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Dermatologic Symptoms in Your Pharmacy The Management of Rosacea and Atopic Dermatitis
June 3 2015 200PM ndash 400PM EDT
Presented by
Gail Newton PhD RPh and Daniel Krinsky MS RPh
copy 2015 by the American Pharmacists Association All rights reserved
Dermatologic Symptoms in Your Pharmacy The Management of Rosacea and Atopic Dermatitis
Activity Description
Many patients with skin conditions do not seek medical care and are likely to need advice regarding self-care treatments A large body of evidence supports the use of topical products to manage symptoms of rosacea and atopic dermatitis (AD) and indicates that such treatment is associated with improved long-term outcomes As drug information experts pharmacists can facilitate successful treatment of AD and rosacea In addition pharmacists can provide patient education to help diminish the stress and anxiety experienced by patients and caregivers In this live webinar experts will use a case-based approach to explore strategies that pharmacists can recommend to patients with rosacea and atopic dermatitis
Learning Objectives
At the completion of this application-based activity participants will be able to 1 Describe the epidemiology and clinical presentation of rosacea and atopic dermatitis (AD) 2 Recommend appropriate self-care treatment for patients with rosacea or AD with regard to the
efficacy and safety of available therapeutic options 3 Discuss areas where pharmacists interventions can improve the care of patients with rosacea
and AD
Target Audience Pharmacists Activity Type Application-based Learning Level 2 Date of Activity Wednesday June 3 2015 Location Virtual meeting Time 200 PMndash400 PM EDT (20 hours)
Speakers
Gail Newton PhD RPh Associate Professor Purdue University School of Pharmacy and Pharmaceutical Sciences West Lafayette Indiana
Daniel Krinsky MS RPh Associate Professor Northeast Ohio Medical University (NEOMED) College of Pharmacy Rootstown Ohio
Disclosures
Gail Newton PhD RPh and Daniel Krinsky MS RPh declare no conflicts of interest real or apparent and no financial interests in any company product or service mentioned in this activity including grants employment gifts stock holdings and honoraria For complete staff disclosures please see the Education and Accreditation Information section at wwwpharmacistcomeducation
copy 2015 by the American Pharmacists Association All rights reserved
Accreditation Information
The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education (CPE) This activity Dermatologic Symptoms in Your Pharmacy The Management of Rosacea and Atopic Dermatitis is approved for 20 contact hours of CPE credit (020 CEUs)
The ACPE Universal Activity Number assigned to this activity by the accredited provider is 0202-0000-15-058-L01-P To obtain CPE credit for this activity participants will be required to actively participate in the entire activity and complete the online assessment and evaluation forms located at wwwpharmacistcomlive-activities by Monday July 6 2015 If you claimed credit for the live offering of this course on March 30 2015 at the APhA Annual Meeting in San Diego California you are NOT eligible to receive credit for this offering
Development and Support
This activity was developed by the American Pharmacists Association and is supported by educational grants from Johnson amp Johnson Consumer Companies and Bayer HealthCare Pharmaceuticals Inc
How to Obtain Your CPE Credit
Go to wwwpharmacistcomlive-activities and under the Live Activities list select the Claim Credit link for Dermatologic Symptoms in Your Pharmacy The Management of Rosacea and Atopic Dermatitis
You will need to enter your pharmacistcom Username and Password If you do not have an account you can create a guest account for free Then continue with the following instructions to obtain your CPE credit for this activity
Select Add to Cart or Enroll Now from the left navigation and successfully complete the Assessment (use Attendance Code DERM) and Evaluation You will need to provide your NABP e-profile ID number to claim credit
Please visit wwwpharmacistcomcpe-monitor for any questions regarding your NABP e-profile ID number (Note that it may take up to 3 hours for your NABP e-profile ID number to become activated)
The filing deadline for this CPE activity is Monday July 6 2015 at 500 PM Eastern Time No credit will be issued after this date
If you have any questions or require additional information to claim your credit please contact Anthony Gary Senior Manager Education Department at the American Pharmacists Association by e-mailing agaryaphanetorg or calling 202-429-7515
copy 2015 by the American Pharmacists Association All rights reserved
1
Dermatologic Symptoms in Your
Pharmacy The Management of
Rosacea and Atopic Dermatitis
Gail Newton PhD RPh
Associate Professor
Department of Pharmacy Practice
Purdue University School of Pharmacy and Pharmaceutical Sciences
Daniel Krinsky MS RPh
Associate Professor
NEOMED College of Pharmacy
Manager MTM Services Giant Eagle Pharmacy
2
Development and Support
This activity was developed by the American
Pharmacists Association and is supported by
educational grants from Bayer HealthCare
Pharmaceuticals Inc and
Johnson amp Johnson Consumer Companies Inc
3
Disclosuresbull Gail Newton PhD RPh and Daniel Krinsky MS RPh
ldquodeclare no conflicts of interest real or apparent and no
financial interests in any company product or service
mentioned in this activity including grants employment
gifts stock holdings and honorariardquo
The American Pharmacists Association is accredited by the Accreditation
Council for Pharmacy Education as a provider of continuing pharmacy
education
copy 2015 by the American Pharmacists Association All rights reserved
4
Attendance Code
DERM
To obtain CPE credit for this activity you are
required to actively participate in this session The
attendance code is needed to access the
assessment and evaluation for this activity
Your CPE must be filed by July 6 2015 in order to
receive credit
5
Accreditation Information
The American Pharmacists Association is accredited by theAccreditation Council for Pharmacy Education as a provider of continuing
pharmacy education This activity Dermatologic Symptoms in Your Pharmacy The Management of Rosacea and Atopic Dermatitis is approved for 20 hours of continuing pharmacy education credit (020 CEUs) The ACPE Universal Activity Number assigned by the accredited provider is 0202-0000-15-058-L01-P
To obtain continuing pharmacy education credit for this activity participants will be required to actively participate in the entire webinar and complete an assessment and evaluation located at wwwpharmacistcomlive-activities by July 6 2015
Initial Release Date June 3 2015
Target Audience Pharmacists
ACPE Activity Type Application-based
Learning Level 2
Fee There is no fee for this activity
6
Learning Objectives
At the completion of this application-based activity
participants will be able to
1 Describe the epidemiology and clinical presentation of
rosacea and atopic dermatitis (AD)
2 Recommend appropriate self-care treatment for patients
with rosacea or AD with regard to the efficacy and safety
of available therapeutic options
3 Discuss areas where pharmacists interventions can
improve the care of patients with rosacea and AD
copy 2015 by the American Pharmacists Association All rights reserved
7
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic dermatitis
B Provides patients with a list of therapeutic options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
8
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with atopic dermatitis (AD)
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
9
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your primary
care provider or dermatologist
C Newer data suggests the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks then
stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not apply on
any other part of your body
copy 2015 by the American Pharmacists Association All rights reserved
10
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at a
local diner
B 45-year-old ad executive of Mediterranean descent who
plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne as a
teenager
D 52-year-old professor with fair skin who blushes easily
11
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
12
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
copy 2015 by the American Pharmacists Association All rights reserved
13
Atopic Dermatitis (AD) IntroBackground
Incidence and prevalence
bull Inflammatory condition of the epidermis and dermis
bull Characterized by episodic flares and periods of remission
bull AD is estimated to affect from 10 to 20 of children - many of
these individuals have symptoms into adulthood
bull 60 patients diagnosed in first year of life
bull 30 lt5 years of age
bull Adult prevalence 1-3 overall lifetime prevalence 7
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
14
Atopic Dermatitis IntroBackground
bull Atopic triad asthma allergic rhinitis and atopic dermatitis
bull Asthma and allergic rhinitis can occur in up to 80 of patients with
AD
bull 80 of AD classified as mild and can be safely treated with
nonprescription products
bull 70 of cases atopic family history
ndash 1 parent atopic 50 chance child will have symptoms
ndash 2 parents 79 chance
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
15
Atopic Dermatitis Cause
bull A protein in the epidermal differentiation complex filaggrin (FLG)
is related to the development of AD
bull Any FLG mutation increases onersquos risk of AD (35 known
mutations) mutation leads to irritation in atopic skin caused by
ndash Increased penetration of allergens
ndash Decrease in skin barrier proteins
ndash Higher peptidase activity
ndash Lack of protease inhibitors
bull Also decreased moisture retention due to lower concentration of
lipid and ceramides
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
16
Atopic Dermatitis Assessment
bull The SCORAD (SCORing Atopic Dermatitis) index is used to
assess severity of AD rate the following 7 factors
ndash Erythema
ndash Edema
ndash Papulation (formation of papules)
ndash Excoriations (abrasion of the epidermis by trauma)
ndash Lichenification (increased epidermal markings)
ndash Oozingcrusting
ndash Dryness
bull Index also includes visual analogue scale
bull A SCORAD index lt25 = mild 25-50 moderate and gt50 = severe
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
17
Atopic Dermatitis Diagnosis
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
TABLE 32-1 Diagnostic Criteria for AD
A pruritic skin disorder plus three or more of the following criteria
bull Onset at younger than 2 years
bull History of skin crease involvement (including cheeks in children younger than 10
years)
bull History of generally dry skin
bull Personal history of other atopic disease that is asthma (or history of any atopic
disease in first-degree relative in children younger than 4 years)
bull Visible flexural dermatitis (or dermatitis of cheeksforehead and other outer limbs in
children younger than 4 years)
18
Atopic Dermatitis Clinical Presentation
bull Initial symptoms erythema and scaling of the infantrsquos cheeks
bull May progress to affect the face neck forehead and extremities
bull Major symptom carrying over to adulthood is xerosis (dry skin)
bull Adults with AD ndash cause usually environmental exposure to
chemicals or skin trauma
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
19
Atopic Dermatitis Clinical Presentation
3 clinical forms of AD
bull Acute AD pruritic erythematous papules or vesicles over
erythematous skin often associated with excoriation and serous
exudate
bull Subacute AD erythematous excoriated papules and scaly
plaques
bull Chronic AD thickened skin plaques and accentuated skin
markings usually involves symptoms seen in all 3 stages
All pts at risk of infection other conditions related to compromised
skin
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
20
Atopic Dermatitis Treatment
Treatment Goals
bull No cure symptom management
bull The goals of self-treatment of AD are to
1 Stop the itch-scratch cycle hydrocortisone
2 Maintain skin hydration emollients and moisturizers
3 Avoid or minimize factors that trigger or aggravate
the disorder
4 Prevent secondary infection
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
21
Atopic Dermatitis Nonpharmacologic
bull Bathing can hydrate the stratum corneum remove allergens and
irritants cleanse and debride crusts and enhance the effects of
moisturizers and topical steroids
ndash Recommended time 3-5 minutes and every other day
ndash Water should be tepid
ndash Add colloidal oatmeal
bull To maintain skin hydration and patency recommend
ndash Emollients
bull Both occlusive and moisturizing used to prevent or relieve the
signs and symptoms of dry skin
bull Apply at least twice daily for preventive and maintenance therapy
bull Creams or ointments better (than lotions) for enhancing softness
and hydration
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
22
bull Bath Oils
ndash Mineral or vegetable oil plus a surfactant help with skin lubrication
may decrease frequency of bathing
bull Cleansers
ndash Avoid traditional bath soaps ndash remove harmful and beneficial
substances
ndash Better option glycerin soaps ndash more soluble closer to neutral pH
less drying
bull Emulsifiers maintain water + lipids in one continuous phase
bull Humectants help draw water into the stratum corneum and to
retain water often added to emollient bases
bull Other key ingredients lubricants and moisturizers 3-4xday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
Atopic Dermatitis Nonpharmacologic
23
Atopic Dermatitis EBM Guideline
Most recent guideline from the American Academy of Dermatology
bull Moisturizers
ndash Xerosis is one of the cardinal clinical features of AD and results from
a dysfunctional epidermal barrier topical moisturizers are used to
combat xerosis and transepidermal water loss with traditional agents
containing varying amounts of emollient occlusive andor humectant
ingredients
bull Emollients (eg glycol and glyceryl stearate soy sterols)
ndash Lubricate and soften the skin occlusive agents (eg petrolatum
dimethicone mineral oil) form a layer to retard evaporation of water
whereas humectants (eg glycerol lactic acid urea) attract and hold
water
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
24
Atopic Dermatitis EBM Guideline
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
Nonpharmacologic options for treatment of AD
bull Strong evidence of the benefit of moisturizers ndash integral to
management ndash reduce severity + need for pharmacologic tx
ndash Apply soon after bathing to maximize hydration
bull Bathing suggested ndash no standard for frequency or duration
ndash Insufficient evidence any of the following offer value when added to
bath water Oils emollients other additives
bull Limited use of nonsoap cleansers (neutrallow pH hypoallergenic
fragrance-free) recommended
bull Use of wet-wrap therapy +- topical corticosteroid appropriate for
pts with moderatesevere AD ndash reduce symptom severity and
water loss during flares
copy 2015 by the American Pharmacists Association All rights reserved
25
bull Multicenter randomized double-blind controlled trial ndash compared
5 urea cream with a reference cream
bull Urea cream significantly better than reference cream in
preventing eczema relapse in patients with AD (HR 0634
pthinsp=thinsp0011)
bull Risk of eczema relapse was reduced by 37
bull At 6 months
ndash 26 of the patients in the test cream group were still eczema free vs
10 in the reference cream group
Ref Aringkerstroumlm U et al Comparison of moisturizing creams for the prevention of
atopic dermatitis relapse a randomized double-blind controlled multicentre clinical
trial Acta Derm Venereol 2015 Jan 16 doi 10234000015555-2051
Atopic Dermatitis Moisturizers
26
bull Colloidal oatmeal suspensions bath soaps shampoos shaving
gels and moisturizing creams
bull The diverse chemical polymorphism of oats translates into
numerous clinical utilities for AD and eczema
bull Avenanthramides
ndash Principal polyphenolic antioxidants in oats
ndash Anti-inflammatory and antipruritic properties in rodent models
ndash Also antioxidant properties
bull Positive effect in pts with AD
Ref Fowler JF Jr Colloidal oatmeal formulations and the treatment of atopic
dermatitis J Drugs Dermatol 2014 Oct 113(10)1180-3
Atopic Dermatitis Colloidal Oatmeal
27
bull METHODS
ndash Four extracts of colloidal oatmeal were made with various solvents
and tested in anti-inflammatory and antioxidant assays
ndash Assessment of benefit in 29 female patients with bilateral mild to
moderate itch with moderate to severe dry skin on their lower legs
used a colloidal oatmeal skin protectant lotion
bull RESULTS
ndash In vitro study Colloidal oatmeal extract activity reduced pro-
inflammatory cytokines
ndash 29 pts colloidal oat skin protectant lotion showed significant clinical
improvements in skin dryness scaling roughness and itch intensity
Ref Reynertson KA et al Anti-inflammatory activities of colloidal oatmeal
contribute to the effectiveness of oats in treatment of itch associated with dry
irritated skin J Drugs Dermatol 2015 Jan 114(1)43-8
Atopic Dermatitis Colloidal Oatmeal
copy 2015 by the American Pharmacists Association All rights reserved
28
Atopic Dermatitis Colloidal Oatmeal
bull Although emollients are recommended in the management of AD
regimens for emollient maintenance therapy are awaiting
validation
bull International multicenter open-label trial to assess the effects of a
3-month maintenance treatment regimen with a sterile
preservative-free emollient cream containing oat plantlets in
children (ages 6 mos-6 yrs) with moderate AD
bull After a 14-day run-in stabilization phase using a topical
corticosteroid (TCS) treatment of medium potency 108 children
with a SCORAD index of 20 or less were included in the study
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
29
Atopic Dermatitis Colloidal Oatmeal
bull Emollient was applied twice daily for 3 months rescue topical
corticosteroid (TCS) treatment used for flare-ups
bull The SCORAD index Patient-Oriented SCORAD (PO-SCORAD)
index number of flares TCS use and tolerance were assessed
monthly x 3 months
bull Results AD severity improved with a highly significant decrease
in the SCORAD and PO-SCORAD indexes 2nd and 3rd months
(p lt 0001)
bull of flares and TCS use significantly decreased by the 3rd month
(both p lt 0001)
bull Intervention = significant improvement of clinical symptoms with
no adverse events
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
30
Bathing is a therapeutic measure commonly advised in atopic dermatitis
(AD) Whether baths improve skin condition remains unclear Objectives of
this study
bull What is the effect of one month of tap water bathing on the bathed skin of
patients with AD
bull How many pts favor baths
bull Interventional studies measuring skin changes after tap water bathing
were selected for the first analysis
bull Observational studies reporting the proportion of AD patients who favor
baths were selected for the second analysis
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
copy 2015 by the American Pharmacists Association All rights reserved
31
bull 7 of 271 studies met the selection criteria
bull Pooled effect size of skin changes after baths was minimal (-010)
bull 291 of patients favored baths
Authors conclude
bull No evidence of a positive effect of 1-month tap water bathing on
skin changes in AD
bull Discuss pros and cons with pts before deciding whether baths are
appropriate and if so frequency products to add to improve
response
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
32
Can probiotics offer benefit in the management of AD
bull Meta-analysis included randomized controlled trials (RCTs)
measuring the effects of probiotics or synbiotics in patients
diagnosed with AD
bull The primary outcome SCORAD values between the treatment
and placebo groups
bull 25 RCTs (n = 1599)
bull Significant improvement in SCORAD values in pts taking
probiotics (mean -451 95 CI -678 to -224)
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
33
Population subgroups
bull Pts 1 to 18 years old (-574 95CI -727 to -420)
bull Adults (-826 95CI -1328 to -325)
bull Infants (lt1 year old) no positive effect
Response to specific probiotic strains
bull Use of a mixture of different bacterial species or Lactobacillus
species showed greater benefit than did use of Bifidobacterium
species alone
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
copy 2015 by the American Pharmacists Association All rights reserved
34
Double-blind prospective randomized placebo-controlled study in
220 children with moderatesevere AD
Evaluated effects of 2 strains of Lactobacillus (and combined) on
disease severity QOL and certain measures of immune function
ndash Lactobacillus paracasei (LP)
ndash Lactobacillus fermentum (LF)
bull Groups
ndash LP
ndash LF
ndash LP+LF mixture
ndash placebo
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
35
bull All pts given 3 months of therapy
bull Response evaluated myriad ways standard evaluation via
SCORAD scores
bull LP LF and LP+LF mixture groups demonstrated benefit via lower
SCORAD scores compared with the placebo group (plt0001)
bull Benefit seen up to 4 months after discontinuing the probiotics
bull In subgroup analyses significant benefit in the following
ndash Younger than age 12
ndash Breast fed gt6 months
ndash Those with documented mite sensitization
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
36
bull Small prospective controlled trial assessed association of
Streptococcus thermophilus ST10 and tara gum complex and the
activity of Lactobacillus salivarius LS01 administered at high
doses to adults with AD
bull Why this complex Improves adherence to intestinal mucus
bull 25 patients randomized to placebo (n=12) or active formulation
(n=13)
bull SCORAD used to evaluate response
bull Also evaluated bacterial counts (for Staphylococcus aureus and
clostridia)
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
copy 2015 by the American Pharmacists Association All rights reserved
37
bull At 1 month study group showed significant improvement in
SCORAD index
bull A slight decrease in fecal S aureus count was observed in
probiotic-treated patients
bull Authors concluded the probiotic strain + tara gum complex =
quicker response and greater efficacy
bull What does this mean Need more data but probiotic
supplementation could offer benefit
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
38
bull Lactobacillus salivarius LS01 in children with AD
bull 43 pts (0 to 11 yrs)
bull Response evaluated by changes in itch index and SCORAD index
bull Those using probiotics showed significant benefit in both
measures
bull Effects sustained for 4 weeks after supplement stopped
Ref Niccoli AA et al Preliminary results on clinical effects of probiotic
Lactobacillus salivarius LS01 in children affected by atopic dermatitis J Clin
Gastroenterol 2014 Nov-Dec48 Suppl 1S34-6
Atopic Dermatitis Probiotics ndash Study 4
39
Atopic Dermatitis Pharmacologic Tx
Antipruritics 3 Options
1 Local anesthetics pramoxine lidocaine and benzocaine
2 Antihistamines
ndash Topical diphenhydramine may be effective as an antihistamine in
addition to having some mild anesthetic properties however may
cause sensitization so use is not recommended
ndash Systemic pruritus with AD likely not related to histamine so most
agents probably not effective also concern regarding adverse effects
(anticholinergic drowsiness) and time to response
3 Hydrocortisone
ndash Dose Apply to Affected Area (AAA) 1-2 timesday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
Dermatologic Symptoms in Your Pharmacy The Management of Rosacea and Atopic Dermatitis
Activity Description
Many patients with skin conditions do not seek medical care and are likely to need advice regarding self-care treatments A large body of evidence supports the use of topical products to manage symptoms of rosacea and atopic dermatitis (AD) and indicates that such treatment is associated with improved long-term outcomes As drug information experts pharmacists can facilitate successful treatment of AD and rosacea In addition pharmacists can provide patient education to help diminish the stress and anxiety experienced by patients and caregivers In this live webinar experts will use a case-based approach to explore strategies that pharmacists can recommend to patients with rosacea and atopic dermatitis
Learning Objectives
At the completion of this application-based activity participants will be able to 1 Describe the epidemiology and clinical presentation of rosacea and atopic dermatitis (AD) 2 Recommend appropriate self-care treatment for patients with rosacea or AD with regard to the
efficacy and safety of available therapeutic options 3 Discuss areas where pharmacists interventions can improve the care of patients with rosacea
and AD
Target Audience Pharmacists Activity Type Application-based Learning Level 2 Date of Activity Wednesday June 3 2015 Location Virtual meeting Time 200 PMndash400 PM EDT (20 hours)
Speakers
Gail Newton PhD RPh Associate Professor Purdue University School of Pharmacy and Pharmaceutical Sciences West Lafayette Indiana
Daniel Krinsky MS RPh Associate Professor Northeast Ohio Medical University (NEOMED) College of Pharmacy Rootstown Ohio
Disclosures
Gail Newton PhD RPh and Daniel Krinsky MS RPh declare no conflicts of interest real or apparent and no financial interests in any company product or service mentioned in this activity including grants employment gifts stock holdings and honoraria For complete staff disclosures please see the Education and Accreditation Information section at wwwpharmacistcomeducation
copy 2015 by the American Pharmacists Association All rights reserved
Accreditation Information
The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education (CPE) This activity Dermatologic Symptoms in Your Pharmacy The Management of Rosacea and Atopic Dermatitis is approved for 20 contact hours of CPE credit (020 CEUs)
The ACPE Universal Activity Number assigned to this activity by the accredited provider is 0202-0000-15-058-L01-P To obtain CPE credit for this activity participants will be required to actively participate in the entire activity and complete the online assessment and evaluation forms located at wwwpharmacistcomlive-activities by Monday July 6 2015 If you claimed credit for the live offering of this course on March 30 2015 at the APhA Annual Meeting in San Diego California you are NOT eligible to receive credit for this offering
Development and Support
This activity was developed by the American Pharmacists Association and is supported by educational grants from Johnson amp Johnson Consumer Companies and Bayer HealthCare Pharmaceuticals Inc
How to Obtain Your CPE Credit
Go to wwwpharmacistcomlive-activities and under the Live Activities list select the Claim Credit link for Dermatologic Symptoms in Your Pharmacy The Management of Rosacea and Atopic Dermatitis
You will need to enter your pharmacistcom Username and Password If you do not have an account you can create a guest account for free Then continue with the following instructions to obtain your CPE credit for this activity
Select Add to Cart or Enroll Now from the left navigation and successfully complete the Assessment (use Attendance Code DERM) and Evaluation You will need to provide your NABP e-profile ID number to claim credit
Please visit wwwpharmacistcomcpe-monitor for any questions regarding your NABP e-profile ID number (Note that it may take up to 3 hours for your NABP e-profile ID number to become activated)
The filing deadline for this CPE activity is Monday July 6 2015 at 500 PM Eastern Time No credit will be issued after this date
If you have any questions or require additional information to claim your credit please contact Anthony Gary Senior Manager Education Department at the American Pharmacists Association by e-mailing agaryaphanetorg or calling 202-429-7515
copy 2015 by the American Pharmacists Association All rights reserved
1
Dermatologic Symptoms in Your
Pharmacy The Management of
Rosacea and Atopic Dermatitis
Gail Newton PhD RPh
Associate Professor
Department of Pharmacy Practice
Purdue University School of Pharmacy and Pharmaceutical Sciences
Daniel Krinsky MS RPh
Associate Professor
NEOMED College of Pharmacy
Manager MTM Services Giant Eagle Pharmacy
2
Development and Support
This activity was developed by the American
Pharmacists Association and is supported by
educational grants from Bayer HealthCare
Pharmaceuticals Inc and
Johnson amp Johnson Consumer Companies Inc
3
Disclosuresbull Gail Newton PhD RPh and Daniel Krinsky MS RPh
