Breaking a stubborn

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Breaking a stubborn horseChallenges 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 Childrens Hospital

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Disclosure

• I have no conflicts of interest to disclose.

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IntroductionThe challenges

• Skin barrier dysfunction
• Pruritus
• Infection
• Patient and family support

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Skin barrier dysfunction
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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 200638337
• Palmar C et al. Nat Genet 200638441

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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 200129175
• Ceramides decreased in AD skin
• Decreased ceramides correlate with increased TEWL
  in AD
• Proksch E et al. Clin Dermatol 200321134

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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

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Traditional moisturizersEfficacy in atopic
dermatitis

• Cork MJ et al. Br J Dermatol 2003149582-9.
• 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

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AD severity decreased as emollient use increased
Goal emollient use was 500 grams per week.
Specific emollients recommended not specified.
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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
  200247198
• CeraVe contains ceramides
• No studies comparing efficacy with other
  moisturizers

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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 20082273
• Atopiclair improved mild-to-moderate AD compared
  to vehicle
• Boguniewicz M, et al. J Pediatr 2008152854-9.
• Patrizi A, et al. Pediatr Allergy Immunol 2008
  Feb 21 Epub.

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Pruritus
dermatlas.org
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The price of pruritus in AD

• AD affects how my child sleeps
• Sometimes (26), often (21), all the time (21)
• My childs 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
  2005159745
• Poor sleep may affect mood, ability to
  concentrate, behavior

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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

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Infection
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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
  200827144.

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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

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Treating S. Aureus

• Treat the AD!
• Oral antibiotics
• Cephalexin (50 mg/kg divided BID-TID)
• Dicloxacillin
• Septra, clindamycin, doxycycline if concerned
  about MRSA

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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

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Patient and family support

• Parents express dissatisfaction with education
  and information offered about AD
• Long et al. Clin Exp Dermatol 199318516.
• Information insufficient
• Information given too quickly
• Information inaccurate
• Concerns or feelings not addressed
• Input not valued

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Education and empowerment

• Use trained assistants to help educate families
• Use written handouts and action plans
• Close follow up after the initial visit

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Chisolm SS et al. JAAD 2008
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Offer support

• NEASE
• www.nationaleczema.org
• www.easeeczema.org