Dr Gayle Taylor Consultant Dermatologist Leeds Teaching Hospitals NHS Trust ATOPIC DERMATITIS.

Dr Gayle TaylorConsultant DermatologistLeeds Teaching Hospitals NHS Trust

ATOPIC DERMATITIS

Commonest inflammatory disease of childhood

Prevalence: 15-20% UK childrenGenetic predisposition Much more prevalent past 30 yearsMost cases handled in primary care

ATOPIC DERMATITIS

• Increased levels of atopic disease + allergy–Smaller families

–Lack of exposure to animals in early life

–Non-communal child care

–Early childhood antibiotic use.

• Lower exposure to microbes which play a crucial role in the maturation of the host immune system (Th2 rather thanTh1) during the first years of life

AetiologyHygiene hypothesis

• Immunological factors

– Predominance of Th2 lymphocytes– High levels of IL4– Drive production of IgE– High levels of IgE in turn prompt antigen capture by

Langerhan’s cells

• Intestinal microflora can be different in individuals with allergic disorders and in those who reside in industrialized countries where the prevalence of allergy is higher

• ? Role for pro-biotics: results thus far disappointing

AetiologyImmunological abnormalities

Children with AD have dry skin

Skin barrier function is abnormal

Level of permeability barrier abnormality precisely parallels AD severity

AetiologyBarrier function

Impairment of barrier functionFilaggrin (protein) and ceramide (fat) required for good barrier function

High level of filaggrin mutations in those with atopic eczema (and eczema associated asthma)Allows enhanced transfer of antigens through the epidermis

Role for prevention in at risk individualsLess washing, more emollient

AetiologyImpairment in barrier function

Onset: rare < 6weeks of ageOnset < 6 months of age in 75% casesGeneral tendency to spontaneous

improvement throughout childhood60% (appx) clear by secondary school ageIncreased incidence of adult hand eczema

ATOPIC DERMATITISNatural History

Flexural distributionReverse pattern eczema can occurFacial involvement prominent in infantsItchyDermatographismPersonal history of atopy (asthma/hayfever)Family history of atopy(Blood tests, allergy tests)

ATOPIC DERMATITISDiagnosis

Eczema variantsDiscoid eczemaNodular prurigoSeborrhoeic eczema

ScabiesFungal infection

ATOPIC DERMATITISDIFFERENTIAL DIAGNOSIS

Education, education, educationImportant role for trained nurse:

explanation, demonstration and supportImproves complianceImproves quality of lifeReduces antibiotic and steroid use

ATOPIC DERMATITISMANAGEMENT: education

Education about the nature of the condition and the role of trigger factorsDry skinStress:Infections: bacterial, viral, candidalIrritants and allergens

ATOPIC DERMATITISEducation, education, education

Emollients: mainstay of treatmentAnalogy of the brick wall where mortar dried outHydration of skin to ‘swell the bricks’ replace the mortar and close the gaps

Barrier : layer of grease on the surface is a barrier which prevents infection/allergy penetration

The greasier the better (creams contain preservatives which can sting)

Essential to apply moisturiser even when the skin is clear: it is a preventor

ATOPIC DERMATITIS: TRIGGERSDry skin

Bath emollients: ‘soften’ the water and prevent other things (such as baby bubble bath) being used

Soap substitutes: light emollients which have mild emollient effect and stop soaps/ shower gels being used

‘Leave-on’ moisturisers:Wide range: lotions through to ointmentsSome contain antiseptics

Quantity: Infant: 125 g/weekSmall child 250g per weekLarge child 500g/week adult, Dry wraps: Comfifast, Clinifast, SkinniesWet wraps

ATOPIC DERMATITIS MANAGEMENTDry skin: emollients

Hydramol Ointment MOST GREASY

Epaderm ointment 50/50 (white soft paraffin/liquid paraffin) Diprobase ointment Diprobase cream Unguentum Merck Oilatum cream Doublebase cream Hydramol cream Zerobase cream Aveeno cream Dermol cream Dermol 500 lotion Balneum Plus cream E45 cream Aqueous cream LEAST GREASY

ATOPIC DERMATITIS MANAGEMENTDry skin: emollients

Tubular bandages: Tubifast/stockinetteSkin suits (Comfifast/Clinifast/Skinnies)No evidence of increased efficacy but

widely used and mostly likedReduce trauma to the skinHold emollient in placeUseful overnight. Day and night during

flaresWet wraps: may get large absorption of

steroid

ATOPIC DERMATITIS MANAGEMENTDRY wraps/WET wraps

Stress IllnessImmunisationTirednessPsychological distress/worries

ATOPIC DERMATITIS: TRIGGERSStress

Childhood illnesses are inevitable: equip parents to recognise signs of skin flaring and step up treatment

Immunisations: try to avoid when eczema active

Tiredness: vicious cycle of eczema flare and poor sleep leading to eczema flaring: use of sedative anti-histamines, short-term (Ucerax)

Psychological factors: family situation/school liason

ATOPIC DERMATITIS MANAGEMENTStress

Bacterial (Staphylococcal)Broken weepy skin, yellow crusts, pustules, red and hot

Confirm with skin swab (+/-nasal swab)Exclude MRSA

Prevention: antiseptic containing bath oils, shower gels and emollients

Early treatment: topical antiseptics or combined steroid/antiseptics.