ldquodeclare no conflicts of interest real or apparent and no
financial interests in any company product or service
mentioned in this activity including grants employment
gifts stock holdings and honorariardquo
The American Pharmacists Association is accredited by the Accreditation
Council for Pharmacy Education as a provider of continuing pharmacy
education
copy 2015 by the American Pharmacists Association All rights reserved
4
Attendance Code
DERM
To obtain CPE credit for this activity you are
required to actively participate in this session The
attendance code is needed to access the
assessment and evaluation for this activity
Your CPE must be filed by July 6 2015 in order to
receive credit
5
Accreditation Information
The American Pharmacists Association is accredited by theAccreditation Council for Pharmacy Education as a provider of continuing
pharmacy education This activity Dermatologic Symptoms in Your Pharmacy The Management of Rosacea and Atopic Dermatitis is approved for 20 hours of continuing pharmacy education credit (020 CEUs) The ACPE Universal Activity Number assigned by the accredited provider is 0202-0000-15-058-L01-P
To obtain continuing pharmacy education credit for this activity participants will be required to actively participate in the entire webinar and complete an assessment and evaluation located at wwwpharmacistcomlive-activities by July 6 2015
Initial Release Date June 3 2015
Target Audience Pharmacists
ACPE Activity Type Application-based
Learning Level 2
Fee There is no fee for this activity
6
Learning Objectives
At the completion of this application-based activity
participants will be able to
1 Describe the epidemiology and clinical presentation of
rosacea and atopic dermatitis (AD)
2 Recommend appropriate self-care treatment for patients
with rosacea or AD with regard to the efficacy and safety
of available therapeutic options
3 Discuss areas where pharmacists interventions can
improve the care of patients with rosacea and AD
copy 2015 by the American Pharmacists Association All rights reserved
7
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic dermatitis
B Provides patients with a list of therapeutic options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
8
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with atopic dermatitis (AD)
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
9
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your primary
care provider or dermatologist
C Newer data suggests the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks then
stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not apply on
any other part of your body
copy 2015 by the American Pharmacists Association All rights reserved
10
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at a
local diner
B 45-year-old ad executive of Mediterranean descent who
plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne as a
teenager
D 52-year-old professor with fair skin who blushes easily
11
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
12
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
copy 2015 by the American Pharmacists Association All rights reserved
13
Atopic Dermatitis (AD) IntroBackground
Incidence and prevalence
bull Inflammatory condition of the epidermis and dermis
bull Characterized by episodic flares and periods of remission
bull AD is estimated to affect from 10 to 20 of children - many of
these individuals have symptoms into adulthood
bull 60 patients diagnosed in first year of life
bull 30 lt5 years of age
bull Adult prevalence 1-3 overall lifetime prevalence 7
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
14
Atopic Dermatitis IntroBackground
bull Atopic triad asthma allergic rhinitis and atopic dermatitis
bull Asthma and allergic rhinitis can occur in up to 80 of patients with
AD
bull 80 of AD classified as mild and can be safely treated with
nonprescription products
bull 70 of cases atopic family history
ndash 1 parent atopic 50 chance child will have symptoms
ndash 2 parents 79 chance
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
15
Atopic Dermatitis Cause
bull A protein in the epidermal differentiation complex filaggrin (FLG)
is related to the development of AD
bull Any FLG mutation increases onersquos risk of AD (35 known
mutations) mutation leads to irritation in atopic skin caused by
ndash Increased penetration of allergens
ndash Decrease in skin barrier proteins
ndash Higher peptidase activity
ndash Lack of protease inhibitors
bull Also decreased moisture retention due to lower concentration of
lipid and ceramides
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
16
Atopic Dermatitis Assessment
bull The SCORAD (SCORing Atopic Dermatitis) index is used to
assess severity of AD rate the following 7 factors
ndash Erythema
ndash Edema
ndash Papulation (formation of papules)
ndash Excoriations (abrasion of the epidermis by trauma)
ndash Lichenification (increased epidermal markings)
ndash Oozingcrusting
ndash Dryness
bull Index also includes visual analogue scale
bull A SCORAD index lt25 = mild 25-50 moderate and gt50 = severe
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
17
Atopic Dermatitis Diagnosis
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
TABLE 32-1 Diagnostic Criteria for AD
A pruritic skin disorder plus three or more of the following criteria
bull Onset at younger than 2 years
bull History of skin crease involvement (including cheeks in children younger than 10
years)
bull History of generally dry skin
bull Personal history of other atopic disease that is asthma (or history of any atopic
disease in first-degree relative in children younger than 4 years)
bull Visible flexural dermatitis (or dermatitis of cheeksforehead and other outer limbs in
children younger than 4 years)
18
Atopic Dermatitis Clinical Presentation
bull Initial symptoms erythema and scaling of the infantrsquos cheeks
bull May progress to affect the face neck forehead and extremities
bull Major symptom carrying over to adulthood is xerosis (dry skin)
bull Adults with AD ndash cause usually environmental exposure to
chemicals or skin trauma
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
19
Atopic Dermatitis Clinical Presentation
3 clinical forms of AD
bull Acute AD pruritic erythematous papules or vesicles over
erythematous skin often associated with excoriation and serous
exudate
bull Subacute AD erythematous excoriated papules and scaly
plaques
bull Chronic AD thickened skin plaques and accentuated skin
markings usually involves symptoms seen in all 3 stages
All pts at risk of infection other conditions related to compromised
skin
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
20
Atopic Dermatitis Treatment
Treatment Goals
bull No cure symptom management
bull The goals of self-treatment of AD are to
1 Stop the itch-scratch cycle hydrocortisone
2 Maintain skin hydration emollients and moisturizers
3 Avoid or minimize factors that trigger or aggravate
the disorder
4 Prevent secondary infection
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
21
Atopic Dermatitis Nonpharmacologic
bull Bathing can hydrate the stratum corneum remove allergens and
irritants cleanse and debride crusts and enhance the effects of
moisturizers and topical steroids
ndash Recommended time 3-5 minutes and every other day
ndash Water should be tepid
ndash Add colloidal oatmeal
bull To maintain skin hydration and patency recommend
ndash Emollients
bull Both occlusive and moisturizing used to prevent or relieve the
signs and symptoms of dry skin
bull Apply at least twice daily for preventive and maintenance therapy
bull Creams or ointments better (than lotions) for enhancing softness
and hydration
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
22
bull Bath Oils
ndash Mineral or vegetable oil plus a surfactant help with skin lubrication
may decrease frequency of bathing
bull Cleansers
ndash Avoid traditional bath soaps ndash remove harmful and beneficial
substances
ndash Better option glycerin soaps ndash more soluble closer to neutral pH
less drying
bull Emulsifiers maintain water + lipids in one continuous phase
bull Humectants help draw water into the stratum corneum and to
retain water often added to emollient bases
bull Other key ingredients lubricants and moisturizers 3-4xday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
Atopic Dermatitis Nonpharmacologic
23
Atopic Dermatitis EBM Guideline
Most recent guideline from the American Academy of Dermatology
bull Moisturizers
ndash Xerosis is one of the cardinal clinical features of AD and results from
a dysfunctional epidermal barrier topical moisturizers are used to
combat xerosis and transepidermal water loss with traditional agents
containing varying amounts of emollient occlusive andor humectant
ingredients
bull Emollients (eg glycol and glyceryl stearate soy sterols)
ndash Lubricate and soften the skin occlusive agents (eg petrolatum
dimethicone mineral oil) form a layer to retard evaporation of water
whereas humectants (eg glycerol lactic acid urea) attract and hold
water
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
24
Atopic Dermatitis EBM Guideline
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
Nonpharmacologic options for treatment of AD
bull Strong evidence of the benefit of moisturizers ndash integral to
management ndash reduce severity + need for pharmacologic tx
ndash Apply soon after bathing to maximize hydration
bull Bathing suggested ndash no standard for frequency or duration
ndash Insufficient evidence any of the following offer value when added to
bath water Oils emollients other additives
bull Limited use of nonsoap cleansers (neutrallow pH hypoallergenic
fragrance-free) recommended
bull Use of wet-wrap therapy +- topical corticosteroid appropriate for
pts with moderatesevere AD ndash reduce symptom severity and
water loss during flares
copy 2015 by the American Pharmacists Association All rights reserved
25
bull Multicenter randomized double-blind controlled trial ndash compared
5 urea cream with a reference cream
bull Urea cream significantly better than reference cream in
preventing eczema relapse in patients with AD (HR 0634
pthinsp=thinsp0011)
bull Risk of eczema relapse was reduced by 37
bull At 6 months
ndash 26 of the patients in the test cream group were still eczema free vs
10 in the reference cream group
Ref Aringkerstroumlm U et al Comparison of moisturizing creams for the prevention of
atopic dermatitis relapse a randomized double-blind controlled multicentre clinical
trial Acta Derm Venereol 2015 Jan 16 doi 10234000015555-2051
Atopic Dermatitis Moisturizers
26
bull Colloidal oatmeal suspensions bath soaps shampoos shaving
gels and moisturizing creams
bull The diverse chemical polymorphism of oats translates into
numerous clinical utilities for AD and eczema
bull Avenanthramides
ndash Principal polyphenolic antioxidants in oats
ndash Anti-inflammatory and antipruritic properties in rodent models
ndash Also antioxidant properties
bull Positive effect in pts with AD
Ref Fowler JF Jr Colloidal oatmeal formulations and the treatment of atopic
dermatitis J Drugs Dermatol 2014 Oct 113(10)1180-3
Atopic Dermatitis Colloidal Oatmeal
27
bull METHODS
ndash Four extracts of colloidal oatmeal were made with various solvents
and tested in anti-inflammatory and antioxidant assays
ndash Assessment of benefit in 29 female patients with bilateral mild to
moderate itch with moderate to severe dry skin on their lower legs
used a colloidal oatmeal skin protectant lotion
bull RESULTS
ndash In vitro study Colloidal oatmeal extract activity reduced pro-
inflammatory cytokines
ndash 29 pts colloidal oat skin protectant lotion showed significant clinical
improvements in skin dryness scaling roughness and itch intensity
Ref Reynertson KA et al Anti-inflammatory activities of colloidal oatmeal
contribute to the effectiveness of oats in treatment of itch associated with dry
irritated skin J Drugs Dermatol 2015 Jan 114(1)43-8
Atopic Dermatitis Colloidal Oatmeal
copy 2015 by the American Pharmacists Association All rights reserved
28
Atopic Dermatitis Colloidal Oatmeal
bull Although emollients are recommended in the management of AD
regimens for emollient maintenance therapy are awaiting
validation
bull International multicenter open-label trial to assess the effects of a
3-month maintenance treatment regimen with a sterile
preservative-free emollient cream containing oat plantlets in
children (ages 6 mos-6 yrs) with moderate AD
bull After a 14-day run-in stabilization phase using a topical
corticosteroid (TCS) treatment of medium potency 108 children
with a SCORAD index of 20 or less were included in the study
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
29
Atopic Dermatitis Colloidal Oatmeal
bull Emollient was applied twice daily for 3 months rescue topical
corticosteroid (TCS) treatment used for flare-ups
bull The SCORAD index Patient-Oriented SCORAD (PO-SCORAD)
index number of flares TCS use and tolerance were assessed
monthly x 3 months
bull Results AD severity improved with a highly significant decrease
in the SCORAD and PO-SCORAD indexes 2nd and 3rd months
(p lt 0001)
bull of flares and TCS use significantly decreased by the 3rd month
(both p lt 0001)
bull Intervention = significant improvement of clinical symptoms with
no adverse events
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
30
Bathing is a therapeutic measure commonly advised in atopic dermatitis
(AD) Whether baths improve skin condition remains unclear Objectives of
this study
bull What is the effect of one month of tap water bathing on the bathed skin of
patients with AD
bull How many pts favor baths
bull Interventional studies measuring skin changes after tap water bathing
were selected for the first analysis
bull Observational studies reporting the proportion of AD patients who favor
baths were selected for the second analysis
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
copy 2015 by the American Pharmacists Association All rights reserved
31
bull 7 of 271 studies met the selection criteria
bull Pooled effect size of skin changes after baths was minimal (-010)
bull 291 of patients favored baths
Authors conclude
bull No evidence of a positive effect of 1-month tap water bathing on
skin changes in AD
bull Discuss pros and cons with pts before deciding whether baths are
appropriate and if so frequency products to add to improve
response
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
32
Can probiotics offer benefit in the management of AD
bull Meta-analysis included randomized controlled trials (RCTs)
measuring the effects of probiotics or synbiotics in patients
diagnosed with AD
bull The primary outcome SCORAD values between the treatment
and placebo groups
bull 25 RCTs (n = 1599)
bull Significant improvement in SCORAD values in pts taking
probiotics (mean -451 95 CI -678 to -224)
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
33
Population subgroups
bull Pts 1 to 18 years old (-574 95CI -727 to -420)
bull Adults (-826 95CI -1328 to -325)
bull Infants (lt1 year old) no positive effect
Response to specific probiotic strains
bull Use of a mixture of different bacterial species or Lactobacillus
species showed greater benefit than did use of Bifidobacterium
species alone
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
copy 2015 by the American Pharmacists Association All rights reserved
34
Double-blind prospective randomized placebo-controlled study in
220 children with moderatesevere AD
Evaluated effects of 2 strains of Lactobacillus (and combined) on
disease severity QOL and certain measures of immune function
ndash Lactobacillus paracasei (LP)
ndash Lactobacillus fermentum (LF)
bull Groups
ndash LP
ndash LF
ndash LP+LF mixture
ndash placebo
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
35
bull All pts given 3 months of therapy
bull Response evaluated myriad ways standard evaluation via
SCORAD scores
bull LP LF and LP+LF mixture groups demonstrated benefit via lower
SCORAD scores compared with the placebo group (plt0001)
bull Benefit seen up to 4 months after discontinuing the probiotics
bull In subgroup analyses significant benefit in the following
ndash Younger than age 12
ndash Breast fed gt6 months
ndash Those with documented mite sensitization
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
36
bull Small prospective controlled trial assessed association of
Streptococcus thermophilus ST10 and tara gum complex and the
activity of Lactobacillus salivarius LS01 administered at high
doses to adults with AD
bull Why this complex Improves adherence to intestinal mucus
bull 25 patients randomized to placebo (n=12) or active formulation
(n=13)
bull SCORAD used to evaluate response
bull Also evaluated bacterial counts (for Staphylococcus aureus and
clostridia)
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
copy 2015 by the American Pharmacists Association All rights reserved
37
bull At 1 month study group showed significant improvement in
SCORAD index
bull A slight decrease in fecal S aureus count was observed in
probiotic-treated patients
bull Authors concluded the probiotic strain + tara gum complex =
quicker response and greater efficacy
bull What does this mean Need more data but probiotic
supplementation could offer benefit
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
38
bull Lactobacillus salivarius LS01 in children with AD
bull 43 pts (0 to 11 yrs)
bull Response evaluated by changes in itch index and SCORAD index
bull Those using probiotics showed significant benefit in both
measures
bull Effects sustained for 4 weeks after supplement stopped
Ref Niccoli AA et al Preliminary results on clinical effects of probiotic
Lactobacillus salivarius LS01 in children affected by atopic dermatitis J Clin
Gastroenterol 2014 Nov-Dec48 Suppl 1S34-6
Atopic Dermatitis Probiotics ndash Study 4
39
Atopic Dermatitis Pharmacologic Tx
Antipruritics 3 Options
1 Local anesthetics pramoxine lidocaine and benzocaine
2 Antihistamines
ndash Topical diphenhydramine may be effective as an antihistamine in
addition to having some mild anesthetic properties however may
cause sensitization so use is not recommended
ndash Systemic pruritus with AD likely not related to histamine so most
agents probably not effective also concern regarding adverse effects
(anticholinergic drowsiness) and time to response
3 Hydrocortisone
ndash Dose Apply to Affected Area (AAA) 1-2 timesday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
Accreditation Information
The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education (CPE) This activity Dermatologic Symptoms in Your Pharmacy The Management of Rosacea and Atopic Dermatitis is approved for 20 contact hours of CPE credit (020 CEUs)
The ACPE Universal Activity Number assigned to this activity by the accredited provider is 0202-0000-15-058-L01-P To obtain CPE credit for this activity participants will be required to actively participate in the entire activity and complete the online assessment and evaluation forms located at wwwpharmacistcomlive-activities by Monday July 6 2015 If you claimed credit for the live offering of this course on March 30 2015 at the APhA Annual Meeting in San Diego California you are NOT eligible to receive credit for this offering
Development and Support
This activity was developed by the American Pharmacists Association and is supported by educational grants from Johnson amp Johnson Consumer Companies and Bayer HealthCare Pharmaceuticals Inc
How to Obtain Your CPE Credit
Go to wwwpharmacistcomlive-activities and under the Live Activities list select the Claim Credit link for Dermatologic Symptoms in Your Pharmacy The Management of Rosacea and Atopic Dermatitis
You will need to enter your pharmacistcom Username and Password If you do not have an account you can create a guest account for free Then continue with the following instructions to obtain your CPE credit for this activity
Select Add to Cart or Enroll Now from the left navigation and successfully complete the Assessment (use Attendance Code DERM) and Evaluation You will need to provide your NABP e-profile ID number to claim credit
Please visit wwwpharmacistcomcpe-monitor for any questions regarding your NABP e-profile ID number (Note that it may take up to 3 hours for your NABP e-profile ID number to become activated)
The filing deadline for this CPE activity is Monday July 6 2015 at 500 PM Eastern Time No credit will be issued after this date
If you have any questions or require additional information to claim your credit please contact Anthony Gary Senior Manager Education Department at the American Pharmacists Association by e-mailing agaryaphanetorg or calling 202-429-7515
copy 2015 by the American Pharmacists Association All rights reserved
1
Dermatologic Symptoms in Your
Pharmacy The Management of
Rosacea and Atopic Dermatitis
Gail Newton PhD RPh
Associate Professor
Department of Pharmacy Practice
Purdue University School of Pharmacy and Pharmaceutical Sciences
Daniel Krinsky MS RPh
Associate Professor
NEOMED College of Pharmacy
Manager MTM Services Giant Eagle Pharmacy
2
Development and Support
This activity was developed by the American
Pharmacists Association and is supported by
educational grants from Bayer HealthCare
Pharmaceuticals Inc and
Johnson amp Johnson Consumer Companies Inc
3
Disclosuresbull Gail Newton PhD RPh and Daniel Krinsky MS RPh
ldquodeclare no conflicts of interest real or apparent and no
financial interests in any company product or service
mentioned in this activity including grants employment
gifts stock holdings and honorariardquo
The American Pharmacists Association is accredited by the Accreditation
Council for Pharmacy Education as a provider of continuing pharmacy
education
copy 2015 by the American Pharmacists Association All rights reserved
4
Attendance Code
DERM
To obtain CPE credit for this activity you are
required to actively participate in this session The
attendance code is needed to access the
assessment and evaluation for this activity
Your CPE must be filed by July 6 2015 in order to
receive credit
5
Accreditation Information
The American Pharmacists Association is accredited by theAccreditation Council for Pharmacy Education as a provider of continuing
pharmacy education This activity Dermatologic Symptoms in Your Pharmacy The Management of Rosacea and Atopic Dermatitis is approved for 20 hours of continuing pharmacy education credit (020 CEUs) The ACPE Universal Activity Number assigned by the accredited provider is 0202-0000-15-058-L01-P
To obtain continuing pharmacy education credit for this activity participants will be required to actively participate in the entire webinar and complete an assessment and evaluation located at wwwpharmacistcomlive-activities by July 6 2015
Initial Release Date June 3 2015
Target Audience Pharmacists
ACPE Activity Type Application-based
Learning Level 2
Fee There is no fee for this activity
6
Learning Objectives
At the completion of this application-based activity
participants will be able to
1 Describe the epidemiology and clinical presentation of
rosacea and atopic dermatitis (AD)
2 Recommend appropriate self-care treatment for patients
with rosacea or AD with regard to the efficacy and safety
of available therapeutic options
3 Discuss areas where pharmacists interventions can
improve the care of patients with rosacea and AD
copy 2015 by the American Pharmacists Association All rights reserved
7
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic dermatitis
B Provides patients with a list of therapeutic options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
8
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with atopic dermatitis (AD)
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
9
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your primary
care provider or dermatologist
C Newer data suggests the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks then
stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not apply on
any other part of your body
copy 2015 by the American Pharmacists Association All rights reserved
10
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at a
local diner
B 45-year-old ad executive of Mediterranean descent who
plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne as a
teenager
D 52-year-old professor with fair skin who blushes easily
11
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
12
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
copy 2015 by the American Pharmacists Association All rights reserved
13
Atopic Dermatitis (AD) IntroBackground
Incidence and prevalence
bull Inflammatory condition of the epidermis and dermis
bull Characterized by episodic flares and periods of remission
bull AD is estimated to affect from 10 to 20 of children - many of
these individuals have symptoms into adulthood
bull 60 patients diagnosed in first year of life
bull 30 lt5 years of age
bull Adult prevalence 1-3 overall lifetime prevalence 7
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
14
Atopic Dermatitis IntroBackground
bull Atopic triad asthma allergic rhinitis and atopic dermatitis
bull Asthma and allergic rhinitis can occur in up to 80 of patients with
AD
bull 80 of AD classified as mild and can be safely treated with
nonprescription products
bull 70 of cases atopic family history
ndash 1 parent atopic 50 chance child will have symptoms
ndash 2 parents 79 chance
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
15
Atopic Dermatitis Cause
bull A protein in the epidermal differentiation complex filaggrin (FLG)
is related to the development of AD
bull Any FLG mutation increases onersquos risk of AD (35 known
mutations) mutation leads to irritation in atopic skin caused by
ndash Increased penetration of allergens
ndash Decrease in skin barrier proteins
ndash Higher peptidase activity
ndash Lack of protease inhibitors
bull Also decreased moisture retention due to lower concentration of
lipid and ceramides
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
16
Atopic Dermatitis Assessment
bull The SCORAD (SCORing Atopic Dermatitis) index is used to
assess severity of AD rate the following 7 factors
ndash Erythema
ndash Edema
ndash Papulation (formation of papules)
ndash Excoriations (abrasion of the epidermis by trauma)
ndash Lichenification (increased epidermal markings)
ndash Oozingcrusting
ndash Dryness
bull Index also includes visual analogue scale
bull A SCORAD index lt25 = mild 25-50 moderate and gt50 = severe
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
17
Atopic Dermatitis Diagnosis
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
TABLE 32-1 Diagnostic Criteria for AD
A pruritic skin disorder plus three or more of the following criteria
bull Onset at younger than 2 years
bull History of skin crease involvement (including cheeks in children younger than 10
years)
bull History of generally dry skin
bull Personal history of other atopic disease that is asthma (or history of any atopic
disease in first-degree relative in children younger than 4 years)
bull Visible flexural dermatitis (or dermatitis of cheeksforehead and other outer limbs in
children younger than 4 years)
18
Atopic Dermatitis Clinical Presentation
bull Initial symptoms erythema and scaling of the infantrsquos cheeks
bull May progress to affect the face neck forehead and extremities
bull Major symptom carrying over to adulthood is xerosis (dry skin)
bull Adults with AD ndash cause usually environmental exposure to
chemicals or skin trauma
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
19
Atopic Dermatitis Clinical Presentation
3 clinical forms of AD
bull Acute AD pruritic erythematous papules or vesicles over
erythematous skin often associated with excoriation and serous
exudate
bull Subacute AD erythematous excoriated papules and scaly
plaques
bull Chronic AD thickened skin plaques and accentuated skin
markings usually involves symptoms seen in all 3 stages
All pts at risk of infection other conditions related to compromised
skin
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
20
Atopic Dermatitis Treatment
Treatment Goals
bull No cure symptom management
bull The goals of self-treatment of AD are to
1 Stop the itch-scratch cycle hydrocortisone
2 Maintain skin hydration emollients and moisturizers
3 Avoid or minimize factors that trigger or aggravate
the disorder
4 Prevent secondary infection
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
21
Atopic Dermatitis Nonpharmacologic
bull Bathing can hydrate the stratum corneum remove allergens and
irritants cleanse and debride crusts and enhance the effects of
moisturizers and topical steroids
ndash Recommended time 3-5 minutes and every other day
ndash Water should be tepid
ndash Add colloidal oatmeal
bull To maintain skin hydration and patency recommend
ndash Emollients
bull Both occlusive and moisturizing used to prevent or relieve the
