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Dr Gayle TaylorConsultant DermatologistLeeds Teaching Hospitals NHS Trust
ATOPIC DERMATITIS
Commonest inflammatory disease of childhood
Prevalence: 15-20% UK childrenGenetic predisposition Much more prevalent past 30 yearsMost cases handled in primary care
ATOPIC DERMATITIS
• Increased levels of atopic disease + allergy–Smaller families
–Lack of exposure to animals in early life
–Non-communal child care
–Early childhood antibiotic use.
• Lower exposure to microbes which play a crucial role in the maturation of the host immune system (Th2 rather thanTh1) during the first years of life
AetiologyHygiene hypothesis
• Immunological factors
– Predominance of Th2 lymphocytes– High levels of IL4– Drive production of IgE– High levels of IgE in turn prompt antigen capture by
Langerhan’s cells
• Intestinal microflora can be different in individuals with allergic disorders and in those who reside in industrialized countries where the prevalence of allergy is higher
• ? Role for pro-biotics: results thus far disappointing
AetiologyImmunological abnormalities
Children with AD have dry skin
Skin barrier function is abnormal
Level of permeability barrier abnormality precisely parallels AD severity
AetiologyBarrier function
Impairment of barrier functionFilaggrin (protein) and ceramide (fat) required for good barrier function
High level of filaggrin mutations in those with atopic eczema (and eczema associated asthma)Allows enhanced transfer of antigens through the epidermis
Role for prevention in at risk individualsLess washing, more emollient
AetiologyImpairment in barrier function
Onset: rare < 6weeks of ageOnset < 6 months of age in 75% casesGeneral tendency to spontaneous
improvement throughout childhood60% (appx) clear by secondary school ageIncreased incidence of adult hand eczema
ATOPIC DERMATITISNatural History
Flexural distributionReverse pattern eczema can occurFacial involvement prominent in infantsItchyDermatographismPersonal history of atopy (asthma/hayfever)Family history of atopy(Blood tests, allergy tests)
ATOPIC DERMATITISDiagnosis
Eczema variantsDiscoid eczemaNodular prurigoSeborrhoeic eczema
ScabiesFungal infection
ATOPIC DERMATITISDIFFERENTIAL DIAGNOSIS
Education, education, educationImportant role for trained nurse:
explanation, demonstration and supportImproves complianceImproves quality of lifeReduces antibiotic and steroid use
ATOPIC DERMATITISMANAGEMENT: education
Education about the nature of the condition and the role of trigger factorsDry skinStress:Infections: bacterial, viral, candidalIrritants and allergens
ATOPIC DERMATITISEducation, education, education
Emollients: mainstay of treatmentAnalogy of the brick wall where mortar dried outHydration of skin to ‘swell the bricks’ replace the mortar and close the gaps
Barrier : layer of grease on the surface is a barrier which prevents infection/allergy penetration
The greasier the better (creams contain preservatives which can sting)
Essential to apply moisturiser even when the skin is clear: it is a preventor
ATOPIC DERMATITIS: TRIGGERSDry skin
Bath emollients: ‘soften’ the water and prevent other things (such as baby bubble bath) being used
Soap substitutes: light emollients which have mild emollient effect and stop soaps/ shower gels being used
‘Leave-on’ moisturisers:Wide range: lotions through to ointmentsSome contain antiseptics
Quantity: Infant: 125 g/weekSmall child 250g per weekLarge child 500g/week adult, Dry wraps: Comfifast, Clinifast, SkinniesWet wraps
ATOPIC DERMATITIS MANAGEMENTDry skin: emollients
Hydramol Ointment MOST GREASY
Epaderm ointment 50/50 (white soft paraffin/liquid paraffin) Diprobase ointment Diprobase cream Unguentum Merck Oilatum cream Doublebase cream Hydramol cream Zerobase cream Aveeno cream Dermol cream Dermol 500 lotion Balneum Plus cream E45 cream Aqueous cream LEAST GREASY
ATOPIC DERMATITIS MANAGEMENTDry skin: emollients
Tubular bandages: Tubifast/stockinetteSkin suits (Comfifast/Clinifast/Skinnies)No evidence of increased efficacy but
widely used and mostly likedReduce trauma to the skinHold emollient in placeUseful overnight. Day and night during
flaresWet wraps: may get large absorption of
steroid
ATOPIC DERMATITIS MANAGEMENTDRY wraps/WET wraps
Stress IllnessImmunisationTirednessPsychological distress/worries
ATOPIC DERMATITIS: TRIGGERSStress
Childhood illnesses are inevitable: equip parents to recognise signs of skin flaring and step up treatment
Immunisations: try to avoid when eczema active
Tiredness: vicious cycle of eczema flare and poor sleep leading to eczema flaring: use of sedative anti-histamines, short-term (Ucerax)
Psychological factors: family situation/school liason
ATOPIC DERMATITIS MANAGEMENTStress
Bacterial (Staphylococcal)Broken weepy skin, yellow crusts, pustules, red and hot
Confirm with skin swab (+/-nasal swab)Exclude MRSA
Prevention: antiseptic containing bath oils, shower gels and emollients
Early treatment: topical antiseptics or combined steroid/antiseptics.
