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To an Exceptional Eczema Experience Richard J. Antaya, MD, FAAP, FAAD Professor of Dermatology and Pediatrics Director, Pediatric Dermatology Yale University.

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Presentation on theme: "To an Exceptional Eczema Experience Richard J. Antaya, MD, FAAP, FAAD Professor of Dermatology and Pediatrics Director, Pediatric Dermatology Yale University."— Presentation transcript:

1 to an Exceptional Eczema Experience Richard J. Antaya, MD, FAAP, FAAD Professor of Dermatology and Pediatrics Director, Pediatric Dermatology Yale University School of Medicine New Haven, CT The 5 E ’s

2 Potential Conflict of Interest Disclosure Astellas Research local PI for APPLES registry for long term safety evaluation of Protopic 1

3 Impact of Atopic Dermatitis prevalence % of all children* mild in 85% mod to severe -- profound effect on QOL –intractable itching and sleep loss –soreness, scarring, dyspigmentation –messy topicals –social stigma –QOL impairment equivalent to CF –costs more than childhood diabetes 4% of adults with persistent disease 40-60% continue to experience disease intermittent exacerbations *adapted from Laughter D. J Am Acad Dermatol 2000; 43:

4 Diagnosis of Atopic Dermatitis Diagnosis of Atopic Dermatitis Diagnostic Criteria Pruritus Eczema (from Greek - to boil, to erupt) –chronic & recurring acute chronic subacute Adapted from Hanifin, Rajka. Acta Dermato Venereol. 92(suppl):44-7;1980 and AAD Consensus Conference on Pediatric Atopic Dermatitis 3

5 Atopic Dermatitis Clinical Presentation 6 skin findings of eczema 1.erythema 2.papules/edema 3.exudation - oozing and crusting 4.scale 5.excoriations linear erosions from scratching 6.Lichenification thickened, hyperpigmented, leathery skin due to rubbing (accentuated skin markings) symmetric > asymmetric 4

6 5

7 Diagnosis of Atopic Dermatitis Diagnosis of Atopic Dermatitis Diagnostic Criteria Pruritus Eczema (from Greek - to boil, to erupt) –chronic & recurring acute chronic subacute –age-specific distribution Adapted from Hanifin, Rajka. Acta Dermato Venereol. 92(suppl):44-7;1980 and AAD Consensus Conference on Pediatric Atopic Dermatitis 6

8 ATOPIC DERMATITIS Infantile Distribution face - cheeks and chin “head light” sign – mid-facial sparing extensor extremities, dorsal hands and feet very rarely on palms or soles can have widespread involvement diaper area often spared pruritus 7

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10 ATOPIC DERMATITIS ATOPIC DERMATITIS Childhood-Adult Distribution antecubital and popliteal fossae posterior neck presacral back, buttocks, flanks eyelids scalp hands, feet  palms and soles may be severe and generalized “head light” sign 9

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14 Diagnosis of Atopic Dermatitis Associated Features early age at onset –80-90% by 5 years personal or family history of atopy xerosis –associated with ichthyosis vulgaris (IV) –worse prognosis in patients with IV 1313

15 Deleted Old Secondary Criteria keratosis pilaris infra-auricular fissures periorbital/ocular changes e.g. Dennie-Morgan folds prurigo lesions atypical vascular responses hyperlinear palms and ichthyosis 1414

16 ATOPIC DERMATITIS Differential Diagnosis infancy seborrheic dermatitis scabies Wiskott-Aldrich Syndrome hyper-IgE syndrome (Job syndrome) Bruton’s agammaglobulinemia childhood contact dermatitis tinea corporis dermatophytid scabies pityriasis lichenoides CTCL (cutaneous T-cell lymphoma) 1515

17 Complications of AD 1616

18 Eczema Herpeticum 1717

19 1717

20 1919

21 Eczema Vaccinatum 2020

22 Impetigo 2121

23 S. aureus and Atopic Dermatitis Endogenous Antimicrobial Peptides antimicrobial peptides in the skin –cathelicidins –human  -defensin-2 (HBD-2) accumulate in response to skin inflammation normal levels in psoriasis lesions decreased levels in lesions –AD, eczema herpeticum, eczema vaccinatum IL-4 and IL-13 inhibit HBD-2 production Adapted from Ong P. N Engl J Med. 347(15), Oct 10,

24 Treatment of Atopic Dermatitis 2323

25 What proof do we have regarding the efficacy of our treatments for AD? 2424

26 Atopic Dermatitis Treatments Randomized Controlled Trials (RCT) RCT evidence supports –topical corticosteroids –oral cyclosporin –ultraviolet light therapy –psychological approaches (habit-reversal techniques) –topical calcineurin inhibitors Hoare C, Li Wan Po A,Williams H. Health Technol Assess; 2000;4(37) 2525

27 Atopic Dermatitis Treatments Randomized Controlled Trials (RCT) maternal allergen avoidance to avoid AD oral antihistamines Chinese herbs dietary restriction in established AD homeopathy topical coal tar massage therapy hypnotherapy evening primrose oil topical doxepin house dust mite reduction emollients Insufficient evidence to make recommendations on Hoare C, Li Wan Po A,Williams H. Health Technol Assess; 2000;4(37) 2626