signs and symptoms of dry skin
bull Apply at least twice daily for preventive and maintenance therapy
bull Creams or ointments better (than lotions) for enhancing softness
and hydration
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
22
bull Bath Oils
ndash Mineral or vegetable oil plus a surfactant help with skin lubrication
may decrease frequency of bathing
bull Cleansers
ndash Avoid traditional bath soaps ndash remove harmful and beneficial
substances
ndash Better option glycerin soaps ndash more soluble closer to neutral pH
less drying
bull Emulsifiers maintain water + lipids in one continuous phase
bull Humectants help draw water into the stratum corneum and to
retain water often added to emollient bases
bull Other key ingredients lubricants and moisturizers 3-4xday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
Atopic Dermatitis Nonpharmacologic
23
Atopic Dermatitis EBM Guideline
Most recent guideline from the American Academy of Dermatology
bull Moisturizers
ndash Xerosis is one of the cardinal clinical features of AD and results from
a dysfunctional epidermal barrier topical moisturizers are used to
combat xerosis and transepidermal water loss with traditional agents
containing varying amounts of emollient occlusive andor humectant
ingredients
bull Emollients (eg glycol and glyceryl stearate soy sterols)
ndash Lubricate and soften the skin occlusive agents (eg petrolatum
dimethicone mineral oil) form a layer to retard evaporation of water
whereas humectants (eg glycerol lactic acid urea) attract and hold
water
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
24
Atopic Dermatitis EBM Guideline
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
Nonpharmacologic options for treatment of AD
bull Strong evidence of the benefit of moisturizers ndash integral to
management ndash reduce severity + need for pharmacologic tx
ndash Apply soon after bathing to maximize hydration
bull Bathing suggested ndash no standard for frequency or duration
ndash Insufficient evidence any of the following offer value when added to
bath water Oils emollients other additives
bull Limited use of nonsoap cleansers (neutrallow pH hypoallergenic
fragrance-free) recommended
bull Use of wet-wrap therapy +- topical corticosteroid appropriate for
pts with moderatesevere AD ndash reduce symptom severity and
water loss during flares
copy 2015 by the American Pharmacists Association All rights reserved
25
bull Multicenter randomized double-blind controlled trial ndash compared
5 urea cream with a reference cream
bull Urea cream significantly better than reference cream in
preventing eczema relapse in patients with AD (HR 0634
pthinsp=thinsp0011)
bull Risk of eczema relapse was reduced by 37
bull At 6 months
ndash 26 of the patients in the test cream group were still eczema free vs
10 in the reference cream group
Ref Aringkerstroumlm U et al Comparison of moisturizing creams for the prevention of
atopic dermatitis relapse a randomized double-blind controlled multicentre clinical
trial Acta Derm Venereol 2015 Jan 16 doi 10234000015555-2051
Atopic Dermatitis Moisturizers
26
bull Colloidal oatmeal suspensions bath soaps shampoos shaving
gels and moisturizing creams
bull The diverse chemical polymorphism of oats translates into
numerous clinical utilities for AD and eczema
bull Avenanthramides
ndash Principal polyphenolic antioxidants in oats
ndash Anti-inflammatory and antipruritic properties in rodent models
ndash Also antioxidant properties
bull Positive effect in pts with AD
Ref Fowler JF Jr Colloidal oatmeal formulations and the treatment of atopic
dermatitis J Drugs Dermatol 2014 Oct 113(10)1180-3
Atopic Dermatitis Colloidal Oatmeal
27
bull METHODS
ndash Four extracts of colloidal oatmeal were made with various solvents
and tested in anti-inflammatory and antioxidant assays
ndash Assessment of benefit in 29 female patients with bilateral mild to
moderate itch with moderate to severe dry skin on their lower legs
used a colloidal oatmeal skin protectant lotion
bull RESULTS
ndash In vitro study Colloidal oatmeal extract activity reduced pro-
inflammatory cytokines
ndash 29 pts colloidal oat skin protectant lotion showed significant clinical
improvements in skin dryness scaling roughness and itch intensity
Ref Reynertson KA et al Anti-inflammatory activities of colloidal oatmeal
contribute to the effectiveness of oats in treatment of itch associated with dry
irritated skin J Drugs Dermatol 2015 Jan 114(1)43-8
Atopic Dermatitis Colloidal Oatmeal
copy 2015 by the American Pharmacists Association All rights reserved
28
Atopic Dermatitis Colloidal Oatmeal
bull Although emollients are recommended in the management of AD
regimens for emollient maintenance therapy are awaiting
validation
bull International multicenter open-label trial to assess the effects of a
3-month maintenance treatment regimen with a sterile
preservative-free emollient cream containing oat plantlets in
children (ages 6 mos-6 yrs) with moderate AD
bull After a 14-day run-in stabilization phase using a topical
corticosteroid (TCS) treatment of medium potency 108 children
with a SCORAD index of 20 or less were included in the study
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
29
Atopic Dermatitis Colloidal Oatmeal
bull Emollient was applied twice daily for 3 months rescue topical
corticosteroid (TCS) treatment used for flare-ups
bull The SCORAD index Patient-Oriented SCORAD (PO-SCORAD)
index number of flares TCS use and tolerance were assessed
monthly x 3 months
bull Results AD severity improved with a highly significant decrease
in the SCORAD and PO-SCORAD indexes 2nd and 3rd months
(p lt 0001)
bull of flares and TCS use significantly decreased by the 3rd month
(both p lt 0001)
bull Intervention = significant improvement of clinical symptoms with
no adverse events
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
30
Bathing is a therapeutic measure commonly advised in atopic dermatitis
(AD) Whether baths improve skin condition remains unclear Objectives of
this study
bull What is the effect of one month of tap water bathing on the bathed skin of
patients with AD
bull How many pts favor baths
bull Interventional studies measuring skin changes after tap water bathing
were selected for the first analysis
bull Observational studies reporting the proportion of AD patients who favor
baths were selected for the second analysis
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
copy 2015 by the American Pharmacists Association All rights reserved
31
bull 7 of 271 studies met the selection criteria
bull Pooled effect size of skin changes after baths was minimal (-010)
bull 291 of patients favored baths
Authors conclude
bull No evidence of a positive effect of 1-month tap water bathing on
skin changes in AD
bull Discuss pros and cons with pts before deciding whether baths are
appropriate and if so frequency products to add to improve
response
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
32
Can probiotics offer benefit in the management of AD
bull Meta-analysis included randomized controlled trials (RCTs)
measuring the effects of probiotics or synbiotics in patients
diagnosed with AD
bull The primary outcome SCORAD values between the treatment
and placebo groups
bull 25 RCTs (n = 1599)
bull Significant improvement in SCORAD values in pts taking
probiotics (mean -451 95 CI -678 to -224)
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
33
Population subgroups
bull Pts 1 to 18 years old (-574 95CI -727 to -420)
bull Adults (-826 95CI -1328 to -325)
bull Infants (lt1 year old) no positive effect
Response to specific probiotic strains
bull Use of a mixture of different bacterial species or Lactobacillus
species showed greater benefit than did use of Bifidobacterium
species alone
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
copy 2015 by the American Pharmacists Association All rights reserved
34
Double-blind prospective randomized placebo-controlled study in
220 children with moderatesevere AD
Evaluated effects of 2 strains of Lactobacillus (and combined) on
disease severity QOL and certain measures of immune function
ndash Lactobacillus paracasei (LP)
ndash Lactobacillus fermentum (LF)
bull Groups
ndash LP
ndash LF
ndash LP+LF mixture
ndash placebo
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
35
bull All pts given 3 months of therapy
bull Response evaluated myriad ways standard evaluation via
SCORAD scores
bull LP LF and LP+LF mixture groups demonstrated benefit via lower
SCORAD scores compared with the placebo group (plt0001)
bull Benefit seen up to 4 months after discontinuing the probiotics
bull In subgroup analyses significant benefit in the following
ndash Younger than age 12
ndash Breast fed gt6 months
ndash Those with documented mite sensitization
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
36
bull Small prospective controlled trial assessed association of
Streptococcus thermophilus ST10 and tara gum complex and the
activity of Lactobacillus salivarius LS01 administered at high
doses to adults with AD
bull Why this complex Improves adherence to intestinal mucus
bull 25 patients randomized to placebo (n=12) or active formulation
(n=13)
bull SCORAD used to evaluate response
bull Also evaluated bacterial counts (for Staphylococcus aureus and
clostridia)
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
copy 2015 by the American Pharmacists Association All rights reserved
37
bull At 1 month study group showed significant improvement in
SCORAD index
bull A slight decrease in fecal S aureus count was observed in
probiotic-treated patients
bull Authors concluded the probiotic strain + tara gum complex =
quicker response and greater efficacy
bull What does this mean Need more data but probiotic
supplementation could offer benefit
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
38
bull Lactobacillus salivarius LS01 in children with AD
bull 43 pts (0 to 11 yrs)
bull Response evaluated by changes in itch index and SCORAD index
bull Those using probiotics showed significant benefit in both
measures
bull Effects sustained for 4 weeks after supplement stopped
Ref Niccoli AA et al Preliminary results on clinical effects of probiotic
Lactobacillus salivarius LS01 in children affected by atopic dermatitis J Clin
Gastroenterol 2014 Nov-Dec48 Suppl 1S34-6
Atopic Dermatitis Probiotics ndash Study 4
39
Atopic Dermatitis Pharmacologic Tx
Antipruritics 3 Options
1 Local anesthetics pramoxine lidocaine and benzocaine
2 Antihistamines
ndash Topical diphenhydramine may be effective as an antihistamine in
addition to having some mild anesthetic properties however may
cause sensitization so use is not recommended
ndash Systemic pruritus with AD likely not related to histamine so most
agents probably not effective also concern regarding adverse effects
(anticholinergic drowsiness) and time to response
3 Hydrocortisone
ndash Dose Apply to Affected Area (AAA) 1-2 timesday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
1
Dermatologic Symptoms in Your
Pharmacy The Management of
Rosacea and Atopic Dermatitis
Gail Newton PhD RPh
Associate Professor
Department of Pharmacy Practice
Purdue University School of Pharmacy and Pharmaceutical Sciences
Daniel Krinsky MS RPh
Associate Professor
NEOMED College of Pharmacy
Manager MTM Services Giant Eagle Pharmacy
2
Development and Support
This activity was developed by the American
Pharmacists Association and is supported by
educational grants from Bayer HealthCare
Pharmaceuticals Inc and
Johnson amp Johnson Consumer Companies Inc
3
Disclosuresbull Gail Newton PhD RPh and Daniel Krinsky MS RPh
ldquodeclare no conflicts of interest real or apparent and no
financial interests in any company product or service
mentioned in this activity including grants employment
gifts stock holdings and honorariardquo
The American Pharmacists Association is accredited by the Accreditation
Council for Pharmacy Education as a provider of continuing pharmacy
education
copy 2015 by the American Pharmacists Association All rights reserved
4
Attendance Code
DERM
To obtain CPE credit for this activity you are
required to actively participate in this session The
attendance code is needed to access the
assessment and evaluation for this activity
Your CPE must be filed by July 6 2015 in order to
receive credit
5
Accreditation Information
The American Pharmacists Association is accredited by theAccreditation Council for Pharmacy Education as a provider of continuing
pharmacy education This activity Dermatologic Symptoms in Your Pharmacy The Management of Rosacea and Atopic Dermatitis is approved for 20 hours of continuing pharmacy education credit (020 CEUs) The ACPE Universal Activity Number assigned by the accredited provider is 0202-0000-15-058-L01-P
To obtain continuing pharmacy education credit for this activity participants will be required to actively participate in the entire webinar and complete an assessment and evaluation located at wwwpharmacistcomlive-activities by July 6 2015
Initial Release Date June 3 2015
Target Audience Pharmacists
ACPE Activity Type Application-based
Learning Level 2
Fee There is no fee for this activity
6
Learning Objectives
At the completion of this application-based activity
participants will be able to
1 Describe the epidemiology and clinical presentation of
rosacea and atopic dermatitis (AD)
2 Recommend appropriate self-care treatment for patients
with rosacea or AD with regard to the efficacy and safety
of available therapeutic options
3 Discuss areas where pharmacists interventions can
improve the care of patients with rosacea and AD
copy 2015 by the American Pharmacists Association All rights reserved
7
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic dermatitis
B Provides patients with a list of therapeutic options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
8
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with atopic dermatitis (AD)
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
9
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your primary
care provider or dermatologist
C Newer data suggests the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks then
stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not apply on
any other part of your body
copy 2015 by the American Pharmacists Association All rights reserved
10
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at a
local diner
B 45-year-old ad executive of Mediterranean descent who
plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne as a
teenager
D 52-year-old professor with fair skin who blushes easily
11
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
12
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
copy 2015 by the American Pharmacists Association All rights reserved
13
Atopic Dermatitis (AD) IntroBackground
Incidence and prevalence
bull Inflammatory condition of the epidermis and dermis
bull Characterized by episodic flares and periods of remission
bull AD is estimated to affect from 10 to 20 of children - many of
these individuals have symptoms into adulthood
bull 60 patients diagnosed in first year of life
bull 30 lt5 years of age
bull Adult prevalence 1-3 overall lifetime prevalence 7
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
14
Atopic Dermatitis IntroBackground
bull Atopic triad asthma allergic rhinitis and atopic dermatitis
bull Asthma and allergic rhinitis can occur in up to 80 of patients with
AD
bull 80 of AD classified as mild and can be safely treated with
nonprescription products
bull 70 of cases atopic family history
ndash 1 parent atopic 50 chance child will have symptoms
ndash 2 parents 79 chance
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
15
Atopic Dermatitis Cause
bull A protein in the epidermal differentiation complex filaggrin (FLG)
is related to the development of AD
bull Any FLG mutation increases onersquos risk of AD (35 known
mutations) mutation leads to irritation in atopic skin caused by
ndash Increased penetration of allergens
ndash Decrease in skin barrier proteins
ndash Higher peptidase activity
ndash Lack of protease inhibitors
bull Also decreased moisture retention due to lower concentration of
lipid and ceramides
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
16
Atopic Dermatitis Assessment
bull The SCORAD (SCORing Atopic Dermatitis) index is used to
assess severity of AD rate the following 7 factors
ndash Erythema
ndash Edema
ndash Papulation (formation of papules)
ndash Excoriations (abrasion of the epidermis by trauma)
ndash Lichenification (increased epidermal markings)
ndash Oozingcrusting
ndash Dryness
bull Index also includes visual analogue scale
bull A SCORAD index lt25 = mild 25-50 moderate and gt50 = severe
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
17
Atopic Dermatitis Diagnosis
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
TABLE 32-1 Diagnostic Criteria for AD
A pruritic skin disorder plus three or more of the following criteria
bull Onset at younger than 2 years
bull History of skin crease involvement (including cheeks in children younger than 10
years)
bull History of generally dry skin
bull Personal history of other atopic disease that is asthma (or history of any atopic
disease in first-degree relative in children younger than 4 years)
bull Visible flexural dermatitis (or dermatitis of cheeksforehead and other outer limbs in
children younger than 4 years)
18
Atopic Dermatitis Clinical Presentation
bull Initial symptoms erythema and scaling of the infantrsquos cheeks
bull May progress to affect the face neck forehead and extremities
bull Major symptom carrying over to adulthood is xerosis (dry skin)
bull Adults with AD ndash cause usually environmental exposure to
chemicals or skin trauma
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
19
Atopic Dermatitis Clinical Presentation
3 clinical forms of AD
bull Acute AD pruritic erythematous papules or vesicles over
erythematous skin often associated with excoriation and serous
exudate
bull Subacute AD erythematous excoriated papules and scaly
plaques
bull Chronic AD thickened skin plaques and accentuated skin
markings usually involves symptoms seen in all 3 stages
All pts at risk of infection other conditions related to compromised
skin
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
20
Atopic Dermatitis Treatment
Treatment Goals
bull No cure symptom management
bull The goals of self-treatment of AD are to
1 Stop the itch-scratch cycle hydrocortisone
2 Maintain skin hydration emollients and moisturizers
3 Avoid or minimize factors that trigger or aggravate
the disorder
4 Prevent secondary infection
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
21
Atopic Dermatitis Nonpharmacologic
bull Bathing can hydrate the stratum corneum remove allergens and
irritants cleanse and debride crusts and enhance the effects of
moisturizers and topical steroids
ndash Recommended time 3-5 minutes and every other day
ndash Water should be tepid
ndash Add colloidal oatmeal
bull To maintain skin hydration and patency recommend
ndash Emollients
bull Both occlusive and moisturizing used to prevent or relieve the
signs and symptoms of dry skin
bull Apply at least twice daily for preventive and maintenance therapy
bull Creams or ointments better (than lotions) for enhancing softness
and hydration
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
22
bull Bath Oils
ndash Mineral or vegetable oil plus a surfactant help with skin lubrication
may decrease frequency of bathing
bull Cleansers
ndash Avoid traditional bath soaps ndash remove harmful and beneficial
substances
ndash Better option glycerin soaps ndash more soluble closer to neutral pH
less drying
bull Emulsifiers maintain water + lipids in one continuous phase
bull Humectants help draw water into the stratum corneum and to
retain water often added to emollient bases
bull Other key ingredients lubricants and moisturizers 3-4xday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
Atopic Dermatitis Nonpharmacologic
23
Atopic Dermatitis EBM Guideline
Most recent guideline from the American Academy of Dermatology
bull Moisturizers
ndash Xerosis is one of the cardinal clinical features of AD and results from
a dysfunctional epidermal barrier topical moisturizers are used to
combat xerosis and transepidermal water loss with traditional agents
containing varying amounts of emollient occlusive andor humectant
ingredients
bull Emollients (eg glycol and glyceryl stearate soy sterols)
ndash Lubricate and soften the skin occlusive agents (eg petrolatum
dimethicone mineral oil) form a layer to retard evaporation of water
whereas humectants (eg glycerol lactic acid urea) attract and hold
water
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
24
Atopic Dermatitis EBM Guideline
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
Nonpharmacologic options for treatment of AD
bull Strong evidence of the benefit of moisturizers ndash integral to
management ndash reduce severity + need for pharmacologic tx
ndash Apply soon after bathing to maximize hydration
bull Bathing suggested ndash no standard for frequency or duration
ndash Insufficient evidence any of the following offer value when added to
bath water Oils emollients other additives
bull Limited use of nonsoap cleansers (neutrallow pH hypoallergenic
fragrance-free) recommended
bull Use of wet-wrap therapy +- topical corticosteroid appropriate for
pts with moderatesevere AD ndash reduce symptom severity and
water loss during flares
copy 2015 by the American Pharmacists Association All rights reserved
25
bull Multicenter randomized double-blind controlled trial ndash compared
5 urea cream with a reference cream
bull Urea cream significantly better than reference cream in
preventing eczema relapse in patients with AD (HR 0634
pthinsp=thinsp0011)
bull Risk of eczema relapse was reduced by 37
bull At 6 months
ndash 26 of the patients in the test cream group were still eczema free vs
10 in the reference cream group
Ref Aringkerstroumlm U et al Comparison of moisturizing creams for the prevention of
atopic dermatitis relapse a randomized double-blind controlled multicentre clinical
trial Acta Derm Venereol 2015 Jan 16 doi 10234000015555-2051
Atopic Dermatitis Moisturizers
26
bull Colloidal oatmeal suspensions bath soaps shampoos shaving
gels and moisturizing creams
bull The diverse chemical polymorphism of oats translates into
numerous clinical utilities for AD and eczema
bull Avenanthramides
ndash Principal polyphenolic antioxidants in oats
ndash Anti-inflammatory and antipruritic properties in rodent models
ndash Also antioxidant properties
bull Positive effect in pts with AD
Ref Fowler JF Jr Colloidal oatmeal formulations and the treatment of atopic
dermatitis J Drugs Dermatol 2014 Oct 113(10)1180-3
Atopic Dermatitis Colloidal Oatmeal
27
bull METHODS
ndash Four extracts of colloidal oatmeal were made with various solvents
and tested in anti-inflammatory and antioxidant assays
ndash Assessment of benefit in 29 female patients with bilateral mild to
moderate itch with moderate to severe dry skin on their lower legs
used a colloidal oatmeal skin protectant lotion
bull RESULTS
ndash In vitro study Colloidal oatmeal extract activity reduced pro-
inflammatory cytokines
ndash 29 pts colloidal oat skin protectant lotion showed significant clinical
improvements in skin dryness scaling roughness and itch intensity
Ref Reynertson KA et al Anti-inflammatory activities of colloidal oatmeal
contribute to the effectiveness of oats in treatment of itch associated with dry
irritated skin J Drugs Dermatol 2015 Jan 114(1)43-8
Atopic Dermatitis Colloidal Oatmeal
copy 2015 by the American Pharmacists Association All rights reserved
28
Atopic Dermatitis Colloidal Oatmeal
bull Although emollients are recommended in the management of AD
regimens for emollient maintenance therapy are awaiting
validation
bull International multicenter open-label trial to assess the effects of a
3-month maintenance treatment regimen with a sterile
preservative-free emollient cream containing oat plantlets in
children (ages 6 mos-6 yrs) with moderate AD
bull After a 14-day run-in stabilization phase using a topical
corticosteroid (TCS) treatment of medium potency 108 children
with a SCORAD index of 20 or less were included in the study
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
29
Atopic Dermatitis Colloidal Oatmeal
bull Emollient was applied twice daily for 3 months rescue topical
corticosteroid (TCS) treatment used for flare-ups
bull The SCORAD index Patient-Oriented SCORAD (PO-SCORAD)
index number of flares TCS use and tolerance were assessed
monthly x 3 months
bull Results AD severity improved with a highly significant decrease
in the SCORAD and PO-SCORAD indexes 2nd and 3rd months
(p lt 0001)
bull of flares and TCS use significantly decreased by the 3rd month
(both p lt 0001)
bull Intervention = significant improvement of clinical symptoms with
no adverse events
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
30
Bathing is a therapeutic measure commonly advised in atopic dermatitis
(AD) Whether baths improve skin condition remains unclear Objectives of
this study
bull What is the effect of one month of tap water bathing on the bathed skin of
patients with AD
bull How many pts favor baths
bull Interventional studies measuring skin changes after tap water bathing
were selected for the first analysis
bull Observational studies reporting the proportion of AD patients who favor
baths were selected for the second analysis
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
copy 2015 by the American Pharmacists Association All rights reserved
31
bull 7 of 271 studies met the selection criteria
bull Pooled effect size of skin changes after baths was minimal (-010)
bull 291 of patients favored baths
Authors conclude
bull No evidence of a positive effect of 1-month tap water bathing on
skin changes in AD
bull Discuss pros and cons with pts before deciding whether baths are
appropriate and if so frequency products to add to improve
response
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
32
Can probiotics offer benefit in the management of AD
bull Meta-analysis included randomized controlled trials (RCTs)
measuring the effects of probiotics or synbiotics in patients
diagnosed with AD
bull The primary outcome SCORAD values between the treatment
and placebo groups
bull 25 RCTs (n = 1599)
bull Significant improvement in SCORAD values in pts taking
probiotics (mean -451 95 CI -678 to -224)
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
33
Population subgroups
bull Pts 1 to 18 years old (-574 95CI -727 to -420)
bull Adults (-826 95CI -1328 to -325)
bull Infants (lt1 year old) no positive effect
Response to specific probiotic strains
bull Use of a mixture of different bacterial species or Lactobacillus
species showed greater benefit than did use of Bifidobacterium
species alone
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
copy 2015 by the American Pharmacists Association All rights reserved
34
Double-blind prospective randomized placebo-controlled study in
220 children with moderatesevere AD
Evaluated effects of 2 strains of Lactobacillus (and combined) on
disease severity QOL and certain measures of immune function
ndash Lactobacillus paracasei (LP)
ndash Lactobacillus fermentum (LF)
bull Groups
ndash LP
ndash LF
ndash LP+LF mixture
ndash placebo
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
35
bull All pts given 3 months of therapy
bull Response evaluated myriad ways standard evaluation via
SCORAD scores
bull LP LF and LP+LF mixture groups demonstrated benefit via lower
SCORAD scores compared with the placebo group (plt0001)
bull Benefit seen up to 4 months after discontinuing the probiotics
bull In subgroup analyses significant benefit in the following
ndash Younger than age 12
ndash Breast fed gt6 months
ndash Those with documented mite sensitization
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
36
bull Small prospective controlled trial assessed association of
Streptococcus thermophilus ST10 and tara gum complex and the
activity of Lactobacillus salivarius LS01 administered at high
doses to adults with AD
bull Why this complex Improves adherence to intestinal mucus
bull 25 patients randomized to placebo (n=12) or active formulation
(n=13)
bull SCORAD used to evaluate response
bull Also evaluated bacterial counts (for Staphylococcus aureus and
clostridia)
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
copy 2015 by the American Pharmacists Association All rights reserved
37
bull At 1 month study group showed significant improvement in
SCORAD index
bull A slight decrease in fecal S aureus count was observed in
probiotic-treated patients
bull Authors concluded the probiotic strain + tara gum complex =
quicker response and greater efficacy
bull What does this mean Need more data but probiotic
