atopic%20dermatitis%20(pediatric)
ATOPIC DERMATITIS (PEDIATRIC)
Atopic dermatitis is a familial, chronic relapsing inflammatory skin disease characterized by intense itching, dry skin, with inflammation and exudation that commonly presents during early infancy and childhood, but can persist or start in adulthood.
It is also referred to as atopic eczema.
It is one of the most common skin diseases afflicting both adults and children.

Pharmacotherapy

Corticosteroids (Topical)

  • Used as 1st-line treatment for mild to severe atopic dermatitis
  • Moderately potent & potent corticosteroids should be used for the treatment of clinical exacerbation over short periods of time
  • Mildly potent corticosteroids are recommended for maintenance therapy
  • Anti-inflammatory & antipruritic activity through several mechanisms
    • Alteration in leukocyte number & activity
    • Suppression of mediator release (histamine, prostaglandins)
    • Enhanced response to agents that increase cyclic adenosine monophosphate (prostaglandin E2 & histamine via the histamine-2 receptor)
  • Rapid symptomatic relief of acute flare-ups
  • Continuous use can lead to adverse effects
  • Follow the recommended restrictions regarding intensity & duration of use on delicate skin areas (eg face, neck & skin folds)
  • Topical corticosteroids are available in different potencies from mild to very potent
    • Potency is also affected by the vehicle the product is formulated in (eg cream, ointment)
  • Choice of product will depend on severity of flare-up, distribution of lesions & other factors (eg humidity)
  • Least potent but effective product should be used
  • Rebound flaring can occur if higher potency preparations are discontinued abruptly
    •  A gradual decrease in potency should follow use of higher potency preparations
  •  Therapy-resistant lesions may require potent topical corticosteroid used under occlusion for a short period of time & under close supervision

Calcineurin Inhibitors (Topical)

  • Inhibit inflammatory cytokine transcription in activated T cells & other inflammatory cells through inhibition of calcineurin
  • May be used on all body locations for extended periods of time, especially the face, hands & feet
  • All preparations are of a standard potency
  • Not recommended for patient <2 years of age

Pimecrolimus

  • Safety & efficacy has been shown in infants & children w/ mild-moderate atopic dermatitis
    • Pruritus relief has been seen as early as day 3 of use
    • Prevents flare-ups & results in significant steroid-sparing effect when used for up to 12 months
  • When used in early stages of disease, it has shown to be therapeutically advantageous over typical moisturizers plus topical corticosteroids in long-term use

Tacrolimus

  • Indicated for moderate-severe atopic dermatitis
    • May be used for up to 1 year w/o loss of effectiveness, increase in infection risk or other non-application-site adverse effects
    • Well-tolerated w/ transient skin burning/irritation
  • Studies have confirmed the efficacy of Tacrolimus 0.03% compared to low potency topical corticosteroids in children

Skin Infections1

  • Clinical infections at treatment sites should be cleared before starting anti-inflammatory agents
  • May need to treat reservoirs of the infection to prevent recurrence (eg nose, groin)

Bacterial Infections

  • S aureus is commonly cultured from eczematous skin & is often the cause of localized infections
  • Topical therapy
    • May be used to treat mild & localized secondary infection
    • Fusidic acid, Mupirocin, & Retapamulin are treatment options
    • Neomycin may cause allergic contact dermatitis
    • Retapamulin is recommended for children ≥ 9 months
  • Oral therapy
    •  Usually necessary to treat widespread infected lesions
    •  Anti-staphylococcal penicillins, macrolides, 1st & 2nd generation cephalosporins & Clindamycin are treatment options

Viral Infections

  • Patients may develop secondary herpes infections inclusive of eczema herpeticum (Kaposi’s varicelliform eruption) & may require systemic Acyclovir treatment in a hospital setting
  • Prophylactic oral antiviral agents may be used to suppress recurrent cutaneous herpetic infections

Fungal Infections

  • Role of fungi in atopic dermatitis is questionable
  • Superficial dermatophytosis & Pityrosporum ovale may be treated w/ systemic or topical antifungals

Viral Infections

  • Patients may develop secondary herpes infections inclusive of eczema herpeticum (Kaposi’s varicelliform eruption) & may require systemic Acyclovir treatment in a hospital setting
  • Prophylactic oral antiviral agents may be used to suppress recurrent cutaneous herpetic infections

Fungal Infections

  • Role of fungi in atopic dermatitis is questionable
  • Superficial dermatophytosis & Pityrosporum ovale may be treated w/ systemic or topical antifungals

Antihistamines1

  • Oral sedating antihistamines may be useful if the patient has comorbidities (allergic rhinitis, urticaria or dermatographism) & sleep disturbance
    • They are best used at bedtime since pruritus is typically worse at night
  • Studies of oral non-sedating antihistamines have shown variable results in controlling pruritus, however they may be useful in a small group of patients w/ associated urticaria
  •  Topical antihistamines are usually not helpful in relieving pruritus & may cause allergic contact dermatitis

