Guidelines of care for atopic dermatitis, developed in accordance with the American Academy of Dermatology (AAD)/American Academy of Dermatology Association "Administrative Regulations for Evidence-Based Clinical Practice Guidelines"

Pediatric atopic dermatitis: should we treat it differently?

Atopic dermatitis is an extremely common childhood skin disease that can have far-reaching impact on patients and families. Pediatric patients, particularly infants, pose special concerns for parents and providers, and equal emphasis must be placed on both nonpharmacologic and prescription interventions. Concerns for adverse effects of prescription therapies and a universal parental fear of an undetected allergy are hallmarks of pediatric atopic dermatitis care. The purpose of the present study is to highlight important educational and therapeutic strategies designed to optimally care for this patient population.

Atopic dermatitis prevention

A shift in focus from disease therapy toward disease prevention is occurring in many medical specialties, including dermatology. There are no generally accepted strategies for the prevention of atopic dermatitis. Most research has focused on allergen avoidance and has not produced consistently effective interventions. Immune cell modulation and skin barrier protection are examples of new approaches that hold promise for preventing, or modifying the course of, this common disease.

Effects of glucocorticosteroids on the skin and eye

The dermatologic anachronistic adage, "If wet--dry it, if dry--wet it!" has bee perhaps justifiably replaced by "Call the dermatologist to prescribe a steroid!" To say this without knowledge of the contents of this article and more importantly, to accept such cliches, is a disservice to the patient and a litigious liability to the prescriber. Recognizing the risk/benefit ratio of the most commonly used anti-inflammatory agents is essential. All therapies are most effective when used for their specific diagnosis. This article attempts to provide an update on the geometrically progressing knowledge regarding the uses and misuses of GCSs for the eye and skin.

Atopic dermatitis

Atopic dermatitis (AD) is an eczematous, highly pruritic chronic inflammatory skin disease. It usually begins early in life and often occurs in people with a personal or family history of asthma and allergic rhinitis. The prevalence is high, especially in children,and it has been rising in recent decades, in parallel with asthma prevalence. Although AD is often described as an "allergic" dis-ease, allergic causation is difficult to document, and AD is increasingly viewed as a skin disease that predisposes to allergies. This interpretation, based on clinical, epidemiologic, and animal stu-dies, may greatly influence our approach to therapy and prevention of atopic diseases in the coming years.

Low-Dose Triamcinolone Acetonide in the Phytocosmetic Lichtena® Reduces Inflammation in Mild to Moderate Atopic Dermatitis

BACKGROUND

Previously, we reported the efficacy of Lichtena--a phytocosmetic cream product--in atopic dermatitis (AD). Later, fraudulent triamcinolone acetonide (TACA) was detected at low doses (16-40 microg/g) in Lichtena. This suggested that TACA may be effective at much lower concentrations than used in commercial products (1,000 microg/g).

OBJECTIVES

To investigate the efficacy in AD of low-dose TACA in Lichtena compared to plain Lichtena.

METHODS

Fourteen patients presenting symmetrical lesions of AD were treated for 1 month with Lichtena plus 25 microg/g TACA (= verum) and plain Lichtena (= placebo). The severity of the lesions was assessed by the Severity Scoring of Atopic Dermatitis (SCORAD) on days 0 (= baseline), 7, 14 and 28.

RESULTS

Already after 1 week of treatment, significant SCORAD differences to baseline were observed comparing verum- and placebo-treated areas. No improvement was observed using plain Lichtena.

CONCLUSIONS

TACA displayed a significant improvement of AD at doses up to 40 times lower than in commercial products.

Suggestions regarding a more appropriate understanding of atopic dermatitis

PURPOSE OF REVIEW

The importance of consistency and accuracy of medical terminology must be recognized by all health care providers and researchers. Yet, recent publications by recognized authorities regarding atopic dermatitis seem to defy that basic tenet. I (an allergist/dermatologist) have (objectively) reviewed and (subjectively) interpreted the currently (peer reviewed) published designations etymologically, and some of their concepts scientifically.

