Presentation on theme: "UNC Department of Family Medicine"— Presentation transcript:
1 UNC Department of Family Medicine Atopic DermatitisAdam Goldstein, MDAssociate ProfessorUNC Department of Family MedicineChapel Hill, NC
2 ObjectivesImprove ability to accurately diagnose and manage 90% of cases of atopic dermatitisRecognize differences in infant, childhood and adult presentations of atopic dermatitisImprove ability to diagnose and manage conditions associated with and sometimes confused with atopic dermatitis
3 Atopic Dermatitis: Definition Atopic dermatitis = eczema = itchy skinGreek- meaning(ec-) over(-ze) out(-ma) boilingInfants & small children (affects 1 in 7)Atopic dermatitis of childhood may reappear at different site later in life.
4 Atopic Dermatitis: Cause The exact cause is unknown.
5 Atopic Dermatitis: Cause (Charlesworth, Am J Med, 2002)
6 Atopic Dermatitis: Cause ? Inborn skin defect that tends to run in families, e.g. asthma or hay fever85% with high serum IgE and + skin tests food & inhalant(Jones, Clin Rev Allergy, 1993)
8 DistributionIn 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.
17 Atopic Dermatitis: Associated features The skin is usually dry, itchy & easily irritated by:soapdetergentswool clothingMay worsen in hot weather & emotional stress.May worsen with exposure to dust & cats.
23 Diagnosis Major characteristics Pruritus with or without excoriation Typical morphology and distributionChronic relapsing dermatitisPersonal or family history of atopy (asthma, allergy, atopic derm, contact urticaria)Other characteristicsXerosis/Ichthyosis/palmar hyper/kerat. pilarisEarly age of onsetCutaneous colonization and/or overt infectionsHand/foot/nipple/contact dermatitis, cheilitis, conjunctivitis, Erythroderma, subcapsular cataracts(Drake, JAAD, 1992)
30 Atopic Dermatitis: Treatment 1. Reduce contact with irritants (soap substitutes)2. Reduce exposure to allergens3. Emollients4. Topical Steroids5. Antihistamines6. Antibiotics7. Steroid sparing8. Other (herbals, soaps)
31 1. Reduce contact with irritants Avoid overheating: lukewarm baths, 100% cotton clothes, & keep bedding to minimumAvoid direct skin contact with rough fibers, particularly wool, & limit/eliminate detergentsAvoid dusty conditions & low humidityAvoid cosmetics (make-ups, perfumes) as all can irritateAvoid soap- use soap substituteUse gloves to handle chemicals and detergents
32 Soap SubstitutesCetaphil- soap substitute- far less drying and irritating than soapCleansing & moisturizing formulations, all OTCLotion, bar, ‘soap’, cream, sunscreenCosts about $8-9 for 16 oz.
33 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.
34 3. Emollients Emollients soften the skin soft and reduce itching. Moisture Trapping effectivenessBest: Oils (e.g. Petroleum Jelly)Moderate: CreamsLeast: LotionsApply emollients after bathing and times when the skin is unusually dry (e.g. winter months).
35 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 creamsOils
36 Emollients: Alpha-Hydroxy acid Creams are excellent for relieving dryness, but can sting & sometimes aggravate eczemaUseful for maintenance when no longer inflamedForces epidermal cells to produce keratin that is softer, more flexible and less likely to crackPreparationsGlycolic Acid (8%)Lactic Acid or Lac-Hydrin (5-12%)Urea (3-6%)Use 1X/ day
37 Emollients: OilsConsider using bath oil or mineral oil-based lotions in lukewarm bath waterAdd to tub 15 minutes into bathBath oil preparations:Alpha-KeriAveeno bathJeri-BathColloidal oatmeal (Aveeno) reduces itching
38 4. Corticosteroids Topical steroids very effective Ointments for dry or lichenified skinCreams for weeping skin or body foldsLotions or scalp applications for hair-areas.
39 Corticosteroids Hydrocortisone 1-2.5% applied to all skin. Quite safe used even for monthsUse 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.
40 CorticosteroidsOnce under control, intermittent use of topical corticosteroid may prevent relapseSystemic steroids may bring under rapid control, but may precipitate reboundOnce daily probably most cost effective(Green, Br J Dermatol, 2005)
41 Steroids and Young Children Fluticasone proprionate cream 0.05%Moderate- severe atopic derm > 3 monthsApplied bid 3-4 weeks- mean 64% BSANo HPA suppression(Friedlander, J Am Acad Dermatol, 2002)
42 Corticosteroids: Pearls Different preparations prescribed for different parts of body or for different situationsEducate onpotencies & proper usagewrite down directionsBring all topicals each appointment to clarify use
43 5. AntibioticsAtopic eczema frequently secondarily colonized with a bacteria (up to 30%).Use oral antibiotics in recalcitrant or widespread cases.
