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Breaking a stubborn "horse": Challenges in treating pediatric ... Breaking a stubborn "horse": Challenges in treating pediatric ... Presentation Transcript

  • Breaking a stubborn “horse”: Challenges in treating pediatric atopic dermatitis Anna L. Bruckner, M.D. Assistant Professor of Dermatology and Pediatrics Stanford University School of Medicine Director, Pediatric Dermatology Lucile Packard Children’s Hospital
  • Disclosure
    • I have no conflicts of interest to disclose.
  • Introduction: The challenges
    • Skin barrier dysfunction
    • Pruritus
    • Infection
    • Patient and family support
    View slide
  • Skin barrier dysfunction View slide
  • Epidermal barrier dysfunction is central to pathogenesis of atopic dermatitis
    • Loss of function mutations in the filaggrin gene are associated with ichthyosis vulgaris, atopic dermatitis (AD), and asthma associated with AD
      • 37-50% with IV have AD
      • 8% with AD have evidence of IV
          • Smith FT et al. Nat Genet 2006;38:337
          • Palmar C et al. Nat Genet 2006;38:441
  • Epidermal barrier dysfunction is central to pathogenesis of atopic dermatitis
    • SPINK5 polymorphisms are associated with atopy and AD in some families
          • Walley AJ et al. Nat Genet 2001;29:175
    • Ceramides decreased in AD skin
    • Decreased ceramides correlate with increased TEWL in AD
          • Proksch E et al. Clin Dermatol 2003;21:134
  • Repairing the skin barrier
    • Repairing the skin barrier will:
      • Improve xerosis
      • Decrease severity of AD
      • Lessen dependence on prescription medications
    • Moisturizers can be used as:
      • Primary treatment for mild disease
      • Preventative / maintenance therapy
  • Traditional moisturizers: Efficacy in atopic dermatitis
    • Cork MJ et al. Br J Dermatol 2003;149:582-9.
    • Evaluated the effect of education and demonstration of topical therapies by a dermatology nurse on therapy utilization and severity of AD
    • 51 pediatric patients enrolled and followed for 1 year
  • AD severity decreased as emollient use increased Goal emollient use was 500 grams per week. Specific emollients recommended not specified.
  • What about ceramides?
    • In a small (24 children), uncontrolled study a ceramide dominant moisturizer (TriCeram™) improved both the xerotic and inflammatory components of AD
          • Chamlin SL and Kao J et al. J Am Acad Dermatol 2002;47:198
    • CeraVe™ contains ceramides
      • No studies comparing efficacy with other moisturizers
  • Topical barrier repair “devices” for AD?
    • NOT cost-effective for use as daily moisturizer
    • May be useful as an adjuctive therapy or as an alternative to topical steroids, TIMS
    • Physiogel® A.I. (MimyX®) decreased AD symptoms in an uncontrolled study of adults and children
          • Eberlein B et al. JEADV 2008;22:73
    • Atopiclair® improved mild-to-moderate AD compared to vehicle
          • Boguniewicz M, et al. J Pediatr 2008;152:854-9.
          • Patrizi A, et al. Pediatr Allergy Immunol 2008 Feb 21 [Epub].
  • Pruritus dermatlas.org
  • “ The price of pruritus” in AD
    • AD affects how my child sleeps:
      • Sometimes (26%), often (21%), all the time (21%)
    • My child’s AD affects how my spouse and I sleep:
      • Sometimes (23%), often (21%), all the time (17%)
    • My child sleeps in my bed because of his / her AD:
      • Sometimes (12%), often (7%), all the time (11%)
          • Chamlin SL et al. Arch Pediatr Adolesc Med 2005;159:745
    • Poor sleep may affect mood, ability to concentrate, behavior
  • Addressing pruritus and sleep disturbance
    • Wet dressings overnight
    • Sedating antihistamines
      • Diphenhydramine (1mg/kg/dose)
      • Hydroxyzine (1-2 mg/kg as single dose at bedtime)
      • Doxepin (1mg/kg as single dose at bedtime)
    • Cognitive and behavioral therapy
  • Infection
  • Our defenses against infection, and how they fail in AD
    • The epidermis is our first line of defense against infections
    • The epidermal barrier is bad in AD
    • The innate immune system is a molecular line of defense against microbes
    • Recognition of pathogens is faulty in AD
    • Anti-microbial peptides are poorly expressed and have diminished function in AD
    • Hata TR and Gallo RL. Semin Cutan Med Surg 2008;27:144.
  • Our defenses against infection, and how they fail in AD
    • Acquired immunity
    • Th2 cytokine milieu of AD leads to down-regulation of anti-microbial peptides and reduced activation of PMNs, monocytes, macrophages, and NK cells against pathogens
    • 90% of atopics (lesional skin) are colonized with S. Aureus
    • Adherence of S. Aureus to skin worsens AD severity
  • Treating S. Aureus
    • Treat the AD!
    • Oral antibiotics
      • Cephalexin (50 mg/kg divided BID-TID)
      • Dicloxacillin
      • Septra, clindamycin, doxycycline if concerned about MRSA
  • Treating S. Aureus
    • Dilute bleach
      • ¼ cup household bleach in half-full bathtub once to twice weekly
      • Dilute bleach + intranasal mupirocin improved AD severity over 3 month study period
          • Huang et al. Poster at SPD meeting, July, 2008
    • Swimming in chlorinated pool may have similar effect
  • Patient and family support
    • Parents express dissatisfaction with education and information offered about AD
          • Long et al. Clin Exp Dermatol 1993;18:516.
      • Information insufficient
      • Information given too quickly
      • Information inaccurate
      • Concerns or feelings not addressed
      • Input not valued
  • Education and empowerment
    • Use trained assistants to help educate families
    • Use written handouts and action plans
    • Close follow up after the initial visit
  • Chisolm SS et al. JAAD 2008
  • Offer support
    • NEASE
      • www.nationaleczema.org
      • www.easeeczema.org