1 / 51

to an Exceptional Eczema Experience

The 5 E ’s. to an Exceptional Eczema Experience. Richard J. Antaya, MD, FAAP, FAAD Professor of Dermatology and Pediatrics Director, Pediatric Dermatology Yale University School of Medicine New Haven, CT. Potential Conflict of Interest Disclosure. Astellas Research

rhea
Download Presentation

to an Exceptional Eczema Experience

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The 5 E ’s to an Exceptional Eczema Experience Richard J. Antaya, MD, FAAP, FAAD Professor of Dermatology and Pediatrics Director, Pediatric Dermatology Yale University School of Medicine New Haven, CT

  2. Potential Conflict of Interest Disclosure • Astellas Research local PI for APPLES registry for long term safety evaluation of Protopic 1

  3. Impact of Atopic Dermatitis • prevalence -- 10-17% of all children* • mild in 85% • mod to severe -- profound effect on QOL • intractable itching and sleep loss • soreness, scarring, dyspigmentation • messy topicals • social stigma • QOL impairment equivalent to CF • costs more than childhood diabetes • 4% of adults with persistent disease • 40-60% continue to experience disease intermittent exacerbations *adapted from Laughter D. J Am Acad Dermatol 2000; 43:649-55. 2

  4. Diagnosis of Atopic DermatitisDiagnostic Criteria • Pruritus • Eczema (from Greek - to boil, to erupt) • chronic & recurring • acute • chronic • subacute Adapted fromHanifin, Rajka. Acta Dermato Venereol. 92(suppl):44-7;1980 and AAD Consensus Conference on Pediatric Atopic Dermatitis 3

  5. Atopic DermatitisClinical Presentation • 6 skin findings of eczema • erythema • papules/edema • exudation - oozing and crusting • scale • excoriations linear erosions from scratching • Lichenification thickened, hyperpigmented, leathery skin due to rubbing (accentuated skin markings) • symmetric > asymmetric 4

  6. Diagnosis of Atopic DermatitisDiagnostic Criteria • Pruritus • Eczema (from Greek - to boil, to erupt) • chronic & recurring • acute • chronic • subacute • age-specific distribution Adapted fromHanifin, Rajka. Acta Dermato Venereol. 92(suppl):44-7;1980 and AAD Consensus Conference on Pediatric Atopic Dermatitis 6

  7. ATOPIC DERMATITIS Infantile Distribution • face - cheeks and chin • “head light” sign – mid-facial sparing • extensor extremities, dorsal hands and feet • very rarely on palms or soles • can have widespread involvement • diaper area often spared • pruritus 7

  8. 8

  9. ATOPIC DERMATITISChildhood-Adult Distribution • antecubital and poplitealfossae • posterior neck • presacral back, buttocks, flanks • eyelids • scalp • hands, feet  palms and soles • may be severe and generalized • “head light” sign 9

  10. 11

  11. 12

  12. Diagnosis of Atopic DermatitisAssociated Features • early age at onset • 80-90% by 5 years • personal or family history of atopy • xerosis • associated with ichthyosis vulgaris (IV) • worse prognosis in patients with IV 13

  13. Complications of AD 16

  14. Eczema Herpeticum 17

  15. 17

  16. 19

  17. Eczema Vaccinatum 20

  18. Impetigo 21

  19. S. aureus and Atopic Dermatitis Endogenous Antimicrobial Peptides • antimicrobial peptides in the skin • cathelicidins • human -defensin-2 (HBD-2) • accumulate in response to skin inflammation • normal levels in psoriasis lesions • decreased levels in lesions • AD, eczema herpeticum, eczema vaccinatum • IL-4 and IL-13 inhibit HBD-2 production Adapted from Ong P. N Engl J Med. 347(15), Oct 10, 2002 1151-60 22

  20. Treatment Approach 27

  21. ATOPIC DERMATITIS5 E’s to an Exceptional Eczema Experience • Education - level of success is directly related to how much education patients and their families receive about AD* • Expectations • Endpoints • Clearance vs Maintenance phases of therapy • Encouragement • Enough medication – campfire analogy • Early return visit (2 weeks) *Staab, D. BMJ 332:933-938. 28

