Atopic Dermatitis

DR. SHILPA SONIDR. SHILPA SONI

Atopic Dermatitis: Definition Atopic dermatitis = eczema = itchy skinAtopic dermatitis = eczema = itchy skin Greek- meaning Greek- meaning

(ec-) over(ec-) over (-ze) out (-ze) out (-ma) boiling (-ma) boiling

Infants & small children (affects 1 in 7)Infants & small children (affects 1 in 7) Atopic dermatitis of childhood may reappear at Atopic dermatitis of childhood may reappear at

different site later in life.different site later in life.

Etiology DECREASED SKIN BARRIER FUNCTION- DECREASED SKIN BARRIER FUNCTION- - reduced filaggrin & loricrin ceramide levels reduced filaggrin & loricrin ceramide levels

((loss of FLG gene on chr 1q21loss of FLG gene on chr 1q21))- Reduced ceramide levelsReduced ceramide levels- increased levels of endogenous proteolytic increased levels of endogenous proteolytic

enzymesenzymes- Enhanced TEWLEnhanced TEWL

SKIN BARRIER MAY ALSO BE SKIN BARRIER MAY ALSO BE DAMAGED BY EXOGENOUS DAMAGED BY EXOGENOUS PROTEASES BY –PROTEASES BY –

- HOUSE DUST MITES HOUSE DUST MITES - Staphylococcus aureusStaphylococcus aureus

Atopic Dermatitis: Cause The exact cause is unknown. The exact cause is unknown.

Atopic Dermatitis: Cause

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

Morphology

Distribution In infantsIn infants, the , the faceface is often affected first, is often affected first,

then the hands and feet; dry red patches then the hands and feet; dry red patches may appear all over the body.may appear all over the body.

In older children,In older children, the the skin foldsskin folds are most are most often affected, especially the elbow creases often affected, especially the elbow creases and behind the knees.and behind the knees.

In adultsIn adults, the , the faceface and and handshands are more likely are more likely to be involved.to be involved.

Distribution

Hand Eczema

Foot Eczema

Atopic Derm Adults

Atopic Derm Adults

Atopic Dermatitis: Associated features

The skin is usually dry, itchy & easily irritated by:The skin is usually dry, itchy & easily irritated by: soap soap detergents detergents wool clothingwool 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.

Associated Findings Pityriasis albaPityriasis alba

Associated Findings

XerosisXerosis

Associated Findings

Keratosis PilarisKeratosis Pilaris

Associated Findings IchthyosisIchthyosis

Hyperlinear Palmar Creases

Pharmacological & vascular abnormalities in patients with AD White dermographismWhite dermographism Delayed blanch with acetylcholineDelayed blanch with acetylcholine White reaction to nicotinic acid estersWhite reaction to nicotinic acid esters Abnormal reactions to histamine in affected skinAbnormal reactions to histamine in affected skin Low finger temperatureLow finger temperature Pronounced vasoconstriction on exposure to Pronounced vasoconstriction on exposure to

coldcold

Diagnosis Major characteristicsMajor characteristics

Pruritus with or without excoriationPruritus with or without excoriation Typical morphology and distributionTypical morphology and distribution Chronic relapsing dermatitisChronic relapsing dermatitis Personal or family history of atopy (asthma, allergy, atopic derm, Personal or family history of atopy (asthma, allergy, atopic derm,

contact urticaria)contact urticaria) OtherOther characteristics characteristics

Xerosis/Ichthyosis/palmar hyper kerat. pilarisXerosis/Ichthyosis/palmar hyper kerat. pilaris Early age of onsetEarly age of onset Cutaneous colonization and/or overt infectionsCutaneous colonization and/or overt infections Hand/foot/nipple/contact dermatitis, cheilitis, conjunctivitis, Hand/foot/nipple/contact dermatitis, cheilitis, conjunctivitis,

ErythrodermaErythroderma, subcapsular cataracts, dennie morgan folds, allergic , subcapsular cataracts, dennie morgan folds, allergic shiners, facial pallor.shiners, facial pallor.

