1. Eichenfield Atopic Dermatitis Primer
Atopic Dermatitis: Improving Your Pediatric Dermatology Dx and Management Skills
Lawrence F. Eichenfield, M.D. Professor of Dermatology and Pediatrics University of California, San Diego Rady Children’s Hospital, San Diego

2. Lawrence F. Eichenfield, MD
DISCLOSURES
Lawrence F. Eichenfield, MD
Has served as an investigator or consultant for:
Anacor/Pfizer
Genentech
Lilly
Regeneron/Sanofi
Medimetriks
Otsuka
Galderma Laboratories
Novan
Valeant Pharmaceuticals

3. CASE
A 7-mo-old with erythematous, edematous and scaling papules and plaques for 2 months
Bathes twice a week
Treated with moisturizers once a day
Used hydrocortisone and it ‘worked a little’ but didn’t clear

4. Bathing Studies: Newer
AAD Pediatric Dermatology Course Atopic Dermatitis: Itching to Know More Lawrence F. Eichenfield, M.D.
Bathing Studies: Newer
Prospective, randomized, 28 kids 6 mth-10 yrs
DAILY bath vs. Bi-weekly followed by appropriate care
BOTH groups improved; NO DIFFERENCE
Conclusion: Emollients important, bathing frequency not -
Koutroulis Clin Pediatr 2014;53(7):

5. What do I recommend? Generally: Daily or every other day bathing
And….I don’t like to argue with grandmothers
But I mention AAD Guidelines and lack of data

6. Guidelines: Emollient Therapy
Current US national and international guidelines recommend regular emollient therapy as the mainstay of AD therapy1,2,3,4
Emollients are a standard of care, steroid-sparing, and useful for both prevention and maintenance therapy. Moisturizers should be applied within 2-3 minutes after bathing to improve skin hydration in patients with AD.
NOTES
Current US and EU guidelines recommend daily emollient therapy as the standard of care for both prevention and maintenance therapy.1,2
References
Hanifin JM, Cooper KD, Ho VC, et al. 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.” J Am Acad Dermatol. 2004;50(3):
Ring J, Alomar A, Bieber T, et al. Guidelines for treatment of atopic eczema (atopic dermatitis) part I. J Eur Acad Dermatol Venereol. 2012;26(8):1045–1060.
Schneider L, Tilles S, Lio P, et al. Atopic dermatitis: a practice parameter update J Allergy Clin Immunol 2013;131(2):295-9.
Ring J, Alomar A, Bieber T, et al. Guidelines for treatment of atopic eczema (atopic dermatitis) part I. J Eur Acad Dermatol Venereol. 2012;26(8):1045–1060.
Akdis CA, Akdis M, Bieber T, et al. Diagnosis and treatment of atopic dermatitis in children and adults: European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Report. J Allergy Clin Immunol 2006;118(1):
Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol 2014; 71(1):

7. Moisturizers, Emollients
Frequency
Type
How
When in relation to anti-inflammatory medication

8. Emollient from birth: atopic dermatitis prevention
Randomized controlled UA and UK: 124 neonates high risk.
Full-body emollient therapy at least once per day starting within 3 weeks of birth. Parents in the control arm were asked to use no emollients
Statistically significant protective effect
Relative risk reduction of AD: 50% (relative risk, 0.50; 95% CI, ; P = .017).
Simpson EL et al. J All Clin Immunol 2014;134:4:818-23

9. Neonatal Moisturizer Intervention
AAD Pediatric Dermatology Course Atopic Dermatitis: Itching to Know More Lawrence F. Eichenfield, M.D.
Neonatal Moisturizer Intervention
Prospective, RCT: emulsion-type moisturizer applied qd for 32 wks
59 of 118 high risk neonates for AD (parent or sib with AD)
32% fewer moisturized neonates had AD at 32 wks
No impact: allergic sensitization (IgE Ab to egg white)
Daily moisturizer application during the first 32 weeks of life reduces the risk of AD
J Allergy Clin Immunol Oct;134(4): e6. doi: /j.jaci
Application of moisturizer to neonates prevents development of atopic dermatitis.
Horimukai K1
Horimukai K et al. J Allergy Clin Immunol :824-30

10. Topical Corticosteroids
Eichenfield Atopic Dermatitis Primer
Topical Corticosteroids
Mainstay of therapy for acute disease
Anti-inflammatory
Used for acute flare management
Intermittently for maintenance therapy
Many methods of use
“As low potency as needed”
“Start high, control, back to as low as needed”

11. Used hydrocortisone and it ‘worked a little’ but didn’t clear
How much in the last week?
How much in total?
Assess comfort, knowledge, fear!

