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ATOPIC DERMATITIS (2003)
PHILIPPINE DERMATOLOGICAL SOCIETY
103
Philippine Dermatological Society
Officers & Board of Trustees
PresidentVice President
SecretaryTreasurer
Board Members
Immediate Past President
Rm. 1015 Front Tower, Cathedral Heights Complex, St. Lukes Medical Center, E. Rodriguez Sr. Ave, Quezon CityEmail: [email protected] Website: http://www.pds.org.ph Tel/Fax No.: 727-7309 Fax No.: 932-9269
Francisca C. Roa, MDEvangeline B. Handog MDMa. Lorna F. Frez, MDMa. Teresita Gabriel MD
Benjamin Bince, MDMarcellano Cruz MDMa. Juiet Macarayo MDArnelfa Paliza MDGeorgina Pastorfide MDCarmela Veronica Reyes MDLilian Villafuerte MD
Amelia V. Tianco, MD
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Guidelines of Care for Atopic Dermatitis
I. Definition
Atopic Dermatitis (AD) is a chronic and recurrent inflammatory dermatologic problem marked by severe pruritus causing excoriations, erosions, lichenification and susceptibility to skin infections. The distribution of the lesions are age-related, and a family / personal history of atopy, asthma or allergic rhinoconjunctivitis is elicited. AD has no biological marker.
II.Rationale
A. Scope
AD is a disease causing great burden on the qual-ity of life of the patient and family alike. This familial disease has a genetic predisposition and environmentally influenced expression.
B. issue
Recognizing AD relies on good patient history (includes family history) and a thorough physical examination especially that of the skin.
III. Diagnosticcriteria
A. Clinical
1. Major Characteristics:
a. Pruritus
b. Typical Morphology & Distribution
1) Eczematous dermatitis
2) Flexural lichenification or linearity in adults
3) Facial & extensor involvement in infants
4) Any of these patterns or combination of patterns can appear in both adults & children
c. Chronic or chronical ly re lapsing dermatitis
d. P e r s o n a l o r f a m i l y h i s t o r y o f atopy (asthma, allergic rhinoconjunctivitis, atopic dermatitis, contact urticaria)
2. Other Characteristics
a. Xerosis
b. Ichtyosis/ palmar hyperlinearity in adults
c. Early age of onset
d. Cutaneous colonization and/or overt infections
1) Staphylococcus aureus
2) Herpes simplex virus
3) Warts
4) Molluscum
5) Others
e. Nonspecific hand and/or foot dermatitis, increased susceptibility to irritant contact dermatitis
f. Nipple eczema
g. Cheilitis
h. Recurrent conjunctivitis
i. Infraorbital fold
j. Keratoconus
k. Anterior subcapsular cataracts
l. Orbital darkening
m. Facial pallor / facial erythema
n. Erythroderma
o. Pityriasis alba
p. Anterior neck folds
q. Perifollicular accentuation
r. White dermographism / delayed blanch
s. Impaired cell-mediated immunity
t. Other
B. Diagnostic/ConfirmatoryTests
1. Uncomplicated AD with definite clinical characteristics: none required
2. For definitive diagnosis or complicating factors
a. Hematological
1) Complete blood count
a) Differential count
b) Total count for eosinophilia
b. Immunologic Testing
1) Complement levels
Prepared by: Maria Victoria C. Dizon, MD
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2) Serum IgE
c. Smears for infective agents
1) Tzanck test
2) KOH preparation
d. Cultures
1) Bacterial (with antibiotic sensitivity)
2) Viral
3) Fungal
e. Skin biopsy
f. Patch test
g. Radioallergosorbent tests may be appropriate in special cases
h. Scratch / prick / intradermal tests
i. Food elimination
j. Psychological evaluation: AD tends to flare during periods of psychic stress (anxiety, depression, anger, embar-rass-ment, shame, resentment). If factors cannot be adequately evaluated and treated by the dermatologist, psycho-logical evaluation and care, including testing, may be of value and should be considered.
iV. Recommendations
Goal: Management is individualized to improve the quality of life of the patient allowing optimal productive daily activities. The aim is to hydrate the skin, reduce inflammation, prevent the itch and eruption of the lesions and relieve sleep disturbance.
1. Prevention / Modulation of trigger factors
a. Patient Comprehension and avoidance of trigger factors
1) Skin care products that cause skin irritation or dryness
a) Soaps
(1) Germicidal / fragrant
(2) Non-moisturized
(3) Shower gels / bubble baths
(4) Fabric softeners
(5) Harsh detergents
b) Fabrics
(1) Rough
(2) Occlusive
2) Environment
a) Excessive heat (ill-ventilated rooms, summer months)
b) Extreme cold (air-conditioned rooms)
c) Exposure to known allergens (in gested, inhaled, contactants like herb concoctions)
3) Emotional stress
4) Strenuous physical activities
5) Hygienic practices
a) Improper bathing practices
(1) Frequency of bathing – too fre-quent bathing or prolonged water exposure dries out the skin.