Avoid topical fusidic acid.

ATOPIC DERMATITIS: TRIGGERSInfection

Herpes (cold sore) InfectionPainful small blisters usually starting on the face and then spreading

If localised and child well, oral aciclovirIf extensive: consider admission for IV therapy

If eyes involved: urgent ophthalmological opinion (eye casualty). Risk of permanent corneal ulceration.


Candidal infectionAround the mouth, neck creases, nappy area

Red, glazed sore skin occasionally with little pustules

Can be flared by antibiotic therapyTreat with topical anti-yeast therapy (Canesten/Canesten HC, Timodine)


IrritantsHeat Cold dry weatherCentral heatingLow humidityWoollen clothingDustBiological washing powders

ATOPIC DERMATITIS: TRIGGERSIrritants and Allergens

Airbourne allergiesHouse dust mite, cats, dogs, pollens, moulds

Contact allergensMetal jewellery, fragrances

Dietary allergensMost common: dairy, eggs, nuts, wheat, soya, cod

Urticarial skin reaction, vomiting, diarhhoea, swelling, wheezing

ATOPIC DERMATITIS: TRIGGERSAllergens

No role for ‘routine’ allergy testingThorough history Blood test: IgE, RASTS (specific IgE) to

airbourne allergens: HDM, pollens, pet dander, moulds. Occasionally foods: milk, eggs, fish, soya, wheat, PEANUT

Prick tests: as aboveBoth have false pos. and neg. ratePatch tests: sometimes indicated in

longstanding disease

ATOPIC DERMATITISAllergy Testing

Necessary to treat acutely inflamed or very itchy areas

Parental anxiety needs to be addressedUse with emollients, never on their ownApply (ideally) 20 mins before emollientsDon’t rub: smooth (to avoid folliculitis)

ATOPIC DERMATITIS MANAGEMENTTopical steroids

4 potencies: mild to ultrapotentMild: 1% hydrocortisone, Synalar 1:10Moderate: Eumovate, Betnovate RD, Synalar 1:4

Potent: Betnovate, Elocon, Cutivate, Synalar, Locoid, Nerisone cream

Ultrapotent: Dermovate


Weakest for shortest period possible but be realistic

Use ointments unless the skin is infected (creams +/- antimicrobial)

How much is enough: do fingertip units help?

Monitor useage Finger tip units: 0.5g treats 2 adult hand prints: limited flexural eczema Limited flexural eczema: 30g tube would last a month (b.d

treatment) 8 year old with 90% eczema: 65g per week


Treat early: a mild steroid, twice daily, when eczema starts to flare, can avoid having to use a stronger steroid

If the eczema doesn’t improve in 3-4 days, step up to a stronger steroid.

Once the eczema is improving for 3-4 days, reduce the strength of the steroid.

Once the eczema has cleared, reduce the mild steroid to once daily, then alternate daily for 3-4 days after the eczema has cleared

ATOPIC DERMATITIS MANAGEMENTTopical steroids:

Mild flares/delicate sites

Treat earlyModerate potency twice daily Once improved for 3-4 days, reduce the

strength of the steroid and step down as for mild flares

ATOPIC DERMATITIS MANAGEMENTTopical Steroids: moderate flares

Potent topical steroid twice daily until improving for 3-4 days (up to maximum 7-10 days), then reduce to moderate potency twice daily for 3-4 days, then to once daily 3-4 days

EITHER down to mild or use moderate 2-3 times per week depending on past response

Do not use potent steroids around the eyesCan be used short term (3-5 days) and very

infrequently on the face

ATOPIC DERMATITIS MANAGEMENTTopical Steroids: severe flares

Difficult area to treatThin delicate skin: increased liklihood of

steroid side effects (atrophy, cataracts)But uncontrolled diseaseassociated with:

Conjunctival inflammation and damageCorneal damage/keratoconusAiming to use intermittent mild topical steroids with very occasional use of moderate potency

Consider topical immunomodulators

ATOPIC DERMATITIS MANAGEMENTPeriorbital involvement

Elidel (pimecrolimus)Mild to moderate eczemaAims to reduce number of flares requiring topical steroids

