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Atopic Dermatitis Adam Goldstein, MD Associate Professor UNC Department of Family Medicine Chapel Hill, NC aog@med.unc.edu Slide 2 Objectives Improve ability to accurately diagnose and manage 90% of cases of atopic dermatitis Improve ability to accurately diagnose and manage 90% of cases of atopic dermatitis Recognize differences in infant, childhood and adult presentations of atopic dermatitis Recognize differences in infant, childhood and adult presentations of atopic dermatitis Improve ability to diagnose and manage conditions associated with and sometimes confused with atopic dermatitis Improve ability to diagnose and manage conditions associated with and sometimes confused with atopic dermatitis Slide 3 Atopic Dermatitis: Definition Atopic dermatitis = eczema = itchy skin Atopic dermatitis = eczema = itchy skin Greek- meaning Greek- meaning (ec-) over (-ze) out (-ma) boiling Infants & small children (affects 1 in 7) Infants & small children (affects 1 in 7) Atopic dermatitis of childhood may reappear at different site later in life. Atopic dermatitis of childhood may reappear at different site later in life. Slide 4 Atopic Dermatitis: Cause The exact cause is unknown. The exact cause is unknown. Slide 5 Atopic Dermatitis: Cause (Charlesworth, Am J Med, 2002) Slide 6 Atopic Dermatitis: Cause ? Inborn skin defect that tends to run in families, e.g. asthma or hay fever ? Inborn skin defect that tends to run in families, e.g. asthma or hay fever 85% with high serum IgE and + skin tests food & inhalant 85% with high serum IgE and + skin tests food & inhalant (Jones, Clin Rev Allergy, 1993) Slide 7 Morphology Slide 8 Distribution In infants, the face is often affected first, then the hands and feet; dry red patches may appear all over the body. In infants, the face is often affected first, then the hands and feet; dry red patches may appear all over the body. In older children, the skin folds are most often affected, especially the elbow creases and behind the knees. In older children, the skin folds are most often affected, especially the elbow creases and behind the knees. In adults, the face and hands are more likely to be involved. In adults, the face and hands are more likely to be involved. Slide 9 Distribution Slide 10 Slide 11 Slide 12 Slide 13 Hand Eczema Slide 14 Foot Eczema Slide 15 Atopic Derm Adults Slide 16 Slide 17 Atopic Dermatitis: Associated features The skin is usually dry, itchy & easily irritated by: The skin is usually dry, itchy & easily irritated by: soap detergents wool clothing May worsen in hot weather & emotional stress. May worsen in hot weather & emotional stress. May worsen with exposure to dust & cats. May worsen with exposure to dust & cats. Slide 18 Associated Findings Pityriasis alba Pityriasis alba Slide 19 Associated Findings Xerosis Xerosis Slide 20 Associated Findings Keratosis Pilaris Keratosis Pilaris Slide 21 Associated Findings Ichthyosis Ichthyosis Slide 22 Hyperlinear Palmar Creases Slide 23 Diagnosis Major characteristics Major characteristics Pruritus with or without excoriation Typical morphology and distribution Chronic relapsing dermatitis Personal or family history of atopy (asthma, allergy, atopic derm, contact urticaria) Other characteristics Other characteristics Xerosis/Ichthyosis/palmar hyper/kerat. pilaris Early age of onset Cutaneous colonization and/or overt infections Hand/foot/nipple/contact dermatitis, cheilitis, conjunctivitis, Erythroderma, subcapsular cataracts (Drake, JAAD, 1992) Slide 24 Differential Diagnosis Seborrheic dermatitis Seborrheic dermatitis Slide 25 Differential Diagnosis Seborrheic dermatitis Seborrheic dermatitis Scabies Scabies Slide 26 Differential Diagnosis Seborrheic dermatitis Seborrheic dermatitis Scabies Scabies Drugs Drugs Slide 27 Differential Diagnosis Seborrheic dermatitis Seborrheic dermatitis Scabies Scabies Drugs Drugs Psoriasis Psoriasis Slide 28 Differential Diagnosis Seborrheic dermatitis Seborrheic dermatitis Scabies Scabies Drugs Drugs Psoriasis Psoriasis Allergic contact dermatitis Allergic contact dermatitis Slide 29 Differential Diagnosis Seborrheic dermatitis Seborrheic dermatitis Scabies Scabies Drugs Drugs Psoriasis Psoriasis Allergic contact dermatitis Allergic contact dermatitis Cutaneous T-cell lymphoma Cutaneous T-cell