Paediatric Dermatology: Atopic dermatitis Dr Danielle Greenblatt Consultant 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

Clinical features 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

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 Ultrapotent Potent Moderately potent Mildly potent Dermovate Nerisone Forte Ultrapotent Betnovate Elocon Synalar Fucibet Potent Eumovate Betnovate RD Synalar 1:4 Moderately potent 1% Hydrocortisone 0.5% Hydrocortisone Mildly potent

Induction of remission Tang et al JACI 2014 Systematic 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?