Systemic corticosteroids1

  • Should only be considered in treatment-resistant atopic dermatitis
  • Improves lesions but rebound flare-up usually occurs upon discontinuation
  • Use short-term & decrease chance of rebound effect by tapering oral form slowly while increasing topical corticosteroid treatment & continuously hydrating the skin

Immunosuppressants (Oral)1 

Ciclosporin

  • Effective for short-term use in severe refractory disease
    • Condition tends to return after discontinuation of therapy but not always at the original severity level
  •  Long-term use is not justified because of risks of hypertension & renal dysfunction

Azathioprine

  • Used for severe/refractory disease
  • Thiopurine methyltransferase (TMPT) levels should be monitored while patient is on Azathioprine to test for myelosuppression
  • Safer than Ciclosporin & has been used long-term
    • Most patients respond to low doses
  • Adverse reactions: Nausea, fatigue, myalgia, liver dysfunction & bone marrow depression in patients deficient in thiopurine methyltransferase

1Various antibiotics, antifungals & antivirals are available. Please see prescribing information for specific formulations in the latest MIMS.

Non-Pharmacological Therapy

Avoidance of Trigger Factors

All irritants

  • Lipid solvents (soaps, detergents)
    • New clothes should be laundered before wearing to decrease levels of formaldehyde & other chemicals added
    • When washing, use liquid instead of powder detergent, & do another rinse cycle to remove detergent completely from clothes
  • Disinfectants (swimming pool chlorine)
  •  Occupational irritants
  •  Household fluids (meats, juices from fresh fruits)

Contact & aeroallergens

  • Dust mites
    • Avoidance include use of dust mite-proof encasings on pillows & mattresses, washing bedding in hot water weekly remove bedroom carpeting & curtains, decrease indoor humidity level by air conditioning, avoid upholstered sofa
  • Furry animals (cats, dogs)
  •  Molds
  •  Human dander (dandruff) resulting in overgrowth of yeast

Others

  • Foods
    • Flaring/occurrence of atopic dermatitis w/ a specific food may warrant elimination diet in patients w/ moderate-severe atopic dermatitis
    • Skin prick tests (SPT) & measurement of specific immunoglobulin E (IgE) are used to determine sensitization to a particular food
    • Dietary restriction of eggs may be beneficial in patients w/ IgE reactivity to egg
  • Climate
    •  Consider temp & humidity control to avoid increased pruritus due to heat & perspiration
    •  Prolonged sun exposure may increase evaporative losses due to sweating
  •  Hormones (menstrual cycle)
  •  Psychological factors
    •  Emotional factors (eg anxiety & anger) cause disease exacerbation, induce immune activation & increase pruritus & scratching
    •  Psychological evaluation & counseling should be considered in patients who have difficulty w/ emotional triggers or who have psychological problems

Skin Care

  • Hydration of skin w/ emollients is essential in atopic dermatitis treatment

Bathing1

  • Soap substitutes w/ minimal defatting activity & a neutral pH are preferred
  • If possible, limit soap use to hands, feet, genitalia, axillae
  • Limit bathing to once daily for 5-10 minutes using warm water
  • Pat dry after bath & apply moisturizer w/in 3-5 minutes of bath
  • Oatmeal products added to bath may be soothing but do not increase water absorption by the skin
  • Topical medications are best applied after bathing because of greater penetration of hydrated skin

Moisturizers1

  • Water-in-oil emollients are preferred
  • Patient preference & treatment area will determine formula used in emollients (eg palmitoylethanolamide (PEA), liqd paraffin, mineral oils, glycerin, etc)
  • Effects: Moisturizers help re-establish & preserve the stratum corneum
    • Can decrease the need for topical corticosteroids
  • Should be applied all over at least twice daily or as often as possible, regardless of the presence of active dermatitis
  •  Avoid products w/ preservatives or fragrances
  •  If product stings, it should not be used

Wet Dressings

  • May be used on weeping lesions or severely affected areas
    • Discomfort, folliculitis & impetigo reported as common adverse effects
  •  
    •  Temporary increased systemic absorption of corticosteroids reported

Phototherapy

  • Broad-band ultraviolet B (UVB) & ultraviolet A (UVA), narrow-band UVB & UVA-1 or combined UVA & UVB can be useful in atopic dermatitis
  • Relapse following cessation of therapy frequently occurs
  • Photochemotherapy w/ Psoralens & UVA should be restricted to patients w/ widespread severe atopic dermatitis
  • UV therapy should be restricted to patients >12 years except when absolutely necessary
  • Adverse reactions:
    • Short-term: Erythema, skin pain, pigmentation, itching
    • Long-term: Premature skin aging & potential cutaneous malignant diseases
1Various products are available. Please see prescribing information for specific formulations in the latest MIMS.
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