lymphoma Slide 30 Atopic Dermatitis: Treatment 1. Reduce contact with irritants (soap substitutes) 2. Reduce exposure to allergens 3. Emollients 4. Topical Steroids 5. Antihistamines 6. Antibiotics 7. Steroid sparing 8. Other (herbals, soaps) Slide 31 1. Reduce contact with irritants Avoid overheating: lukewarm baths, 100% cotton clothes, & keep bedding to minimum Avoid direct skin contact with rough fibers, particularly wool, & limit/eliminate detergents Avoid dusty conditions & low humidity Avoid cosmetics (make-ups, perfumes) as all can irritate Avoid soap- use soap substitute Use gloves to handle chemicals and detergents Slide 32 Soap Substitutes Cetaphil- soap substitute- far less drying and irritating than soap Cleansing & moisturizing formulations, all OTC Lotion, bar, soap, cream, sunscreen. Costs about $8-9 for 16 oz. Slide 33 2. Reduce exposure to allergens Keep home, especially bedroom, free of dust. Keep home, especially bedroom, free of dust. Allergic reactions include house dust mite, molds, grass pollens & animal dander. Allergic reactions include house dust mite, molds, grass pollens & animal dander. Special diets will not help most individuals b/c little evidence that food is major culprit. Special diets will not help most individuals b/c little evidence that food is major culprit. If food allergies exists, most likely d/t dairy products, eggs, wheat, nuts, shellfish, certain fruits or food additives. If food allergies exists, most likely d/t dairy products, eggs, wheat, nuts, shellfish, certain fruits or food additives. Slide 34 3. Emollients Emollients soften the skin soft and reduce itching. Emollients soften the skin soft and reduce itching. Moisture Trapping effectiveness Moisture Trapping effectiveness Best: Oils (e.g. Petroleum Jelly) Moderate: Creams Least: Lotions Apply emollients after bathing and times when the skin is unusually dry (e.g. winter months). Apply emollients after bathing and times when the skin is unusually dry (e.g. winter months). Slide 35 Emollients (contd) Large variety (e.g. Vanicream, Eucerin, Lubriderm, Moisturel, Curel, Neutrogena) Large variety (e.g. Vanicream, Eucerin, Lubriderm, Moisturel, Curel, Neutrogena) Inexpensive emollients include vegetable shortening (Snowdrift by Martha White) and petroleum jelly (Vaseline) Inexpensive emollients include vegetable shortening (Snowdrift by Martha White) and petroleum jelly (Vaseline) Urea creams Urea creams Oils Oils Slide 36 Emollients: Alpha-Hydroxy acid Creams are excellent for relieving dryness, but can sting & sometimes aggravate eczema Creams are excellent for relieving dryness, but can sting & sometimes aggravate eczema Useful for maintenance when no longer inflamed Useful for maintenance when no longer inflamed Forces epidermal cells to produce keratin that is softer, more flexible and less likely to crack Forces epidermal cells to produce keratin that is softer, more flexible and less likely to crack Preparations Preparations Glycolic Acid (8%) Lactic Acid or Lac-Hydrin (5-12%) Urea (3-6%) Use 1X/ day Use 1X/ day Slide 37 Emollients: Oils Consider using bath oil or mineral oil-based lotions in lukewarm bath water Consider using bath oil or mineral oil-based lotions in lukewarm bath water Add to tub 15 minutes into bath Add to tub 15 minutes into bath Bath oil preparations: Bath oil preparations: Alpha-Keri Aveeno bath Jeri-Bath Colloidal oatmeal (Aveeno) reduces itching Colloidal oatmeal (Aveeno) reduces itching Slide 38 4. Corticosteroids Topical steroids very effective Ointments for dry or lichenified skin Creams for weeping skin or body folds Lotions or scalp applications for hair-areas. Slide 39 Corticosteroids Hydrocortisone 1-2.5% applied to all skin. Quite safe used even for months Use intermittently thin areas- (eg-face & genitals) Stronger potency topical steroids for nonfacial/genital regions. Avoid potent/ultrapotent topical steroid preparations on face, armpits, groins & bottom. Slide 40 Corticosteroids Once under control, intermittent use of topical corticosteroid may prevent relapse Systemic steroids may bring under rapid control, but may precipitate rebound Once daily probably most cost effective (Green, Br J Dermatol, 2005) Slide 41 Steroids and Young Children Fluticasone proprionate cream 0.05% Fluticasone proprionate cream 0.05% Moderate- severe atopic derm > 3 months Moderate- severe atopic derm > 3 months Applied bid 3-4 weeks- mean 64% BSA Applied bid 3-4 weeks- mean 64% BSA No HPA suppression No HPA suppression (Friedlander, J Am Acad Dermatol, 2002 ) Slide 42 Corticosteroids : Pearls Different preparations prescribed for different parts of body or for different situations Educate on potencies & proper usage write down directions Bring all topicals each appointment to clarify use Slide 43 5. Antibiotics Atopic eczema frequently secondarily colonized with a bacteria (up to 30%). Use oral antibiotics in recalcitrant or widespread cases. Slide 44 Slide 45 Keep it simple Slide 46 Slide 47 6. Antihistamines Oral antihistamines can reduce urticaria & itch Non-sedating antihistamines less side effects but more expensive Sedative effect of hydroxyzine & diphenhydramine helpful Slide 48 7. Steroid Sparing Topical calcineurin inhibitors Topical calcineurin inhibitors Tacrolimus ointment & pimecrolimus cream Oral Cyclosporine Oral Cyclosporine Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation) or combinations of UVA & UVB Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation) or combinations of UVA & UVB (Jekler, J Am Acad Dermatol, 1990) Slide 49 Tacrolimus ointment (0.03%, 0.1% [Protopic]) Mild to moderate eczema Mild to moderate eczema Steroid dependent or signs of atrophy Steroid dependent or signs of atrophy Non-steroid responsive Non-steroid responsive BID x 2-4 weeks to evaluate response BID x 2-4 weeks to evaluate response Transient stinging possible Transient stinging possible Longer disease-free intervals Longer disease-free intervals Cost similar to high potency steroids (30gm/$60) Cost similar to high potency steroids (30gm/$60) (Ruzicka, N Engl J Med, 1997) Slide 50 Pimecrolimus cream 1% (15, 30, 100 gm [Elidel]) Approved Dec. 2001 Approved Dec. 2001 Blocks production/release cytokines T-cells Blocks production/release cytokines T-cells Moderate eczema Moderate eczema Steroid sparing Steroid sparing Transient stinging 8% children, 26% adults Transient stinging 8% children, 26% adults Cost similar to high potency steroids (30gm/$60) Cost similar to high potency steroids (30gm/$60) (Ruzicka, N Engl J Med, 1997) (Eichenfield, J Am Acad Dermatol, 2002) Slide 51 Tacrolimus ointment & pimecrolimus cream Licensed for patients > 2 years old mild-moderate eczema\ Licensed for patients > 2 years old mild-moderate eczema\ Safety? Safety? In controlled trials appear safe in adults and children In 2005, FDA issued warnings about a possible link between the topical calcineurin inhibitors and cancer (? increased risk of lymphoma and skin cancers with topical exposure) However, no definite causal relationship established However, no definite causal relationship established FDA recommends that these agents are used only as second-line therapy in patients unresponsive to or intolerant of other treatments FDA recommends that these agents are used only as second-line therapy in patients unresponsive to or intolerant of other treatments Avoid in children younger than two years of age Use for short periods of time and minimum amount necessary Avoid continuous use Avoid in patients with compromised immune systems Slide 52 Ointments (Tacrolimus) better than cream (Pimecrolimus) Slide 53 Oral Cyclosporine and PUVA Slide 54 (Charman, Arch Dermatol, 2004) The patient- oriented eczema measure Self Monitoring Slide 55 Other Psychological support Alternative treatments Chinese herbal tea Variably effective-not very palatable Liver toxicity possible Slide 56 Slide 57 Other Evening Primrose Oil / Star Flower Oil Contains gamma linolenic acid, fatty acid (deficient some atopic subjects) Slide 58 Alternative medications some patients may use for eczema Licorice Licorice Calendula Calendula Echinacea Echinacea Golden Seal Golden Seal Nettle Nettle Oats Oats Slide 59 Probiotics in primary prevention of atopic disease: a randomized placebo-controlled trial. Lactobacillus prenatally to mothers (FH eczema, AR, asthma) postnatally for 6 months to infants Endpoint: Chronic recurring eczema Eczema in probiotic 50% < than placebo (23% vs 46%) Number needed to treat = 4.5 (95% CI 2.6-15.6). (Kalliomaki, Lancet 2001) Slide 60 Other Laughter May Be Best Medicine...For Allergies NEW YORK, NY - Although few would consider allergies to be funny, results