(2) Use of abrasives (scrub cloths, loofahs, pumice stones)
2. Therapy
a. Topical 1) Anti-inflammatory agents a) Corticosteroids : mid to high
strength steroids after bathing may be used for brief periods, low strength steroids for mainte nance. Certain vehi cles may act as irritants, so alternative products or compounded prepa rations may be indicated.
b) Tar preparation c) Phototherapy (1) UVA (with or without psoralen)
(2) UVB
(3) Goeckerman and/or Ingram
d) Antibiotics: for localized sites
(1) Mupirocin
(2) Fusidic acid
e) Moisturizers / Emollients: applied within 3 minutes from bathing.
f) Immunomodulators
(1) Tacrolimus (FK506)
(2) Pimecrolimus (ASM 981)
g) Therapeutic baths, compresses, cleansers
(1) Tars
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(2) Emollients / moisturizing soaps
(3) Colloidals
(4) Skin cleansers
2) Oral / Systemic
a) Antihistamines – single or multiple
(1) Hydroxyzine hydrochloride
(2) Chlorpheneramine maleate
(3) Cetirizine
(4) Other
b) Antibiotics
c) Corticosteroids (rarely)
d) Immunotherapy
(1) Cyclosporine
(2) Mycophenolate mofetil
(3) Methotrexate
(4) Azathioprine
(5) Interferon-alpha and -gamma
(6) Other
e) Ketotifen (a mast cell stabilizer)
3) Dietary
a) Elimination diet
b) Supplements
c) Other
4) Hyposensitization
5) Others may include but are not limited to the following:
a) Occupational and / or psychological counseling
b) Bed rest
c) Psychotherapy
6) Hospitalization when indicated
V. Supportingevidence
See References.
Vi. Disclaimer
Despite strict adherence to these guidelines, a complete cure of atopic patients will not be ensured. Patient management is individualized and deciding on the management solely depends on the physician.
References:1. Absolon CM, Cottrell D, Eldridge SM, Glover MT.
Psychological disturbance in atopic eczema: the extent of the problem in school-aged children. Br J Dermatol 1997; 137: 241-45.
2. Coleman R, Trembath R, Harper JI. Genetic studies of atopy and atopic dermatitis. Br J Dermatol 1997; 136. 1-5.
3. Dorner W, Baylock KW, et al. Guidelines of care for atopic dermatitis. J Am Acad Dermatol 1992; 26: 485- 8.
4. Eichenfield LF, Lucky AW, Boguniewicz M, et al. Safety and efficacy of pimecrolimus (ASM 981) cream 1% in the treatment of mild and moderate atopic dermatitis in children and adolescents. J Am Acad Dermatol 2002; 46: 495-504.
5. Hanifin JM, Chan S. Biochemical and immunologic mechanisms in atopic dermatitis: new targets for emerging therapies. J Am Acad Dermatol 1999; 41: 72-7.
6. Harper JI, Ahmed I, Barclay G, et al. Cyclosporin for severe childhood atopic dermatitis: short course versus continuous therapy. Br J Dermatol 2000; 142: 52-8.
7. Krafchik BR. Diagnosis and management of atopic dermatitis. Dermatol Ther 1997: 2;18-28.
8. Leent EJM, Gräber M, Thurston M, et al. Effectiveness of the ascomycin macrolactam SDZ ASM 981 in the topical treatment of atopic dermatitis. Arch Dermatol 1998; 134: 805-9. :127
10. Leung DYM, Soter NA. Cellular and immunologic mechanisms in atopic dermatitis. J Am Acad Dermatol 2001; 44: S1-12.
11. Neuber K, Schwartz L, Itschert G, Tom Dieck A. Treatment of atopic eczema with oral mycophenolate mofetil. Br. J Dermatol 2000: 143: 385-391.
12. Paller AS, Eichenfield LF, Leung DYM, et al. A 12-week study of tacrolimus ointment for the treatment of atopic dermatitis in pediatric patients. J Am Acad Dermatol 2001; 44: S47-57.
13. Ramsay CA, Savole JM, Gilbert M, et al. The treatment of atopic dermatitis with topical fusidic acid and hydrocortisone acetate. J Eur Acad Dermatol Venerol 1995; 7: S15-S22.
14. Ricci G, Patrizi A, Specchia F, et al. Effect of house dust mite avoidance measures in children with atopic dermatitis. Br J Dermatol 2000; 143: 379-384.