RECENT FINDINGS

Interdisciplinary, regional and international meetings have been discussing, assessing, and deliberating the newest data and observations, consistently realizing little consensus. The concluding trivial agreement denotes their individual bias. Given the same information, allergists, dermatologists, and generalists do not conceptualize, and yet dogmatically manage patients with atopic dermatitis.

SUMMARY

Etymologically, and scientifically, atopic dermatitis can only be distinctively designated as the dermatologic syndrome, which heralds the atopic diathesis. Concomitantly, atopic dermatitis without atopy would be an oxymoron. Definitions based on anachronistic criteria demand updating. IgE, like eosinophilia, must be appreciated as epiphenomena of the transient Th1/Th2 cell reversal, which clearly differentiates 'atopic eczema' from all the 'other' eczemas. Failure to recognize the isomorphic feature of the eczema of atopic dermatitis denies patients with an essential therapeutic modality, namely 'Do not scratch, nor rub'. Education regarding the 'triggers' of itch would yield greater success (from recurrences), than prescribing immunomodulation.

Atopic dermatitis: beyond the itch that rashes

The prevalence of atopic dermatitis is increasing, and more than 50% of children with atopic dermatitis go on to develop asthma and allergies. A better understanding of the underlying immune abnormalities of this complex chronic relapsing skin disease is needed. Although the optimal treatment approach remains to be defined, several recent studies suggest a rationale for using topical calcineurin inhibitors as early intervention and adding topical corticosteroids as rescue therapy if needed.

Tacrolimus ointment 0.03% is safe and effective for the treatment of mild to moderate atopic dermatitis in pediatric patients: results from a randomized, double-blind, vehicle-controlled study

OBJECTIVE

This study was designed to compare the safety and efficacy of tacrolimus ointment 0.03% with vehicle ointment for the treatment of mild to moderate atopic dermatitis (AD) in pediatric patients.

METHODS

A total of 317 patients (2-15 years of age) with mild to moderate AD were randomized to receive tacrolimus ointment or vehicle ointment twice daily in a 6-week, multicenter, double-blind study. Efficacy evaluations, including the Investigators' Global Atopic Dermatitis Assessment, eczema area and severity index, percentage of total body surface area affected, and patient assessment of itch occurred at baseline, day 4, and weeks 2, 4, and 6. Cutaneous adverse events were recorded to evaluate safety.

RESULTS

At the end of study, 50.6% (80 of 158) of the patients were treated successfully with tacrolimus ointment based on Investigators' Global Atopic Dermatitis Assessment scores, a significant improvement compared with patients treated with vehicle ointment (25.8% [41 of 159]). The percent improvement from baseline in eczema area and severity index scores was also significantly greater in tacrolimus-treated patients (54.8%) compared with vehicle-treated patients (20.8%). There was also a significant improvement in the percentage of total body surface area affected of tacrolimus-treated patients (50.5% reduction from baseline) compared with vehicle-treated patients (16.4%). Patient itch scores were significantly lower in tacrolimus-treated patients (2.1) versus vehicle-treated patients (3.7). Overall, the incidence of cutaneous adverse events reported was similar for both treatment groups. There was no significant difference in the incidence of burning or stinging between treatment groups. Significantly fewer tacrolimus-treated patients prematurely discontinued from the study because of a cutaneous adverse event in the treatment area or experienced increased itching and erythema at the application site.

CONCLUSION

Monotherapy with tacrolimus ointment 0.03% is a safe and effective treatment alternative for pediatric patients with mild to moderate AD.

Consumers appropriately self-treat based on labeling for over-the-counter hydrocortisone

BACKGROUND

Over-the-counter (OTC) topical corticosteroids, such as hydrocortisone cream (HC), are commonly used for the treatment of minor dermatological conditions. The safety and efficacy of such products are well documented, but details on patterns of use and self-treatment with HC in the OTC environment remain scarce.

OBJECTIVE

We sought to determine compliance with label directions of OTC HCs by examining self-reported patterns of OTC HC use in adults and children.

METHODS

A random digit-dialed telephone survey was conducted with 2000 US adults. Following identification of users of OTC HC in the last 6 months, respondents were asked questions about the conditions being treated with OTC HC and the frequency and duration of use in both adults and children.

RESULTS

Of adults completing the survey, 20% (n = 396) had used OTC HC. In 83% of cases, the conditions treated were consistent with the OTC label. Use was limited; HC was applied < or =4 times daily in 98% of adult users and lasted < or =7 days in 92%. Patterns of pediatric use were similar and almost always consistent with the labeling. Of households with children, 25% (n = 168) had used OTC HC to treat pediatric dermatological conditions. Of child users, 93% were 2 years of age or older, treatment was limited (97% applied HC < or =4 times daily and 94% of treatments lasted < or =7 days), and the conditions treated were appropriate in 86% of cases.

LIMITATIONS

This telephone survey relied on respondents' recall and self-reporting. Our data on pediatric use of OTC HC are skewed toward treatment of younger children.

CONCLUSION

The data suggest that OTC HC products are used for self-treatment in a limited and appropriate fashion that is likely to be safe in both adults and children.

A clinician's paradigm in the treatment of atopic dermatitis

Successful management of atopic dermatitis requires a multipronged approach that includes skin barrier function care, use of topical or systemic agents, and identification and elimination of precipitating or exacerbating factors. Because the origin of atopic dermatitis is multifactorial and trigger factors differ among patients, treatment plans must be specific to the individual patient. This article offers an example of a permutational, or flexible, treatment paradigm. The approach utilizes 4 topical regimens--high-potency topical corticosteroids, lowest effective potency topical corticosteroids, topical calcineurin inhibitors (TCIs), or topical corticosteroid/TCI combinations--as initial therapy in a variety of induction protocols, as determined by the severity of a patient's condition and history. The paradigm permits treatment to progress from a chosen induction therapy to maintenance therapy. During the patient's induction therapy, as soon as an acceptable level of clearance is achieved, therapy should be adjusted to a maintenance regimen, such as monotherapy with either a TCI or a lowest effective potency topical corticosteroid (the latter used intermittently) or an alternation of the two agents. If there is no clearance or positive response with the initial induction protocol, the clinician should move to one of the alternative regimens.

An Alternative Approach to Atopic Dermatitis: Part II-Summary of Cases and Discussion

In the first part of this Review, we presented case-series where Kampo treatment was introduced for those atopic dermatitis (AD) patients who had failed with conventional therapy, in an attempt to prove that there exists a definite subgroup of AD patients for whom Kampo treatment is effective. In this second part, we will first provide the summary of the results for 140 AD patients we treated in 2000. The results suggest that Kampo treatment is effective for more than half of AD patients who fail with conventional therapy. In the Discussion, we will examine the evidential basis for conventional AD therapy and discuss how Kampo treatment should be integrated into the guidelines for AD therapy. We contend that Kampo treatment should be tried before systematic immunosuppressive agents are considered. As each Kampo treatment is highly individualized, it should be regarded more as 'art' than technology, and special care should be taken to assess its efficacy in clinical trial.

Atopic dermatitis update

PURPOSE OF REVIEW

Atopic dermatitis, one of the most common chronic illnesses of childhood, is encountered routinely by all providers of health care to children.

RECENT FINDINGS

In recent years there has been a dramatic rise in the prevalence of atopic dermatitis and therefore a rapid increase in the number of studies investigating various aspects of the disease. Consequently, hundreds of publications are released each year, and it is difficult to stay up to date on the latest advances.

SUMMARY

This review will examine and summarize recent literature on the diagnosis, epidemiology, pathogenesis, treatment, and complications of atopic dermatitis.

Consensus guidelines in diagnosis and treatment of atopic dermatitis

Atopic dermatitis is a common condition of great health significance. Consensus-driven guidelines of care or specific practice parameters may be useful, as are treatment algorithms based upon disease severity. Development of consensus guidelines on diagnosis and treatment of atopic dermatitis are discussed, and disease-severity-based guidelines of care proposed.