of a new study suggest that laughing them off might actually work. Dr. Hajime Kimata, of Unitika Central Hospital in Japan, induced allergic responses on the skin of 26 people with allergic dermatitis by exposing them to house dust mites, cedar pollen and cat hair, and then had them watch ``Modern Times'', featuring Charlie Chaplin. The participants exhibited a significant reduction in their allergic responses after watching the classic comedy, according to the report in the February 14th issue of The Journal of the American Medical Association. The effect lasted for 4 hours after the viewing Slide 61 Other Coal tar or less messy preps (liquid carbonis detergent 5-10%) in Eucerin or Aquaphor Chronic lichenified eczema patches Coal tar smells & stains clothes so apply qhs using old clothes and old linens Coal tar can provoke a folliculitis. Slide 62 Soaps Mild or Hypoallergenic Dove (unscented): Contains lotion Keri Oil of Olay Basis Purpose Cetaphil Skin Cleanser (non-soap) Neutrogena bar Pure Ivory soap is very drying/irritating Slide 63 Antibacterial Soaps Dial and Lever 2000 Cetaphil antibacterial cleansing bar Slide 64 Evidenced-based review 2002 (BMJ Clinical Evidence) Positive evidence that: Positive evidence that: topical corticosteroids relieve symptoms and are safe emollients & steroids better than steroids alone excellent control of house dust mite reduces symptoms if positive mite RAST scores & children bedding covers most effective Little to no evidence that: Little to no evidence that: dietary change reduces symptoms breast feeding or mother's diet prevents infant eczema Slide 65 Systematic review 2000 Positive evidence: Positive evidence: Topical steroids Oral cyclosporine UV light Psychological approaches Insufficient evidence Ag avoidance pregnancy Antihistamines Dietary restriction Dust mite avoidance Hypnotherapy Emollients Massage Evening primrose oil Topical coal tar Topical doxepin Chinese herbs (Hoare, Health Technol Assess, 2000) Slide 66 Systematic review Not beneficial: Not beneficial: Cotton clothing Biofeedback Bid vs qd topical steroids Bath additives Topical antibiotic/steroids vs steroids alone (Hoare, Health Technol Assess, 2000) Slide 67 Final Pearls Educate parents that the goal is CONTROL not CURE Educate parents that the goal is CONTROL not CURE Atopics exposed to herpes virus or smallpox vaccination may get severe infection with widespread involvement d/t altered skin barrier. Atopics exposed to herpes virus or smallpox vaccination may get severe infection with widespread involvement d/t altered skin barrier. Slide 68 Severe herpes infections in children with eczema Slide 69 Atopic Derm and Smallpox Vaccine (Ann Intern Med 2003;139) Slide 70 Costs H/C 1% Bid-tid 30 gm $3.00 TAC 0.1% Bid 30 gm $8.00 Fluticasone propionate 0.05% Qd-bid 30 gm $42.00 Mometasone furoate 0.1% Qd 30 gm $45.00 Betamethasone dipropionate 0.05% Bid 30 gm $20.00 Clobetasol propionate 0.05% Bid 30 gm $15.00 Halobetasol propionate 0.05% Qd-bid 30 gm $72.00 Pimecrolimus 1% Bid 30 gm $56.00 Tacrolimus 0.1% Bid 30 gm $60.00 Drugstore.com 2004 Slide 71 CASE 1 3 year old female with h/o eczema since 4 months old. Had done well on hydrocortisone 2.5% ointment when flared last winter. Parents ran out of the ointment and have been using vaseline and OTC hydrocortisone 0.5% without improvement. Child is now waking at night and constantly scratching. What do you want to do? What do you want to do? Slide 72 Case Treatment strategy: Review mild skin care regimen Confirm use of mild cleanser daily moisturizers & mild laundry detergent Prescribe sufficient potency & quantity of topical corticosteroids Which steroid class(es) would you px? Slide 73 Case- topical steroid choices TAC 0.1% oint. bid worse areas x 7-14 days Switch to H/C 2.5% ointment BID Taper over 4 weeks to emollients if possible Confirm parents understand dangers of prolonged steroid use and not to use potent steroids on face Slide 74 F/U 2 weeks later: Only slightly improved- now what? Slide 75 Now... Add oral antistaphylococcal agent for 7-14 days. REVIEW mild skin care regimen Follow-up in 2 weeks and SUCCESS! Slide 76 CASE 2 34 yo female with h/o hand eczema diagnosed by former MD for 6 years. Seems to get worse in winter, but never goes away entirely. A friend told her it could be a fungus. She was given fluocinonide (lidex) 0.05% cream and it helps some. She wants a refill. Slide 77 CASE 2 Not likely fungus given chronicity May have secondary staph infection May need more potent Class I steroid initially, e.g. clobetasol propionate (temovate) ointment Class II Fluocinonide (lidex) 0.05% cream ok less severe Slide 78 Case 3 75 YO male with chronic itchy spots- Using hydrocortisone cream 2.5% bid to ankle- minimal improvement Using Class II Fluocinonide (lidex) 0.05% ointment under occlusion to hip area- only thing that works Slide 79 Case 3 2.5% H/C too weak Fluocinonide (lidex) 0.05% ointment under occlusion causing atrophy Good case for topical tacrolimus Slide 80 Patient Education National Eczema Association National Eczema Association www.eczema-assn.org Slide 81 Thank you. Slide 82 References Drake LA, et al. Guidelines of Care For Atopic Dermatitis. J Am Acad Dermatol 1992;26:485-8. Drake LA, et al. Guidelines of Care For Atopic Dermatitis. J Am Acad Dermatol 1992;26:485-8. Atopic eczema. In Clinical Evidence British Medical Journal 2001. Available online at www.clinicalevidence.org Atopic eczema. In Clinical Evidence British Medical Journal 2001. Available online at www.clinicalevidence.org Correale CE, Walker C, Murphy L, Craig TJ. Atopic Dermatitis: A Review of Diagnosis and Treatment. J Fam Pract 1999; available at http://www.aafp.org/afp/990915ap/1191.html Correale CE, Walker C, Murphy L, Craig TJ. Atopic Dermatitis: A Review of Diagnosis and Treatment. J Fam Pract 1999; available at http://www.aafp.org/afp/990915ap/1191.html Ruzicka T, Bieber T, Schopf E, et al. A short-term trial of tacrolimus ointment for atopic dermatitis. European Tacrolimus Multicenter Atopic Dermatitis Study Group. N Engl J Med 1997; 337(12): 816-21. Ruzicka T, Bieber T, Schopf E, et al. A short-term trial of tacrolimus ointment for atopic dermatitis. European Tacrolimus Multicenter Atopic Dermatitis Study Group. N Engl J Med 1997; 337(12): 816-21. Eichenfield LF, LuckyAW, Boguniewicz M, et al. Safety and efficacy of pimecrolimus cream 1% in the treatment of mild and moderate atopic dermatitis in children and adolescents. J A Acad Dermatol 2002; 46; 495-504. Eichenfield LF, LuckyAW, Boguniewicz M, et al. Safety and efficacy of pimecrolimus cream 1% in the treatment of mild and moderate atopic dermatitis in children and adolescents. J A Acad Dermatol 2002; 46; 495-504. Slide 83 References Charlesworth EN. Pruritic dermatoses: overview of etiology and therapy. Am J Med 2002; 113S, 9A: 25S-33S. Charlesworth EN. Pruritic dermatoses: overview of etiology and therapy. Am J Med 2002; 113S, 9A: 25S-33S. Wahn U, et al. Efficacy and safety of pimecrolimus cream in the long-term management of atopic dermatitis in children. Pediatrics 2002; 110 (1 Pt 1): e2. Wahn U, et al. Efficacy and safety of pimecrolimus cream in the long-term management of atopic dermatitis in children. Pediatrics 2002; 110 (1 Pt 1): e2. Friedlander SF, et al. Safety of fluticasone proprionate cream 0.05% for the treatment of severe and extensive atopic dermatitis in children as young as 3 months. J Am Acad Dermatol 2002; 46: 387-394. Friedlander SF, et al. Safety of fluticasone proprionate cream 0.05% for the treatment of severe and extensive atopic dermatitis in children as young as 3 months. J Am Acad Dermatol 2002; 46: 387-394. Hoare C, et al. Systematic review of treatments for atopic eczema. Health Technol Assess 2000; 2: 1-191. Hoare C, et al. Systematic review of treatments for atopic eczema. Health Technol Assess 2000; 2: 1-191. Green C, Colquitt JL, Kirby J, Davidson P. Topical corticosteroids for atopic eczema: clinical and cost effectiveness of once-daily vs. more frequent use. Br J Dermatol 2005; 152: 130-41. Green C, Colquitt JL, Kirby J, Davidson P. Topical corticosteroids for atopic eczema: clinical and cost effectiveness of once-daily vs. more frequent use. Br J Dermatol 2005; 152: 130-41. Charman CR, Venn AJ, Williams HC. The patient-oriented eczema measure: development and initial validation of a new tool for measuring atopic eczema severity from the patients' perspective. Arch Dermatol 2004; 140: 1513-9. Charman CR, Venn AJ, Williams HC. The patient-oriented eczema measure: development and initial validation of a new tool for measuring atopic eczema severity from the patients' perspective. Arch Dermatol 2004; 140: 1513-9.