Eczema Update. Objectives 05/19/2016. I have no relevant disclosures. There will be some discussion of medications being used off-label

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1 Eczema Update 38th Annual Common Childhood Problem Conference Kari Martin, MD Assistant Professor of Dermatology & Child Health May 20, 2016 I have no relevant disclosures There will be some discussion of medications being used off-label Objectives 1419 publications found with key words atopic dermatitis in the last year on pub med Highlight reel Changes to your practice Diagnosis Quality of Life/Counseling Management 1

2 Diagnosis Clinical diagnosis still the most useful way to make diagnosis Diagnostic criteria exist, but are typically only used in research settings Complicating factors? What caused my child s eczema? Food allergies Airborne allergies Contact allergies Irritants Wollenberg A, Oranje A, Deleuran M, et al; European Task Force on Atopic Dermatitis/EADV Eczema Task Force. ETFAD/EADV Eczema task force 2015 position paper on diagnosis and treatment of atopic dermatitis in adult and paediatric patients J Eur Acad Dermatol Venereol May;30(5): doi: /jdv Epub 2016 Mar 23 Food Allergies 1/3 of kids with mod to severe eczema have food allergies Common misconception that food allergies CAUSE eczema Important to advise parents against general elimination diets: generally not helpful and may be harmful Serum IgE testing shows sensitivity but not clinical relevance Prick testing and/or food challenges may be helpful Recent study of 1186 double-blinded food challenges showed much higher rate of sensitization in kids with prior AD If eczema flare was the only food allergy symptom noted, it was very unlikely that the food challenge was positive Roerdink EM, Flokstra-de Blok BM, Blok JL, et al. Association of food allergy and atopic dermatitis exacerbations. Ann Allergy Asthma Immunol Apr;116(4):334-8 Airborne Allergies Dust mites, animal dander, pollen Can be tested with prick testing or serum IgE levels (similar to food) Avoidance is helpful but not always completely preventable Allergen-specific immunotherapy helpful in some patients Darsow U. Allergen-specific immunotherapy for atopic eczema updated. Curr Opin Allergy Clin Immunol 2012; 12:

3 Contact Allergies Contact allergies occur in 40-65% of kids with eczema Patch testing rec d in kids with: recalcitrant disease not responding to standard therapies Unusual pattern/location of disease Late or sudden onset or sudden worsening Chronic hand or foot component When considering systemic therapies Common allergens: preservatives, fragrances, emulsifiers, components of topical therapies Only treatment is avoidance of the allergen List available of soaps, moisturizers, shampoos, etc. free of the top ten allergens in kids Herro EM, Matiz C, Sullivan K, et al. Frequency of contact allergens in pediatric patients with atopic dermatitis. J Clin Aesthet Dermatol 2011; 4: Hill H, Goldenberg A, Golkar L, et al. Pre-Emptive Avoidance Strategy (P.E.A.S.) - addressing allergic contact dermatitis in pediatric populations. Expert Rev Clin Immunol May;12(5): doi: / X Epub 2016 Feb 29. Irritants Harsh soaps, detergents Wool clothing/accessories Water Frequent bathing or hand washing, swimming without proper skin care, etc. Heat, sweat Quality of Life/Counseling Good table in EADV Guidelines paper to give to families regarding general counseling Two recent papers with specific issues related to AD: Physical activity Self-esteem and self-identity Wollenberg A, Oranje A, Deleuran M, et al; European Task Force on Atopic Dermatitis/EADV Eczema Task Force. ETFAD/EADV Eczema task force 2015 position paper on diagnosis and treatment of atopic dermatitis in adult and paediatric patients J Eur Acad Dermatol Venereol May;30(5): doi: /jdv Epub 2016 Mar 23 3

4 Physical Activity Pruritus often worsens with heat and sweat Adults with AD exercise less often and have less vigorous activity Ongoing studies to see if there is an increase in cardiovascular disease Counsel Exercise when weather is cooler (early or late in the day) If playing/exercising outside, use water rinses, sprinklers, cooling towels etc. to stay cool Swimming, yoga Silverberg JI, Song J, Pinto D, et al. Atopic dermatitis is associated with less physical activity in US adults. J Invest Dermatol May 14 Self-Esteem and Identity Mother of kids with AD less discipline, conceded to child s demands more often Leads to poor coping skills Difficulty with separation anxiety and addressing fears in preschool ages Kids feel stigmatized or may be bullied because of the appearance of lesions and fear of infectious nature Leads to social isolation and poor self-esteem Significantly greater incidence of behavior problems, family disruption and stressed parenting Nguyen CM, Koo J, Cordoro KM. Psychodermatologic Effects of Atopic Dermatitis and Acne: A Review on Self-Esteem and Identity Pediatr Dermatol Mar;33(2): Management Sensitive skin care: bathing practices, moisturizers, avoiding irritants Topical antiinflammatories Phototherapy Systemic therapies Treat secondary infections: bacterial, viral, fungal?manage colonization Anti-histamines? Diet Immunotherapy Stein SL, Cifu AS. Management of Atopic Dermatitis. JAMA Apr 12;315(14):