supplementation could offer benefit
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
38
bull Lactobacillus salivarius LS01 in children with AD
bull 43 pts (0 to 11 yrs)
bull Response evaluated by changes in itch index and SCORAD index
bull Those using probiotics showed significant benefit in both
measures
bull Effects sustained for 4 weeks after supplement stopped
Ref Niccoli AA et al Preliminary results on clinical effects of probiotic
Lactobacillus salivarius LS01 in children affected by atopic dermatitis J Clin
Gastroenterol 2014 Nov-Dec48 Suppl 1S34-6
Atopic Dermatitis Probiotics ndash Study 4
39
Atopic Dermatitis Pharmacologic Tx
Antipruritics 3 Options
1 Local anesthetics pramoxine lidocaine and benzocaine
2 Antihistamines
ndash Topical diphenhydramine may be effective as an antihistamine in
addition to having some mild anesthetic properties however may
cause sensitization so use is not recommended
ndash Systemic pruritus with AD likely not related to histamine so most
agents probably not effective also concern regarding adverse effects
(anticholinergic drowsiness) and time to response
3 Hydrocortisone
ndash Dose Apply to Affected Area (AAA) 1-2 timesday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
4
Attendance Code
DERM
To obtain CPE credit for this activity you are
required to actively participate in this session The
attendance code is needed to access the
assessment and evaluation for this activity
Your CPE must be filed by July 6 2015 in order to
receive credit
5
Accreditation Information
The American Pharmacists Association is accredited by theAccreditation Council for Pharmacy Education as a provider of continuing
pharmacy education This activity Dermatologic Symptoms in Your Pharmacy The Management of Rosacea and Atopic Dermatitis is approved for 20 hours of continuing pharmacy education credit (020 CEUs) The ACPE Universal Activity Number assigned by the accredited provider is 0202-0000-15-058-L01-P
To obtain continuing pharmacy education credit for this activity participants will be required to actively participate in the entire webinar and complete an assessment and evaluation located at wwwpharmacistcomlive-activities by July 6 2015
Initial Release Date June 3 2015
Target Audience Pharmacists
ACPE Activity Type Application-based
Learning Level 2
Fee There is no fee for this activity
6
Learning Objectives
At the completion of this application-based activity
participants will be able to
1 Describe the epidemiology and clinical presentation of
rosacea and atopic dermatitis (AD)
2 Recommend appropriate self-care treatment for patients
with rosacea or AD with regard to the efficacy and safety
of available therapeutic options
3 Discuss areas where pharmacists interventions can
improve the care of patients with rosacea and AD
copy 2015 by the American Pharmacists Association All rights reserved
7
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic dermatitis
B Provides patients with a list of therapeutic options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
8
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with atopic dermatitis (AD)
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
9
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your primary
care provider or dermatologist
C Newer data suggests the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks then
stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not apply on
any other part of your body
copy 2015 by the American Pharmacists Association All rights reserved
10
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at a
local diner
B 45-year-old ad executive of Mediterranean descent who
plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne as a
teenager
D 52-year-old professor with fair skin who blushes easily
11
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
12
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
copy 2015 by the American Pharmacists Association All rights reserved
13
Atopic Dermatitis (AD) IntroBackground
Incidence and prevalence
bull Inflammatory condition of the epidermis and dermis
bull Characterized by episodic flares and periods of remission
bull AD is estimated to affect from 10 to 20 of children - many of
these individuals have symptoms into adulthood
bull 60 patients diagnosed in first year of life
bull 30 lt5 years of age
bull Adult prevalence 1-3 overall lifetime prevalence 7
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
14
Atopic Dermatitis IntroBackground
bull Atopic triad asthma allergic rhinitis and atopic dermatitis
bull Asthma and allergic rhinitis can occur in up to 80 of patients with
AD
bull 80 of AD classified as mild and can be safely treated with
nonprescription products
bull 70 of cases atopic family history
ndash 1 parent atopic 50 chance child will have symptoms
ndash 2 parents 79 chance
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
15
Atopic Dermatitis Cause
bull A protein in the epidermal differentiation complex filaggrin (FLG)
is related to the development of AD
bull Any FLG mutation increases onersquos risk of AD (35 known
mutations) mutation leads to irritation in atopic skin caused by
ndash Increased penetration of allergens
ndash Decrease in skin barrier proteins
ndash Higher peptidase activity
ndash Lack of protease inhibitors
bull Also decreased moisture retention due to lower concentration of
lipid and ceramides
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
16
Atopic Dermatitis Assessment
bull The SCORAD (SCORing Atopic Dermatitis) index is used to
assess severity of AD rate the following 7 factors
ndash Erythema
ndash Edema
ndash Papulation (formation of papules)
ndash Excoriations (abrasion of the epidermis by trauma)
ndash Lichenification (increased epidermal markings)
ndash Oozingcrusting
ndash Dryness
bull Index also includes visual analogue scale
bull A SCORAD index lt25 = mild 25-50 moderate and gt50 = severe
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
17
Atopic Dermatitis Diagnosis
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
TABLE 32-1 Diagnostic Criteria for AD
A pruritic skin disorder plus three or more of the following criteria
bull Onset at younger than 2 years
bull History of skin crease involvement (including cheeks in children younger than 10
years)
bull History of generally dry skin
bull Personal history of other atopic disease that is asthma (or history of any atopic
disease in first-degree relative in children younger than 4 years)
bull Visible flexural dermatitis (or dermatitis of cheeksforehead and other outer limbs in
children younger than 4 years)
18
Atopic Dermatitis Clinical Presentation
bull Initial symptoms erythema and scaling of the infantrsquos cheeks
bull May progress to affect the face neck forehead and extremities
bull Major symptom carrying over to adulthood is xerosis (dry skin)
bull Adults with AD ndash cause usually environmental exposure to
chemicals or skin trauma
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
19
Atopic Dermatitis Clinical Presentation
3 clinical forms of AD
bull Acute AD pruritic erythematous papules or vesicles over
erythematous skin often associated with excoriation and serous
exudate
bull Subacute AD erythematous excoriated papules and scaly
plaques
bull Chronic AD thickened skin plaques and accentuated skin
markings usually involves symptoms seen in all 3 stages
All pts at risk of infection other conditions related to compromised
skin
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
20
Atopic Dermatitis Treatment
Treatment Goals
bull No cure symptom management
bull The goals of self-treatment of AD are to
1 Stop the itch-scratch cycle hydrocortisone
2 Maintain skin hydration emollients and moisturizers
3 Avoid or minimize factors that trigger or aggravate
the disorder
4 Prevent secondary infection
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
21
Atopic Dermatitis Nonpharmacologic
bull Bathing can hydrate the stratum corneum remove allergens and
irritants cleanse and debride crusts and enhance the effects of
moisturizers and topical steroids
ndash Recommended time 3-5 minutes and every other day
ndash Water should be tepid
ndash Add colloidal oatmeal
bull To maintain skin hydration and patency recommend
ndash Emollients
bull Both occlusive and moisturizing used to prevent or relieve the
signs and symptoms of dry skin
bull Apply at least twice daily for preventive and maintenance therapy
bull Creams or ointments better (than lotions) for enhancing softness
and hydration
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
22
bull Bath Oils
ndash Mineral or vegetable oil plus a surfactant help with skin lubrication
may decrease frequency of bathing
bull Cleansers
ndash Avoid traditional bath soaps ndash remove harmful and beneficial
substances
ndash Better option glycerin soaps ndash more soluble closer to neutral pH
less drying
bull Emulsifiers maintain water + lipids in one continuous phase
bull Humectants help draw water into the stratum corneum and to
retain water often added to emollient bases
bull Other key ingredients lubricants and moisturizers 3-4xday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
Atopic Dermatitis Nonpharmacologic
23
Atopic Dermatitis EBM Guideline
Most recent guideline from the American Academy of Dermatology
bull Moisturizers
ndash Xerosis is one of the cardinal clinical features of AD and results from
a dysfunctional epidermal barrier topical moisturizers are used to
combat xerosis and transepidermal water loss with traditional agents
containing varying amounts of emollient occlusive andor humectant
ingredients
bull Emollients (eg glycol and glyceryl stearate soy sterols)
ndash Lubricate and soften the skin occlusive agents (eg petrolatum
dimethicone mineral oil) form a layer to retard evaporation of water
whereas humectants (eg glycerol lactic acid urea) attract and hold
water
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
24
Atopic Dermatitis EBM Guideline
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
Nonpharmacologic options for treatment of AD
bull Strong evidence of the benefit of moisturizers ndash integral to
management ndash reduce severity + need for pharmacologic tx
ndash Apply soon after bathing to maximize hydration
bull Bathing suggested ndash no standard for frequency or duration
ndash Insufficient evidence any of the following offer value when added to
bath water Oils emollients other additives
bull Limited use of nonsoap cleansers (neutrallow pH hypoallergenic
fragrance-free) recommended
bull Use of wet-wrap therapy +- topical corticosteroid appropriate for
pts with moderatesevere AD ndash reduce symptom severity and
water loss during flares
copy 2015 by the American Pharmacists Association All rights reserved
25
bull Multicenter randomized double-blind controlled trial ndash compared
5 urea cream with a reference cream
bull Urea cream significantly better than reference cream in
preventing eczema relapse in patients with AD (HR 0634
pthinsp=thinsp0011)
bull Risk of eczema relapse was reduced by 37
bull At 6 months
ndash 26 of the patients in the test cream group were still eczema free vs
10 in the reference cream group
Ref Aringkerstroumlm U et al Comparison of moisturizing creams for the prevention of
atopic dermatitis relapse a randomized double-blind controlled multicentre clinical
trial Acta Derm Venereol 2015 Jan 16 doi 10234000015555-2051
Atopic Dermatitis Moisturizers
26
bull Colloidal oatmeal suspensions bath soaps shampoos shaving
gels and moisturizing creams
bull The diverse chemical polymorphism of oats translates into
numerous clinical utilities for AD and eczema
bull Avenanthramides
ndash Principal polyphenolic antioxidants in oats
ndash Anti-inflammatory and antipruritic properties in rodent models
ndash Also antioxidant properties
bull Positive effect in pts with AD
Ref Fowler JF Jr Colloidal oatmeal formulations and the treatment of atopic
dermatitis J Drugs Dermatol 2014 Oct 113(10)1180-3
Atopic Dermatitis Colloidal Oatmeal
27
bull METHODS
ndash Four extracts of colloidal oatmeal were made with various solvents
and tested in anti-inflammatory and antioxidant assays
ndash Assessment of benefit in 29 female patients with bilateral mild to
moderate itch with moderate to severe dry skin on their lower legs
used a colloidal oatmeal skin protectant lotion
bull RESULTS
ndash In vitro study Colloidal oatmeal extract activity reduced pro-
inflammatory cytokines
ndash 29 pts colloidal oat skin protectant lotion showed significant clinical
improvements in skin dryness scaling roughness and itch intensity
Ref Reynertson KA et al Anti-inflammatory activities of colloidal oatmeal
contribute to the effectiveness of oats in treatment of itch associated with dry
irritated skin J Drugs Dermatol 2015 Jan 114(1)43-8
Atopic Dermatitis Colloidal Oatmeal
copy 2015 by the American Pharmacists Association All rights reserved
28
Atopic Dermatitis Colloidal Oatmeal
bull Although emollients are recommended in the management of AD
regimens for emollient maintenance therapy are awaiting
validation
bull International multicenter open-label trial to assess the effects of a
3-month maintenance treatment regimen with a sterile
preservative-free emollient cream containing oat plantlets in
children (ages 6 mos-6 yrs) with moderate AD
bull After a 14-day run-in stabilization phase using a topical
corticosteroid (TCS) treatment of medium potency 108 children
with a SCORAD index of 20 or less were included in the study
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
29
Atopic Dermatitis Colloidal Oatmeal
bull Emollient was applied twice daily for 3 months rescue topical
corticosteroid (TCS) treatment used for flare-ups
bull The SCORAD index Patient-Oriented SCORAD (PO-SCORAD)
index number of flares TCS use and tolerance were assessed
monthly x 3 months
bull Results AD severity improved with a highly significant decrease
in the SCORAD and PO-SCORAD indexes 2nd and 3rd months
(p lt 0001)
bull of flares and TCS use significantly decreased by the 3rd month
(both p lt 0001)
bull Intervention = significant improvement of clinical symptoms with
no adverse events
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
30
Bathing is a therapeutic measure commonly advised in atopic dermatitis
(AD) Whether baths improve skin condition remains unclear Objectives of
this study
bull What is the effect of one month of tap water bathing on the bathed skin of
patients with AD
bull How many pts favor baths
bull Interventional studies measuring skin changes after tap water bathing
were selected for the first analysis
bull Observational studies reporting the proportion of AD patients who favor
baths were selected for the second analysis
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
copy 2015 by the American Pharmacists Association All rights reserved
31
bull 7 of 271 studies met the selection criteria
bull Pooled effect size of skin changes after baths was minimal (-010)
bull 291 of patients favored baths
Authors conclude
bull No evidence of a positive effect of 1-month tap water bathing on
skin changes in AD
bull Discuss pros and cons with pts before deciding whether baths are
appropriate and if so frequency products to add to improve
response
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
32
Can probiotics offer benefit in the management of AD
bull Meta-analysis included randomized controlled trials (RCTs)
measuring the effects of probiotics or synbiotics in patients
diagnosed with AD
bull The primary outcome SCORAD values between the treatment
and placebo groups
bull 25 RCTs (n = 1599)
bull Significant improvement in SCORAD values in pts taking
probiotics (mean -451 95 CI -678 to -224)
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
33
Population subgroups
bull Pts 1 to 18 years old (-574 95CI -727 to -420)
bull Adults (-826 95CI -1328 to -325)
bull Infants (lt1 year old) no positive effect
Response to specific probiotic strains
bull Use of a mixture of different bacterial species or Lactobacillus
species showed greater benefit than did use of Bifidobacterium
species alone
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
copy 2015 by the American Pharmacists Association All rights reserved
34
Double-blind prospective randomized placebo-controlled study in
220 children with moderatesevere AD
Evaluated effects of 2 strains of Lactobacillus (and combined) on
disease severity QOL and certain measures of immune function
ndash Lactobacillus paracasei (LP)
ndash Lactobacillus fermentum (LF)
bull Groups
ndash LP
ndash LF
ndash LP+LF mixture
ndash placebo
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
35
bull All pts given 3 months of therapy
bull Response evaluated myriad ways standard evaluation via
SCORAD scores
bull LP LF and LP+LF mixture groups demonstrated benefit via lower
SCORAD scores compared with the placebo group (plt0001)
bull Benefit seen up to 4 months after discontinuing the probiotics
bull In subgroup analyses significant benefit in the following
ndash Younger than age 12
ndash Breast fed gt6 months
ndash Those with documented mite sensitization
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
36
bull Small prospective controlled trial assessed association of
Streptococcus thermophilus ST10 and tara gum complex and the
activity of Lactobacillus salivarius LS01 administered at high
doses to adults with AD
bull Why this complex Improves adherence to intestinal mucus
bull 25 patients randomized to placebo (n=12) or active formulation
(n=13)
bull SCORAD used to evaluate response
bull Also evaluated bacterial counts (for Staphylococcus aureus and
clostridia)
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
copy 2015 by the American Pharmacists Association All rights reserved
37
bull At 1 month study group showed significant improvement in
SCORAD index
bull A slight decrease in fecal S aureus count was observed in
probiotic-treated patients
bull Authors concluded the probiotic strain + tara gum complex =
quicker response and greater efficacy
bull What does this mean Need more data but probiotic
supplementation could offer benefit
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
38
bull Lactobacillus salivarius LS01 in children with AD
bull 43 pts (0 to 11 yrs)
bull Response evaluated by changes in itch index and SCORAD index
bull Those using probiotics showed significant benefit in both
measures
bull Effects sustained for 4 weeks after supplement stopped
Ref Niccoli AA et al Preliminary results on clinical effects of probiotic
Lactobacillus salivarius LS01 in children affected by atopic dermatitis J Clin
Gastroenterol 2014 Nov-Dec48 Suppl 1S34-6
Atopic Dermatitis Probiotics ndash Study 4
39
Atopic Dermatitis Pharmacologic Tx
Antipruritics 3 Options
1 Local anesthetics pramoxine lidocaine and benzocaine
2 Antihistamines
ndash Topical diphenhydramine may be effective as an antihistamine in
addition to having some mild anesthetic properties however may
cause sensitization so use is not recommended
ndash Systemic pruritus with AD likely not related to histamine so most
agents probably not effective also concern regarding adverse effects
(anticholinergic drowsiness) and time to response
3 Hydrocortisone
ndash Dose Apply to Affected Area (AAA) 1-2 timesday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
7
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic dermatitis
B Provides patients with a list of therapeutic options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
8
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with atopic dermatitis (AD)
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
9
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your primary
care provider or dermatologist
C Newer data suggests the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks then
stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not apply on
any other part of your body
copy 2015 by the American Pharmacists Association All rights reserved
10
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at a
local diner
B 45-year-old ad executive of Mediterranean descent who
plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne as a
teenager
D 52-year-old professor with fair skin who blushes easily
11
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
12
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
copy 2015 by the American Pharmacists Association All rights reserved
13
Atopic Dermatitis (AD) IntroBackground
Incidence and prevalence
bull Inflammatory condition of the epidermis and dermis
bull Characterized by episodic flares and periods of remission
bull AD is estimated to affect from 10 to 20 of children - many of
these individuals have symptoms into adulthood
bull 60 patients diagnosed in first year of life
bull 30 lt5 years of age
bull Adult prevalence 1-3 overall lifetime prevalence 7
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
14
Atopic Dermatitis IntroBackground
bull Atopic triad asthma allergic rhinitis and atopic dermatitis
bull Asthma and allergic rhinitis can occur in up to 80 of patients with
AD
bull 80 of AD classified as mild and can be safely treated with
nonprescription products
bull 70 of cases atopic family history
ndash 1 parent atopic 50 chance child will have symptoms
ndash 2 parents 79 chance
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
15
Atopic Dermatitis Cause
bull A protein in the epidermal differentiation complex filaggrin (FLG)
is related to the development of AD
bull Any FLG mutation increases onersquos risk of AD (35 known
mutations) mutation leads to irritation in atopic skin caused by
ndash Increased penetration of allergens
ndash Decrease in skin barrier proteins
ndash Higher peptidase activity
ndash Lack of protease inhibitors
bull Also decreased moisture retention due to lower concentration of
lipid and ceramides
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
16
Atopic Dermatitis Assessment
bull The SCORAD (SCORing Atopic Dermatitis) index is used to
assess severity of AD rate the following 7 factors
ndash Erythema
ndash Edema
ndash Papulation (formation of papules)
ndash Excoriations (abrasion of the epidermis by trauma)
ndash Lichenification (increased epidermal markings)
ndash Oozingcrusting
ndash Dryness
bull Index also includes visual analogue scale
bull A SCORAD index lt25 = mild 25-50 moderate and gt50 = severe
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
17
Atopic Dermatitis Diagnosis
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
TABLE 32-1 Diagnostic Criteria for AD
A pruritic skin disorder plus three or more of the following criteria
bull Onset at younger than 2 years
bull History of skin crease involvement (including cheeks in children younger than 10
years)
bull History of generally dry skin
bull Personal history of other atopic disease that is asthma (or history of any atopic
disease in first-degree relative in children younger than 4 years)
bull Visible flexural dermatitis (or dermatitis of cheeksforehead and other outer limbs in
children younger than 4 years)
18
Atopic Dermatitis Clinical Presentation
bull Initial symptoms erythema and scaling of the infantrsquos cheeks
bull May progress to affect the face neck forehead and extremities
bull Major symptom carrying over to adulthood is xerosis (dry skin)
bull Adults with AD ndash cause usually environmental exposure to
chemicals or skin trauma
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
19
Atopic Dermatitis Clinical Presentation
3 clinical forms of AD
bull Acute AD pruritic erythematous papules or vesicles over
erythematous skin often associated with excoriation and serous
exudate
bull Subacute AD erythematous excoriated papules and scaly
plaques
bull Chronic AD thickened skin plaques and accentuated skin
markings usually involves symptoms seen in all 3 stages
All pts at risk of infection other conditions related to compromised
skin
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
20
Atopic Dermatitis Treatment
Treatment Goals
bull No cure symptom management
bull The goals of self-treatment of AD are to
1 Stop the itch-scratch cycle hydrocortisone
2 Maintain skin hydration emollients and moisturizers
3 Avoid or minimize factors that trigger or aggravate
the disorder
4 Prevent secondary infection
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
21
Atopic Dermatitis Nonpharmacologic
bull Bathing can hydrate the stratum corneum remove allergens and
irritants cleanse and debride crusts and enhance the effects of
moisturizers and topical steroids
ndash Recommended time 3-5 minutes and every other day
ndash Water should be tepid
ndash Add colloidal oatmeal
bull To maintain skin hydration and patency recommend
ndash Emollients
bull Both occlusive and moisturizing used to prevent or relieve the
signs and symptoms of dry skin
bull Apply at least twice daily for preventive and maintenance therapy
bull Creams or ointments better (than lotions) for enhancing softness
and hydration
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
22
bull Bath Oils
ndash Mineral or vegetable oil plus a surfactant help with skin lubrication
may decrease frequency of bathing
bull Cleansers
ndash Avoid traditional bath soaps ndash remove harmful and beneficial
substances
ndash Better option glycerin soaps ndash more soluble closer to neutral pH
less drying
bull Emulsifiers maintain water + lipids in one continuous phase
bull Humectants help draw water into the stratum corneum and to
retain water often added to emollient bases
bull Other key ingredients lubricants and moisturizers 3-4xday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
Atopic Dermatitis Nonpharmacologic
23
Atopic Dermatitis EBM Guideline
Most recent guideline from the American Academy of Dermatology
bull Moisturizers
ndash Xerosis is one of the cardinal clinical features of AD and results from
a dysfunctional epidermal barrier topical moisturizers are used to
combat xerosis and transepidermal water loss with traditional agents
containing varying amounts of emollient occlusive andor humectant
ingredients
bull Emollients (eg glycol and glyceryl stearate soy sterols)
ndash Lubricate and soften the skin occlusive agents (eg petrolatum
dimethicone mineral oil) form a layer to retard evaporation of water
whereas humectants (eg glycerol lactic acid urea) attract and hold
water
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
24
Atopic Dermatitis EBM Guideline
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
Nonpharmacologic options for treatment of AD
bull Strong evidence of the benefit of moisturizers ndash integral to
management ndash reduce severity + need for pharmacologic tx
ndash Apply soon after bathing to maximize hydration
bull Bathing suggested ndash no standard for frequency or duration
ndash Insufficient evidence any of the following offer value when added to
bath water Oils emollients other additives
bull Limited use of nonsoap cleansers (neutrallow pH hypoallergenic
fragrance-free) recommended
bull Use of wet-wrap therapy +- topical corticosteroid appropriate for
pts with moderatesevere AD ndash reduce symptom severity and
water loss during flares
copy 2015 by the American Pharmacists Association All rights reserved
25
bull Multicenter randomized double-blind controlled trial ndash compared
5 urea cream with a reference cream
bull Urea cream significantly better than reference cream in
preventing eczema relapse in patients with AD (HR 0634
pthinsp=thinsp0011)
bull Risk of eczema relapse was reduced by 37
bull At 6 months
ndash 26 of the patients in the test cream group were still eczema free vs
10 in the reference cream group
Ref Aringkerstroumlm U et al Comparison of moisturizing creams for the prevention of
atopic dermatitis relapse a randomized double-blind controlled multicentre clinical
trial Acta Derm Venereol 2015 Jan 16 doi 10234000015555-2051
Atopic Dermatitis Moisturizers
26
bull Colloidal oatmeal suspensions bath soaps shampoos shaving
gels and moisturizing creams
bull The diverse chemical polymorphism of oats translates into
numerous clinical utilities for AD and eczema
bull Avenanthramides
ndash Principal polyphenolic antioxidants in oats
ndash Anti-inflammatory and antipruritic properties in rodent models
ndash Also antioxidant properties
bull Positive effect in pts with AD
Ref Fowler JF Jr Colloidal oatmeal formulations and the treatment of atopic
dermatitis J Drugs Dermatol 2014 Oct 113(10)1180-3
Atopic Dermatitis Colloidal Oatmeal
27
bull METHODS
ndash Four extracts of colloidal oatmeal were made with various solvents
and tested in anti-inflammatory and antioxidant assays
ndash Assessment of benefit in 29 female patients with bilateral mild to
moderate itch with moderate to severe dry skin on their lower legs
used a colloidal oatmeal skin protectant lotion
bull RESULTS
ndash In vitro study Colloidal oatmeal extract activity reduced pro-
inflammatory cytokines
