Paediatric Dermatology:Atopic dermatitis

Dr Danielle GreenblattConsultant Dermatologist

Royal Free Hospital

Scope of the Problem

• Common; burden on patient QOL and healthcare resources

• Systematic review – 69 cross-sectional and cohort studies– AD worldwide phenomenon– lifetime prevalence > 20%– Increasing prevalence low income countries, Africa and

East Asia– Deckers IA et al. PLoS ONE 2012

Epidemiology• urban–rural gradient of disease• broad-spectrum antibiotic exposure• traffic-related air pollution • obesity

• UV light• maternal contact with farm animals during pregnancy;

consumption of unprocessed milk• helminth infection during pregnancy• dog exposure in early life

• No consistent evidence that prolonged exclusive breastfeeding, routine childhood vaccinations and other viral/bacterial pathogens influence AD risk. Flohr. Allergy 2014

Pathogenesis

• Skin barrier defect- Filaggrin mutation

• Altered immunological pathways

Impact of Atopic Dermatitis

• Significant impact on health related QOL scores: – Sleep disturbance– Negative impact on schooling

• The effect comparable to other chronic disease of childhood such as diabetes and asthma– Lewis-Jones S. Quality of life and childhood atopic dermatitis: the misery of living

with childhood eczema. Int J Clin Pract 2006

• Altered family dynamics• loss of employment,• time-consuming treatment, and financial costs

• Emerson et Br J Dermatol 1998– Survey of 1760 children– Aged 1-5 years– AD– 96% attended GP in previous 12 months– 6% had been seen within secondary care

Clinical features

Guidelines

Management

Dietary interventions

• Maternal diet– No evidence that maternal Ag avoidance during

pregnancy can affect infant’s risk of eczema

– ? Ag avoidance diet to a high risk woman during lactation

– ? Ag avoidance by lactating mothers of infants with AD

• Kramer et al. Maternal dietary antigen avoidance during pregnancy lactation, or both, for preventing or treating atopic disease in the child. Cochrane Database Syst Rev. 2012

Dietary interventions

• Food allergies in child

IgE mediated Non-IgE mediated

Tests can be helpful Tests often not helpful

Food sensitisation 50% amongst infants with severe and early onset eczema (<3/12) - Hill D. Clin Exp Allergy 2007

Dietary interventions

• Risk assessment of child

• Consider GI symptoms

• Food diaries

• Consider risks of withdrawal of food from diet – nutritional

Other Allergens

• Inhalant allergens– Seasonal flares of eczema– Associated asthma and rhinitis– Facial eczema > 3 years

• Allergic contact dermatitis– Exacerbation of eczema previously controlled– If reaction to topical steroids

Infections

• 90% of patients with AD show colonisation with Staph aureus

• Cochrane review: little benefit of topical or oral antimicrobial therapy outside context of clinically infected eczema

Control of bacterial colonisation

Topical antiseptics

• Dermol 500• Octenisan• Bleach baths

Topical antibiotics

• Fucidin• Nasal

mupirocin

Systemic antibiotics

• If clinically impetiginised

• Significant reduction in Eczema Area and Severity (EASI) Index• Well tolerated

Topical treatment

• Emollients– Essential for all severities of eczema– provide skin with exogenous lipids; reduce TEWL– NICE guidance: children should be prescribed

250-500g/week

– Creamy – Rich cream – Greasy – Very Greasy

Bath emollients

• NHS spends > £16million on bath emollients (average cost of £6.29 per item)

• This is 38% of total cost of treatments prescribed for preschool children with eczema (matches spend on emollients directly applied to skin)

• BMJ Drugs and Therapeutics Bulletin 2007

Topical steroids

• Until recently little known about optimum usage

• Traditionally twice a day preparations

• 10 RCTs – no convincing evidence that 2x/day better than 1x (Williams et al)

• Once a day preparations such as mometasone furoate, fluticasone proprionate

• Potency tailored to the severity of eczema (NICE)

Topical steroids

• Dermovate • Nerisone ForteUltrapotent

• Betnovate• Elocon• Synalar• Fucibet

Potent

• Eumovate• Betnovate RD• Synalar 1:4

Moderately potent

• 1% Hydrocortisone• 0.5% Hydrocortisone

Mildly potent

Tang et al JACI 2014Systematic review 26 trials • Induction of remission

• Maintenance therapy• Weekend treatment

Adherence

Steroid phobia

• Common barrier to effective treatment in AD

• Caregivers concerned about TCs treat suboptimally– Insufficient quantities– Reduced frequency– “the creams don’t work”

• Education regarding appropriate strength, quantity, duration– Perceived risks of skin thinning– Concern that analagous to anabolic/oral steroids

Calcineurin inhibitors

• Tacrolimus and pimecrolimus• Approved in 2000-1• NICE advise “second line for moderate to severe eczema”• In practice: delicate areas

• FDA Black box warning in 2006– Theoretical concerns based on mouse model work– AAD taskforce concluded no causal evidence of link with

malignancy/immunosuppression unlikely

• Advise against long term use• Recommend photoprotection

When to refer• Uncertain diagnosis

• Management ineffective

• Non-responsive facial eczema

• Child/parent may benefit from advice

• Suspect an allergic contact dermatitis

• Significant psychosocial concerns

• AD with severe/recurrent infection

Secondary care

• Education– treatments– recognising infection– Step-up step-down therapy

• Written treatment plans• Access to nursing, dietician, allergists• Tailored management +/- occlusive therapy, phototherapy,

systemic agents, clinical trials

Questions?