Avoid topical fusidic acid.
ATOPIC DERMATITIS: TRIGGERSInfection
Herpes (cold sore) InfectionPainful small blisters usually starting on the face and then spreading
If localised and child well, oral aciclovirIf extensive: consider admission for IV therapy
If eyes involved: urgent ophthalmological opinion (eye casualty). Risk of permanent corneal ulceration.
ATOPIC DERMATITIS: TRIGGERSInfection
Candidal infectionAround the mouth, neck creases, nappy area
Red, glazed sore skin occasionally with little pustules
Can be flared by antibiotic therapyTreat with topical anti-yeast therapy (Canesten/Canesten HC, Timodine)
ATOPIC DERMATITIS: TRIGGERSInfection
IrritantsHeat Cold dry weatherCentral heatingLow humidityWoollen clothingDustBiological washing powders
ATOPIC DERMATITIS: TRIGGERSIrritants and Allergens
Airbourne allergiesHouse dust mite, cats, dogs, pollens, moulds
Contact allergensMetal jewellery, fragrances
Dietary allergensMost common: dairy, eggs, nuts, wheat, soya, cod
Urticarial skin reaction, vomiting, diarhhoea, swelling, wheezing
ATOPIC DERMATITIS: TRIGGERSAllergens
No role for ‘routine’ allergy testingThorough history Blood test: IgE, RASTS (specific IgE) to
airbourne allergens: HDM, pollens, pet dander, moulds. Occasionally foods: milk, eggs, fish, soya, wheat, PEANUT
Prick tests: as aboveBoth have false pos. and neg. ratePatch tests: sometimes indicated in
longstanding disease
ATOPIC DERMATITISAllergy Testing
Necessary to treat acutely inflamed or very itchy areas
Parental anxiety needs to be addressedUse with emollients, never on their ownApply (ideally) 20 mins before emollientsDon’t rub: smooth (to avoid folliculitis)
ATOPIC DERMATITIS MANAGEMENTTopical steroids
4 potencies: mild to ultrapotentMild: 1% hydrocortisone, Synalar 1:10Moderate: Eumovate, Betnovate RD, Synalar 1:4
Potent: Betnovate, Elocon, Cutivate, Synalar, Locoid, Nerisone cream
Ultrapotent: Dermovate
ATOPIC DERMATITIS MANAGEMENTTopical steroids
Weakest for shortest period possible but be realistic
Use ointments unless the skin is infected (creams +/- antimicrobial)
How much is enough: do fingertip units help?
Monitor useage Finger tip units: 0.5g treats 2 adult hand prints: limited flexural eczema Limited flexural eczema: 30g tube would last a month (b.d
treatment) 8 year old with 90% eczema: 65g per week
ATOPIC DERMATITIS MANAGEMENTTopical steroids
Treat early: a mild steroid, twice daily, when eczema starts to flare, can avoid having to use a stronger steroid
If the eczema doesn’t improve in 3-4 days, step up to a stronger steroid.
Once the eczema is improving for 3-4 days, reduce the strength of the steroid.