47 6. Antihistamines Oral antihistamines can reduce urticaria & itch Non-sedating antihistamines less side effects but more expensiveSedative effect of hydroxyzine & diphenhydramine helpful
48 (Jekler, J Am Acad Dermatol, 1990) 7. Steroid SparingTopical calcineurin inhibitorsTacrolimus ointment & pimecrolimus creamOral CyclosporineUltraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation) or combinations of UVA & UVB(Jekler, J Am Acad Dermatol, 1990)
49 Tacrolimus ointment (0.03%, 0.1% [Protopic]) Mild to moderate eczemaSteroid dependent or signs of atrophyNon-steroid responsiveBID x 2-4 weeks to evaluate responseTransient stinging possibleLonger disease-free intervalsCost similar to high potency steroids (30gm/$60)(Ruzicka, N Engl J Med, 1997)
50 Pimecrolimus cream 1% (15, 30, 100 gm [Elidel]) Approved Dec. 2001Blocks production/release cytokines T-cellsModerate eczemaSteroid sparingTransient stinging 8% children, 26% adultsCost similar to high potency steroids (30gm/$60)(Ruzicka, N Engl J Med, 1997)(Eichenfield, J Am Acad Dermatol, 2002)
51 Tacrolimus ointment & pimecrolimus cream Licensed for patients > 2 years old mild-moderate eczema\Safety?In controlled trials appear safe in adults and childrenIn 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 treatmentsAvoid in children younger than two years of ageUse for short periods of time and minimum amount necessaryAvoid continuous useAvoid in patients with compromised immune systems
52 Ointments (Tacrolimus) better than cream (Pimecrolimus)
57 Other Evening Primrose Oil / Star Flower Oil Contains gamma linolenic acid, fatty acid (deficient some atopic subjects)
58 Alternative medications some patients may use for eczema LicoriceCalendulaEchinaceaGolden SealNettleOats
59 Probiotics in primary prevention of atopic disease: a randomized placebo-controlled trial. Lactobacillusprenatally to mothers – (FH eczema, AR, asthma)postnatally for 6 months to infantsEndpoint: Chronic recurring eczemaEczema in probiotic 50% < than placebo (23% vs 46%)Number needed to treat = 4.5 (95% CI ).(Kalliomaki, Lancet 2001)
60 Laughter May Be Best Medicine...For Allergies OtherLaughter May Be Best Medicine...For AllergiesNEW 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 of The Journal of the American Medical Association. The effect lasted for 4 hours after the viewing
61 OtherCoal tar or less messy preps (liquid carbonis detergent 5-10%) in Eucerin or AquaphorChronic lichenified eczema patchesCoal tar smells & stains clothes so apply qhs using old clothes and old linensCoal tar can provoke a folliculitis.
62 Soaps Mild or Hypoallergenic Dove (unscented): Contains lotion Keri Oil of OlayBasisPurposeCetaphil Skin Cleanser (non-soap)Neutrogena barPure Ivory soap is very drying/irritating
63 Antibacterial Soaps Dial and Lever 2000 Cetaphil antibacterial cleansing bar
64 Evidenced-based review 2002 (BMJ Clinical Evidence) Positive evidence that:topical corticosteroids relieve symptoms and are safeemollients & steroids better than steroids aloneexcellent control of house dust mite reduces symptoms if positive mite RAST scores & childrenbedding covers most effectiveLittle to no evidence that:dietary change reduces symptomsbreast feeding or mother's diet prevents infant eczema
71 CASE 13 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?
72 Case Treatment strategy: Review mild skin care regimenConfirm use ofmild cleanserdaily moisturizers &mild laundry detergentPrescribe sufficient potency & quantity of topical corticosteroidsWhich steroid class(es) would you px?
73 Case- topical steroid choices TAC 0.1% oint. bid worse areas x 7-14 daysSwitch to H/C 2.5% ointment BIDTaper over 4 weeks to emollients if possibleConfirm parents understand dangers of prolonged steroid use and not to use potent steroids on face
74 F/U 2 weeks later:Only slightly improved- now what?
75 Now... Add oral antistaphylococcal agent for 7-14 days. REVIEW mild skin care regimenFollow-up in 2 weeks and SUCCESS!
76 CASE 234 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.
77 CASE 2 Not likely fungus given chronicity May have secondary staph infectionMay need more potent Class I steroid initially, e.g. clobetasol propionate (temovate) ointmentClass II Fluocinonide (lidex) 0.05% cream ok less severe
78 Case 3 75 YO male with chronic itchy spots- Using hydrocortisone cream 2.5% bid to ankle- minimal improvementUsing Class II Fluocinonide (lidex) 0.05% ointment under occlusion to hip area- “only thing that works”
79 Case 32.5% H/C too weakFluocinonide (lidex) 0.05% ointment under occlusion causing atrophyGood case for topical tacrolimus
82 ReferencesDrake 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 Available online atCorreale CE, Walker C, Murphy L, Craig TJ. Atopic Dermatitis: A Review of Diagnosis and Treatment. J Fam Pract 1999; available atRuzicka 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):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;
83 ReferencesCharlesworth 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:Hoare C, et al. Systematic review of treatments for atopic eczema. Health Technol Assess 2000; 2: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: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: