Main Issue November 2011

Therapies in Practice: New Directions in Pediatric Atopic Dermatitis Care

New therapies as well as practical treatment strategies give clinicians more options in the management of atopic dermatitis.

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Atopic dermatitis (AD) remains fertile ground for scientific inquiry. There have been a number of noteworthy publications during the past year in the realm of epidemiology and therapy. Ahead I will present some of these reports and offer reflections on the state of care.

Connections and Associations

In recent years, atopic dermatitis has been linked to various other medical conditions and medical and non-medical therapies. However, a recent review suggests that some of these associations are not based in good science. For example, organic foods and fish oils have no effect on atopic dermatitis and therefore should not be recommended as a treatment or preventive measure. In addition, though some studies have suggested AD patients are at greater risk for some cancers like lymphoma, AD patients may actually have decreased risk of glioma and leukemia, according to available data. Also, no link has been found between eczema and MS. Finally, though cross sectional studies have suggested an association between eczema and ADHD, no causal connection has been established.

New research has also helped elucidate the relationship between AD and community acquired methicillin-resistant Staphylococcus aureus (CAMRSA). In one study, patients with AD were less likely to have CA-MRSA than patients without AD. Eczema patients had lower present rates (44 percent vs. 14 percent), as well as a lower rate of increase in MRSA infection over time. Inducible clindamycin resistance was also found to be low in AD patients. Counter-intuitive to the notion that AD patients are more susceptible to all skin infections, this data seems to suggest that they may be at reduced risk for CA-MRSA.

Action Plan: Bathing and Moisturizing

Eczema patients would likely benefit from written instructions for present and future care. As with Asthma Action Plans, Eczema Action Plans (EAP) may improve outcomes, research suggests. These written instructions might include a daily skin care routine, indicating when and how long to bathe, moisturize, and use medication. This level of detailed, dynamic clinical education and documentation can increase understanding and adherence and improve treatment response.

The age-old question asked by all AD patients, “To bathe or not to bathe?”, lives on. A very small but intriguing study begins the process of perhaps replacing opinions about bathing with actual evidence. Dr. Lawrence Eichenfield’s group in San Diego performed a crossover study of five patients with atopic dermatitis and five controls, in which each patient underwent four different bathing regimens, including:

  • A 10 minute bath with no moisturizer;
  • A 10 minute bath with immediate post-bath moisturizer
  • A 10 minute bath, with moisturizer application 30 minutes after; and
  • No bath, just moisturizer.

The outcome measure was mean hydration and final hydration at 90 minutes. The results showed that peak hydration occurred in the group that did not bathe at all, while the lowest hydration was measured in the group that bathed but did not moisturize. While this study is far too small to generate definitive conclusions, it supports longheld notions that, first, the skin of patients with atopic dermatitis is more difficult to hydrate than that of patients without AD, and second, bathing without moisturizing is inadvisable.

Therapeutic Update

On the treatment front, several new findings offer perspective on the value of individual treatments. In a study looking at maintanence of eczema control by systemic therapies, 55 patients received cyclosporine A 5mg/kg for six weeks, after which they divided into two groups, with 26 patients receiving cyclosporine A at 3mg/kg and 24 patients receiving enteric-coated mycophenylate sodium. While both groups acheived equal efficacy during the maintenance therapy arm, the cyclosporine A group had a faster onset of action.

Long recognized but often overlooked, at least in the pediatric population, phototherapy may provide benefit for AD patients. In a study of 12 patients with moderate to severe AD, NB-UVB was administered three times weekly for 12 weeks. All treated patients had greater than 50 percent reduction in SCORAD (SCORing Atopic Dermatitis), improved biomarkers, and improved epidermal hyperplasia.

For severe AD patients requiring aggressive therapy, my typical algorithm involves wet wrap therapy followed by phototherapy. If these interventions do not provide benefit, the next appropriate step would likely be cyclosporine, then perhaps mycophenylate and azathoprine. Methotrexate and other systemic agents can also be considered. Prednisone is generally not an appropriate therapy for atopic dermatitis and should only be considered if there is no alternative. If prednisone must be prescribe, I recommend 1-2mg/kg daily, tapered over two to three weeks, during which time you can bridge back to topical steroids or light therapy.

TCIs have long been considered effective for treatment of AD, but lingering questions regarding their potential association with several cancers have given many clinicians pause. A retrospective observational cohort study found no association with overall cancer rate in nearly one million patients treated with TCIs from 2001 to 2004. In another meta-analysis of cancer risk in AD patients using TCI therapy, the researchers concluded that there is insufficient data to answer the TCI-cancer question.

Now and the Future

Our knowledge base regarding AD management continues to evolve. Epidemiologic studies refine those associations that must be thoughtfully considered in the clinic—AD patients are, for example, at increased risk for developing asthma—from those that remain unproven, such as the purported association between AD and ADHD. Treatment of the most severely affected patients can include systemic immunomodulatory agents as well as phototherapy, but we should never forget about the variety of practical approaches (such as wet wraps) that may also aid in bringing relief to our patients.

This article is based on Dr. Sidbury’s presentation for the Atopic Dermatitis Symposium at the Summer Meeting of the American Academy of Dermatology in New York, NY, August 2011.

Dr. Sidbury is Associate Professor in the Department of Pediatrics and Chief of the Division of Dermatology at Seattle Children’s Hospital and the University of Washington School of Medicine. Fall

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