ndash 29 pts colloidal oat skin protectant lotion showed significant clinical
improvements in skin dryness scaling roughness and itch intensity
Ref Reynertson KA et al Anti-inflammatory activities of colloidal oatmeal
contribute to the effectiveness of oats in treatment of itch associated with dry
irritated skin J Drugs Dermatol 2015 Jan 114(1)43-8
Atopic Dermatitis Colloidal Oatmeal
copy 2015 by the American Pharmacists Association All rights reserved
28
Atopic Dermatitis Colloidal Oatmeal
bull Although emollients are recommended in the management of AD
regimens for emollient maintenance therapy are awaiting
validation
bull International multicenter open-label trial to assess the effects of a
3-month maintenance treatment regimen with a sterile
preservative-free emollient cream containing oat plantlets in
children (ages 6 mos-6 yrs) with moderate AD
bull After a 14-day run-in stabilization phase using a topical
corticosteroid (TCS) treatment of medium potency 108 children
with a SCORAD index of 20 or less were included in the study
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
29
Atopic Dermatitis Colloidal Oatmeal
bull Emollient was applied twice daily for 3 months rescue topical
corticosteroid (TCS) treatment used for flare-ups
bull The SCORAD index Patient-Oriented SCORAD (PO-SCORAD)
index number of flares TCS use and tolerance were assessed
monthly x 3 months
bull Results AD severity improved with a highly significant decrease
in the SCORAD and PO-SCORAD indexes 2nd and 3rd months
(p lt 0001)
bull of flares and TCS use significantly decreased by the 3rd month
(both p lt 0001)
bull Intervention = significant improvement of clinical symptoms with
no adverse events
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
30
Bathing is a therapeutic measure commonly advised in atopic dermatitis
(AD) Whether baths improve skin condition remains unclear Objectives of
this study
bull What is the effect of one month of tap water bathing on the bathed skin of
patients with AD
bull How many pts favor baths
bull Interventional studies measuring skin changes after tap water bathing
were selected for the first analysis
bull Observational studies reporting the proportion of AD patients who favor
baths were selected for the second analysis
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
copy 2015 by the American Pharmacists Association All rights reserved
31
bull 7 of 271 studies met the selection criteria
bull Pooled effect size of skin changes after baths was minimal (-010)
bull 291 of patients favored baths
Authors conclude
bull No evidence of a positive effect of 1-month tap water bathing on
skin changes in AD
bull Discuss pros and cons with pts before deciding whether baths are
appropriate and if so frequency products to add to improve
response
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
32
Can probiotics offer benefit in the management of AD
bull Meta-analysis included randomized controlled trials (RCTs)
measuring the effects of probiotics or synbiotics in patients
diagnosed with AD
bull The primary outcome SCORAD values between the treatment
and placebo groups
bull 25 RCTs (n = 1599)
bull Significant improvement in SCORAD values in pts taking
probiotics (mean -451 95 CI -678 to -224)
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
33
Population subgroups
bull Pts 1 to 18 years old (-574 95CI -727 to -420)
bull Adults (-826 95CI -1328 to -325)
bull Infants (lt1 year old) no positive effect
Response to specific probiotic strains
bull Use of a mixture of different bacterial species or Lactobacillus
species showed greater benefit than did use of Bifidobacterium
species alone
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
copy 2015 by the American Pharmacists Association All rights reserved
34
Double-blind prospective randomized placebo-controlled study in
220 children with moderatesevere AD
Evaluated effects of 2 strains of Lactobacillus (and combined) on
disease severity QOL and certain measures of immune function
ndash Lactobacillus paracasei (LP)
ndash Lactobacillus fermentum (LF)
bull Groups
ndash LP
ndash LF
ndash LP+LF mixture
ndash placebo
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
35
bull All pts given 3 months of therapy
bull Response evaluated myriad ways standard evaluation via
SCORAD scores
bull LP LF and LP+LF mixture groups demonstrated benefit via lower
SCORAD scores compared with the placebo group (plt0001)
bull Benefit seen up to 4 months after discontinuing the probiotics
bull In subgroup analyses significant benefit in the following
ndash Younger than age 12
ndash Breast fed gt6 months
ndash Those with documented mite sensitization
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
36
bull Small prospective controlled trial assessed association of
Streptococcus thermophilus ST10 and tara gum complex and the
activity of Lactobacillus salivarius LS01 administered at high
doses to adults with AD
bull Why this complex Improves adherence to intestinal mucus
bull 25 patients randomized to placebo (n=12) or active formulation
(n=13)
bull SCORAD used to evaluate response
bull Also evaluated bacterial counts (for Staphylococcus aureus and
clostridia)
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
copy 2015 by the American Pharmacists Association All rights reserved
37
bull At 1 month study group showed significant improvement in
SCORAD index
bull A slight decrease in fecal S aureus count was observed in
probiotic-treated patients
bull Authors concluded the probiotic strain + tara gum complex =
quicker response and greater efficacy
bull What does this mean Need more data but probiotic
supplementation could offer benefit
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
38
bull Lactobacillus salivarius LS01 in children with AD
bull 43 pts (0 to 11 yrs)
bull Response evaluated by changes in itch index and SCORAD index
bull Those using probiotics showed significant benefit in both
measures
bull Effects sustained for 4 weeks after supplement stopped
Ref Niccoli AA et al Preliminary results on clinical effects of probiotic
Lactobacillus salivarius LS01 in children affected by atopic dermatitis J Clin
Gastroenterol 2014 Nov-Dec48 Suppl 1S34-6
Atopic Dermatitis Probiotics ndash Study 4
39
Atopic Dermatitis Pharmacologic Tx
Antipruritics 3 Options
1 Local anesthetics pramoxine lidocaine and benzocaine
2 Antihistamines
ndash Topical diphenhydramine may be effective as an antihistamine in
addition to having some mild anesthetic properties however may
cause sensitization so use is not recommended
ndash Systemic pruritus with AD likely not related to histamine so most
agents probably not effective also concern regarding adverse effects
(anticholinergic drowsiness) and time to response
3 Hydrocortisone
ndash Dose Apply to Affected Area (AAA) 1-2 timesday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
10
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at a
local diner
B 45-year-old ad executive of Mediterranean descent who
plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne as a
teenager
D 52-year-old professor with fair skin who blushes easily
11
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
12
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
copy 2015 by the American Pharmacists Association All rights reserved
13
Atopic Dermatitis (AD) IntroBackground
Incidence and prevalence
bull Inflammatory condition of the epidermis and dermis
bull Characterized by episodic flares and periods of remission
bull AD is estimated to affect from 10 to 20 of children - many of
these individuals have symptoms into adulthood
bull 60 patients diagnosed in first year of life
bull 30 lt5 years of age
bull Adult prevalence 1-3 overall lifetime prevalence 7
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
14
Atopic Dermatitis IntroBackground
bull Atopic triad asthma allergic rhinitis and atopic dermatitis
bull Asthma and allergic rhinitis can occur in up to 80 of patients with
AD
bull 80 of AD classified as mild and can be safely treated with
nonprescription products
bull 70 of cases atopic family history
ndash 1 parent atopic 50 chance child will have symptoms
ndash 2 parents 79 chance
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
15
Atopic Dermatitis Cause
bull A protein in the epidermal differentiation complex filaggrin (FLG)
is related to the development of AD
bull Any FLG mutation increases onersquos risk of AD (35 known
mutations) mutation leads to irritation in atopic skin caused by
ndash Increased penetration of allergens
ndash Decrease in skin barrier proteins
ndash Higher peptidase activity
ndash Lack of protease inhibitors
bull Also decreased moisture retention due to lower concentration of
lipid and ceramides
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
16
Atopic Dermatitis Assessment
bull The SCORAD (SCORing Atopic Dermatitis) index is used to
assess severity of AD rate the following 7 factors
ndash Erythema
ndash Edema
ndash Papulation (formation of papules)
ndash Excoriations (abrasion of the epidermis by trauma)
ndash Lichenification (increased epidermal markings)
ndash Oozingcrusting
ndash Dryness
bull Index also includes visual analogue scale
bull A SCORAD index lt25 = mild 25-50 moderate and gt50 = severe
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
17
Atopic Dermatitis Diagnosis
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
TABLE 32-1 Diagnostic Criteria for AD
A pruritic skin disorder plus three or more of the following criteria
bull Onset at younger than 2 years
bull History of skin crease involvement (including cheeks in children younger than 10
years)
bull History of generally dry skin
bull Personal history of other atopic disease that is asthma (or history of any atopic
disease in first-degree relative in children younger than 4 years)
bull Visible flexural dermatitis (or dermatitis of cheeksforehead and other outer limbs in
children younger than 4 years)
18
Atopic Dermatitis Clinical Presentation
bull Initial symptoms erythema and scaling of the infantrsquos cheeks
bull May progress to affect the face neck forehead and extremities
bull Major symptom carrying over to adulthood is xerosis (dry skin)
bull Adults with AD ndash cause usually environmental exposure to
chemicals or skin trauma
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
19
Atopic Dermatitis Clinical Presentation
3 clinical forms of AD
bull Acute AD pruritic erythematous papules or vesicles over
erythematous skin often associated with excoriation and serous
exudate
bull Subacute AD erythematous excoriated papules and scaly
plaques
bull Chronic AD thickened skin plaques and accentuated skin
markings usually involves symptoms seen in all 3 stages
All pts at risk of infection other conditions related to compromised
skin
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
20
Atopic Dermatitis Treatment
Treatment Goals
bull No cure symptom management
bull The goals of self-treatment of AD are to
1 Stop the itch-scratch cycle hydrocortisone
2 Maintain skin hydration emollients and moisturizers
3 Avoid or minimize factors that trigger or aggravate
the disorder
4 Prevent secondary infection
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
21
Atopic Dermatitis Nonpharmacologic
bull Bathing can hydrate the stratum corneum remove allergens and
irritants cleanse and debride crusts and enhance the effects of
moisturizers and topical steroids
ndash Recommended time 3-5 minutes and every other day
ndash Water should be tepid
ndash Add colloidal oatmeal
bull To maintain skin hydration and patency recommend
ndash Emollients
bull Both occlusive and moisturizing used to prevent or relieve the
signs and symptoms of dry skin
bull Apply at least twice daily for preventive and maintenance therapy
bull Creams or ointments better (than lotions) for enhancing softness
and hydration
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
22
bull Bath Oils
ndash Mineral or vegetable oil plus a surfactant help with skin lubrication
may decrease frequency of bathing
bull Cleansers
ndash Avoid traditional bath soaps ndash remove harmful and beneficial
substances
ndash Better option glycerin soaps ndash more soluble closer to neutral pH
less drying
bull Emulsifiers maintain water + lipids in one continuous phase
bull Humectants help draw water into the stratum corneum and to
retain water often added to emollient bases
bull Other key ingredients lubricants and moisturizers 3-4xday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
Atopic Dermatitis Nonpharmacologic
23
Atopic Dermatitis EBM Guideline
Most recent guideline from the American Academy of Dermatology
bull Moisturizers
ndash Xerosis is one of the cardinal clinical features of AD and results from
a dysfunctional epidermal barrier topical moisturizers are used to
combat xerosis and transepidermal water loss with traditional agents
containing varying amounts of emollient occlusive andor humectant
ingredients
bull Emollients (eg glycol and glyceryl stearate soy sterols)
ndash Lubricate and soften the skin occlusive agents (eg petrolatum
dimethicone mineral oil) form a layer to retard evaporation of water
whereas humectants (eg glycerol lactic acid urea) attract and hold
water
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
24
Atopic Dermatitis EBM Guideline
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
Nonpharmacologic options for treatment of AD
bull Strong evidence of the benefit of moisturizers ndash integral to
management ndash reduce severity + need for pharmacologic tx
ndash Apply soon after bathing to maximize hydration
bull Bathing suggested ndash no standard for frequency or duration
ndash Insufficient evidence any of the following offer value when added to
bath water Oils emollients other additives
bull Limited use of nonsoap cleansers (neutrallow pH hypoallergenic
fragrance-free) recommended
bull Use of wet-wrap therapy +- topical corticosteroid appropriate for
pts with moderatesevere AD ndash reduce symptom severity and
water loss during flares
copy 2015 by the American Pharmacists Association All rights reserved
25
bull Multicenter randomized double-blind controlled trial ndash compared
5 urea cream with a reference cream
bull Urea cream significantly better than reference cream in
preventing eczema relapse in patients with AD (HR 0634
pthinsp=thinsp0011)
bull Risk of eczema relapse was reduced by 37
bull At 6 months
ndash 26 of the patients in the test cream group were still eczema free vs
10 in the reference cream group
Ref Aringkerstroumlm U et al Comparison of moisturizing creams for the prevention of
atopic dermatitis relapse a randomized double-blind controlled multicentre clinical
trial Acta Derm Venereol 2015 Jan 16 doi 10234000015555-2051
Atopic Dermatitis Moisturizers
26
bull Colloidal oatmeal suspensions bath soaps shampoos shaving
gels and moisturizing creams
bull The diverse chemical polymorphism of oats translates into
numerous clinical utilities for AD and eczema
bull Avenanthramides
ndash Principal polyphenolic antioxidants in oats
ndash Anti-inflammatory and antipruritic properties in rodent models
ndash Also antioxidant properties
bull Positive effect in pts with AD
Ref Fowler JF Jr Colloidal oatmeal formulations and the treatment of atopic
dermatitis J Drugs Dermatol 2014 Oct 113(10)1180-3
Atopic Dermatitis Colloidal Oatmeal
27
bull METHODS
ndash Four extracts of colloidal oatmeal were made with various solvents
and tested in anti-inflammatory and antioxidant assays
ndash Assessment of benefit in 29 female patients with bilateral mild to
moderate itch with moderate to severe dry skin on their lower legs
used a colloidal oatmeal skin protectant lotion
bull RESULTS
ndash In vitro study Colloidal oatmeal extract activity reduced pro-
inflammatory cytokines
ndash 29 pts colloidal oat skin protectant lotion showed significant clinical
improvements in skin dryness scaling roughness and itch intensity
Ref Reynertson KA et al Anti-inflammatory activities of colloidal oatmeal
contribute to the effectiveness of oats in treatment of itch associated with dry
irritated skin J Drugs Dermatol 2015 Jan 114(1)43-8
Atopic Dermatitis Colloidal Oatmeal
copy 2015 by the American Pharmacists Association All rights reserved
28
Atopic Dermatitis Colloidal Oatmeal
bull Although emollients are recommended in the management of AD
regimens for emollient maintenance therapy are awaiting
validation
bull International multicenter open-label trial to assess the effects of a
3-month maintenance treatment regimen with a sterile
preservative-free emollient cream containing oat plantlets in
children (ages 6 mos-6 yrs) with moderate AD
bull After a 14-day run-in stabilization phase using a topical
corticosteroid (TCS) treatment of medium potency 108 children
with a SCORAD index of 20 or less were included in the study
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
29
Atopic Dermatitis Colloidal Oatmeal
bull Emollient was applied twice daily for 3 months rescue topical
corticosteroid (TCS) treatment used for flare-ups
bull The SCORAD index Patient-Oriented SCORAD (PO-SCORAD)
index number of flares TCS use and tolerance were assessed
monthly x 3 months
bull Results AD severity improved with a highly significant decrease
in the SCORAD and PO-SCORAD indexes 2nd and 3rd months
(p lt 0001)
bull of flares and TCS use significantly decreased by the 3rd month
(both p lt 0001)
bull Intervention = significant improvement of clinical symptoms with
no adverse events
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
30
Bathing is a therapeutic measure commonly advised in atopic dermatitis
(AD) Whether baths improve skin condition remains unclear Objectives of
this study
bull What is the effect of one month of tap water bathing on the bathed skin of
patients with AD
bull How many pts favor baths
bull Interventional studies measuring skin changes after tap water bathing
were selected for the first analysis
bull Observational studies reporting the proportion of AD patients who favor
baths were selected for the second analysis
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
copy 2015 by the American Pharmacists Association All rights reserved
31
bull 7 of 271 studies met the selection criteria
bull Pooled effect size of skin changes after baths was minimal (-010)
bull 291 of patients favored baths
Authors conclude
bull No evidence of a positive effect of 1-month tap water bathing on
skin changes in AD
bull Discuss pros and cons with pts before deciding whether baths are
appropriate and if so frequency products to add to improve
response
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
32
Can probiotics offer benefit in the management of AD
bull Meta-analysis included randomized controlled trials (RCTs)
measuring the effects of probiotics or synbiotics in patients
diagnosed with AD
bull The primary outcome SCORAD values between the treatment
and placebo groups
bull 25 RCTs (n = 1599)
bull Significant improvement in SCORAD values in pts taking
probiotics (mean -451 95 CI -678 to -224)
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
33
Population subgroups
bull Pts 1 to 18 years old (-574 95CI -727 to -420)
bull Adults (-826 95CI -1328 to -325)
bull Infants (lt1 year old) no positive effect
Response to specific probiotic strains
bull Use of a mixture of different bacterial species or Lactobacillus
species showed greater benefit than did use of Bifidobacterium
species alone
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
copy 2015 by the American Pharmacists Association All rights reserved
34
Double-blind prospective randomized placebo-controlled study in
220 children with moderatesevere AD
Evaluated effects of 2 strains of Lactobacillus (and combined) on
disease severity QOL and certain measures of immune function
ndash Lactobacillus paracasei (LP)
ndash Lactobacillus fermentum (LF)
bull Groups
ndash LP
ndash LF
ndash LP+LF mixture
ndash placebo
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
35
bull All pts given 3 months of therapy
bull Response evaluated myriad ways standard evaluation via
SCORAD scores
bull LP LF and LP+LF mixture groups demonstrated benefit via lower
SCORAD scores compared with the placebo group (plt0001)
bull Benefit seen up to 4 months after discontinuing the probiotics
bull In subgroup analyses significant benefit in the following
ndash Younger than age 12
ndash Breast fed gt6 months
ndash Those with documented mite sensitization
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
36
bull Small prospective controlled trial assessed association of
Streptococcus thermophilus ST10 and tara gum complex and the
activity of Lactobacillus salivarius LS01 administered at high
doses to adults with AD
bull Why this complex Improves adherence to intestinal mucus
bull 25 patients randomized to placebo (n=12) or active formulation
(n=13)
bull SCORAD used to evaluate response
bull Also evaluated bacterial counts (for Staphylococcus aureus and
clostridia)
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
copy 2015 by the American Pharmacists Association All rights reserved
37
bull At 1 month study group showed significant improvement in
SCORAD index
bull A slight decrease in fecal S aureus count was observed in
probiotic-treated patients
bull Authors concluded the probiotic strain + tara gum complex =
quicker response and greater efficacy
bull What does this mean Need more data but probiotic
supplementation could offer benefit
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
38
bull Lactobacillus salivarius LS01 in children with AD
bull 43 pts (0 to 11 yrs)
bull Response evaluated by changes in itch index and SCORAD index
bull Those using probiotics showed significant benefit in both
measures
bull Effects sustained for 4 weeks after supplement stopped
Ref Niccoli AA et al Preliminary results on clinical effects of probiotic
Lactobacillus salivarius LS01 in children affected by atopic dermatitis J Clin
Gastroenterol 2014 Nov-Dec48 Suppl 1S34-6
Atopic Dermatitis Probiotics ndash Study 4
39
Atopic Dermatitis Pharmacologic Tx
Antipruritics 3 Options
1 Local anesthetics pramoxine lidocaine and benzocaine
2 Antihistamines
ndash Topical diphenhydramine may be effective as an antihistamine in
addition to having some mild anesthetic properties however may
cause sensitization so use is not recommended
ndash Systemic pruritus with AD likely not related to histamine so most
agents probably not effective also concern regarding adverse effects
(anticholinergic drowsiness) and time to response
3 Hydrocortisone
ndash Dose Apply to Affected Area (AAA) 1-2 timesday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
13
Atopic Dermatitis (AD) IntroBackground
Incidence and prevalence
bull Inflammatory condition of the epidermis and dermis
bull Characterized by episodic flares and periods of remission
bull AD is estimated to affect from 10 to 20 of children - many of
these individuals have symptoms into adulthood
bull 60 patients diagnosed in first year of life
bull 30 lt5 years of age
bull Adult prevalence 1-3 overall lifetime prevalence 7
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
14
Atopic Dermatitis IntroBackground
bull Atopic triad asthma allergic rhinitis and atopic dermatitis
bull Asthma and allergic rhinitis can occur in up to 80 of patients with
AD
bull 80 of AD classified as mild and can be safely treated with
nonprescription products
bull 70 of cases atopic family history
ndash 1 parent atopic 50 chance child will have symptoms
ndash 2 parents 79 chance
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
15
Atopic Dermatitis Cause
bull A protein in the epidermal differentiation complex filaggrin (FLG)
is related to the development of AD
bull Any FLG mutation increases onersquos risk of AD (35 known
mutations) mutation leads to irritation in atopic skin caused by
ndash Increased penetration of allergens
ndash Decrease in skin barrier proteins
ndash Higher peptidase activity
ndash Lack of protease inhibitors
bull Also decreased moisture retention due to lower concentration of
lipid and ceramides
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
16
Atopic Dermatitis Assessment
bull The SCORAD (SCORing Atopic Dermatitis) index is used to
assess severity of AD rate the following 7 factors
ndash Erythema
ndash Edema
ndash Papulation (formation of papules)
ndash Excoriations (abrasion of the epidermis by trauma)
ndash Lichenification (increased epidermal markings)
ndash Oozingcrusting
ndash Dryness
bull Index also includes visual analogue scale
bull A SCORAD index lt25 = mild 25-50 moderate and gt50 = severe
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
17
Atopic Dermatitis Diagnosis
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
TABLE 32-1 Diagnostic Criteria for AD
A pruritic skin disorder plus three or more of the following criteria
bull Onset at younger than 2 years
bull History of skin crease involvement (including cheeks in children younger than 10
years)
bull History of generally dry skin
bull Personal history of other atopic disease that is asthma (or history of any atopic
disease in first-degree relative in children younger than 4 years)
bull Visible flexural dermatitis (or dermatitis of cheeksforehead and other outer limbs in
children younger than 4 years)
18
Atopic Dermatitis Clinical Presentation
bull Initial symptoms erythema and scaling of the infantrsquos cheeks
bull May progress to affect the face neck forehead and extremities
bull Major symptom carrying over to adulthood is xerosis (dry skin)
bull Adults with AD ndash cause usually environmental exposure to
chemicals or skin trauma
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
19
Atopic Dermatitis Clinical Presentation
3 clinical forms of AD
bull Acute AD pruritic erythematous papules or vesicles over
erythematous skin often associated with excoriation and serous
exudate
bull Subacute AD erythematous excoriated papules and scaly
plaques
bull Chronic AD thickened skin plaques and accentuated skin
markings usually involves symptoms seen in all 3 stages
All pts at risk of infection other conditions related to compromised
skin
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
20
Atopic Dermatitis Treatment
Treatment Goals
bull No cure symptom management
bull The goals of self-treatment of AD are to
1 Stop the itch-scratch cycle hydrocortisone
2 Maintain skin hydration emollients and moisturizers
3 Avoid or minimize factors that trigger or aggravate
the disorder
4 Prevent secondary infection
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
21
Atopic Dermatitis Nonpharmacologic
bull Bathing can hydrate the stratum corneum remove allergens and
irritants cleanse and debride crusts and enhance the effects of
moisturizers and topical steroids
ndash Recommended time 3-5 minutes and every other day
ndash Water should be tepid
ndash Add colloidal oatmeal
bull To maintain skin hydration and patency recommend
ndash Emollients
bull Both occlusive and moisturizing used to prevent or relieve the
signs and symptoms of dry skin
bull Apply at least twice daily for preventive and maintenance therapy
bull Creams or ointments better (than lotions) for enhancing softness
and hydration
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
22
bull Bath Oils
ndash Mineral or vegetable oil plus a surfactant help with skin lubrication
may decrease frequency of bathing
bull Cleansers
ndash Avoid traditional bath soaps ndash remove harmful and beneficial
substances
ndash Better option glycerin soaps ndash more soluble closer to neutral pH
less drying
bull Emulsifiers maintain water + lipids in one continuous phase
bull Humectants help draw water into the stratum corneum and to
retain water often added to emollient bases
bull Other key ingredients lubricants and moisturizers 3-4xday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
Atopic Dermatitis Nonpharmacologic
23
Atopic Dermatitis EBM Guideline
Most recent guideline from the American Academy of Dermatology
bull Moisturizers
ndash Xerosis is one of the cardinal clinical features of AD and results from
a dysfunctional epidermal barrier topical moisturizers are used to
combat xerosis and transepidermal water loss with traditional agents
containing varying amounts of emollient occlusive andor humectant
ingredients
bull Emollients (eg glycol and glyceryl stearate soy sterols)
ndash Lubricate and soften the skin occlusive agents (eg petrolatum
dimethicone mineral oil) form a layer to retard evaporation of water
whereas humectants (eg glycerol lactic acid urea) attract and hold
water
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
24
Atopic Dermatitis EBM Guideline
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
Nonpharmacologic options for treatment of AD
bull Strong evidence of the benefit of moisturizers ndash integral to
management ndash reduce severity + need for pharmacologic tx
ndash Apply soon after bathing to maximize hydration