28 Treatment Approach 2727

29 ATOPIC DERMATITIS 5 E’s to an Exceptional Eczema Experience 1.Education - level of success is directly related to how much education patients and their families receive about AD* 2.Expectations –Endpoints –Clearance vs Maintenance phases of therapy 3.Encouragement 4.Enough medication – campfire analogy 5.Early return visit (2 weeks) *Staab, D. BMJ 332:

30 to Atopic Dermatitis Clinical Approach to Atopic Dermatitis My Spiel Educate Explain what it is and what it is not –No cure, not a single allergy, but can be controlled –“The itch that rashes” –Alloknesis (cutaneous hyperaesthesia)* perceive normally “nonitchy” stimuli as “itchy” Explain the provokers of itch in A.D. –heat and perspiration 96% –wool 91% –emotional stress 81% –certain foods (rarely) –“common cold” 36% *Hagermark O. in Bernhard JD. Pruritus in skin disease. McGraw-Hill, 1994 pp

31 to Atopic Dermatitis Clinical Approach to Atopic Dermatitis My Spiel Expectations –Endpoints –Clearance with anti-inflammatory meds –Maintenance with trigger avoidance and moisturization Explain rationale for proposed therapy –Enough medicine -- Campfire analogy 3030

32 ATOPIC DERMATITIS The Spiel on General Skin Care soaps avoid “true soaps” –Dial, Ivory, Irish Spring moisturizing cleansers –Dove, Tone, Olay Complete soap free cleansers –Cetaphil, Aquanil avoid entirely during flares 3131

33 Nice & Smooth Not nice, Rough & Yucky 3232

34 ATOPIC DERMATITIS The Spiel on General Skin Care moisturizers immediately after bathing and prn (multiple times/day) avoid lotions; use creams and ointments Eucerin, Aquaphor, petrolatum, Cetaphil, Acid Mantle cream, Vanicream, Theraplex Emollient Ceremide-based – Epiceram, CeraVe, Cetaphil Restoraderm 3

35 ATOPIC DERMATITIS The Spiel on General Skin Care –laundry detergents hypoallergenic detergents Dreft, Ivory Snow –avoid dryer sheets and fabric softeners wool and polyester fabrics extremes of temperature, humidity dust mites (mattress, box spring, pillow covers) Certain foods – milk, wheat, egg, soy 3434

36 Truisms of Bathing ATOPIC DERMATITIS Hanifin’s Truisms of Bathing “Bathing dries the skin” A: True If skin allowed to air dry. “Bathing hydrates the skin” A: True If moisturizer is applied immediately after. No conclusive data supported by studies 3535

37 ATOPIC DERMATITIS Bathing Recommendations showers - o.k. if not flaring bath - if more severe b.i.d. for 10 min, tepid do not rub, scrub or use washcloths pat dry partially with a towel - don’t rub within 3 minutes apply moisturizer and/or topical medication 3636

38 ATOPIC DERMATITIS For more severe flares Open Wet Dressings –cools and helps relieve pruritus –regimen (q.d.- q.i.d.) soft cotton cloth (bed sheet, pillowcase) soak in tepid water, wring out apply one layer thick to affected area for min (don’t let dry out) remove and apply medication/moisturizer Wet Wraps –apply low to medium potency topical steroid –damp PJ’s or gauze covered by dry PJ’s or gauze –night time usually, can continue during day also for very severe flares –up to 2 weeks 3737

39 ATOPIC DERMATITIS MEDICAL TREATMENT  weak topical corticosteroids  non-fluorinated ointments or creams  Hydrocortisone acetate 0.5, 1.0, or 2.5%  Hydrocortisone valerate 0.2%  Desonide, fluticasone lotion/cr (low), aclometasone  medium to high potency steroids  Triamcinolone (med)  Fluticasone ointment (med)  Mometasone cream (med)  mometasone ointment (high) 3838

40 Topical Steroid Monotherapy Regimen Standard regimen –Twice daily for 2 weeks (esp. first treatment) –Then p.r.n. based on need and response to Rx More severe regimen  Pulse dose (once or twice) on weekends  3 consecutive days/week  Most severe regimen  Single application 3 days/week during maintenance phase  Mon, Wed, and Fri  Decreases frequency of flares 3939

41 Enough Medication Frequency Duration Recommended amount per dose –adult hand = ~ 0.5 gm –total BSA of 3-6 mo = 4-5 gm –total BSA of 6-10 yo = 10 gm –total BSA of an adult = gm Topical meds dispensed as –15, 30, 45, 60, 80 or 100 gram tubes –1 lb (454 gm) jars 4040

42 Enough Medication ESTIMATES FOR QUICK MEMORIZATION Recommended amount per dose –total BSA of a 5 mo = 5 gm –total BSA of a 5-10 yo= 10 gm –total BSA of a 20 yo = 20 gm Do the math… –5 m.o. 100% BSA = 5gm x 2 = 10gm x 14 days = 140 gm –7 y.o. 100% BSA = 10gm x 2 = 20gm x 14 days = 280 gm 4141