  22. Clinical Approach to Atopic DermatitisMy Spiel Educate • Explain what it is and what it is not • No cure, not a single allergy, but can be controlled • “The itch that rashes” • Alloknesis (cutaneoushyperaesthesia)* • perceive normally “nonitchy” stimuli as “itchy” • Explain the provokers of itch in A.D. • heat and perspiration 96% • wool 91% • emotional stress 81% • certain foods (rarely) • “common cold” 36% *Hagermark O. in Bernhard JD. Pruritus in skin disease. McGraw-Hill, 1994 pp37-67 29

  23. Clinical Approach to Atopic DermatitisMy Spiel • Expectations • Endpoints • Clearance with anti-inflammatory meds • Maintenance with trigger avoidance and moisturization • Explain rationale for proposed therapy • Enough medicine -- Campfire analogy 30

  24. ATOPIC DERMATITISThe Spiel onGeneral Skin Care soaps • avoid “true soaps” • Dial, Ivory, Irish Spring • moisturizing cleansers • Dove, Tone, Olay Complete • soap free cleansers • Cetaphil, Aquanil • avoid entirely during flares 31

  25. Nice & Smooth Not nice, Rough & Yucky 32

  26. ATOPIC DERMATITISThe Spiel onGeneral Skin Care moisturizers • immediately after bathing and prn (multiple times/day) • avoid lotions; use creams and ointments • Eucerin, Aquaphor, petrolatum, Cetaphil, Acid Mantle cream, Vanicream, Theraplex Emollient • Ceremide-based – Epiceram, CeraVe, CetaphilRestoraderm 33

  27. ATOPIC DERMATITISThe Spiel onGeneral Skin Care • laundry detergents • hypoallergenic detergents • Dreft, Ivory Snow • avoid • dryer sheets and fabric softeners • wool and polyester fabrics • extremes of temperature, humidity • dust mites (mattress, box spring, pillow covers) • Certain foods – milk, wheat, egg, soy 34

  28. ATOPIC DERMATITISHanifin’sTruisms of Bathing “Bathing dries the skin” A: True If skin allowed to air dry. “Bathing hydrates the skin” A: True If moisturizer is applied immediately after. No conclusive data supported by studies 35

  29. ATOPIC DERMATITISBathing Recommendations • showers - o.k. if not flaring • bath - if more severe b.i.d. for 10 min, tepid • do not rub, scrub or use washcloths • pat dry partially with a towel - don’t rub • within 3 minutes apply moisturizer and/or topical medication 36

  30. ATOPIC DERMATITISMEDICAL TREATMENT • weak topical corticosteroids • non-fluorinated ointments or creams • Hydrocortisone acetate 0.5, 1.0, or 2.5% • Hydrocortisone valerate 0.2% • Desonide, fluticasone lotion/cr (low), aclometasone • medium to high potency steroids • Triamcinolone (med) • Fluticasone ointment (med) • Mometasone cream (med)  mometasone ointment (high) 38

  31. Topical Steroid Monotherapy Regimen • Standard regimen • Twice daily for 2 weeks (esp. first treatment) • Then p.r.n. based on need and response to Rx • More severe regimen • Pulse dose (once or twice) on weekends • 3 consecutive days/week • Most severe regimen • Single application 3 days/week during maintenance phase • Mon, Wed, and Fri • Decreases frequency of flares 39

  32. Enough Medication • Frequency • Duration • Recommended amount per dose • adult hand = ~ 0.5 gm • total BSA of 3-6 mo = 4-5 gm • total BSA of 6-10 yo = 10 gm • total BSA of an adult = 20-30 gm • Topical meds dispensed as • 15, 30, 45, 60, 80 or 100 gram tubes • 1 lb (454 gm) jars 40

  33. Enough Medication ESTIMATES FOR QUICK MEMORIZATION • Recommended amount per dose • total BSA of a 5 mo = 5 gm • total BSA of a 5-10 yo = 10 gm • total BSA of a 20 yo = 20 gm • Do the math… • 5 m.o. 100% BSA = 5gm x 2 = 10gm x 14 days = 140 gm • 7 y.o. 100% BSA = 10gm x 2 = 20gm x 14 days = 280 gm 41

