The
5 E ’s
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
Potential Conflict of Interest Disclosure
Astellas
Research
local PI for APPLES registry for long term
safety evaluation of Protopic
1
Impact of Atopic Dermatitis
• prevalence -- 10-17% 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; 43:649-55.
2
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
Atopic Dermatitis
Clinical Presentation
• 6 skin findings of eczema
1.
2.
3.
4.
5.
erythema
papules/edema
exudation - oozing and crusting
scale
excoriations
linear erosions from scratching
6.
Lichenification
thickened, hyperpigmented, leathery skin due to
rubbing (accentuated skin markings)
• symmetric > asymmetric
4
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
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
8
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
1
1
1
2
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
1
3
Complications of AD
1
6
Eczema Herpeticum
1
7
1
7
1
9
Eczema
Vaccinatum
2
0
Impetigo
2
1
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, 2002 1151-60
2
2
Treatment Approach
2
7
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 332:933-938.
2
8
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 pp37-67
2
9
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
3
0
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
3
1
Nice
&
Smooth
Not nice,
Rough
& Yucky
3
2
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
3
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
3
4
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
3
5
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
3
6
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)
3
8
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
3
9
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 = 20-30 gm
• Topical meds dispensed as
– 15, 30, 45, 60, 80 or 100 gram tubes
– 1 lb (454 gm) jars
4
0
Enough Medication
ESTIMATES FOR QUICK MEMORIZATION
• Recommended amount per dose
– total BSA of a 5 mo
– total BSA of a 5-10 yo
– total BSA of a 20 yo
= 5 gm
= 10 gm
= 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
4
1
Enough Medication
Only topical steroids sold in 1 lb jars
– triamcinolone acetonide
– hydrocortisone acetate
x 16 =
30 gram tube
1 lb (454 gm) jar
4
2
Clinical Approach to Atopic Dermatitis
Campfire Analogy
v
4
3
“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;141:1556-59
4
5
STEROID-INDUCED ATROPHY
5
0
STRIAE DISTENSAE
mometasone ointment x
several months in a teen
5
1
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-
5
2
Tacrolimus 0.1% Open label Phase III b Study:
Baseline
5
3
Tacrolimus 0.1% Open label Phase III b Study:
Month 9
5
4
Pimecrolimus Treatment of Atopic Dermatitis
3 weeks
Baseline
5
5
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
5
6
ATOPIC DERMATITIS
ADJUNCTIVE ANTIBIOTICS/ANTIBACTERIALS
• Treat impetigo/ superinfection
– oral antibiotics
• Reduce S aureus topically
– N3 (Nose, Nails, Navel) mupirocin b.i.d. 5 days/mo
– Bleach baths*
• 4 oz/ ~25 gal (tubful) water or ~2 tsp/gal H2O
• 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.
5
7
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
5
8
AD Habit-Reversal Techniques (HRT)
Breaking the itch-scratch cycle
Scratching
Epidermal Damage
 pruritus
Increased Adhesin Exposure
collagen, fibronectin, fibrinogen
Increased S. aureus binding/ inflammation
5
9
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
6
0
Atopic Dermatitis Therapeutic Pyramid
Systemic Immunomodulators
UV Phototherapy
Allergy Testing/Avoidance
Habit Reversal
Antihistamines
Topical Steroids
Anti-Staph Antibiotics
Topical Calcineurin Inhibitors
Protective Skin Care & Trigger Avoidance
6
1
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)
6
2
Thanks for your attention!
6
3
Cure sometimes
Relieve often
Comfort always
6
4