Management of childhood eczema

1. Management of childhood eczema

2. �Eczema� Eczema is an inflammatory skin reaction � histologically : spongiosis; acanthosis; a predominantly lymphohistiocytic infiltrate and vascular dilatation in the dermis - clinically : vesiculation (acute) and lichenification (chronic)

4. Atopic dermatitisin children aged 1�5 yrs prevalence of 16.5% 10-20% of referrals to dermatology 30% of dermatological GP consultations annual UK cost of �47 million

5. There is now strong evidence that:- Atopic dermatitis is a primary disorder of the skin barrier. The atopic (IgE) component occurs as a secondary phenomenon as a consequence of the increased permeability of the skin

7. Atopic eczema:- defective skin barrier genetic studies indicate abnormalities in the stratum corneum and stratum granulosum clinical features of AD include dry scaly skin, increased TEWL, increased percutaneous absorption and an increased susceptibility to allergic reactions and infection.

8. Common loss-of-function variants of the epidermal barrier protein filaggrin are a major predisposing factor for atopic dermatitis Palmer C, Irvine A, Terron-Kwiatkowski A et al. Nature Genetics 2006; 38(4): 441-6

9. Relevance to treatment of atopic dermatitis Addressing the barrier defect Treating the inflammation

10. NICE guidelines for eczemahttp://guidance.nice.org.uk/CG57

11. Assessment of severity, pyschosocial wellbeing + quality of life

12. Education and adherence to therapy

13. Treatment strategy

14. A pro-active approach to treatment acute exacerbation long-term management

15. First line treatment for AD Emollients Topical steroids Antihistamines

16. Emollients Bath oils Cleansing cream Moisturizing agent

17. Use of topical steroids

18. Treatment for infections

19. Aggravating factors HDM: mattress, carpets.... cats and dogs home : heating, dry air grass pollen food allergy

20. Apparent failure of treatment non-compliance under-treatment ? aggravating factors

21. Non-compliance Anxiety concerning steroids Social circumstances Are the treatments being used correctly ?

22. Nursing Support to provide information and support for the family to communicate with the GP and/or the Dermatologist

23. Second line treatment for AD Anti-staph approach Wet dressings Paste bandages Dietary manipulation Admission to hospital

24. Anti-staph approach Minimize the use of topical antibiotics Risk of MRSA Use of an oily bath additive containing an antiseptic agent

25. Dietary manipulation Mainly in the under 1 year olds with a clinical presentation of cows� milk allergy Those with a clear history of an allergic reaction to a specific food

26. Allergy testing Not indicated for all children with eczema Should be considered for those children with poorly responding eczema in whom allergy may play a significant role RASTs are generally informative but skin prick tests are more accurate and the wheals can be serially measured

27. Are antihistamines helpful? YES with reservations:- Antihistamines do not help the itch of AD A long acting sedative antihistamine is useful at night initially A non-sedative antihistamine taken on a regular daily basis is indicated for grass or HDM allergy

28. Topical Calcineurin Inhibitors

29. Protopic + Elidel Topical calcineurin inhibitors Both effective treatments for AD FDA: a boxed warning on both products

30. Both: safety and tolerability may cause transient �burning� minimal percutaneous absorption no adverse systemic effects no potential for skin atrophy no increased risk of skin infections well tolerated especially in delicate skin areas like the face and neck folds

31. potential for skin malignancy

32. European Medicines AgencyPress Release 27th March 2006 The benefits of use outweigh the risks based on available data It is not possible on the evidence available so far either to confirm or refute a causal link between the use of Protopic� / Elidel� and cancer Recommendation to modify the product information but no boxed warning on the label (as in the USA)

33. Recommendations by EMEA/CHMP Patients over the age of 2 years Avoid long-term treatment Not for use in the immunocompromised Not for treatment of cancerous lesions Monitor pre-treatment lymphadenopathy Once daily application whenever possible

34. Is it safe to use TCIs? YES but guidelines need to be adhered to and strict monitoring / follow-up is important Parents need to be fully informed of the long-term concerns

35. Indications for use in children As an alternative for children requiring frequent long-term POTENT topical steroids to keep their eczema under control the face, especially around the eyes; the neck; elbow and knee creases and the groin

36. A new licensed indication for Protopic ointment March 2009: European Medicines Agency agreed a new licensed indication for Protopic ointment based on preventing flares of eczema by using Protopic ointment twice weekly to designated susceptible areas of skin after the eczema has cleared.

38. Prophylaxis of eczema: a new approach to management For children with persistent recurrent eczema at designated sites despite intensive topical treatment Using Protopic ointment twice weekly once the eczema has cleared for one to 3 months and keep under review

39. Third line treatment for AD [Prednisolone] Azathioprine Ciclosporin

40. -TPMT-thiopurine methyltransferase screening advised prior to commencement of azathioprine

41. AD: some take home messages AD is now thought to be due to a primary defect in the epidermal barrier The skin requires �barrier repair� with emollients combined with appropriate anti-inflammatory treatment.

42. The way forward for better treatment of AD���. Clear standarised treatment guidelines Prescribing adequate quantities of topical agents Nursing support Regular reviews

43. THE END - Thank you !