bull Bathing suggested ndash no standard for frequency or duration
ndash Insufficient evidence any of the following offer value when added to
bath water Oils emollients other additives
bull Limited use of nonsoap cleansers (neutrallow pH hypoallergenic
fragrance-free) recommended
bull Use of wet-wrap therapy +- topical corticosteroid appropriate for
pts with moderatesevere AD ndash reduce symptom severity and
water loss during flares
copy 2015 by the American Pharmacists Association All rights reserved
25
bull Multicenter randomized double-blind controlled trial ndash compared
5 urea cream with a reference cream
bull Urea cream significantly better than reference cream in
preventing eczema relapse in patients with AD (HR 0634
pthinsp=thinsp0011)
bull Risk of eczema relapse was reduced by 37
bull At 6 months
ndash 26 of the patients in the test cream group were still eczema free vs
10 in the reference cream group
Ref Aringkerstroumlm U et al Comparison of moisturizing creams for the prevention of
atopic dermatitis relapse a randomized double-blind controlled multicentre clinical
trial Acta Derm Venereol 2015 Jan 16 doi 10234000015555-2051
Atopic Dermatitis Moisturizers
26
bull Colloidal oatmeal suspensions bath soaps shampoos shaving
gels and moisturizing creams
bull The diverse chemical polymorphism of oats translates into
numerous clinical utilities for AD and eczema
bull Avenanthramides
ndash Principal polyphenolic antioxidants in oats
ndash Anti-inflammatory and antipruritic properties in rodent models
ndash Also antioxidant properties
bull Positive effect in pts with AD
Ref Fowler JF Jr Colloidal oatmeal formulations and the treatment of atopic
dermatitis J Drugs Dermatol 2014 Oct 113(10)1180-3
Atopic Dermatitis Colloidal Oatmeal
27
bull METHODS
ndash Four extracts of colloidal oatmeal were made with various solvents
and tested in anti-inflammatory and antioxidant assays
ndash Assessment of benefit in 29 female patients with bilateral mild to
moderate itch with moderate to severe dry skin on their lower legs
used a colloidal oatmeal skin protectant lotion
bull RESULTS
ndash In vitro study Colloidal oatmeal extract activity reduced pro-
inflammatory cytokines
ndash 29 pts colloidal oat skin protectant lotion showed significant clinical
improvements in skin dryness scaling roughness and itch intensity
Ref Reynertson KA et al Anti-inflammatory activities of colloidal oatmeal
contribute to the effectiveness of oats in treatment of itch associated with dry
irritated skin J Drugs Dermatol 2015 Jan 114(1)43-8
Atopic Dermatitis Colloidal Oatmeal
copy 2015 by the American Pharmacists Association All rights reserved
28
Atopic Dermatitis Colloidal Oatmeal
bull Although emollients are recommended in the management of AD
regimens for emollient maintenance therapy are awaiting
validation
bull International multicenter open-label trial to assess the effects of a
3-month maintenance treatment regimen with a sterile
preservative-free emollient cream containing oat plantlets in
children (ages 6 mos-6 yrs) with moderate AD
bull After a 14-day run-in stabilization phase using a topical
corticosteroid (TCS) treatment of medium potency 108 children
with a SCORAD index of 20 or less were included in the study
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
29
Atopic Dermatitis Colloidal Oatmeal
bull Emollient was applied twice daily for 3 months rescue topical
corticosteroid (TCS) treatment used for flare-ups
bull The SCORAD index Patient-Oriented SCORAD (PO-SCORAD)
index number of flares TCS use and tolerance were assessed
monthly x 3 months
bull Results AD severity improved with a highly significant decrease
in the SCORAD and PO-SCORAD indexes 2nd and 3rd months
(p lt 0001)
bull of flares and TCS use significantly decreased by the 3rd month
(both p lt 0001)
bull Intervention = significant improvement of clinical symptoms with
no adverse events
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
30
Bathing is a therapeutic measure commonly advised in atopic dermatitis
(AD) Whether baths improve skin condition remains unclear Objectives of
this study
bull What is the effect of one month of tap water bathing on the bathed skin of
patients with AD
bull How many pts favor baths
bull Interventional studies measuring skin changes after tap water bathing
were selected for the first analysis
bull Observational studies reporting the proportion of AD patients who favor
baths were selected for the second analysis
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
copy 2015 by the American Pharmacists Association All rights reserved
31
bull 7 of 271 studies met the selection criteria
bull Pooled effect size of skin changes after baths was minimal (-010)
bull 291 of patients favored baths
Authors conclude
bull No evidence of a positive effect of 1-month tap water bathing on
skin changes in AD
bull Discuss pros and cons with pts before deciding whether baths are
appropriate and if so frequency products to add to improve
response
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
32
Can probiotics offer benefit in the management of AD
bull Meta-analysis included randomized controlled trials (RCTs)
measuring the effects of probiotics or synbiotics in patients
diagnosed with AD
bull The primary outcome SCORAD values between the treatment
and placebo groups
bull 25 RCTs (n = 1599)
bull Significant improvement in SCORAD values in pts taking
probiotics (mean -451 95 CI -678 to -224)
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
33
Population subgroups
bull Pts 1 to 18 years old (-574 95CI -727 to -420)
bull Adults (-826 95CI -1328 to -325)
bull Infants (lt1 year old) no positive effect
Response to specific probiotic strains
bull Use of a mixture of different bacterial species or Lactobacillus
species showed greater benefit than did use of Bifidobacterium
species alone
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
copy 2015 by the American Pharmacists Association All rights reserved
34
Double-blind prospective randomized placebo-controlled study in
220 children with moderatesevere AD
Evaluated effects of 2 strains of Lactobacillus (and combined) on
disease severity QOL and certain measures of immune function
ndash Lactobacillus paracasei (LP)
ndash Lactobacillus fermentum (LF)
bull Groups
ndash LP
ndash LF
ndash LP+LF mixture
ndash placebo
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
35
bull All pts given 3 months of therapy
bull Response evaluated myriad ways standard evaluation via
SCORAD scores
bull LP LF and LP+LF mixture groups demonstrated benefit via lower
SCORAD scores compared with the placebo group (plt0001)
bull Benefit seen up to 4 months after discontinuing the probiotics
bull In subgroup analyses significant benefit in the following
ndash Younger than age 12
ndash Breast fed gt6 months
ndash Those with documented mite sensitization
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
36
bull Small prospective controlled trial assessed association of
Streptococcus thermophilus ST10 and tara gum complex and the
activity of Lactobacillus salivarius LS01 administered at high
doses to adults with AD
bull Why this complex Improves adherence to intestinal mucus
bull 25 patients randomized to placebo (n=12) or active formulation
(n=13)
bull SCORAD used to evaluate response
bull Also evaluated bacterial counts (for Staphylococcus aureus and
clostridia)
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
copy 2015 by the American Pharmacists Association All rights reserved
37
bull At 1 month study group showed significant improvement in
SCORAD index
bull A slight decrease in fecal S aureus count was observed in
probiotic-treated patients
bull Authors concluded the probiotic strain + tara gum complex =
quicker response and greater efficacy
bull What does this mean Need more data but probiotic
supplementation could offer benefit
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
38
bull Lactobacillus salivarius LS01 in children with AD
bull 43 pts (0 to 11 yrs)
bull Response evaluated by changes in itch index and SCORAD index
bull Those using probiotics showed significant benefit in both
measures
bull Effects sustained for 4 weeks after supplement stopped
Ref Niccoli AA et al Preliminary results on clinical effects of probiotic
Lactobacillus salivarius LS01 in children affected by atopic dermatitis J Clin
Gastroenterol 2014 Nov-Dec48 Suppl 1S34-6
Atopic Dermatitis Probiotics ndash Study 4
39
Atopic Dermatitis Pharmacologic Tx
Antipruritics 3 Options
1 Local anesthetics pramoxine lidocaine and benzocaine
2 Antihistamines
ndash Topical diphenhydramine may be effective as an antihistamine in
addition to having some mild anesthetic properties however may
cause sensitization so use is not recommended
ndash Systemic pruritus with AD likely not related to histamine so most
agents probably not effective also concern regarding adverse effects
(anticholinergic drowsiness) and time to response
3 Hydrocortisone
ndash Dose Apply to Affected Area (AAA) 1-2 timesday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
16
Atopic Dermatitis Assessment
bull The SCORAD (SCORing Atopic Dermatitis) index is used to
assess severity of AD rate the following 7 factors
ndash Erythema
ndash Edema
ndash Papulation (formation of papules)
ndash Excoriations (abrasion of the epidermis by trauma)
ndash Lichenification (increased epidermal markings)
ndash Oozingcrusting
ndash Dryness
bull Index also includes visual analogue scale
bull A SCORAD index lt25 = mild 25-50 moderate and gt50 = severe
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
17
Atopic Dermatitis Diagnosis
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
TABLE 32-1 Diagnostic Criteria for AD
A pruritic skin disorder plus three or more of the following criteria
bull Onset at younger than 2 years
bull History of skin crease involvement (including cheeks in children younger than 10
years)
bull History of generally dry skin
bull Personal history of other atopic disease that is asthma (or history of any atopic
disease in first-degree relative in children younger than 4 years)
bull Visible flexural dermatitis (or dermatitis of cheeksforehead and other outer limbs in
children younger than 4 years)
18
Atopic Dermatitis Clinical Presentation
bull Initial symptoms erythema and scaling of the infantrsquos cheeks
bull May progress to affect the face neck forehead and extremities
bull Major symptom carrying over to adulthood is xerosis (dry skin)
bull Adults with AD ndash cause usually environmental exposure to
chemicals or skin trauma
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
19
Atopic Dermatitis Clinical Presentation
3 clinical forms of AD
bull Acute AD pruritic erythematous papules or vesicles over
erythematous skin often associated with excoriation and serous
exudate
bull Subacute AD erythematous excoriated papules and scaly
plaques
bull Chronic AD thickened skin plaques and accentuated skin
markings usually involves symptoms seen in all 3 stages
All pts at risk of infection other conditions related to compromised
skin
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
20
Atopic Dermatitis Treatment
Treatment Goals
bull No cure symptom management
bull The goals of self-treatment of AD are to
1 Stop the itch-scratch cycle hydrocortisone
2 Maintain skin hydration emollients and moisturizers
3 Avoid or minimize factors that trigger or aggravate
the disorder
4 Prevent secondary infection
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
21
Atopic Dermatitis Nonpharmacologic
bull Bathing can hydrate the stratum corneum remove allergens and
irritants cleanse and debride crusts and enhance the effects of
moisturizers and topical steroids
ndash Recommended time 3-5 minutes and every other day
ndash Water should be tepid
ndash Add colloidal oatmeal
bull To maintain skin hydration and patency recommend
ndash Emollients
bull Both occlusive and moisturizing used to prevent or relieve the
signs and symptoms of dry skin
bull Apply at least twice daily for preventive and maintenance therapy
bull Creams or ointments better (than lotions) for enhancing softness
and hydration
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
22
bull Bath Oils
ndash Mineral or vegetable oil plus a surfactant help with skin lubrication
may decrease frequency of bathing
bull Cleansers
ndash Avoid traditional bath soaps ndash remove harmful and beneficial
substances
ndash Better option glycerin soaps ndash more soluble closer to neutral pH
less drying
bull Emulsifiers maintain water + lipids in one continuous phase
bull Humectants help draw water into the stratum corneum and to
retain water often added to emollient bases
bull Other key ingredients lubricants and moisturizers 3-4xday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
Atopic Dermatitis Nonpharmacologic
23
Atopic Dermatitis EBM Guideline
Most recent guideline from the American Academy of Dermatology
bull Moisturizers
ndash Xerosis is one of the cardinal clinical features of AD and results from
a dysfunctional epidermal barrier topical moisturizers are used to
combat xerosis and transepidermal water loss with traditional agents
containing varying amounts of emollient occlusive andor humectant
ingredients
bull Emollients (eg glycol and glyceryl stearate soy sterols)
ndash Lubricate and soften the skin occlusive agents (eg petrolatum
dimethicone mineral oil) form a layer to retard evaporation of water
whereas humectants (eg glycerol lactic acid urea) attract and hold
water
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
24
Atopic Dermatitis EBM Guideline
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
Nonpharmacologic options for treatment of AD
bull Strong evidence of the benefit of moisturizers ndash integral to
management ndash reduce severity + need for pharmacologic tx
ndash Apply soon after bathing to maximize hydration
bull Bathing suggested ndash no standard for frequency or duration
ndash Insufficient evidence any of the following offer value when added to
bath water Oils emollients other additives
bull Limited use of nonsoap cleansers (neutrallow pH hypoallergenic
fragrance-free) recommended
bull Use of wet-wrap therapy +- topical corticosteroid appropriate for
pts with moderatesevere AD ndash reduce symptom severity and
water loss during flares
copy 2015 by the American Pharmacists Association All rights reserved
25
bull Multicenter randomized double-blind controlled trial ndash compared
5 urea cream with a reference cream
bull Urea cream significantly better than reference cream in
preventing eczema relapse in patients with AD (HR 0634
pthinsp=thinsp0011)
bull Risk of eczema relapse was reduced by 37
bull At 6 months
ndash 26 of the patients in the test cream group were still eczema free vs
10 in the reference cream group
Ref Aringkerstroumlm U et al Comparison of moisturizing creams for the prevention of
atopic dermatitis relapse a randomized double-blind controlled multicentre clinical
trial Acta Derm Venereol 2015 Jan 16 doi 10234000015555-2051
Atopic Dermatitis Moisturizers
26
bull Colloidal oatmeal suspensions bath soaps shampoos shaving
gels and moisturizing creams
bull The diverse chemical polymorphism of oats translates into
numerous clinical utilities for AD and eczema
bull Avenanthramides
ndash Principal polyphenolic antioxidants in oats
ndash Anti-inflammatory and antipruritic properties in rodent models
ndash Also antioxidant properties
bull Positive effect in pts with AD
Ref Fowler JF Jr Colloidal oatmeal formulations and the treatment of atopic
dermatitis J Drugs Dermatol 2014 Oct 113(10)1180-3
Atopic Dermatitis Colloidal Oatmeal
27
bull METHODS
ndash Four extracts of colloidal oatmeal were made with various solvents
and tested in anti-inflammatory and antioxidant assays
ndash Assessment of benefit in 29 female patients with bilateral mild to
moderate itch with moderate to severe dry skin on their lower legs
used a colloidal oatmeal skin protectant lotion
bull RESULTS
ndash In vitro study Colloidal oatmeal extract activity reduced pro-
inflammatory cytokines
ndash 29 pts colloidal oat skin protectant lotion showed significant clinical
improvements in skin dryness scaling roughness and itch intensity
Ref Reynertson KA et al Anti-inflammatory activities of colloidal oatmeal
contribute to the effectiveness of oats in treatment of itch associated with dry
irritated skin J Drugs Dermatol 2015 Jan 114(1)43-8
Atopic Dermatitis Colloidal Oatmeal
copy 2015 by the American Pharmacists Association All rights reserved
28
Atopic Dermatitis Colloidal Oatmeal
bull Although emollients are recommended in the management of AD
regimens for emollient maintenance therapy are awaiting
validation
bull International multicenter open-label trial to assess the effects of a
3-month maintenance treatment regimen with a sterile
preservative-free emollient cream containing oat plantlets in
children (ages 6 mos-6 yrs) with moderate AD
bull After a 14-day run-in stabilization phase using a topical
corticosteroid (TCS) treatment of medium potency 108 children
with a SCORAD index of 20 or less were included in the study
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
29
Atopic Dermatitis Colloidal Oatmeal
bull Emollient was applied twice daily for 3 months rescue topical
corticosteroid (TCS) treatment used for flare-ups
bull The SCORAD index Patient-Oriented SCORAD (PO-SCORAD)
index number of flares TCS use and tolerance were assessed
monthly x 3 months
bull Results AD severity improved with a highly significant decrease
in the SCORAD and PO-SCORAD indexes 2nd and 3rd months
(p lt 0001)
bull of flares and TCS use significantly decreased by the 3rd month
(both p lt 0001)
bull Intervention = significant improvement of clinical symptoms with
no adverse events
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
30
Bathing is a therapeutic measure commonly advised in atopic dermatitis
(AD) Whether baths improve skin condition remains unclear Objectives of
this study
bull What is the effect of one month of tap water bathing on the bathed skin of
patients with AD
bull How many pts favor baths
bull Interventional studies measuring skin changes after tap water bathing
were selected for the first analysis
bull Observational studies reporting the proportion of AD patients who favor
baths were selected for the second analysis
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
copy 2015 by the American Pharmacists Association All rights reserved
31
bull 7 of 271 studies met the selection criteria
bull Pooled effect size of skin changes after baths was minimal (-010)
bull 291 of patients favored baths
Authors conclude
bull No evidence of a positive effect of 1-month tap water bathing on
skin changes in AD
bull Discuss pros and cons with pts before deciding whether baths are
appropriate and if so frequency products to add to improve
response
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
32
Can probiotics offer benefit in the management of AD
bull Meta-analysis included randomized controlled trials (RCTs)
measuring the effects of probiotics or synbiotics in patients
diagnosed with AD
bull The primary outcome SCORAD values between the treatment
and placebo groups
bull 25 RCTs (n = 1599)
bull Significant improvement in SCORAD values in pts taking
probiotics (mean -451 95 CI -678 to -224)
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
33
Population subgroups
bull Pts 1 to 18 years old (-574 95CI -727 to -420)
bull Adults (-826 95CI -1328 to -325)
bull Infants (lt1 year old) no positive effect
Response to specific probiotic strains
bull Use of a mixture of different bacterial species or Lactobacillus
species showed greater benefit than did use of Bifidobacterium
species alone
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
copy 2015 by the American Pharmacists Association All rights reserved
34
Double-blind prospective randomized placebo-controlled study in
220 children with moderatesevere AD
Evaluated effects of 2 strains of Lactobacillus (and combined) on
disease severity QOL and certain measures of immune function
ndash Lactobacillus paracasei (LP)
ndash Lactobacillus fermentum (LF)
bull Groups
ndash LP
ndash LF
ndash LP+LF mixture
ndash placebo
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
35
bull All pts given 3 months of therapy
bull Response evaluated myriad ways standard evaluation via
SCORAD scores
bull LP LF and LP+LF mixture groups demonstrated benefit via lower
SCORAD scores compared with the placebo group (plt0001)
bull Benefit seen up to 4 months after discontinuing the probiotics
bull In subgroup analyses significant benefit in the following
ndash Younger than age 12
ndash Breast fed gt6 months
ndash Those with documented mite sensitization
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
36
bull Small prospective controlled trial assessed association of
Streptococcus thermophilus ST10 and tara gum complex and the
activity of Lactobacillus salivarius LS01 administered at high
doses to adults with AD
bull Why this complex Improves adherence to intestinal mucus
bull 25 patients randomized to placebo (n=12) or active formulation
(n=13)
bull SCORAD used to evaluate response
bull Also evaluated bacterial counts (for Staphylococcus aureus and
clostridia)
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
copy 2015 by the American Pharmacists Association All rights reserved
37
bull At 1 month study group showed significant improvement in
SCORAD index
bull A slight decrease in fecal S aureus count was observed in
probiotic-treated patients
bull Authors concluded the probiotic strain + tara gum complex =
quicker response and greater efficacy
bull What does this mean Need more data but probiotic
supplementation could offer benefit
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
38
bull Lactobacillus salivarius LS01 in children with AD
bull 43 pts (0 to 11 yrs)
bull Response evaluated by changes in itch index and SCORAD index
bull Those using probiotics showed significant benefit in both
measures
bull Effects sustained for 4 weeks after supplement stopped
Ref Niccoli AA et al Preliminary results on clinical effects of probiotic
Lactobacillus salivarius LS01 in children affected by atopic dermatitis J Clin
Gastroenterol 2014 Nov-Dec48 Suppl 1S34-6
Atopic Dermatitis Probiotics ndash Study 4
39
Atopic Dermatitis Pharmacologic Tx
Antipruritics 3 Options
1 Local anesthetics pramoxine lidocaine and benzocaine
2 Antihistamines
ndash Topical diphenhydramine may be effective as an antihistamine in
addition to having some mild anesthetic properties however may
cause sensitization so use is not recommended
ndash Systemic pruritus with AD likely not related to histamine so most
agents probably not effective also concern regarding adverse effects
(anticholinergic drowsiness) and time to response
3 Hydrocortisone
ndash Dose Apply to Affected Area (AAA) 1-2 timesday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
19
Atopic Dermatitis Clinical Presentation
3 clinical forms of AD
bull Acute AD pruritic erythematous papules or vesicles over
erythematous skin often associated with excoriation and serous
exudate
bull Subacute AD erythematous excoriated papules and scaly
plaques
bull Chronic AD thickened skin plaques and accentuated skin
markings usually involves symptoms seen in all 3 stages
All pts at risk of infection other conditions related to compromised
skin
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
20
Atopic Dermatitis Treatment
Treatment Goals
bull No cure symptom management
bull The goals of self-treatment of AD are to
1 Stop the itch-scratch cycle hydrocortisone
2 Maintain skin hydration emollients and moisturizers
3 Avoid or minimize factors that trigger or aggravate
the disorder
4 Prevent secondary infection
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
21
Atopic Dermatitis Nonpharmacologic
bull Bathing can hydrate the stratum corneum remove allergens and
irritants cleanse and debride crusts and enhance the effects of
moisturizers and topical steroids
ndash Recommended time 3-5 minutes and every other day
ndash Water should be tepid
ndash Add colloidal oatmeal
bull To maintain skin hydration and patency recommend
ndash Emollients
bull Both occlusive and moisturizing used to prevent or relieve the
signs and symptoms of dry skin
bull Apply at least twice daily for preventive and maintenance therapy
bull Creams or ointments better (than lotions) for enhancing softness
and hydration
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
22
bull Bath Oils
ndash Mineral or vegetable oil plus a surfactant help with skin lubrication
may decrease frequency of bathing
bull Cleansers
ndash Avoid traditional bath soaps ndash remove harmful and beneficial
substances
ndash Better option glycerin soaps ndash more soluble closer to neutral pH
less drying
bull Emulsifiers maintain water + lipids in one continuous phase
bull Humectants help draw water into the stratum corneum and to
retain water often added to emollient bases
bull Other key ingredients lubricants and moisturizers 3-4xday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
Atopic Dermatitis Nonpharmacologic
23
Atopic Dermatitis EBM Guideline
Most recent guideline from the American Academy of Dermatology
bull Moisturizers
ndash Xerosis is one of the cardinal clinical features of AD and results from
a dysfunctional epidermal barrier topical moisturizers are used to
combat xerosis and transepidermal water loss with traditional agents
containing varying amounts of emollient occlusive andor humectant
ingredients
bull Emollients (eg glycol and glyceryl stearate soy sterols)
ndash Lubricate and soften the skin occlusive agents (eg petrolatum
dimethicone mineral oil) form a layer to retard evaporation of water
whereas humectants (eg glycerol lactic acid urea) attract and hold
water
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
24
Atopic Dermatitis EBM Guideline
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
Nonpharmacologic options for treatment of AD
bull Strong evidence of the benefit of moisturizers ndash integral to
management ndash reduce severity + need for pharmacologic tx
ndash Apply soon after bathing to maximize hydration
bull Bathing suggested ndash no standard for frequency or duration
ndash Insufficient evidence any of the following offer value when added to
bath water Oils emollients other additives
bull Limited use of nonsoap cleansers (neutrallow pH hypoallergenic
fragrance-free) recommended
bull Use of wet-wrap therapy +- topical corticosteroid appropriate for
pts with moderatesevere AD ndash reduce symptom severity and
water loss during flares
copy 2015 by the American Pharmacists Association All rights reserved
25
bull Multicenter randomized double-blind controlled trial ndash compared
5 urea cream with a reference cream
bull Urea cream significantly better than reference cream in
preventing eczema relapse in patients with AD (HR 0634
pthinsp=thinsp0011)
bull Risk of eczema relapse was reduced by 37
bull At 6 months
ndash 26 of the patients in the test cream group were still eczema free vs
10 in the reference cream group
Ref Aringkerstroumlm U et al Comparison of moisturizing creams for the prevention of
atopic dermatitis relapse a randomized double-blind controlled multicentre clinical
trial Acta Derm Venereol 2015 Jan 16 doi 10234000015555-2051
Atopic Dermatitis Moisturizers
26
bull Colloidal oatmeal suspensions bath soaps shampoos shaving
gels and moisturizing creams
bull The diverse chemical polymorphism of oats translates into
numerous clinical utilities for AD and eczema
bull Avenanthramides
ndash Principal polyphenolic antioxidants in oats
ndash Anti-inflammatory and antipruritic properties in rodent models
ndash Also antioxidant properties
bull Positive effect in pts with AD
Ref Fowler JF Jr Colloidal oatmeal formulations and the treatment of atopic
dermatitis J Drugs Dermatol 2014 Oct 113(10)1180-3
Atopic Dermatitis Colloidal Oatmeal
27
bull METHODS
ndash Four extracts of colloidal oatmeal were made with various solvents
and tested in anti-inflammatory and antioxidant assays
ndash Assessment of benefit in 29 female patients with bilateral mild to
moderate itch with moderate to severe dry skin on their lower legs
used a colloidal oatmeal skin protectant lotion
bull RESULTS
ndash In vitro study Colloidal oatmeal extract activity reduced pro-
inflammatory cytokines
ndash 29 pts colloidal oat skin protectant lotion showed significant clinical
improvements in skin dryness scaling roughness and itch intensity
Ref Reynertson KA et al Anti-inflammatory activities of colloidal oatmeal
contribute to the effectiveness of oats in treatment of itch associated with dry
irritated skin J Drugs Dermatol 2015 Jan 114(1)43-8
Atopic Dermatitis Colloidal Oatmeal
copy 2015 by the American Pharmacists Association All rights reserved
28
Atopic Dermatitis Colloidal Oatmeal
bull Although emollients are recommended in the management of AD