Free from skin atrophy side effectsMild burning sensation in some patientsCan’t be used in presence of skin infectionUnlicensed under 2 years?long term effects ?skin cancer risk

TOPICAL IMMUNOMODULATORS

Protopic Ointment (Tacrolimus)Moderate to severe eczemaStops lymphocyte proliferationAs effective as potent topical steroid but no skin atrophy

Causes burning sensation on the skin (usually mild)

Licensed from the age of 2 upwardsCan’t be used in presence of skin infection?Effect of long term immuno-supression on skin cancer risk/lymphoma

TOPICAL IMMUNOMODULATORS

Non-sedative agents generally not helpful for itch but can reduce dermatographism

Sedative agent can be used for central effect, ideally short term, to aid sleeping during flare-ups

ANTIHISTAMINES

Failure may be due toSeverity of diseaseSecondary infectionUndiagnosed allergyPoor compliance with topical treatmentHigh stress levels/unresolved family issues

ATOPIC DERMATITISFailure to respond

Topical immunomodulators

Phototherapy

Systemic drugs

ATOPIC ECZEMA: 2ND LINE TREATMENTS


Phototherapy

Systemic agents


Most patients report that skin improves with sunlight

‘Artificial sunlight’: UVB, TLO1, PUVA

PHOTOTHERAPY

Broadband UVBUsed for many years: much less common

now 2-5 times weeklyCombine with standard topical treatmentMay need steroid coverRelatively long treatment times Heat can exacerbate eczema

PHOTOTHERAPYUVB

Narrow range UV within therapeutic spectrum

Excludes many erythrogenic raysShorter treatment timesMore effectiveConcern re long term side effects: skin

cancer risk

PHOTOTHERAPYNarrowband UVB (TLO1)

Photochemotherapy :Psoralen/ UVAPsoralen tablet or bath followed by

irradiation with UVAEffective but….Remain photosensitive for 24 hoursDefinite skin cancer risk Limited to lifetime total 200 treatments

PHOTOTHERAPYPUVA


Phototherapy

Systemic agents


• Systemic steroids: prednisolone• Highly effective for emergencies• Profound adverse effects on growth • Seldom used longterm in childhood:

monitor–Growth –POEM –SCORAD

SYSTEMIC AGENTSPrednisolone

Azathioprine: immunosuppressantCommonly used in transplantation medicineEffective though not in all casesMonitor TPMT, FBC, LFTsProven increase in non-melanoma skin

cancer risk with long-term useIncreased risk of infection

SYSTEMIC AGENTSAzathioprine

Ciclosporin (Neoral): immunosupressantUsed in transplantation medicineLicensed in adults for short term use (8

weeks) for eczemaExcellent efficacyIncreased risk of infectionIncreased risk of non-melanoma skin cancer

with long-term use

SYSTEMIC AGENTSCiclosporin

May be helpful in some casesUse increasing in children

SYSTEMIC THERAPIESMethotrexate

Systematic review of treatment for atopic eczemaReasonable RCT evidence to support the use of oral

ciclosporin, topical corticosteroids, psychological approaches and ultraviolet light therapy

ATOPIC DERMATITISEvidence based Management

• Insufficient evidence to make recommendations on emollients, cotton clothing, maternal allergen avoidance, antihistamines–Evidence on emollients and barrier function likely to be forthcoming

• Insufficient evidence to make recommendations on homeopathy, Chinese herbal remedies, hypnotherapy, antihistamines

ATOPIC DERMATITISEvidence based management

Complete absence of evidence on short bursts of steroids vs longer term weaker steroids, bandages, oral prednisolone and azathioprine

ATOPIC DERMATITISEvidence based management

Discourage use of soaps/detergents on infants’ skinRegular moisturiser: prescribe enoughBe familiar with 5-6 emollients with different

greasinessFull emollient regime: bath oil, soap substitute,

moisuriserBe familiar with steroid potenciesOintments rather than creams (unless infected)Severe/stubborn: short term potent and step down

gradually

ATOPIC ECZEMA: SUMMARY

Avoid topical antibioticsUse topical antiseptics, short-term, if necessaryConsider sedative anti-histamine at night if poor

sleepConsider checking ferritin, zinc, vitamin DIf poor response, consider

Severe disease: refer Secondary infection: refer if not responding Undiagnosed allergy: refer Poor compliance with topical treatment: frequent reminders, nurse

input High stress levels/unresolved family issues: enquire

ATOPIC ECZEMA: SUMMARY

Thank you for your attention

Any Questions?

ATOPIC DERMATITIS

Dr Gayle Taylor Consultant Dermatologist Leeds Teaching Hospitals NHS Trust ATOPIC DERMATITIS.

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