Once the eczema has cleared, reduce the mild steroid to once daily, then alternate daily for 3-4 days after the eczema has cleared
ATOPIC DERMATITIS MANAGEMENTTopical steroids:
Mild flares/delicate sites
Treat earlyModerate potency twice daily Once improved for 3-4 days, reduce the
strength of the steroid and step down as for mild flares
ATOPIC DERMATITIS MANAGEMENTTopical Steroids: moderate flares
Potent topical steroid twice daily until improving for 3-4 days (up to maximum 7-10 days), then reduce to moderate potency twice daily for 3-4 days, then to once daily 3-4 days
EITHER down to mild or use moderate 2-3 times per week depending on past response
Do not use potent steroids around the eyesCan be used short term (3-5 days) and very
infrequently on the face
ATOPIC DERMATITIS MANAGEMENTTopical Steroids: severe flares
Difficult area to treatThin delicate skin: increased liklihood of
steroid side effects (atrophy, cataracts)But uncontrolled diseaseassociated with:
Conjunctival inflammation and damageCorneal damage/keratoconusAiming to use intermittent mild topical steroids with very occasional use of moderate potency
Consider topical immunomodulators
ATOPIC DERMATITIS MANAGEMENTPeriorbital involvement
Elidel (pimecrolimus)Mild to moderate eczemaAims to reduce number of flares requiring topical steroids
Free from skin atrophy side effectsMild burning sensation in some patientsCan’t be used in presence of skin infectionUnlicensed under 2 years?long term effects ?skin cancer risk
TOPICAL IMMUNOMODULATORS
Protopic Ointment (Tacrolimus)Moderate to severe eczemaStops lymphocyte proliferationAs effective as potent topical steroid but no skin atrophy
Causes burning sensation on the skin (usually mild)
Licensed from the age of 2 upwardsCan’t be used in presence of skin infection?Effect of long term immuno-supression on skin cancer risk/lymphoma
TOPICAL IMMUNOMODULATORS
Non-sedative agents generally not helpful for itch but can reduce dermatographism
Sedative agent can be used for central effect, ideally short term, to aid sleeping during flare-ups
ANTIHISTAMINES
Failure may be due toSeverity of diseaseSecondary infectionUndiagnosed allergyPoor compliance with topical treatmentHigh stress levels/unresolved family issues
ATOPIC DERMATITISFailure to respond
Topical immunomodulators
Phototherapy
Systemic drugs
ATOPIC ECZEMA: 2ND LINE TREATMENTS
Topical immunomodulators
Phototherapy
Systemic agents
ATOPIC ECZEMA: 2ND LINE TREATMENTS
Most patients report that skin improves with sunlight
‘Artificial sunlight’: UVB, TLO1, PUVA
PHOTOTHERAPY
Broadband UVBUsed for many years: much less common
now 2-5 times weeklyCombine with standard topical treatmentMay need steroid coverRelatively long treatment times Heat can exacerbate eczema
PHOTOTHERAPYUVB
Narrow range UV within therapeutic spectrum
Excludes many erythrogenic raysShorter treatment timesMore effectiveConcern re long term side effects: skin
cancer risk
PHOTOTHERAPYNarrowband UVB (TLO1)
Photochemotherapy :Psoralen/ UVAPsoralen tablet or bath followed by
irradiation with UVAEffective but….Remain photosensitive for 24 hoursDefinite skin cancer risk Limited to lifetime total 200 treatments
PHOTOTHERAPYPUVA
Topical immunomodulators
Phototherapy
Systemic agents
ATOPIC ECZEMA: 2ND LINE TREATMENTS
• Systemic steroids: prednisolone• Highly effective for emergencies• Profound adverse effects on growth • Seldom used longterm in childhood:
monitor–Growth –POEM –SCORAD
SYSTEMIC AGENTSPrednisolone
Azathioprine: immunosuppressantCommonly used in transplantation medicineEffective though not in all casesMonitor TPMT, FBC, LFTsProven increase in non-melanoma skin
cancer risk with long-term useIncreased risk of infection
SYSTEMIC AGENTSAzathioprine
Ciclosporin (Neoral): immunosupressantUsed in transplantation medicineLicensed in adults for short term use (8
weeks) for eczemaExcellent efficacyIncreased risk of infectionIncreased risk of non-melanoma skin cancer
with long-term use
SYSTEMIC AGENTSCiclosporin
May be helpful in some casesUse increasing in children
SYSTEMIC THERAPIESMethotrexate
Systematic review of treatment for atopic eczemaReasonable RCT evidence to support the use of oral
ciclosporin, topical corticosteroids, psychological approaches and ultraviolet light therapy
ATOPIC DERMATITISEvidence based Management
• Insufficient evidence to make recommendations on emollients, cotton clothing, maternal allergen avoidance, antihistamines–Evidence on emollients and barrier function likely to be forthcoming
• Insufficient evidence to make recommendations on homeopathy, Chinese herbal remedies, hypnotherapy, antihistamines
ATOPIC DERMATITISEvidence based management
Complete absence of evidence on short bursts of steroids vs longer term weaker steroids, bandages, oral prednisolone and azathioprine
ATOPIC DERMATITISEvidence based management
Discourage use of soaps/detergents on infants’ skinRegular moisturiser: prescribe enoughBe familiar with 5-6 emollients with different
greasinessFull emollient regime: bath oil, soap substitute,
moisuriserBe familiar with steroid potenciesOintments rather than creams (unless infected)Severe/stubborn: short term potent and step down
gradually
ATOPIC ECZEMA: SUMMARY
Avoid topical antibioticsUse topical antiseptics, short-term, if necessaryConsider sedative anti-histamine at night if poor
sleepConsider checking ferritin, zinc, vitamin DIf poor response, consider
Severe disease: refer Secondary infection: refer if not responding Undiagnosed allergy: refer Poor compliance with topical treatment: frequent reminders, nurse
input High stress levels/unresolved family issues: enquire
ATOPIC ECZEMA: SUMMARY
Thank you for your attention
Any Questions?
ATOPIC DERMATITIS