HANIFIN & RAJKAS DIAGNOSTIC CRITARIA FOR AD An itchy skin condition (or parentral report of scrathing or An itchy skin condition (or parentral report of scrathing or

rubbing in a child) rubbing in a child) PLUS PLUS 3 or more than 3 of the following-- Onset <2 yrs of age.- H/O skin crease involvement. (including cheeks in children

<10 yrs of age.)- H/O generally dry skin.- Personal H/O other atopic disease child below 4 yrs or FDR

+- Visible flexural dermatitis.

UK WORKING PARTY CRITERIA.- H/O flexural dermatitis;H/O flexural dermatitis;- Onset under age of 2 years;Onset under age of 2 years;- Presence of an itchy rash;Presence of an itchy rash;- Personal H/O asthma;Personal H/O asthma;- H/O dry skin; andH/O dry skin; and- Visible flexural dermatitis.Visible flexural dermatitis.1 MAJOR + 3 MINOR1 MAJOR + 3 MINOR

LABORATORY TESTS

Raised serum IgE levels (70-80%)Raised serum IgE levels (70-80%) Allergic to food /+ inhalant allergensAllergic to food /+ inhalant allergens Concomitent rhinitis and asthama Concomitent rhinitis and asthama Eosinophilia Eosinophilia Increased histamine levesIncreased histamine leves

Differential Diagnosis

Seborrheic Seborrheic dermatitisdermatitis

Differential Diagnosis

Seborrheic dermatitisSeborrheic dermatitis ScabiesScabies

Differential Diagnosis

Seborrheic dermatitisSeborrheic dermatitis ScabiesScabies DrugsDrugs

Differential Diagnosis

Seborrheic dermatitisSeborrheic dermatitis ScabiesScabies DrugsDrugs PsoriasisPsoriasis

Differential Diagnosis

Seborrheic Seborrheic dermatitisdermatitis

ScabiesScabies DrugsDrugs PsoriasisPsoriasis Allergic contact Allergic contact

dermatitisdermatitis

Differential Diagnosis Seborrheic dermatitisSeborrheic dermatitis ScabiesScabies DrugsDrugs PsoriasisPsoriasis Allergic contact dermatitisAllergic contact dermatitis Cutaneous T-cell lymphomaCutaneous T-cell lymphoma Hyper IgE syndrome(Job’s Hyper IgE syndrome(Job’s

synd.)synd.) Hypereosinophilic syndHypereosinophilic synd Wiskott-Aldrich syndWiskott-Aldrich synd Netherton syndNetherton synd

Atopic Dermatitis: Treatment1. Reduce contact with irritants 1. Reduce contact with irritants (soap substitutes)(soap substitutes)2. Reduce exposure to allergens2. Reduce exposure to allergens3. Emollients3. Emollients4. Topical Steroids4. Topical Steroids5. Antihistamines5. Antihistamines6. Antibiotics6. Antibiotics7. Steroid sparing7. Steroid sparing8. Other (herbals, soaps)8. Other (herbals, soaps)9. Systmic therapies9. Systmic therapies10. Other therapies10. Other therapies

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

Soap Substitutes Cetaphil / moiz - soap substitute- far less drying and

irritating than soap Cleansing & moisturizing formulations Lotion, bar, ‘soap’, cream, sunscreen

2. Reduce exposure to allergens Keep home, especially bedroom, free Keep home, especially bedroom, free

of dust. of dust. Allergic reactions include house dust Allergic reactions include house dust

mite, molds, grass pollens & animal mite, molds, grass pollens & animal dander. dander.

Special diets will Special diets will notnot help most help most individuals b/c little evidence that individuals b/c little evidence that food is major culprit. food is major culprit.

If food allergies exists, most likely d/t If food allergies exists, most likely d/t dairy products, eggs, wheat, nuts, dairy products, eggs, wheat, nuts, shellfish, certain fruits or food shellfish, certain fruits or food additives. additives.

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:Best: Oils (e.g. Petroleum Jelly) Oils (e.g. Petroleum Jelly) ModerateModerate: Creams : Creams Least: Lotions Least: Lotions

Apply emollients Apply emollients after bathingafter bathing and times when the skin and times when the skin is unusually dry (e.g. winter months).is unusually dry (e.g. winter months).