5 Bathing Study comparing bathing once weekly vs. twice weekly showed frequency of bathing unimportant as long as skin was hydrated well with moisturizers Recent AAD guidelines had expert opinion only (not enough studies for strong rec s) Non-soap-based surfactant and synthetic detergents with acidic ph closer to that of skin are rec d Koutroulis I, Pyle T, Kopylov D, et al. The Association Between Bathing Habits and Severity of Atopic Dermatitis in Children. Clin Pediatr (Phila) 2016; 55: Stein SL, Cifu AS. Management of Atopic Dermatitis. JAMA Apr 12;315(14): Emollient Skin barrier abnormality = allergen penetration and easier irritation = inflammation Filaggrin defects Loss of (or imbalance of) lipids in the stratum corneum: ceramides, essential fatty acids, cholesterol Microfissures Emollients most helpful when applied right after bathing Wet wraps very helpful during flares Can burn (lotion>cream>ointment/oil), so may need to treat flare first Newer emollients may contain missing lipids or bacterial products to enhance the stratum corneum and skin flora balance Gelmetti C, Wollenberg A. Atopic dermatitis - all you can do from the outside. Br J Dermatol 2014; 170(Suppl 1): Gueniche A, Knaudt B, Schuck E et al. Effects of nonpathogenic gram-negative bacterium Vitreoscilla filiformis lysate on atopic dermatitis: a prospective, randomized, double-blind, placebo-controlled clinical study. Br J Dermatol 2008; 159: Janmohamed SR, Oranje AP, Devillers AC, et al. The proactive wet-wrap method with diluted corticosteroids versus emollients in children with atopic dermatitis: a prospective, randomized, double-blind, placebo-controlled trial. J Am Acad Dermatol Jun;70(6):

6 Calcineurin Inhibitors Calcineurin inhibitors (CI) vs. topical steroids Meta-analysis of 12 RCTs Similar percentage of improvement in dermatitis and treatment success CI associated with higher costs and more adverse events (pruritus and burning) No difference in skin infections, atrophy or AEs requiring discontinuation Broeders JA, Ahmed Ali U, Fischer G. Systematic review and meta-analysis of randomized clinical trials (RCTs) comparing topical calcineurin inhibitors with topical corticosteroids for atopic dermatitis: a 15-year experience. J Am Acad Dermatol May 11. pii: S (16)01495-X. doi: /j.jaad [Epub ahead of print] Phosphodiesterase 4 Inhibitors Several undergoing trials; crisaborole is the only to make it to phase 3 trials to date Early trials showing efficacy and safety as young as 2yo Improves pruritus within 5d Silverberg JI, Nelson DB, Yosipovitch G. Addressing treatment challenges in atopic dermatitis with novel topical therapies. J Dermatolog Treat May 11:1-9. Jarnagin K, Chanda S, Coronado D, et al. Crisaborole Topical Ointment, 2%: A Nonsteroidal, Topical, Anti- Inflammatory Phosphodiesterase 4 Inhibitor in Clinical Development for the Treatment of Atopic Dermatitis. J Drugs Dermatol Apr 1;15(4):

7 Reactive vs. Proactive Therapy Reactive therapy traditional Treat a lesion once to twice daily until resolved, then taper or stop and maintain with emollients until next lesion appears Proactive Clear lesions with once to twice daily application of antiinflammatory Wean to daily or twice daily emollient with 1-2 times per week of anti-inflammatory Wollenberg A, Ehmann LM. Long term treatment concepts and proactive therapy for atopic eczema. Ann Dermatol 2012; 24: Systemic Therapies Traditional Methotrexate Azathioprine Mycofenolate mofetil Cyclosporine Emerging Case reports on TNF alpha inhibitors: equivocal at this time Case reports of ustekinumab (anti-il12 and IL-23) Apremilast (systemic PDE4 inhibitor) Omalizumab (anti-ige) showed improvement in some pts, but no difference compared to placebo in larger RCTs. Combo tx may be helpful Samrao A, Berry TM, Goreshi R, Simpson EL. A pilot study of an oral phosphodiesterase inhibitor (apremilast) for atopic dermatitis in adults. Arch Dermatol 2012; 148:

8 Dupuilumab Antibody blocking IL-4 and IL-13 receptors Quick and marked improvement in symptoms as well as fewer infections Recent RCT of 380 patients to assess ideal dosing and safety. All arms of varying doses showed statistically significant improvement in EASI (eczema area severity index) scores Equal adverse events between placebo and medication arms with nasopharyngitis being most common. Very well tolerated. Beck LA, Thaci D, Hamilton JD et al. Dupilumab treatment in adults with moderate-to-severe atopic dermatitis. N Engl J Med 2014; 371: Thaçi D, Simpson EL, Beck LA, et al. Efficacy and safety of dupilumab in adults with moderate-to-severe atopic dermatitis inadequately controlled by topical treatments: a randomised, placebo-controlled, dose-ranging phase 2b trial. Lancet Jan 2;387(10013): The End martinkar@health.missouri.edu Good review references with patient education materials: Wollenberg A, Oranje A, Deleuran M, et al; European Task Force on Atopic Dermatitis/EADV Eczema Task Force. ETFAD/EADV Eczema task force 2015 position paper on diagnosis and treatment of atopic dermatitis in adult and paediatric patients. J Eur Acad Dermatol Venereol May;30(5): doi: /jdv Epub 2016 Mar 23 Barbarot S, Bernier C, Deleuran M et al. Therapeutic patient education in children with atopic dermatitis: position paper on objectives and recommendations. Pediatr Dermatol 2013; 30: