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Atopic dermatitis: Chronic and relapsing disorder
Nestor Cisneros MD FRCPC
Assistant professor Allergy and Clinical immunology
Training Program Director Allergy and Clinical Immunology
Conflict of interest
• Shires: speaker
Objectives
➢At the end of this session,
➢ participants will be able to recognize the prevalence of atopic dermatitis.
➢ Review the current management of atopic dermatitis
➢ Recognize the psychosocial impact of atopic dermatitis.
Atopic Dermatitis: Epidemiology.• Chronic and relapsing disorder
• AD is the most common skin condition. • Affect 20 % children.
• 20-33% of AD patients have moderate to severe disease
• AD first manifestation with allergic disorder.
• Impact QoL to patients & their families
Burden of AD.
Infants with Eczema, sleeping problems and mental health at 10 yrs of age
Variable Odds ratio (95 CI)
• Emotional problemsInfant eczema with
sleep problems 2.63 (1.20-5.78)
• Conduct problemsInfant eczema with sleep problems 3.03 (1.01-9.2)
• Hyperactivity -Infant eczema 1.78 (1.02-3.09)- ever eczema 2.12 (1.34-3.37) Schmitt et al Allergy 2011Schmitt et al Allergy 2011
InfectionURI/OMBacterial, fungalViral infection
AllergensFood (egg)Environmental (mites)Contact dermatitis (Nickel)
Heat, drynessAnxiety
Triggers for atopic dermatitis
Itch-scratch cycle AD flares
How to treat Atopic Dermatitis
Education
Maintenance and repair of skin barrier
managing infectious triggers
Minimizing triggersSkin directed TXAntihistamines ( caution)
TCSTCI
/Bleach bath
Maintenance skin care
• Foundation of the AD management ( soaking bath)• Bathe daily
• Soak 10-15 minutes in lukewarm water
• Use moisturizing cleanser where needed
• Apply medication &moisturizing after bath
• Lubrication/moisturization:• Reduce the needs for topical steroids.
• Help to repair the skin barrier
Nicol NH, Boguniewicz M .Dematology Nursing Oct 2008
Topical therapy: emollient
Clark A et al J Drugs Dermatol 2011;10(5):531-7
Day 7
Day 21
N:392-17 year with mild to moderate AD
Topical Treatment of inflammation: TCS and TCI• Goal of therapy to treat inflammation
• Topical steroids: effective and extremely safe when use correctly
• Topical Calcineurin inhibitor: ( second line)• Acute therapy for inflammation and proactive therapy
• Key-give skin break.
Use of anti-inflammatory therapy to "put out the fire”
Topical corticosteroids
• First line treatment
• Potency classification• Class I –most potent
• Class VII – least potent
• Potency differ and can be confusing
• Address the steroid phobia.
Topical Corticosteroids
Vehicle or form of the products
TCI: topical calcineurin inhibitor
• Do not cause the side effects of TCS
• Beneficial to treat AD • Concern about long term use of TCS
• In areas on the face, eyelids
• Side effect: burning and stinging
• Higher cost
• FDA:• Black box warning (2006) due to the theoretical risk of lymphoma.
• Pediatric eczema elective registry :no increase in the risk of eczema (2014)
Black warming
Topical steroids-pearl
For patient saying
“As soon as I stop , it comes RIGHT BACK”
OR
“I HAVE TO USE IT EVERY DAY”
Then steroids potency is probably too low
Provided that all other areas of the treatment are being maximized
Management of the AD exacerbation
Zubierbier et al JACI 2006
Anti-inflammatory treatment
AD flare
Topical steroids application
Day 7-14;Low potency _faceMid high potency
Daily useEOD Emollients
Recovery
Aim for rare flares up
Proactive therapy for AD
Preventing eczema flare up William HC BJD 2011
How much to dispense
Area treated* Once BID x 1 week
Hands, head, face 2 g 88 g
Leg 4 g 56 g
Entire body 30 g 420 g
* 70 kg adult
Bleach bath
• Randomized• 31 patients ( 6 m-17 year with
moderated to severe eczema and bacteria infection)
• All treated with cephalexin 14 days prior.
Mean EASI score at one month and 3 month.
Huang J et al Pediatrics Vol. 123 No. 5 May 1, 2009
Mupirocin oint.Bleach bath
Intranasal petroleum ointPlain water bath
EASI: Eczema area and severity index score
Step care management.