regimens for emollient maintenance therapy are awaiting
validation
bull International multicenter open-label trial to assess the effects of a
3-month maintenance treatment regimen with a sterile
preservative-free emollient cream containing oat plantlets in
children (ages 6 mos-6 yrs) with moderate AD
bull After a 14-day run-in stabilization phase using a topical
corticosteroid (TCS) treatment of medium potency 108 children
with a SCORAD index of 20 or less were included in the study
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
29
Atopic Dermatitis Colloidal Oatmeal
bull Emollient was applied twice daily for 3 months rescue topical
corticosteroid (TCS) treatment used for flare-ups
bull The SCORAD index Patient-Oriented SCORAD (PO-SCORAD)
index number of flares TCS use and tolerance were assessed
monthly x 3 months
bull Results AD severity improved with a highly significant decrease
in the SCORAD and PO-SCORAD indexes 2nd and 3rd months
(p lt 0001)
bull of flares and TCS use significantly decreased by the 3rd month
(both p lt 0001)
bull Intervention = significant improvement of clinical symptoms with
no adverse events
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
30
Bathing is a therapeutic measure commonly advised in atopic dermatitis
(AD) Whether baths improve skin condition remains unclear Objectives of
this study
bull What is the effect of one month of tap water bathing on the bathed skin of
patients with AD
bull How many pts favor baths
bull Interventional studies measuring skin changes after tap water bathing
were selected for the first analysis
bull Observational studies reporting the proportion of AD patients who favor
baths were selected for the second analysis
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
copy 2015 by the American Pharmacists Association All rights reserved
31
bull 7 of 271 studies met the selection criteria
bull Pooled effect size of skin changes after baths was minimal (-010)
bull 291 of patients favored baths
Authors conclude
bull No evidence of a positive effect of 1-month tap water bathing on
skin changes in AD
bull Discuss pros and cons with pts before deciding whether baths are
appropriate and if so frequency products to add to improve
response
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
32
Can probiotics offer benefit in the management of AD
bull Meta-analysis included randomized controlled trials (RCTs)
measuring the effects of probiotics or synbiotics in patients
diagnosed with AD
bull The primary outcome SCORAD values between the treatment
and placebo groups
bull 25 RCTs (n = 1599)
bull Significant improvement in SCORAD values in pts taking
probiotics (mean -451 95 CI -678 to -224)
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
33
Population subgroups
bull Pts 1 to 18 years old (-574 95CI -727 to -420)
bull Adults (-826 95CI -1328 to -325)
bull Infants (lt1 year old) no positive effect
Response to specific probiotic strains
bull Use of a mixture of different bacterial species or Lactobacillus
species showed greater benefit than did use of Bifidobacterium
species alone
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
copy 2015 by the American Pharmacists Association All rights reserved
34
Double-blind prospective randomized placebo-controlled study in
220 children with moderatesevere AD
Evaluated effects of 2 strains of Lactobacillus (and combined) on
disease severity QOL and certain measures of immune function
ndash Lactobacillus paracasei (LP)
ndash Lactobacillus fermentum (LF)
bull Groups
ndash LP
ndash LF
ndash LP+LF mixture
ndash placebo
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
35
bull All pts given 3 months of therapy
bull Response evaluated myriad ways standard evaluation via
SCORAD scores
bull LP LF and LP+LF mixture groups demonstrated benefit via lower
SCORAD scores compared with the placebo group (plt0001)
bull Benefit seen up to 4 months after discontinuing the probiotics
bull In subgroup analyses significant benefit in the following
ndash Younger than age 12
ndash Breast fed gt6 months
ndash Those with documented mite sensitization
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
36
bull Small prospective controlled trial assessed association of
Streptococcus thermophilus ST10 and tara gum complex and the
activity of Lactobacillus salivarius LS01 administered at high
doses to adults with AD
bull Why this complex Improves adherence to intestinal mucus
bull 25 patients randomized to placebo (n=12) or active formulation
(n=13)
bull SCORAD used to evaluate response
bull Also evaluated bacterial counts (for Staphylococcus aureus and
clostridia)
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
copy 2015 by the American Pharmacists Association All rights reserved
37
bull At 1 month study group showed significant improvement in
SCORAD index
bull A slight decrease in fecal S aureus count was observed in
probiotic-treated patients
bull Authors concluded the probiotic strain + tara gum complex =
quicker response and greater efficacy
bull What does this mean Need more data but probiotic
supplementation could offer benefit
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
38
bull Lactobacillus salivarius LS01 in children with AD
bull 43 pts (0 to 11 yrs)
bull Response evaluated by changes in itch index and SCORAD index
bull Those using probiotics showed significant benefit in both
measures
bull Effects sustained for 4 weeks after supplement stopped
Ref Niccoli AA et al Preliminary results on clinical effects of probiotic
Lactobacillus salivarius LS01 in children affected by atopic dermatitis J Clin
Gastroenterol 2014 Nov-Dec48 Suppl 1S34-6
Atopic Dermatitis Probiotics ndash Study 4
39
Atopic Dermatitis Pharmacologic Tx
Antipruritics 3 Options
1 Local anesthetics pramoxine lidocaine and benzocaine
2 Antihistamines
ndash Topical diphenhydramine may be effective as an antihistamine in
addition to having some mild anesthetic properties however may
cause sensitization so use is not recommended
ndash Systemic pruritus with AD likely not related to histamine so most
agents probably not effective also concern regarding adverse effects
(anticholinergic drowsiness) and time to response
3 Hydrocortisone
ndash Dose Apply to Affected Area (AAA) 1-2 timesday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
22
bull Bath Oils
ndash Mineral or vegetable oil plus a surfactant help with skin lubrication
may decrease frequency of bathing
bull Cleansers
ndash Avoid traditional bath soaps ndash remove harmful and beneficial
substances
ndash Better option glycerin soaps ndash more soluble closer to neutral pH
less drying
bull Emulsifiers maintain water + lipids in one continuous phase
bull Humectants help draw water into the stratum corneum and to
retain water often added to emollient bases
bull Other key ingredients lubricants and moisturizers 3-4xday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
Atopic Dermatitis Nonpharmacologic
23
Atopic Dermatitis EBM Guideline
Most recent guideline from the American Academy of Dermatology
bull Moisturizers
ndash Xerosis is one of the cardinal clinical features of AD and results from
a dysfunctional epidermal barrier topical moisturizers are used to
combat xerosis and transepidermal water loss with traditional agents
containing varying amounts of emollient occlusive andor humectant
ingredients
bull Emollients (eg glycol and glyceryl stearate soy sterols)
ndash Lubricate and soften the skin occlusive agents (eg petrolatum
dimethicone mineral oil) form a layer to retard evaporation of water
whereas humectants (eg glycerol lactic acid urea) attract and hold
water
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
24
Atopic Dermatitis EBM Guideline
Ref Eichenfield LF et al Guidelines of care for the management of atopic
dermatitis section 2 Management and treatment of atopic dermatitis with topical
therapies J Am Acad Dermatol 2014 Jul71(1)116-32 doi
101016jjaad201403023 Epub 2014 May 9
Nonpharmacologic options for treatment of AD
bull Strong evidence of the benefit of moisturizers ndash integral to
management ndash reduce severity + need for pharmacologic tx
ndash Apply soon after bathing to maximize hydration
bull Bathing suggested ndash no standard for frequency or duration
ndash Insufficient evidence any of the following offer value when added to
bath water Oils emollients other additives
bull Limited use of nonsoap cleansers (neutrallow pH hypoallergenic
fragrance-free) recommended
bull Use of wet-wrap therapy +- topical corticosteroid appropriate for
pts with moderatesevere AD ndash reduce symptom severity and
water loss during flares
copy 2015 by the American Pharmacists Association All rights reserved
25
bull Multicenter randomized double-blind controlled trial ndash compared
5 urea cream with a reference cream
bull Urea cream significantly better than reference cream in
preventing eczema relapse in patients with AD (HR 0634
pthinsp=thinsp0011)
bull Risk of eczema relapse was reduced by 37
bull At 6 months
ndash 26 of the patients in the test cream group were still eczema free vs
10 in the reference cream group
Ref Aringkerstroumlm U et al Comparison of moisturizing creams for the prevention of
atopic dermatitis relapse a randomized double-blind controlled multicentre clinical
trial Acta Derm Venereol 2015 Jan 16 doi 10234000015555-2051
Atopic Dermatitis Moisturizers
26
bull Colloidal oatmeal suspensions bath soaps shampoos shaving
gels and moisturizing creams
bull The diverse chemical polymorphism of oats translates into
numerous clinical utilities for AD and eczema
bull Avenanthramides
ndash Principal polyphenolic antioxidants in oats
ndash Anti-inflammatory and antipruritic properties in rodent models
ndash Also antioxidant properties
bull Positive effect in pts with AD
Ref Fowler JF Jr Colloidal oatmeal formulations and the treatment of atopic
dermatitis J Drugs Dermatol 2014 Oct 113(10)1180-3
Atopic Dermatitis Colloidal Oatmeal
27
bull METHODS
ndash Four extracts of colloidal oatmeal were made with various solvents
and tested in anti-inflammatory and antioxidant assays
ndash Assessment of benefit in 29 female patients with bilateral mild to
moderate itch with moderate to severe dry skin on their lower legs
used a colloidal oatmeal skin protectant lotion
bull RESULTS
ndash In vitro study Colloidal oatmeal extract activity reduced pro-
inflammatory cytokines
ndash 29 pts colloidal oat skin protectant lotion showed significant clinical
improvements in skin dryness scaling roughness and itch intensity
Ref Reynertson KA et al Anti-inflammatory activities of colloidal oatmeal
contribute to the effectiveness of oats in treatment of itch associated with dry
irritated skin J Drugs Dermatol 2015 Jan 114(1)43-8
Atopic Dermatitis Colloidal Oatmeal
copy 2015 by the American Pharmacists Association All rights reserved
28
Atopic Dermatitis Colloidal Oatmeal
bull Although emollients are recommended in the management of AD
regimens for emollient maintenance therapy are awaiting
validation
bull International multicenter open-label trial to assess the effects of a
3-month maintenance treatment regimen with a sterile
preservative-free emollient cream containing oat plantlets in
children (ages 6 mos-6 yrs) with moderate AD
bull After a 14-day run-in stabilization phase using a topical
corticosteroid (TCS) treatment of medium potency 108 children
with a SCORAD index of 20 or less were included in the study
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
29
Atopic Dermatitis Colloidal Oatmeal
bull Emollient was applied twice daily for 3 months rescue topical
corticosteroid (TCS) treatment used for flare-ups
bull The SCORAD index Patient-Oriented SCORAD (PO-SCORAD)
index number of flares TCS use and tolerance were assessed
monthly x 3 months
bull Results AD severity improved with a highly significant decrease
in the SCORAD and PO-SCORAD indexes 2nd and 3rd months
(p lt 0001)
bull of flares and TCS use significantly decreased by the 3rd month
(both p lt 0001)
bull Intervention = significant improvement of clinical symptoms with
no adverse events
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
30
Bathing is a therapeutic measure commonly advised in atopic dermatitis
(AD) Whether baths improve skin condition remains unclear Objectives of
this study
bull What is the effect of one month of tap water bathing on the bathed skin of
patients with AD
bull How many pts favor baths
bull Interventional studies measuring skin changes after tap water bathing
were selected for the first analysis
bull Observational studies reporting the proportion of AD patients who favor
baths were selected for the second analysis
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
copy 2015 by the American Pharmacists Association All rights reserved
31
bull 7 of 271 studies met the selection criteria
bull Pooled effect size of skin changes after baths was minimal (-010)
bull 291 of patients favored baths
Authors conclude
bull No evidence of a positive effect of 1-month tap water bathing on
skin changes in AD
bull Discuss pros and cons with pts before deciding whether baths are
appropriate and if so frequency products to add to improve
response
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
32
Can probiotics offer benefit in the management of AD
bull Meta-analysis included randomized controlled trials (RCTs)
measuring the effects of probiotics or synbiotics in patients
diagnosed with AD
bull The primary outcome SCORAD values between the treatment
and placebo groups
bull 25 RCTs (n = 1599)
bull Significant improvement in SCORAD values in pts taking
probiotics (mean -451 95 CI -678 to -224)
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
33
Population subgroups
bull Pts 1 to 18 years old (-574 95CI -727 to -420)
bull Adults (-826 95CI -1328 to -325)
bull Infants (lt1 year old) no positive effect
Response to specific probiotic strains
bull Use of a mixture of different bacterial species or Lactobacillus
species showed greater benefit than did use of Bifidobacterium
species alone
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
copy 2015 by the American Pharmacists Association All rights reserved
34
Double-blind prospective randomized placebo-controlled study in
220 children with moderatesevere AD
Evaluated effects of 2 strains of Lactobacillus (and combined) on
disease severity QOL and certain measures of immune function
ndash Lactobacillus paracasei (LP)
ndash Lactobacillus fermentum (LF)
bull Groups
ndash LP
ndash LF
ndash LP+LF mixture
ndash placebo
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
35
bull All pts given 3 months of therapy
bull Response evaluated myriad ways standard evaluation via
SCORAD scores
bull LP LF and LP+LF mixture groups demonstrated benefit via lower
SCORAD scores compared with the placebo group (plt0001)
bull Benefit seen up to 4 months after discontinuing the probiotics
bull In subgroup analyses significant benefit in the following
ndash Younger than age 12
ndash Breast fed gt6 months
ndash Those with documented mite sensitization
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
36
bull Small prospective controlled trial assessed association of
Streptococcus thermophilus ST10 and tara gum complex and the
activity of Lactobacillus salivarius LS01 administered at high
doses to adults with AD
bull Why this complex Improves adherence to intestinal mucus
bull 25 patients randomized to placebo (n=12) or active formulation
(n=13)
bull SCORAD used to evaluate response
bull Also evaluated bacterial counts (for Staphylococcus aureus and
clostridia)
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
copy 2015 by the American Pharmacists Association All rights reserved
37
bull At 1 month study group showed significant improvement in
SCORAD index
bull A slight decrease in fecal S aureus count was observed in
probiotic-treated patients
bull Authors concluded the probiotic strain + tara gum complex =
quicker response and greater efficacy
bull What does this mean Need more data but probiotic
supplementation could offer benefit
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
38
bull Lactobacillus salivarius LS01 in children with AD
bull 43 pts (0 to 11 yrs)
bull Response evaluated by changes in itch index and SCORAD index
bull Those using probiotics showed significant benefit in both
measures
bull Effects sustained for 4 weeks after supplement stopped
Ref Niccoli AA et al Preliminary results on clinical effects of probiotic
Lactobacillus salivarius LS01 in children affected by atopic dermatitis J Clin
Gastroenterol 2014 Nov-Dec48 Suppl 1S34-6
Atopic Dermatitis Probiotics ndash Study 4
39
Atopic Dermatitis Pharmacologic Tx
Antipruritics 3 Options
1 Local anesthetics pramoxine lidocaine and benzocaine
2 Antihistamines
ndash Topical diphenhydramine may be effective as an antihistamine in
addition to having some mild anesthetic properties however may
cause sensitization so use is not recommended
ndash Systemic pruritus with AD likely not related to histamine so most
agents probably not effective also concern regarding adverse effects
(anticholinergic drowsiness) and time to response
3 Hydrocortisone
ndash Dose Apply to Affected Area (AAA) 1-2 timesday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
25
bull Multicenter randomized double-blind controlled trial ndash compared
5 urea cream with a reference cream
bull Urea cream significantly better than reference cream in
preventing eczema relapse in patients with AD (HR 0634
pthinsp=thinsp0011)
bull Risk of eczema relapse was reduced by 37
bull At 6 months
ndash 26 of the patients in the test cream group were still eczema free vs
10 in the reference cream group
Ref Aringkerstroumlm U et al Comparison of moisturizing creams for the prevention of
atopic dermatitis relapse a randomized double-blind controlled multicentre clinical
trial Acta Derm Venereol 2015 Jan 16 doi 10234000015555-2051
Atopic Dermatitis Moisturizers
26
bull Colloidal oatmeal suspensions bath soaps shampoos shaving
gels and moisturizing creams
bull The diverse chemical polymorphism of oats translates into
numerous clinical utilities for AD and eczema
bull Avenanthramides
ndash Principal polyphenolic antioxidants in oats
ndash Anti-inflammatory and antipruritic properties in rodent models
ndash Also antioxidant properties
bull Positive effect in pts with AD
Ref Fowler JF Jr Colloidal oatmeal formulations and the treatment of atopic
dermatitis J Drugs Dermatol 2014 Oct 113(10)1180-3
Atopic Dermatitis Colloidal Oatmeal
27
bull METHODS
ndash Four extracts of colloidal oatmeal were made with various solvents
and tested in anti-inflammatory and antioxidant assays
ndash Assessment of benefit in 29 female patients with bilateral mild to
moderate itch with moderate to severe dry skin on their lower legs
used a colloidal oatmeal skin protectant lotion
bull RESULTS
ndash In vitro study Colloidal oatmeal extract activity reduced pro-
inflammatory cytokines
ndash 29 pts colloidal oat skin protectant lotion showed significant clinical
improvements in skin dryness scaling roughness and itch intensity
Ref Reynertson KA et al Anti-inflammatory activities of colloidal oatmeal
contribute to the effectiveness of oats in treatment of itch associated with dry
irritated skin J Drugs Dermatol 2015 Jan 114(1)43-8
Atopic Dermatitis Colloidal Oatmeal
copy 2015 by the American Pharmacists Association All rights reserved
28
Atopic Dermatitis Colloidal Oatmeal
bull Although emollients are recommended in the management of AD
regimens for emollient maintenance therapy are awaiting
validation
bull International multicenter open-label trial to assess the effects of a
3-month maintenance treatment regimen with a sterile
preservative-free emollient cream containing oat plantlets in
children (ages 6 mos-6 yrs) with moderate AD
bull After a 14-day run-in stabilization phase using a topical
corticosteroid (TCS) treatment of medium potency 108 children
with a SCORAD index of 20 or less were included in the study
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
29
Atopic Dermatitis Colloidal Oatmeal
bull Emollient was applied twice daily for 3 months rescue topical
corticosteroid (TCS) treatment used for flare-ups
bull The SCORAD index Patient-Oriented SCORAD (PO-SCORAD)
index number of flares TCS use and tolerance were assessed
monthly x 3 months
bull Results AD severity improved with a highly significant decrease
in the SCORAD and PO-SCORAD indexes 2nd and 3rd months
(p lt 0001)
bull of flares and TCS use significantly decreased by the 3rd month
(both p lt 0001)
bull Intervention = significant improvement of clinical symptoms with
no adverse events
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
30
Bathing is a therapeutic measure commonly advised in atopic dermatitis
(AD) Whether baths improve skin condition remains unclear Objectives of
this study
bull What is the effect of one month of tap water bathing on the bathed skin of
patients with AD
bull How many pts favor baths
bull Interventional studies measuring skin changes after tap water bathing
were selected for the first analysis
bull Observational studies reporting the proportion of AD patients who favor
baths were selected for the second analysis
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
copy 2015 by the American Pharmacists Association All rights reserved
31
bull 7 of 271 studies met the selection criteria
bull Pooled effect size of skin changes after baths was minimal (-010)
bull 291 of patients favored baths
Authors conclude
bull No evidence of a positive effect of 1-month tap water bathing on
skin changes in AD
bull Discuss pros and cons with pts before deciding whether baths are
appropriate and if so frequency products to add to improve
response
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
32
Can probiotics offer benefit in the management of AD
bull Meta-analysis included randomized controlled trials (RCTs)
measuring the effects of probiotics or synbiotics in patients
diagnosed with AD
bull The primary outcome SCORAD values between the treatment
and placebo groups
bull 25 RCTs (n = 1599)
bull Significant improvement in SCORAD values in pts taking
probiotics (mean -451 95 CI -678 to -224)
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
33
Population subgroups
bull Pts 1 to 18 years old (-574 95CI -727 to -420)
bull Adults (-826 95CI -1328 to -325)
bull Infants (lt1 year old) no positive effect
Response to specific probiotic strains
bull Use of a mixture of different bacterial species or Lactobacillus
species showed greater benefit than did use of Bifidobacterium
species alone
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
copy 2015 by the American Pharmacists Association All rights reserved
34
Double-blind prospective randomized placebo-controlled study in
220 children with moderatesevere AD
Evaluated effects of 2 strains of Lactobacillus (and combined) on
disease severity QOL and certain measures of immune function
ndash Lactobacillus paracasei (LP)
ndash Lactobacillus fermentum (LF)
bull Groups
ndash LP
ndash LF
ndash LP+LF mixture
ndash placebo
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
35
bull All pts given 3 months of therapy
bull Response evaluated myriad ways standard evaluation via
SCORAD scores
bull LP LF and LP+LF mixture groups demonstrated benefit via lower
SCORAD scores compared with the placebo group (plt0001)
bull Benefit seen up to 4 months after discontinuing the probiotics
bull In subgroup analyses significant benefit in the following
ndash Younger than age 12
ndash Breast fed gt6 months
ndash Those with documented mite sensitization
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
36
bull Small prospective controlled trial assessed association of
Streptococcus thermophilus ST10 and tara gum complex and the
activity of Lactobacillus salivarius LS01 administered at high
doses to adults with AD
bull Why this complex Improves adherence to intestinal mucus
bull 25 patients randomized to placebo (n=12) or active formulation
(n=13)
bull SCORAD used to evaluate response
bull Also evaluated bacterial counts (for Staphylococcus aureus and
clostridia)
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
copy 2015 by the American Pharmacists Association All rights reserved
37
bull At 1 month study group showed significant improvement in
SCORAD index
bull A slight decrease in fecal S aureus count was observed in
probiotic-treated patients
bull Authors concluded the probiotic strain + tara gum complex =
quicker response and greater efficacy
bull What does this mean Need more data but probiotic
supplementation could offer benefit
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
38
bull Lactobacillus salivarius LS01 in children with AD
bull 43 pts (0 to 11 yrs)
bull Response evaluated by changes in itch index and SCORAD index
bull Those using probiotics showed significant benefit in both
measures
bull Effects sustained for 4 weeks after supplement stopped
Ref Niccoli AA et al Preliminary results on clinical effects of probiotic
Lactobacillus salivarius LS01 in children affected by atopic dermatitis J Clin
Gastroenterol 2014 Nov-Dec48 Suppl 1S34-6
Atopic Dermatitis Probiotics ndash Study 4
39
Atopic Dermatitis Pharmacologic Tx
Antipruritics 3 Options
1 Local anesthetics pramoxine lidocaine and benzocaine
2 Antihistamines
ndash Topical diphenhydramine may be effective as an antihistamine in
addition to having some mild anesthetic properties however may
cause sensitization so use is not recommended
ndash Systemic pruritus with AD likely not related to histamine so most
agents probably not effective also concern regarding adverse effects
(anticholinergic drowsiness) and time to response
3 Hydrocortisone
ndash Dose Apply to Affected Area (AAA) 1-2 timesday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
28
Atopic Dermatitis Colloidal Oatmeal
bull Although emollients are recommended in the management of AD
regimens for emollient maintenance therapy are awaiting
validation
bull International multicenter open-label trial to assess the effects of a
3-month maintenance treatment regimen with a sterile
preservative-free emollient cream containing oat plantlets in
children (ages 6 mos-6 yrs) with moderate AD
bull After a 14-day run-in stabilization phase using a topical
corticosteroid (TCS) treatment of medium potency 108 children
with a SCORAD index of 20 or less were included in the study
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
29
Atopic Dermatitis Colloidal Oatmeal
bull Emollient was applied twice daily for 3 months rescue topical
corticosteroid (TCS) treatment used for flare-ups
bull The SCORAD index Patient-Oriented SCORAD (PO-SCORAD)
index number of flares TCS use and tolerance were assessed
monthly x 3 months
bull Results AD severity improved with a highly significant decrease
in the SCORAD and PO-SCORAD indexes 2nd and 3rd months
(p lt 0001)
bull of flares and TCS use significantly decreased by the 3rd month
(both p lt 0001)
bull Intervention = significant improvement of clinical symptoms with
no adverse events
Ref Mengeaud V et al An innovative oat-based sterile emollient cream in
the maintenance therapy of childhood atopic dermatitis Pediatr Dermatol
2014 Dec 22 doi 101111pde12464 [Epub ahead of print]
30
Bathing is a therapeutic measure commonly advised in atopic dermatitis
(AD) Whether baths improve skin condition remains unclear Objectives of
this study
bull What is the effect of one month of tap water bathing on the bathed skin of
patients with AD
bull How many pts favor baths
bull Interventional studies measuring skin changes after tap water bathing
were selected for the first analysis
bull Observational studies reporting the proportion of AD patients who favor
baths were selected for the second analysis
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
copy 2015 by the American Pharmacists Association All rights reserved
31
bull 7 of 271 studies met the selection criteria
bull Pooled effect size of skin changes after baths was minimal (-010)
bull 291 of patients favored baths
Authors conclude
bull No evidence of a positive effect of 1-month tap water bathing on
skin changes in AD
bull Discuss pros and cons with pts before deciding whether baths are
appropriate and if so frequency products to add to improve
response
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
32
Can probiotics offer benefit in the management of AD
bull Meta-analysis included randomized controlled trials (RCTs)
measuring the effects of probiotics or synbiotics in patients
diagnosed with AD
bull The primary outcome SCORAD values between the treatment
and placebo groups
bull 25 RCTs (n = 1599)
bull Significant improvement in SCORAD values in pts taking
probiotics (mean -451 95 CI -678 to -224)
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
33
Population subgroups
bull Pts 1 to 18 years old (-574 95CI -727 to -420)
bull Adults (-826 95CI -1328 to -325)
