med, 1997)

(Eichenfield, J Am Acad Dermatol, 2002)

tacrolimus ointment pimecrolimus cream
Tacrolimus ointment & pimecrolimus cream
  • Licensed for patients > 2 years old mild-moderate eczema\
  • Safety?
    • In controlled trials appear safe in adults and children
    • In 2005, FDA issued warnings about a possible link between the topical calcineurin inhibitors and cancer (? increased risk of lymphoma and skin cancers with topical exposure)
    • However, no definite causal relationship established     
  • FDA recommends that these agents are used only as second-line therapy in patients unresponsive to or intolerant of other treatments
    • Avoid in children younger than two years of age
    • Use for short periods of time and minimum amount necessary
    • Avoid continuous use
    • Avoid in patients with compromised immune systems
self monitoring
Self Monitoring

The patient-oriented eczema measure

(Charman, Arch Dermatol, 2004)

other
Other
  • Psychological support
  • Alternative treatments
    • Chinese herbal tea
      • Variably effective-not very palatable
      • Liver toxicity possible
other57
Other
  • Evening Primrose Oil / Star Flower Oil
    • Contains gamma linolenic acid, fatty acid (deficient some atopic subjects)
alternative medications some patients may use for eczema
Alternative medications some patients may use for eczema
  • Licorice
  • Calendula
  • Echinacea
  • Golden Seal
  • Nettle
  • Oats
probiotics in primary prevention of atopic disease a randomized placebo controlled trial
Probiotics in primary prevention of atopic disease: a randomized placebo-controlled trial.
  • Lactobacillus
    • prenatallytomothers – (FH eczema, AR, asthma)
    • postnatally for 6 months to infants
  • Endpoint: Chronic recurring eczema
  • Eczema in probiotic 50% < than placebo (23% vs 46%)
  • Number needed to treat = 4.5 (95% CI 2.6-15.6).

(Kalliomaki, Lancet 2001)

other60
Other

Laughter May Be Best Medicine...For Allergies

NEW YORK, NY - Although few would consider allergies to be funny, results of a new study suggest that laughing them off might actually work. Dr. Hajime Kimata, of Unitika Central Hospital in Japan, induced allergic responses on the skin of 26 people with allergic dermatitis by exposing them to house dust mites, cedar pollen and cat hair, and then had them watch ``Modern Times'', featuring Charlie Chaplin. The participants exhibited a significant reduction in their allergic responses after watching the classic comedy, according to the report in the February 14th issue ofThe Journal of the American Medical Association. The effect lasted for 4 hours after the viewing

other61
Other
  • Coal tar or less messy preps (liquid carbonis detergent 5-10%) in Eucerin or Aquaphor
    • Chronic lichenified eczema patches
    • Coal tar smells & stains clothes so apply qhs using old clothes and old linens
    • Coal tar can provoke a folliculitis.
soaps
Soaps
  • Mild or Hypoallergenic
    • Dove (unscented): Contains lotion
    • Keri
    • Oil of Olay
    • Basis
    • Purpose
    • Cetaphil Skin Cleanser (non-soap)
    • Neutrogena bar
    • Pure Ivory soap is very drying/irritating
antibacterial soaps
Antibacterial Soaps
  • Dial and Lever 2000
  • Cetaphil antibacterial cleansing bar
evidenced based review 2002 bmj clinical evidence
Evidenced-based review 2002(BMJ Clinical Evidence)
  • Positive evidence that:
    • topical corticosteroids relieve symptoms and are safe
    • emollients & steroids better than steroids alone
    • excellent control of house dust mite reduces symptoms if positive mite RAST scores & children
      • bedding covers most effective
  • Little to no evidence that:
    • dietary change reduces symptoms
    • breast feeding or mother's diet prevents infant eczema
systematic review 2000
Positive evidence:

Topical steroids

Oral cyclosporine

UV light

Psychological approaches

Insufficient evidence

Ag avoidance pregnancy

Antihistamines

Dietary restriction

Dust mite avoidance

Hypnotherapy

Emollients

Massage

Evening primrose oil

Topical coal tar

Topical doxepin

Chinese herbs

Systematic review 2000

(Hoare, Health Technol Assess, 2000)

systematic review
Systematic review
  • Not beneficial:
    • Cotton clothing
    • Biofeedback
    • Bid vs qd topical steroids
    • Bath additives
    • Topical antibiotic/steroids vs steroids alone

(Hoare, Health Technol Assess, 2000)

final pearls
Final Pearls
  • Educate parents that the goal is CONTROL not CURE
  • Atopics exposed to herpes virus or smallpox vaccination may get severe infection with widespread involvement d/t altered skin barrier.
atopic derm and smallpox vaccine
Atopic Derm and Smallpox Vaccine