43 Enough Medication Only topical steroids sold in 1 lb jars –triamcinolone acetonide –hydrocortisone acetate x 16 = 30 gram tube 1 lb (454 gm) jar 4242

44 to Atopic Dermatitis Clinical Approach to Atopic Dermatitis Campfire Analogy v v 4343

45 FTU (Finger tip unit) = ½ gm Distal finger of adult …DIP crease to tip 2 FTUs = 1 gram 1 FTU covers 2 adult hands and fingers Dosing of Topical Medications 1 FTU Most topicals have a tube with orifice ~ 5 mm 4

46 “Soak and Smear” of Topical Steroids Soak and Smear regimen –Soak in a bath with plain water (no soap) for 10 min at night (or b.i.d.) –Then smear on the topical steroid (usually triamcinolone 0.1% ointment) immediately without drying –After skin is improved stop soaks but continue the topical steroid at night Gutman AB, Kligman AM, Sciacca J, James WD. Arch Dermatol Dec 2005;141:

47 Soak and Smear 28 adults severe chronic recalcitrant dermatitis (15 with AD) Duration - 3 years Previous treatments –Numerous topical therapies – all failed –17 pts – prednisone –2 pts - CyA –2 pts – UVB phototx Results –17 pts showed complete response –9 pts showed % improvement –Most by several days to 2 weeks Gutman AB, Kligman AM, Sciacca J, James WD. Arch Dermatol Dec 2005;141:

48 4y.o. AD min response TCI’s, TS TAC 0.1% oint bid S&S for 5 day then qd for 2 weeks Vaseline 4747

49 BL 2wk 6wk 4848

50 5 mo with AD No response triamcinolone 0.1% cr mupirocin oint hypoallergenic formula S&S HCO 2.5% qhs 10 min bath, and on dry skin in am x 2wk 4949

51 STEROID-INDUCED ATROPHY 5050

52 STRIAE DISTENSAE mometasone ointment x several months in a teen 5151

53 Protopic Ointment (tacrolimus) Elidel Cream (pimecrolimus) Topical Calcineurin Inhibitors (TCI’s) Protopic Ointment (tacrolimus) Elidel Cream (pimecrolimus) Proposed mechanism of action –CD4+ lymphocytes –inhibits calcineurin –inhibits gene transcription IL-2, IL-3, IL-4, IL-5, GM-CSF, TNF- , IFN-  5252

54 Tacrolimus 0.1% Open label Phase III b Study: Baseline 5353

55 Tacrolimus 0.1% Open label Phase III b Study: Month

56 Pimecrolimus Treatment of Atopic Dermatitis Baseline 3 weeks5

57 When do I use the TCI’s? Concerns about steroid use –Can’t get off topical steroid –Using steroids too frequently or continuously –Location too risky Intertriginous areas Eyelids Steroids ineffective Discuss FDA boxed warning 5656

58 ATOPIC DERMATITIS ADJUNCTIVE ANTIBIOTICS/ANTIBACTERIALS Treat impetigo/ superinfection –oral antibiotics Reduce S aureus topically –N 3 (Nose, Nails, Navel) mupirocin b.i.d. 5 days/mo –Bleach baths* 4 oz/ ~25 gal (tubful) water or ~2 tsp/gal H 2 O 3 times weekly - daily Clinically proven to improve eczema scores in patients who previously had AD-associated impetigo Huang JT et al, Pediatrics. 123(5):e808-14, 2009 May Huang JT, Rademaker A, Paller AS. Arch Dermatol. 147(2):246-7, 2011 Feb. 5757

59 ATOPIC DERMATITIS ANTIHISTAMINES especially hs –hydroxyzine (Atarax) –diphenhydramine (Benadryl) –cyproheptadine (Periactin) –doxepin (Sinequan) – cardiotoxic ! randomized trials have not demonstrated improvement with sedating or non-sedating antihistamines 5858

60 AD Habit-Reversal Techniques (HRT) Breaking the itch-scratch cycle Scratching Epidermal Damage Increased Adhesin Exposure collagen, fibronectin, fibrinogen Increased S. aureus binding/ inflammation  pruritus 5959

61 AD Habit-Reversal Techniques (HRT) Effective for tics and nervous habits Scratching is maintained by operant reinforcement HRT teaches –recognize the habit –identify situations that provoke it –train to develop a “competing response practice” –Striking, patting, or grasping the area Requires a motivated patient and physician 6060

62 Atopic Dermatitis Therapeutic Pyramid Protective Skin Care & Trigger Avoidance Topical Steroids Anti-Staph Antibiotics Antihistamines Topical Calcineurin Inhibitors UV Phototherapy Systemic Immunomodulators Allergy Testing/Avoidance Habit Reversal 6161

63 ATOPIC DERMATITIS 5 E’s to an Exceptional Eczema Experience 1.Education 2.Expectations 1.Endpoints 2.Clearance vs Maintenance 3.Encouragement 4.Enough medication – campfire analogy 5.Early return visit (2 weeks) 6262

64 Thanks for your attention! 6363

65 Cure sometimes Relieve often Comfort always 6464


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