bull Infants (lt1 year old) no positive effect
Response to specific probiotic strains
bull Use of a mixture of different bacterial species or Lactobacillus
species showed greater benefit than did use of Bifidobacterium
species alone
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
copy 2015 by the American Pharmacists Association All rights reserved
34
Double-blind prospective randomized placebo-controlled study in
220 children with moderatesevere AD
Evaluated effects of 2 strains of Lactobacillus (and combined) on
disease severity QOL and certain measures of immune function
ndash Lactobacillus paracasei (LP)
ndash Lactobacillus fermentum (LF)
bull Groups
ndash LP
ndash LF
ndash LP+LF mixture
ndash placebo
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
35
bull All pts given 3 months of therapy
bull Response evaluated myriad ways standard evaluation via
SCORAD scores
bull LP LF and LP+LF mixture groups demonstrated benefit via lower
SCORAD scores compared with the placebo group (plt0001)
bull Benefit seen up to 4 months after discontinuing the probiotics
bull In subgroup analyses significant benefit in the following
ndash Younger than age 12
ndash Breast fed gt6 months
ndash Those with documented mite sensitization
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
36
bull Small prospective controlled trial assessed association of
Streptococcus thermophilus ST10 and tara gum complex and the
activity of Lactobacillus salivarius LS01 administered at high
doses to adults with AD
bull Why this complex Improves adherence to intestinal mucus
bull 25 patients randomized to placebo (n=12) or active formulation
(n=13)
bull SCORAD used to evaluate response
bull Also evaluated bacterial counts (for Staphylococcus aureus and
clostridia)
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
copy 2015 by the American Pharmacists Association All rights reserved
37
bull At 1 month study group showed significant improvement in
SCORAD index
bull A slight decrease in fecal S aureus count was observed in
probiotic-treated patients
bull Authors concluded the probiotic strain + tara gum complex =
quicker response and greater efficacy
bull What does this mean Need more data but probiotic
supplementation could offer benefit
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
38
bull Lactobacillus salivarius LS01 in children with AD
bull 43 pts (0 to 11 yrs)
bull Response evaluated by changes in itch index and SCORAD index
bull Those using probiotics showed significant benefit in both
measures
bull Effects sustained for 4 weeks after supplement stopped
Ref Niccoli AA et al Preliminary results on clinical effects of probiotic
Lactobacillus salivarius LS01 in children affected by atopic dermatitis J Clin
Gastroenterol 2014 Nov-Dec48 Suppl 1S34-6
Atopic Dermatitis Probiotics ndash Study 4
39
Atopic Dermatitis Pharmacologic Tx
Antipruritics 3 Options
1 Local anesthetics pramoxine lidocaine and benzocaine
2 Antihistamines
ndash Topical diphenhydramine may be effective as an antihistamine in
addition to having some mild anesthetic properties however may
cause sensitization so use is not recommended
ndash Systemic pruritus with AD likely not related to histamine so most
agents probably not effective also concern regarding adverse effects
(anticholinergic drowsiness) and time to response
3 Hydrocortisone
ndash Dose Apply to Affected Area (AAA) 1-2 timesday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
31
bull 7 of 271 studies met the selection criteria
bull Pooled effect size of skin changes after baths was minimal (-010)
bull 291 of patients favored baths
Authors conclude
bull No evidence of a positive effect of 1-month tap water bathing on
skin changes in AD
bull Discuss pros and cons with pts before deciding whether baths are
appropriate and if so frequency products to add to improve
response
Ref Sarre ME et al Are baths desirable in atopic dermatitis J Eur Acad
Dermatol Venereol 2015 Jan 27 doi 101111jdv12946
Atopic Dermatitis Bathing
32
Can probiotics offer benefit in the management of AD
bull Meta-analysis included randomized controlled trials (RCTs)
measuring the effects of probiotics or synbiotics in patients
diagnosed with AD
bull The primary outcome SCORAD values between the treatment
and placebo groups
bull 25 RCTs (n = 1599)
bull Significant improvement in SCORAD values in pts taking
probiotics (mean -451 95 CI -678 to -224)
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
33
Population subgroups
bull Pts 1 to 18 years old (-574 95CI -727 to -420)
bull Adults (-826 95CI -1328 to -325)
bull Infants (lt1 year old) no positive effect
Response to specific probiotic strains
bull Use of a mixture of different bacterial species or Lactobacillus
species showed greater benefit than did use of Bifidobacterium
species alone
Ref Kim SO et al Effects of probiotics for the treatment of atopic dermatitis a
meta-analysis of randomized controlled trials Ann Allergy Asthma Immunol 2014
Aug113(2)217-26 doi 101016janai201405021 Epub 2014 Jun 20
Atopic Dermatitis Probiotics ndash Study 1
copy 2015 by the American Pharmacists Association All rights reserved
34
Double-blind prospective randomized placebo-controlled study in
220 children with moderatesevere AD
Evaluated effects of 2 strains of Lactobacillus (and combined) on
disease severity QOL and certain measures of immune function
ndash Lactobacillus paracasei (LP)
ndash Lactobacillus fermentum (LF)
bull Groups
ndash LP
ndash LF
ndash LP+LF mixture
ndash placebo
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
35
bull All pts given 3 months of therapy
bull Response evaluated myriad ways standard evaluation via
SCORAD scores
bull LP LF and LP+LF mixture groups demonstrated benefit via lower
SCORAD scores compared with the placebo group (plt0001)
bull Benefit seen up to 4 months after discontinuing the probiotics
bull In subgroup analyses significant benefit in the following
ndash Younger than age 12
ndash Breast fed gt6 months
ndash Those with documented mite sensitization
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
36
bull Small prospective controlled trial assessed association of
Streptococcus thermophilus ST10 and tara gum complex and the
activity of Lactobacillus salivarius LS01 administered at high
doses to adults with AD
bull Why this complex Improves adherence to intestinal mucus
bull 25 patients randomized to placebo (n=12) or active formulation
(n=13)
bull SCORAD used to evaluate response
bull Also evaluated bacterial counts (for Staphylococcus aureus and
clostridia)
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
copy 2015 by the American Pharmacists Association All rights reserved
37
bull At 1 month study group showed significant improvement in
SCORAD index
bull A slight decrease in fecal S aureus count was observed in
probiotic-treated patients
bull Authors concluded the probiotic strain + tara gum complex =
quicker response and greater efficacy
bull What does this mean Need more data but probiotic
supplementation could offer benefit
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
38
bull Lactobacillus salivarius LS01 in children with AD
bull 43 pts (0 to 11 yrs)
bull Response evaluated by changes in itch index and SCORAD index
bull Those using probiotics showed significant benefit in both
measures
bull Effects sustained for 4 weeks after supplement stopped
Ref Niccoli AA et al Preliminary results on clinical effects of probiotic
Lactobacillus salivarius LS01 in children affected by atopic dermatitis J Clin
Gastroenterol 2014 Nov-Dec48 Suppl 1S34-6
Atopic Dermatitis Probiotics ndash Study 4
39
Atopic Dermatitis Pharmacologic Tx
Antipruritics 3 Options
1 Local anesthetics pramoxine lidocaine and benzocaine
2 Antihistamines
ndash Topical diphenhydramine may be effective as an antihistamine in
addition to having some mild anesthetic properties however may
cause sensitization so use is not recommended
ndash Systemic pruritus with AD likely not related to histamine so most
agents probably not effective also concern regarding adverse effects
(anticholinergic drowsiness) and time to response
3 Hydrocortisone
ndash Dose Apply to Affected Area (AAA) 1-2 timesday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
34
Double-blind prospective randomized placebo-controlled study in
220 children with moderatesevere AD
Evaluated effects of 2 strains of Lactobacillus (and combined) on
disease severity QOL and certain measures of immune function
ndash Lactobacillus paracasei (LP)
ndash Lactobacillus fermentum (LF)
bull Groups
ndash LP
ndash LF
ndash LP+LF mixture
ndash placebo
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
35
bull All pts given 3 months of therapy
bull Response evaluated myriad ways standard evaluation via
SCORAD scores
bull LP LF and LP+LF mixture groups demonstrated benefit via lower
SCORAD scores compared with the placebo group (plt0001)
bull Benefit seen up to 4 months after discontinuing the probiotics
bull In subgroup analyses significant benefit in the following
ndash Younger than age 12
ndash Breast fed gt6 months
ndash Those with documented mite sensitization
Ref Wang IJ et al Children with atopic dermatitis show clinical
improvement after Lactobacillus exposure Clin Exp Allergy 2015 Jan 20
doi 101111cea12489 [Epub ahead of print]
Atopic Dermatitis Probiotics ndash Study 2
36
bull Small prospective controlled trial assessed association of
Streptococcus thermophilus ST10 and tara gum complex and the
activity of Lactobacillus salivarius LS01 administered at high
doses to adults with AD
bull Why this complex Improves adherence to intestinal mucus
bull 25 patients randomized to placebo (n=12) or active formulation
(n=13)
bull SCORAD used to evaluate response
bull Also evaluated bacterial counts (for Staphylococcus aureus and
clostridia)
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
copy 2015 by the American Pharmacists Association All rights reserved
37
bull At 1 month study group showed significant improvement in
SCORAD index
bull A slight decrease in fecal S aureus count was observed in
probiotic-treated patients
bull Authors concluded the probiotic strain + tara gum complex =
quicker response and greater efficacy
bull What does this mean Need more data but probiotic
supplementation could offer benefit
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
38
bull Lactobacillus salivarius LS01 in children with AD
bull 43 pts (0 to 11 yrs)
bull Response evaluated by changes in itch index and SCORAD index
bull Those using probiotics showed significant benefit in both
measures
bull Effects sustained for 4 weeks after supplement stopped
Ref Niccoli AA et al Preliminary results on clinical effects of probiotic
Lactobacillus salivarius LS01 in children affected by atopic dermatitis J Clin
Gastroenterol 2014 Nov-Dec48 Suppl 1S34-6
Atopic Dermatitis Probiotics ndash Study 4
39
Atopic Dermatitis Pharmacologic Tx
Antipruritics 3 Options
1 Local anesthetics pramoxine lidocaine and benzocaine
2 Antihistamines
ndash Topical diphenhydramine may be effective as an antihistamine in
addition to having some mild anesthetic properties however may
cause sensitization so use is not recommended
ndash Systemic pruritus with AD likely not related to histamine so most
agents probably not effective also concern regarding adverse effects
(anticholinergic drowsiness) and time to response
3 Hydrocortisone
ndash Dose Apply to Affected Area (AAA) 1-2 timesday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
37
bull At 1 month study group showed significant improvement in
SCORAD index
bull A slight decrease in fecal S aureus count was observed in
probiotic-treated patients
bull Authors concluded the probiotic strain + tara gum complex =
quicker response and greater efficacy
bull What does this mean Need more data but probiotic
supplementation could offer benefit
Ref Drago L et al Treatment of atopic dermatitis eczema with a high
concentration of Lactobacillus salivarius LS01 associated with an innovative
gelling complex a pilot study on adults J Clin Gastroenterol 2014 Nov-Dec48
Suppl 1S47-51
Atopic Dermatitis Probiotics ndash Study 3
38
bull Lactobacillus salivarius LS01 in children with AD
bull 43 pts (0 to 11 yrs)
bull Response evaluated by changes in itch index and SCORAD index
bull Those using probiotics showed significant benefit in both
measures
bull Effects sustained for 4 weeks after supplement stopped
Ref Niccoli AA et al Preliminary results on clinical effects of probiotic
Lactobacillus salivarius LS01 in children affected by atopic dermatitis J Clin
Gastroenterol 2014 Nov-Dec48 Suppl 1S34-6
Atopic Dermatitis Probiotics ndash Study 4
39
Atopic Dermatitis Pharmacologic Tx
Antipruritics 3 Options
1 Local anesthetics pramoxine lidocaine and benzocaine
2 Antihistamines
ndash Topical diphenhydramine may be effective as an antihistamine in
addition to having some mild anesthetic properties however may
cause sensitization so use is not recommended
ndash Systemic pruritus with AD likely not related to histamine so most
agents probably not effective also concern regarding adverse effects
(anticholinergic drowsiness) and time to response
3 Hydrocortisone
ndash Dose Apply to Affected Area (AAA) 1-2 timesday
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
40
bull H1 antihistamines often used as antipruritic
ndash Pruritus is a significant QOL issue
bull Recent Cochrane systematic review no reliable high-level
evidence to support the use of these drugs in AD particularly as
monotherapy
bull No randomized trials comparing an oral H1 antihistamine with
placebo or control
bull However there may be some value in using an H1 antihistamine ndash
weigh risks and benefits
Ref Church MK et al H1 -Antihistamines and itch in atopic dermatitis Exp
Dermatol 2015 Jan 3 doi 101111exd12626
Atopic Dermatitis Antihistamines
41
Atopic Dermatitis Steroids
Topical Hydrocortisone
bull Mainstay of OTC therapy for AD hydrocortisone in an oil-in-water
base
bull Pts ge2 years old
bull Apply anywhere up to twice daily for flare-ups
bull Response may diminish with continued use (tachyphylaxis) ndash
recommend intermittent rounds of therapy
Ref Chapter 32 Atopic Dermatitis and Dry Skin in Handbook of
Nonprescription Drugs 18th ed 2015 APhA
42
bull Some concern about steroid addiction syndrome ndash is there
evidence of topical corticosteroid (TCS) withdrawaladdiction
bull Authors performed a systematic review of the current literature
ndash 34 studies met inclusion criteria
ndash TCS withdrawal seen primarily in women and when used on the face
and genital area
bull Individuals experiencing adverse effects were using TCS for
inappropriate duration
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
43
bull Most common symptoms
ndash Burning stinging erythema
bull Data not conclusive low quality of evidence lack of controlled
studies to evaluate this effect BUT worth knowing there may be
adverse effects if TCS used inappropriately
bull More of a concern with Rx products but OTC products can be
abused
Ref Hajar T et al A systematic review of topical corticosteroid withdrawal
(steroid addiction) in patients with atopic dermatitis and other dermatoses J Am
Acad Dermatol 2015 Jan 12 pii S0190-9622(14)02209-9 doi
101016jjaad201411024 [Epub ahead of print]
Atopic Dermatitis Steroids-Study 1
44
bull May 2014 American Academy of Dermatology published a new
guideline regarding topical therapy in AD
bull Included discussion of topical steroid addiction (TSA) or red
burning skin syndrome
ndash In milder cases the rebound eruption simply consists of flushing or
erythema with or without exudative edema
ndash More severe cases a myriad of skin manifestations including
papules pustules or erosions can be seen
ndash May be accompanied by a high fever (~102degF)
ndash The peak of the rebound reaction may occur from several days to a
few months
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
45
bull AD usually involves the neck knees or elbows
bull TSA the appearance of a skin lesion is not limited to those sites
bull The only areas not affected by TSA or the rebound eruption are
the palms and soles
bull Longer periods of application and more potent strength of the TCS
lead to more frequent addiction
ndash Data hard to collect
ndash Skin atrophy usually evident after 6 wks of regular use
bull Based on author review of the data recommend TCS should not
be used continuously for longer than 2 weeks off x 2 weeks then
could resume 2 weeks of therapy
Ref Fukaya M et al Topical steroid addiction in atopic dermatitis Drug
Healthc Patient Saf 2014 Oct 146131-8
Atopic Dermatitis Steroids-Study 2
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
46
Background Children with AD have skin colonized with
Staphylococcus aureus more than children wo AD
bull Researchers determined prevalence of S aureus skin and nares
colonization in children with AD and their association with allergy
AD severity and serum vitamin D (25(OH)D)
bull 114 patients with a mean age of 57 yrsplusmn 41 (3 mos to 14 yrs)
bull + S aureus on nasal swabs equated to
ndash S aureus presence on the skin
ndash Lower 25(OH)D levels
bull Authors conclude S aureus colonization is associated with allergy
and severity in AD lower serum 25(OH)D levels
Ref Gilaberte Y et al Correlation between serum 25-hydroxyvitamin D and
virulence genes of staphylococcus aureus isolates colonizing children with atopic
dermatitis Pediatr Dermatol 2014 Dec 10 doi 101111pde12436 [Epub ahead
of print]
Atopic Dermatitis Vitamin D-Study 1
47
bull This article provides an overview of the evidence supporting the
link between vitamin D deficiency and microorganisms (skin
colonizationsensitization) in AD pathogenesis
bull Vitamin D supplementation plays a major role against
microorganisms in the development of AD and should be
considered when treating patients
Ref Benetti C et al Microorganism-induced exacerbations in atopic
dermatitis a possible preventive role for vitamin D Allergy Asthma Proc
2015 Jan36(1)19-25 doi 102500aap2015363807
Atopic Dermatitis Vitamin D-Study 2
48
bull Is there an association between serum vitamin D levels sensitization
to food allergens and the severity of AD in infants
ndash 226 infants with AD or food allergies evaluated regarding serum 25-
hydroxyvitamin D (25[OH]D) and specific immunoglobulin E levels to
common or suspected food allergens
ndash Significant differences in 25(OH)D levels were found between groups on
number and degree of food sensitization
ndash Infants with sensitivities significantly lower levels of 25(OH)D
ndash Vitamin D deficiency increased the risk of sensitization to food allergens
(OR 50 95 CI 18-141) especially to milk (OR 104 95 CI 33-
327) and wheat (OR 42 95 CI 11-158)
bull Also a relationship between vitamin D deficiency and worse
prognosis of AD
Ref Baek JH et al The link between serum vitamin D level sensitization to
food allergens and the severity of atopic dermatitis in infancy J Pediatr 2014
Oct165(4)849-54e1 doi 101016jjpeds201406058 Epub 2014 Aug 6
Atopic Dermatitis Vitamin D-Study 3
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
49
Study aimed to assess the effect of vitamin D supplementation on
winter-related AD
bull Randomized double-blind placebo-controlled trial of Mongolian
children with winter-related AD
bull 107 pts 2-17 years AD score 10 to 72 using the Eczema Area and
Severity Index (EASI)
bull Winter-related AD (eg history of AD worsening during the fall-to-
winter transition)
bull Subjects randomly assigned to oral cholecalciferol (1000 IUday)
versus placebo for 1 month
bull All children and parents received emollient and patient education
about AD and basic skin care
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
50
bull The main outcomes were changes in EASI score and in
Investigators Global Assessment
bull 1-month follow-up data were available for 104 (97) children
bull Clinically and statistically significant improvement in EASI score in
those taking vitamin D
bull Positive change in Investigators Global Assessment
Should AD patients supplement with vitamin D
Ref Carmargo CA Jr et al Randomized trial of vitamin D supplementation
for winter-related atopic dermatitis in children J Allergy Clin Immunol 2014
Oct134(4)831-835e1 doi 101016jjaci201408002
Atopic Dermatitis Vitamin D-Study 4
51
Atopic Dermatitis Key Points
bull AD is more prevalent in infants and pediatric patients than adults
bull Goals of self-treatment include reducingstopping pruritus
maintain hydration trigger avoidance and preventing secondary
infection
bull Nonpharmaceutical options include colloidal oatmeal bath oils
moisturizers emollients
bull Other therapies with proven or suspected benefit include topical
hydrocortisone vitamin D probiotics
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
52
7-year-old girl with recent onset of rash on upper extremities
bull Review the case and determine how yoursquod handle this situation
Is the patient a candidate for self-care
bull If so what would you recommend and why
bull If not what would you recommend and why
Atopic Dermatitis Case Study
Ref Image courtesy of Microsoft Clipart accessed 2-3-2015
53
Rosacea
54
Rosacea
bull Cutaneous disorder of uncertain
etiology
bull Often referred to as adult acne
bull Estimated to affect 13 million
Americans
bull Risk factors include
ndash Gender
ndash History
ndash Fair complexion
ndash Age
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
55
Rosacea Aggravating Factors
bull Hot foods and drinks
bull Spicy foods
bull Ethanol
bull Temperature extremes
bull UV exposure
bull Stress anxiety
embarrassment
bull Hot water bathing
bull Corticosteroids
bull Vasodilators
bull Exercise
56
Rosacea Demodex Mites
bull 20-80 adults have skin
mites
bull Stress illness age-related
skin changes allow growth
bull Rosacea patients have 10x
more mites
bull Dead mites release bacteria
that cause symptoms
57
Rosacea Clinical Presentation
bull In 2002 the National Rosacea Society convened a consensus
committee to develop classification system for rosacea signs and
symptoms
bull The system was reviewed and approved by 21 experts worldwide and
is used to conduct research analyze results compare information from
different studies and serve as a diagnostic reference in practice
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
58
Rosacea Subtype 1
bull Erythematotelangiectatic
rosacea
ndash Flushing persistent
erythema on central face
ndash Telangiectases common but
not essential
ndash Stinging swelling roughness
and scaling also common
59
Rosacea Subtype 2
bull Papulopustular rosacea
ndash Persistent erythema with
papules pustules that
come and go on central
face
ndash No blackheads present
ndash Burning stinging may
also occur
60
Rosacea Subtype 3
bull Phymatous rosacea
ndash Thickening skin irregular
surface nodules and
enlargement
ndash Rhinophyma most
common
ndash May occur after or
concurrent with subtypes
1 or 2
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
61
Rosacea Subtype 4
bull Ocular rosacea
ndash Watery or bloodshot eyes
periocular erythema
conjunctival
telangiectases
ndash Blepharitis conjunctivitis
ndash Foreign body sensation
burning stinging light
sensitivity blurred vision
62
Rosacea Management Overview
bull Therapeutic alternatives for relief of signs and symptoms
are intended as a menu of options versus a treatment
protocol
bull Most clinicians recommend a multidimensional treatment
approach that includes proper skin care and trigger
avoidance measures
63
Rosacea Drug Therapy
bull Papules pustules nodules plaques and perilesional erythema can be
treated with prescription drugs approved by the FDA for this purpose
ndash Topical metronidazole
ndash Topical azelaic acid
ndash Oral controlled-release doxycycline 40 mg
bull Topical sodium sulfacetamide-sulfur also has been used for years
bull Other antibiotics are also used on an off-label basis to treat a variety of
signs and symptoms
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
64
Rosacea Laser and Light Therapy
bull Nonablative lasers and polychromatic light-emitting devices
can be used to reduce erythema flushing and
telangiectases
bull Ablative lasers can be used to destroy excess tissue
associated with phymatous rosacea
65
Rosacea Self-Care
bull Patients should identify and avoid only those lifestyle
factors that trigger or worsen their symptoms
bull Patients can record daily contact with the most common
triggers and other possible factors and then look for those
triggers that seem to worsen their symptoms
66
Rosacea Self-Care
bull The goal of routine skin care is to maintain the integrity of the skin
while avoiding ingredients that irritate the skin
bull As a rule of thumb avoid ingredients that contain either sensory
provoking ingredients volatile substances irritants allergens
botanicals or unnecessary ingredients
bull Broad spectrum sunscreens with a sun protection factor of 15 or higher
should be appliedreapplied as directed on the label during sun
exposure
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
67
Rosacea Self-Care
bull Patients should wash their faces with nonirritating
cleansers and avoid using abrasive washcloths loofahs
and facial brushes
bull Patients should blot the skin dry and wait 30 minutes
before applying topical medications and cosmetics to the
face because stinging most often occurs when the skin is
wet
68
Rosacea Self-Care
bull Avoid all cosmetics that irritate the skin
bull Cosmetics with either a yellow or green tint can help mask redness
bull Avoid waterproof cosmetics because they can be difficult to remove
without the use of irritating agents
bull Purchase new cosmetics often to minimize contamination
bull Use brushes and avoid sponge application because brushes are less
irritating and easier to clean
69
Rosacea Self-Care
bull Patients with ocular rosacea
ndash Use artificial tears to relieve symptoms of dryness stinging itching
and burning
ndash Use warm compresses and cleanse eyelashes twice daily with
baby shampoo on a soft washcloth gently rubbed onto the upper
and lower lashes of the closed eyes for the relief of blepharitis
symptoms
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
70
Rosacea Key Points
bull Rosacea is a cutaneous disorder of uncertain etiology that affects
convex areas of the central face and is classified according to lesion
type location and severity
bull It affects approximately 13 million Americans
bull This incurable disorder can be managed with prescription medications
light and laser therapy
bull Pharmacists are in a unique position to recommend self-care options
that can enhance the effectiveness of these treatments
71
1 The SCORAD (SCORing Atopic
Dermatitis) Index
A Assesses a patientrsquos severity of atopic
dermatitis
B Provides patients with a list of therapeutic
options
C Defines how long patients should use self-care
D Lists diagnostic criteria for atopic dermatitis
72
2 Which of the following therapies does not
have supportive evidence of benefit nor has it
shown potential for management of symptoms
associated with AD
A Colloidal oatmeal
B First-generation antihistamines
C Vitamin D
D Probiotics
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
73
3 Which of the following would be a key
counseling point for a patient interested in
using OTC hydrocortisone for AD
A Use the product on affected area(s) 3-4 times daily for a
minimum of 14 days
B OTC hydrocortisone is ineffective for any symptoms
associated with AD make an appointment with your
primary care provider or dermatologist
C Newer data suggest the best response is achieved with
applications 1-2 times daily for maximum of 2 weeks
then stop for 2 weeks and can resume if needed
D Only apply this product on your arms and legs do not
apply on any other part of your body
74
4 Which of the following patients is at highest
risk for developing rosacea
A 20-year-old college student who works as a fry cook at
a local diner
B 45-year-old ad executive of Mediterranean descent
who plays racquet ball three times a week
C 37-year-old stay-at-home mom who had nodular acne
as a teenager
D 52-year-old professor with fair skin who blushes easily
75
5 Which of the following types of rosacea can be
managed in part by daily gentle skin cleansing
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D All of the above
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit
copy 2015 by the American Pharmacists Association All rights reserved
76
6 Which of the following types of rosacea may
require ablative laser therapy
A Erythematotelangiectatic rosacea
B Papulopustular rosacea
C Phymatous rosacea
D None of the above
77
Attendance Code
DERM
To obtain CPE credit for this activity go to bull Pharmacistcomlive-activities
bull Login
bull Click ldquoclaim creditrdquo
bull ldquoEnrollrdquo in the activity
bull Complete the assessment and evaluation
Your CPE must be filed by July 6 2015 in order to receive credit