(Ann Intern Med 2003;139)

costs
Costs

Drugstore.com 2004

case 1
CASE 1
  • 3 year old female with h/o eczema since 4 months old. Had done well on hydrocortisone 2.5% ointment when flared last winter. Parents ran out of the ointment and have been using vaseline and OTC hydrocortisone 0.5% without improvement. Child is now waking at night and constantly scratching.
  • What do you want to do?
case treatment strategy
Case Treatment strategy:
  • Review mild skin care regimen
  • Confirm use of
    • mild cleanser
    • daily moisturizers &
    • mild laundry detergent
  • Prescribe sufficient potency & quantity of topical corticosteroids
  • Which steroid class(es) would you px?
case topical steroid choices
Case- topical steroid choices
  • TAC 0.1% oint. bid worse areas x 7-14 days
  • Switch to H/C 2.5% ointment BID
  • Taper over 4 weeks to emollients if possible
  • Confirm parents understand dangers of prolonged steroid use and not to use potent steroids on face
f u 2 weeks later
F/U 2 weeks later:
  • Only slightly improved- now what?
slide75
Now...
  • Add oral antistaphylococcal agent for 7-14 days.
  • REVIEW mild skin care regimen
  • Follow-up in 2 weeks and SUCCESS!
case 2
CASE 2

34 yo female with h/o hand eczema diagnosed by former MD for 6 years. Seems to get worse in winter, but never goes away entirely. A friend told her it could be a fungus. She was given fluocinonide (lidex) 0.05% cream and it helps some. She wants a refill.

case 277
CASE 2
  • Not likely fungus given chronicity
  • May have secondary staph infection
  • May need more potent Class I steroid initially, e.g. clobetasol propionate (temovate) ointment
  • Class II Fluocinonide (lidex) 0.05% cream ok less severe
case 3
Case 3
  • 75 YO male with chronic itchy spots-
  • Using hydrocortisone cream 2.5% bid to ankle- minimal improvement
  • Using Class II Fluocinonide (lidex) 0.05% ointment under occlusion to hip area- “only thing that works”
case 379
Case 3
  • 2.5% H/C too weak
  • Fluocinonide (lidex) 0.05% ointment under occlusion causing atrophy
  • Good case for topical tacrolimus
patient education
Patient Education
  • National Eczema Association
    • www.eczema-assn.org
references
References
  • Drake LA, et al. Guidelines of Care For Atopic Dermatitis. J Am Acad Dermatol 1992;26:485-8.
  • Atopic eczema. In Clinical Evidence British Medical Journal 2001. Available online at www.clinicalevidence.org
  • Correale CE, Walker C, Murphy L, Craig TJ. Atopic Dermatitis: A Review of Diagnosis and Treatment. J Fam Pract 1999; available at http://www.aafp.org/afp/990915ap/1191.html
  • Ruzicka T, Bieber T, Schopf E, et al. A short-term trial of tacrolimus ointment for atopic dermatitis. European Tacrolimus Multicenter Atopic Dermatitis Study Group. N Engl J Med 1997; 337(12): 816-21.
  • Eichenfield LF, LuckyAW, Boguniewicz M, et al. Safety and efficacy of pimecrolimus cream 1% in the treatment of mild and moderate atopic dermatitis in children and adolescents. J A Acad Dermatol 2002; 46; 495-504 .
references83
References
  • Charlesworth EN . Pruritic dermatoses: overview of etiology and therapy. Am J Med 2002; 113S, 9A: 25S-33S.
  • Wahn U, et al. Efficacy and safety of pimecrolimus cream in the long-term management of atopic dermatitis in children. Pediatrics 2002; 110 (1 Pt 1): e2.
  • Friedlander SF, et al. Safety of fluticasone proprionate cream 0.05% for the treatment of severe and extensive atopic dermatitis in children as young as 3 months. J Am Acad Dermatol 2002; 46: 387-394.
  • Hoare C, et al. Systematic review of treatments for atopic eczema. Health Technol Assess 2000; 2: 1-191.
  • Green C, Colquitt JL, Kirby J, Davidson P. Topical corticosteroids for atopic eczema: clinical and cost effectiveness of once-daily vs. more frequent use. Br J Dermatol 2005; 152: 130-41.
  • Charman CR, Venn AJ, Williams HC. The patient-oriented eczema measure: development and initial validation of a new tool for measuring atopic eczema severity from the patients' perspective. Arch Dermatol 2004; 140: 1513-9.