15. Ruzicka T, Assmann T, Homey B. Tacrolimus: The drug for the turn of the millenium? Arch Dermatol 1999; 135: 574-580.
16. Tofte SJ, Hanifin JM. Current management and therapy of atopic dermatitis. J Am Acad Dermatol 2001; 44: S13-6.
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Drugs Mentioned in the Treatment GuidelineThis index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing information of these drugs can be found in PPD reference systems.
TopicalCorticosteroidsBetamethasone Betnovate Betnovate Scalp Diprolene Diprosone Steroderm Valezone Bethamethasone/ clioquinol Betnovate-C Diproform Betamethasone/ clotrimazole Clotrasone Betamethasone/ fusidic acid FucicortBetamethasone/ gentamicin DiprogentaBetamethasone/ gentamicin/
clotrimazole Triderm Betamethasone/ gentamicin/
tolnaftate/ clioquinol Quadriderm
Quadrotopic Cream Betamethasone/ neomycin
sulfate Betnovate-N Betamethasone/ salicylic acid Diprosalic Clobetasol Clobenate Clobederm Dermovate Dermovate Scalp Clobetasol/ neomycin/ nystatin
Clobederm-N Dermovate NN Desonide Desowen
Sterax Dexamethasone/ Neomycin
sulfate Decilone CreamDiflucortolone Nerisona/ Nerisona ForteFluocinolone Aplosyn/Aplosyn HP
Flozet Synalar/Synalar HP Syntopic Fluocinolone/ Clioquinol
Aplosyn CFluocinolone/ Neomycin sulfate
Aplosyn N Neo-Synalar 10/ Neo-Synalar 25
Fluocinonide Lidemol Lidex
Fluocinonide/ Neomycin sulfate/ Gramcidin/ Nystatin
Lidex NGN Fluticasone
Cutivate Fluocortolone Ultralan Hydrocortisone Cortizan Efficort Hydrotopic Lacticare-HC Lotion Hydrocortisone/ Miconazole
nitrate Daktacort Hydrocortisone/ Crotamtion
Eurax-HydrocortisoneHydrocortisone/ Oxytetracycline
Terra-Cortril TopicalMometasone furoate
Elica Elocon
Methylprednisolone aceponate Advantan Triamcinolone acetonide Kenacort A 0.1%
TopicalAntibioticsGentamicin sulfate Bactiderm Ointment Garamycin 0.1% Cream/
OintmentMupirocin BactrobanBacitracin/ Neomycin sulfate/
Polymyxin B sulfate BNP OintmentNitrofurazone Drugmaker's Biotech
Nitrofurazone FuracinFusidate Na Fucidin Intertulle/Ointment/
Cream Fusoderm 2% OintmentOxytetracycline HCl/ Polymyxin
B sulfate Terramycin Skin Antibiotic
Keratoplastics Polytar
TopicalImmunomodulatorPimecrolimus ElidelEmollients,Demulcents&Protectants
Cetaphil Dermablend cleansing milk Lactacyd Liquid Lacticare Nutraderm Nutraplus Oilatum Bar/ Gel/ Plus PhysiogelPetroleum jelly
Apollo Petroleum Jelly Zinc oxide/ benzoic acid/ sali-
cylic acid/ sulfur Bioderm Ointment
Zinc oxide/ calamine Calmoseptine OintmentZinc oxide/ econazole nitrate Pevaryl HP
AntihistaminesChlorphenamine maleate Antamin Barominic Chlor-trimeton Clormetamine Drugmaker's Biotech
Chlorphenamine Hargenan Synestal
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UL ChlorphenamineChlorphenoxamine hydrochlo-
ride SystralCetirizine
Virlix Zinex ZyrtecClemastine Tavegyl TavistDesloratadine
Aerius Diphenhydramine
Alertuss Am-Europharma Diphenhydramine
Benadryl Biogenerics Diphenhydramine Dramelin Drugmaker's Biotech Diphenhydramine
Hizon Diphenhydramine Inj Pharex Diphenhydramine
Hydroxyzine Iterax
Levocetirizine Xyzal
Loratadine Claritin Loradex
OralAntibiotics Amoxicillin
Aldemox Amoxil Amoxsteryl Amoxtrex Amusa Apamax/Apamax Forte
Athenalyn Axmel Bacihexal
Biogenerics Amoxicillin Cartrimox
Cilfam Clearamox Curamox Daisamox DLI Amoxicillin Drugmaker's Biotech
Amoxicillin Eleomox Emilex
Glamox Globamox Globapen
Harvimox Himox
IHC-Amoxicillin Intermox Jamox/Jamox Forte Littmox Macropage
Medimoxil Megamox