Emollients (cont’d)

Large variety.Large variety. Inexpensive emollients include vegetable shortening and Inexpensive emollients include vegetable shortening and

petroleum jelly (Vaseline)petroleum jelly (Vaseline) Urea creamsUrea creams OilsOils

Emollients: Alpha-Hydroxy acid

Creams are excellent for relieving dryness, but Creams are excellent for relieving dryness, but cancan stingsting & & sometimes aggravate eczemasometimes aggravate eczema

Useful for maintenance when no longer inflamedUseful for maintenance when no longer inflamed Forces epidermal cells to produce keratin that is softer, Forces epidermal cells to produce keratin that is softer,

more flexible and less likely to crack more flexible and less likely to crack Preparations Preparations

Glycolic Acid (8%) Glycolic Acid (8%) Lactic Acid or Lac-Hydrin (5-12%) Lactic Acid or Lac-Hydrin (5-12%) Urea (3-6%)Urea (3-6%)

Use 1X/ dayUse 1X/ day

Emollients: Oils Consider using bath oil or mineral oil-based lotions in Consider using bath oil or mineral oil-based lotions in

lukewarm bath water lukewarm bath water Add to tub 15 minutes into bath Add to tub 15 minutes into bath Bath oil preparations:Bath oil preparations:

Alpha-KeriAlpha-Keri Aveeno bathAveeno bath Jeri-Bath Jeri-Bath

Colloidal oatmeal Colloidal oatmeal reduces itchingreduces itching

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.

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.

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

Steroids and Young Children

FluticasoneFluticasone proprionate cream 0.05% proprionate cream 0.05% Moderate- severe atopic derm Moderate- severe atopic derm >> 3 months 3 months Applied bid 3-4 weeks- mean 64% BSAApplied bid 3-4 weeks- mean 64% BSA No HPA suppression No HPA suppression

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

5. Antibiotics Atopic eczema frequently secondarily

colonized with a bacteria (up to 30%). Use oral antibiotics in recalcitrant or

widespread cases.

6. Antihistamines Oral antihistamines can

reduce urticaria & itch Non-sedating antihistamines

less side effects but more expensive

Sedative effect of hydroxyzine & diphenhydramine helpful

7. Steroid Sparing

Topical calcineurin inhibitorsTopical calcineurin inhibitors Tacrolimus ointment & pimecrolimus Tacrolimus ointment & pimecrolimus

creamcream Oral CyclosporineOral Cyclosporine Ultraviolet light therapy Ultraviolet light therapy

(phototherapy) with PUVA (psoralens (phototherapy) with PUVA (psoralens plus ultraviolet A radiation) or plus ultraviolet A radiation) or combinations of UVA & UVB combinations of UVA & UVB

Tacrolimus ointment

(0.03%, 0.1% [Protopic]) Mild to moderate eczemaMild to moderate eczema Steroid dependent or signs of Steroid dependent or signs of

atrophyatrophy Non-steroid responsiveNon-steroid responsive BID x 2-4 weeks to evaluate BID x 2-4 weeks to evaluate

responseresponse Transient stinging possibleTransient stinging possible Longer disease-free intervalsLonger disease-free intervals

Pimecrolimus cream 1% (15, 30, 100 gm [Elidel])

Approved Dec. 2001Approved Dec. 2001 Blocks production/release cytokines T-cellsBlocks production/release cytokines T-cells

Moderate eczemaModerate eczema Steroid sparingSteroid sparing Transient stinging 8% children, 26% adults Transient stinging 8% children, 26% adults

9. SYSTEMIC THERAPY

SYSTEMIC GLUCOCORTICOIDSSYSTEMIC GLUCOCORTICOIDS- Rarely indicated in chronic AD.Rarely indicated in chronic AD.- Short course- taperShort course- taper

9. SYSTEMIC THERAPY CYCLOSPPORINCYCLOSPPORIN- Acts on T cell- Acts on T cell-calcineurin inhibittor -calcineurin inhibittor supresses cytokine supresses cytokine

transcription.transcription.- Dose 5mg / kg.Dose 5mg / kg.- S/E – elevated serum creatinine;S/E – elevated serum creatinine;

renal impairement;renal impairement; hypertension. hypertension.