  34. Enough Medication Only topical steroids sold in 1 lb jars • triamcinoloneacetonide • hydrocortisone acetate x 16 = 30 gram tube 1 lb (454 gm) jar 42

  35. Clinical Approach to Atopic DermatitisCampfire Analogy v v 43

  36. “Soak and Smear” of Topical Steroids • Soak and Smear regimen • Soak in a bath with plain water (no soap) for 10 min at night (or b.i.d.) • Then smear on the topical steroid (usually triamcinolone 0.1% ointment) immediately without drying • After skin is improved stop soaks but continue the topical steroid at night Gutman AB, Kligman AM, Sciacca J, James WD. Arch Dermatol Dec 2005;141:1556-59 45

  37. STEROID-INDUCED ATROPHY 50

  38. STRIAE DISTENSAE mometasone ointment x several months in a teen 51

  39. Topical Calcineurin Inhibitors (TCI’s)Protopic Ointment (tacrolimus) Elidel Cream (pimecrolimus) Proposed mechanism of action • CD4+ lymphocytes • inhibits calcineurin • inhibits gene transcription • IL-2, IL-3, IL-4, IL-5, GM-CSF, TNF-, IFN- 52

  40. Tacrolimus 0.1% Open label Phase III b Study: Baseline 53

  41. Tacrolimus 0.1% Open label Phase III b Study: Month 9 54

  42. 3 weeks Baseline Pimecrolimus Treatment of Atopic Dermatitis 55

  43. When do I use the TCI’s? • Concerns about steroid use • Can’t get off topical steroid • Using steroids too frequently or continuously • Location too risky • Intertriginous areas • Eyelids • Steroids ineffective • Discuss FDA boxed warning 56

  44. ATOPIC DERMATITISADJUNCTIVE ANTIBIOTICS/ANTIBACTERIALS • Treat impetigo/ superinfection • oral antibiotics • Reduce S aureustopically • N3 (Nose, Nails, Navel) mupirocinb.i.d. 5 days/mo • Bleach baths* • 4 oz/ ~25 gal (tubful) water or ~2 tsp/gal H2O • 3 times weekly - daily • Clinically proven to improve eczema scores in patients who previously had AD-associated impetigo Huang JT et al, Pediatrics. 123(5):e808-14, 2009 May Huang JT, Rademaker A, Paller AS. Arch Dermatol. 147(2):246-7, 2011 Feb. 57

  45. ATOPIC DERMATITISANTIHISTAMINES • especially hs • hydroxyzine (Atarax) • diphenhydramine (Benadryl) • cyproheptadine (Periactin) • doxepin (Sinequan) – cardiotoxic ! • randomized trials have not demonstrated improvement with sedating or non-sedating antihistamines 58

  46. Epidermal Damage  pruritus Increased Adhesin Exposure collagen, fibronectin, fibrinogen Increased S. aureus binding/ inflammation AD Habit-Reversal Techniques (HRT)Breaking the itch-scratch cycle Scratching 59

  47. AD Habit-Reversal Techniques (HRT) • Effective for tics and nervous habits • Scratching is maintained by operant reinforcement • HRT teaches • recognize the habit • identify situations that provoke it • train to develop a “competing response practice” • Striking, patting, or grasping the area • Requires a motivated patient and physician 60

  48. Atopic Dermatitis Therapeutic Pyramid Prayer and/or divine intervention Systemic Immunomodulators UV Phototherapy Allergy Testing/Avoidance Habit Reversal Antihistamines Anti-Staph Antibiotics Topical Calcineurin Inhibitors Topical Steroids Protective Skin Care & Trigger Avoidance 61

  49. ATOPIC DERMATITIS5 E’s to an Exceptional Eczema Experience • Education • Expectations • Endpoints • Clearance vs Maintenance • Encouragement • Enough medication – campfire analogy • Early return visit (2 weeks) 62

  50. Thanks for your attention! 63

More Related