Montecil Moxillin Multicare Amoxcillin
Novamox Oramox/Oramox Forte
Pediamox Pharex Amoxicillin
Pharmamox Polymox
Promox RiteMED Amoxicillin
Semoxillin Servimox
Shinamox Sumoxil Teramoxyl Zymoxyl
Amoxicillin/ clavulanic acid Amoclav Augmentin Natravox Ampicillin
Ampicin Ampimycin Ampin Amplivacil Apamicin Bactimed Biogenerics Ampicillin Celidam DLI-Ampicillin Drugmaker's Biotech Ampicillin Eurotrexil
Excillin Genaxcin
Pensyn
Pentrexyl
Polypen RiteMED Ampicillin Saloxin
Shinapen Ampicillin/Cloxacillin Cloxamicin PensylcloxAzithromycin Zithromax Bacampicillin Bacacil PenglobeCefaclor Ceclor/Ceclor BID/ Ceclor CD Ceclobid Clorotir Pharex Cefaclor RiteMED Cefaclor XelentCefadroxil Drozid Duracef Cefalexin Asaflex Biogenerics Cefalexin Bloflex Cefalexin-Vamsler Cefalin Capsule/ Drops/
Suspension Ceporex Cidoxine Cromlex Difagen Drugmaker's Biotech
Cefalexin Eliphorin Exel Fensid Fevenil Genflex Gesenal Harvexyl Keflex Lefex
Lexum Lyceplix Medoxine Oneflex Oranil
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Pectril Pharex Cefalexin RiteMED Cefalexin
Servispor VCP Cefalexin Xinflex Zeporin Cefatrizine ZanitrinCefdinir Omnicef Cefprozil Procef Cefradine Sedinef Velodyne VelosefCefuroxime Biogenerics Cefuroxime Kefox Lifurox Profurex RiteMED Cefuroxime Romicef Shincef Zegen Zinacef ZinnatCiprofloxacin Ciloxan Ciprobay Cipromet Cirok Iprolan Pharex Ciprofloxacin Xipro Zyflox ZalvosClarithromycin Klaricid/ Klaricid OD OnexidClindamycin Biogenerics Clindamycin Clindal Dalacin C HCl/Dalacin C
Palmitate/Dalacin C Phosphate
Inprosyn-HPCloxacillin Biogenerics Cloxacillin Cloxigen Drugmaker's Biotech Cloxacillin
Encloxil IHC-Cloxacillin Interclox Myrex Cloxacillin Oxaclen Patriflex Pharex Cloxacillin Prostaphlin-A Ritemed Cloxacillin Cotrimoxazole Bacidal Bactille Forte Bactille-TS Bactrim
Bacxal Biogenerics Cotrimoxazole Cotrexel
Cotribase Cotrimoxazole-Vamsler DLI-Cotrimoxazole Doctrimox Drugmaker's Biotech Cotrimoxazole
Fedimed Genoxzole/
Genoxzole Forte Genzaprim/ Genzaprim Forte
Globamox Globec/Globec Forte Gutrisul Intrafort Kathrex Lagatrim Forte Macromed Microbid/Microbid DS Onetrim Pharex Cotrimoxazole Procor
RiteMED Cotrimoxazole Septrin
Servitrim Synerzole Thoprim Trihexal
Trim-S Trimephar Trimetazole/ Trimetazole DS Trizole Suspension
Doxycycline
Atrax Doryx Doxicon Doxin Drugmaker's Biotech
Doxycycline Harvellin Servidoxyne Vibramycin Erythromycin Am-Europharma Erythromycin Ditron DLI-Erythromycin Drugmaker's Biotech
Erythromycin Ery-max Erycar Erycin Erythrocin/Erythrocin DS
Erythrolan Ethiocin Gentrocin Ilosone Pharex Erythromycin RiteMED Erythromycin Romaxin Sefavex Sensomed Erythromycin ServitrocinFlucloxacillin Na StafloxinLevofloxacin Floxel LevoxLincomycin Harvivin Lincocin Moxifloxacin Avelox Ofloxacin Gyros Inoflox Pharex Ofloxacin Qinolon Oxytetracycline Terramycin Roxithromycin Macrol/Macrol Kiddie/ Toddler/OD RulidSultamicillin Unasyn Oral
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Tetracycline Ritemed Tetracycline
Tetracycline-B Unimycin OralSteroidsBetamethasone Betnelan
Celestamine Celestone
DiprospanBetamethasone/ chlorphenamine
maleate Betneton Dexamethasone Decilone Drenex Oradexon/ Oradexon Forte ScancortinMethylprednisolone Adrena Depo-Medrol Medrol Solu-Medrol Prednisolone Liquipred Optipred RiteMED Prednisolone Prednisone Drazone Drugmaker's Biotech Prednisone GXI Prednisone Orasone 5/ Orasone 20 Pred 5/10/30 Prednisone Organon Triamcinolone Kenacort Ketotifen
Quomyl Zadec / Zadec SRO