9. SYSTEMIC THERAPY

ANTIMETABOLITES ANTIMETABOLITES Indicated in AD Indicated in AD resistant to T/T like topical & oral steroids, resistant to T/T like topical & oral steroids, psoralene and UVA light.psoralene and UVA light.

- Mycophenolate mofetil- Mycophenolate mofetil – purine – purine biosynthesis inhibitor biosynthesis inhibitor

- Dose - 2 gm daily (as monotherapy)Dose - 2 gm daily (as monotherapy)

- Methotrexate - - Methotrexate - inhibits inflammatory cytokines inhibits inflammatory cytokines synthesis & cell chemotaxissynthesis & cell chemotaxis

- Dosing more frequently than typical weekly dosing is Dosing more frequently than typical weekly dosing is advocated.advocated.

- Azathioprine - - Azathioprine - purine analogue with anti purine analogue with anti inflammatory & anti proliferative effect.inflammatory & anti proliferative effect.

- SIDE EFFECTS - SIDE EFFECTS - BONE MARROW BONE MARROW SUPRESSION.SUPRESSION.

10. OTHER THERAPIES INTERFERON – INTERFERON – γγ - Down regulates Th2 cell proliferation & functionDown regulates Th2 cell proliferation & function- Supresses IgE responces.Supresses IgE responces.- S/E – influenza like symptomsS/E – influenza like symptoms OMALIZUMAB OMALIZUMAB monoclonal anti IgE monoclonal anti IgE

- -

EXTRACORPOREAL PHOTOPHERESISEXTRACORPOREAL PHOTOPHERESIS- Passage of psoralen-treated leukocytes Passage of psoralen-treated leukocytes

through an extracorporeal UVA light through an extracorporeal UVA light system.system.

- PlusPlus topical steroids topical steroids

PHOTO THERAPY – PHOTO THERAPY – - UVA- UVA targets epidermal LCs & eosinophilstargets epidermal LCs & eosinophils- UVB exerts immunosuppressive effects by blocking UVB exerts immunosuppressive effects by blocking

of function of LCs & altered keratinocyte cytokine of function of LCs & altered keratinocyte cytokine production.production.

- S/E S/E short term - erythema, pain, pruritus and short term - erythema, pain, pruritus and pigmentaion pigmentaion

long term – premature skin aging & cutaneous long term – premature skin aging & cutaneous malignancies.malignancies.

PROBIOTICS Lactobacillus rhamnosus strain GG

prenatally to mothers for 4 weeks daily before delivery

postnatally for 6 months to infants or either mother (breast feeding).

Has reduced the incidence f AD in at-risk children during first 2 yrs of life.

ORAL VITAMIN D

Improves innate immunityImproves innate immunity

Other Psychological support Alternative treatments

Chinese herbal teaVariably effective-not very palatable

Liver toxicity possible

Thank you.

Ointments (Tacrolimus) better than cream (Pimecrolimus)

Tacrolimus ointment & pimecrolimus cream

Licensed for patients Licensed for patients >> 2 years old mild-moderate eczema\ 2 years old mild-moderate eczema\ Safety?Safety?

In controlled trials appear safe in adults and children In controlled trials appear safe in adults and children In 2005, FDA issued warnings about a possible link between In 2005, FDA issued warnings about a possible link between

the topical calcineurin inhibitors and cancer (? increased risk the topical calcineurin inhibitors and cancer (? increased risk of lymphoma and skin cancers with topical exposure)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-FDA recommends that these agents are used only as second-

line therapy in patients unresponsive to or intolerant of other line therapy in patients unresponsive to or intolerant of other treatmentstreatments

Avoid in children younger than two years of ageAvoid in children younger than two years of age Use for short periods of time and minimum amount Use for short periods of time and minimum amount

necessarynecessary Avoid continuous use Avoid continuous use Avoid in patients with compromised immune systems Avoid in patients with compromised immune systems

Oral Cyclosporine and PUVA

Other Evening Primrose Oil / Star Flower Oil

Contains gamma linolenic acid, fatty acid (deficient some atopic subjects)

Alternative medications some patients may use for eczema

LicoriceLicorice CalendulaCalendula EchinaceaEchinacea Golden SealGolden Seal Nettle Nettle OatsOats