12. Eichenfield Atopic Dermatitis Primer
STEROID PHOBIA:
72.5% of parents worried about TCS on child's skin
24% admitted to not using medicines because of the worries
Br J Dermatol May;142(5): Charman CR, Morris AD, Williams HC. Department of Dermatology, Queen's Medical Centre, Nottingham NG7 2UH, U.K. Topical corticosteroids are widely prescribed by dermatologists caring for patients with atopic eczema. Patients' fears about using topical corticosteroids may have important implications for compliance with treatment.) to assess the prevalence and source of topical corticosteroid phobia. We also questioned patients on their knowledge of the potencies of different topical corticosteroids. Overall,. In addition,. The most commonly used topical corticosteroid was hydrocortisone, yet 31% of patients who used this preparation classified it as either strong, very strong or did not know the potency. Only 62.5% of the 48 patients who had used both Dermovate (Glaxo) and hydrocortisone in the past were able to correctly grade Dermovate as being more potent than hydrocortisone. The most common source of patient information regarding topical corticosteroid safety was the general practitioner. Although skin thinning and systemic effects can develop very occasionally in people using topical corticosteroids, the concern expressed by people using them seems out of proportion in relation to the evidence of harm. This study highlights the need for provision of better information and education to patients and possibly general practitioners regarding the safety, potency and appropriate use of topical corticosteroids
Charman CR, Morris AD, Williams HC. Br J Dermatol. 2000;142(5):931-6

13. For an infant, with 40% BSA, how much corticosteroid?
App. 10 grams per week
App. 15 grams per week
24-40 grams per week
80 grams per week
I don’t use CS in infants

14. BASICS: FLARE MANAGEMENT
Eichenfield Atopic Dermatitis Primer
30-80 grams of…
Triamcinilone 0.1% ointment
Lower strength if younger
Class 7 or 6 if facial (or delicate; or TCIs)
For 1-2 wks (or 3 days post-clearing)
Then…up to 2 times a week

15. Eichenfield LF et al. Pediatrics 2015;138(3)

16. WHAT DO I DO? Establish care regimen Dictate quantity of TCS
Reinforcement of education
Varies; evolving

17. Beyond the Flare Management
Generally treat a few days beyond observed clinical response
Continued excellent skin care
SET GOALS: include relieving pruritus
Nonpharmacologic lifestyle interventions
Avoid allergens, irritants, coarse textiles, heat
Consider/discuss infection

18. Return visit:
Mother is a schoolteacher and is concerned with peanut allergy
She is asking about whether her child should get tested for peanut or other allergies

19. Peanut Consumption: Prevents Allergy!
Negative skin-prick baseline
Prevalence of peanut allergy at 60 mths:
13.7% in the avoidance group
1.9% in the consumption group (P<0.001)
Initially positive skin prick at baseline:
35.3% avoidance group
10.6% consumption group
Du Toit G, et al. N Engl J Med 2015;372:

20. New Food Allergy Guideline: NIAID
AAD Pediatric Dermatology Course Atopic Dermatitis: Itching to Know More Lawrence F. Eichenfield, M.D.
New Food Allergy Guideline: NIAID
2017 Addendum to the 2010 guidelines for Diagnosis and Management of Food Allergy
Identifies infants with severe AD (and/or egg allergy) as group at risk for peanut allergy
Severe eczema: defined as persistent or frequently recurring eczema with typical morphology and distribution, assessed as severe by a health care provider and requiring frequent need for prescription-strength topical corticosteroids, TCI, orother anti-inflammatory agents despite appropriate use of emollients.
Severe eczema is defined as persistent or frequently recurring eczema with typical morphology and distribution, assessed as severe by a health care provider and requiring frequent need for prescription-strength topical corticosteroids, calcineurin inhibitors or other anti-inflammatory agents despite appropriate use of emollients.

21. Direct referral to allergy or
New NIAID Food Allergy Guidelines
Recommends that infants with severe eczema, egg allergy or both have introduction of age- appropriate peanut-containing food as early as 4- 6 months of age to reduce the risk of peanut allergy
Direct referral to allergy or
Serum IgE screen (if negative, feed); if referral to allergy

22. Mild to Moderate Eczema
Introduce peanut-containing food as early as 4-6 months of age
…in accordance with family preferences and cultural practices, to reduce the risk of peanut allergy.
Peanut should not be the initial solid food
Peanut introduced at home without an in-office evaluation.
However, the EP recognizes that some caregivers and health care providers may desire an in-office evaluation

23. Infants without eczema or food allergy
Age-appropriate peanut-containing foods freely introduced in the diet, together with other solid foods, and in accordance with family preferences and cultural practices.

24. What’s your approach? Make sure it’s AD Assess Impact
Childhood onset, typical course
History of other atopic phenomenon, asthma, allergy
CONTACT DERMATITIS: Consider evaluation
Assess Impact

25. What’s my approach: Rx? Consider optimized topical rx
Systemic Rx: Which rx?
Well…interesting question
New age of systemic therapy
Biologic studies (dupilumab) in process
No approved treatment in children

26. Summary Minimal rash, minimal itch, minimal sleep disturbance
Be aggressive!
Raise expectations:
Minimal rash, minimal itch, minimal sleep disturbance