OtherLaughter 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

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

Antibacterial Soaps Dial and Lever 2000 Cetaphil antibacterial cleansing bar

Evidenced-based review 2002 (BMJ Clinical Evidence) Positive evidence that:Positive evidence that:

topical corticosteroidstopical corticosteroids relieve symptoms and are safe relieve symptoms and are safe emollientsemollients & & steroidssteroids better than steroids alone better than steroids alone excellent control of house dustexcellent control of house dust mite reduces symptoms mite reduces symptoms

if positive mite RAST scores & childrenif positive mite RAST scores & children bedding covers most effectivebedding covers most effective

Little to no evidence that: Little to no evidence that: dietary change reduces symptomsdietary change reduces symptoms

Systematic review 2000

Positive evidence:Positive evidence: Topical steroidsTopical steroids Oral cyclosporineOral cyclosporine UV lightUV light Psychological Psychological

approachesapproaches

Insufficient evidenceInsufficient evidence Ag avoidance pregnancyAg avoidance pregnancy AntihistaminesAntihistamines Dietary restrictionDietary restriction Dust mite avoidanceDust mite avoidance HypnotherapyHypnotherapy EmollientsEmollients MassageMassage Evening primrose oilEvening primrose oil Topical coal tarTopical coal tar Topical doxepinTopical doxepin Chinese herbsChinese herbs

(Hoare, Health Technol Assess, 2000)

Systematic review

Not beneficial: Not beneficial: Cotton clothingCotton clothing BiofeedbackBiofeedback Bid vs qd topical steroidsBid vs qd topical steroids Bath additivesBath additives Topical antibiotic/steroids vs steroids Topical antibiotic/steroids vs steroids

alonealone(Hoare, Health Technol Assess, 2000)

Final Pearls Educate parents that the goal is Educate parents that the goal is

CONTROL not CURECONTROL not CURE Atopics exposed to herpes virus or smallpox Atopics exposed to herpes virus or smallpox

vaccination may get severe infection with vaccination may get severe infection with widespread involvement d/t altered skin widespread involvement d/t altered skin barrier.barrier.

Severe herpes infections in children with eczema

Atopic Derm and Smallpox Vaccine

(Ann Intern Med 2003;139)

CostsH/C 1%H/C 1% Bid-tid Bid-tid 30 gm30 gm $3.00$3.00

TAC 0.1%TAC 0.1% BidBid 30 gm30 gm $8.00$8.00

Fluticasone Fluticasone propionate 0.05%propionate 0.05%

QdQd-bid-bid 30 gm30 gm $42.00$42.00

Mometasone Mometasone furoate 0.1%furoate 0.1%

Qd Qd 30 gm30 gm $45.00$45.00

Betamethasone Betamethasone dipropionate dipropionate 0.05%0.05%

BidBid 30 gm30 gm $20.00$20.00

Clobetasol Clobetasol propionate 0.05%propionate 0.05%

BidBid 30 gm30 gm $15.00$15.00

Halobetasol Halobetasol propionate 0.05%propionate 0.05%

QdQd-bid-bid 30 gm30 gm $72.00$72.00

Pimecrolimus 1%Pimecrolimus 1% BidBid 30 gm30 gm $56.00$56.00

Tacrolimus 0.1%Tacrolimus 0.1% BidBid 30 gm30 gm $60.00$60.00

Drugstore.com 2004

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?

Case Treatment strategy:Review mild skin care regimenConfirm use of

• mild cleanser• daily moisturizers & • mild laundry detergent

Prescribe sufficient potency & quantity of topical corticosteroids

Which steroid class(es) would you px?

Objectives Improve ability to accurately diagnose and Improve ability to accurately diagnose and

manage 90% of cases of atopic dermatitismanage 90% of cases of atopic dermatitis Recognize differences in infant, childhood Recognize differences in infant, childhood

and adult presentations of atopic dermatitisand adult presentations of atopic dermatitis Improve ability to diagnose and manage Improve ability to diagnose and manage

conditions associated with and sometimes conditions associated with and sometimes confused with atopic dermatitisconfused with atopic dermatitis

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

F/U 2 weeks later: Only slightly improved- now what?

Now... Add oral antistaphylococcal agent for 7-14 days. REVIEW mild skin care regimen Follow-up in 2 weeks and SUCCESS!

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.

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

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”

Case 3 2.5% H/C too weak Fluocinonide (lidex) 0.05% ointment under

occlusion causing atrophy Good case for topical tacrolimus

Patient Education National Eczema AssociationNational Eczema Association

www.eczema-assn.orgwww.eczema-assn.org

(Charman, Arch Dermatol, 2004)

The patient-oriented eczema

measure

Self Monitoring

References Drake LA, et al. Guidelines of Care For Atopic Dermatitis. J Am Acad Drake LA, et al. Guidelines of Care For Atopic Dermatitis. J Am Acad

Dermatol 1992;26:485-8. Dermatol 1992;26:485-8. Atopic eczema. In Atopic eczema. In Clinical EvidenceClinical Evidence British Medical Journal 2001. British Medical Journal 2001.

Available online at www.clinicalevidence.orgAvailable online at www.clinicalevidence.org Correale CE, Walker C, Murphy L, Craig TJ. Atopic Dermatitis: A Correale CE, Walker C, Murphy L, Craig TJ. Atopic Dermatitis: A

Review of Diagnosis and Treatment. J Fam Pract 1999; available at Review of Diagnosis and Treatment. J Fam Pract 1999; available at http://www.aafp.org/afp/990915ap/1191.htmlhttp://www.aafp.org/afp/990915ap/1191.html

Ruzicka T, Bieber T, Schopf E, et al. A short-term trial of tacrolimus Ruzicka T, Bieber T, Schopf E, et al. A short-term trial of tacrolimus ointment for atopic dermatitis. European Tacrolimus Multicenter ointment for atopic dermatitis. European Tacrolimus Multicenter Atopic Dermatitis Study Group. N Engl J Med 1997; 337(12): 816-21.Atopic Dermatitis Study Group. N Engl J Med 1997; 337(12): 816-21.

Eichenfield LF, LuckyAW, Boguniewicz M, et al. Safety and efficacy Eichenfield LF, LuckyAW, Boguniewicz M, et al. Safety and efficacy of pimecrolimus cream 1% in the treatment of mild and moderate of pimecrolimus cream 1% in the treatment of mild and moderate atopic dermatitis in children and adolescents. J A Acad Dermatol atopic dermatitis in children and adolescents. J A Acad Dermatol 2002; 46; 495-504 .2002; 46; 495-504 .

References Charlesworth EN . Pruritic dermatoses: overview of etiology and therapy. Am Charlesworth EN . Pruritic dermatoses: overview of etiology and therapy. Am

J Med 2002; 113S, 9A: 25S-33S.J Med 2002; 113S, 9A: 25S-33S. Wahn U, et al. Efficacy and safety of pimecrolimus cream in the long-term 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. 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 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 treatment of severe and extensive atopic dermatitis in children as young as 3 months. J Am Acad Dermatol 2002; 46: 387-394.months. J Am Acad Dermatol 2002; 46: 387-394.

Hoare C, et al. Systematic review of treatments for atopic eczema. Health Hoare C, et al. Systematic review of treatments for atopic eczema. Health Technol Assess 2000; 2: 1-191.Technol Assess 2000; 2: 1-191.

Green C, Colquitt JL, Kirby J, Davidson P. Topical corticosteroids for atopic 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 eczema: clinical and cost effectiveness of once-daily vs. more frequent use. Br J Dermatol 2005; 152: 130-41. J Dermatol 2005; 152: 130-41.

Charman CR, Venn AJ, Williams HC. The patient-oriented eczema measure: Charman CR, Venn AJ, Williams HC. The patient-oriented eczema measure: development and initial validation of a new tool for measuring atopic eczema development and initial validation of a new tool for measuring atopic eczema severity from the patients' perspective. Arch Dermatol 2004; 140: 1513-9. severity from the patients' perspective. Arch Dermatol 2004; 140: 1513-9.

Other

Coal tar or less messy preps (liquid carbonis detergent 5-10%) in Eucerin or AquaphorChronic lichenified eczema patches Coal tar smells & stains clothes so apply

qhs using old clothes and old linensCoal tar can provoke a folliculitis.