1. Paediatric Dermatology: Atopic dermatitis
Dr Danielle Greenblatt
Consultant Dermatologist
Royal Free Hospital

2. 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

3. 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

4. Pathogenesis Skin barrier defect - Filaggrin mutation
Altered immunological pathways

5. 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

6. 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

7. Guidelines

8. Management

9. 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

10. 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

11. Dietary interventions
Risk assessment of child
Consider GI symptoms
Food diaries
Consider risks of withdrawal of food from diet – nutritional

12. 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

13. 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

14. 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

15. Topical treatment Emollients Essential for all severities of eczema
provide skin with exogenous lipids; reduce TEWL
NICE guidance: children should be prescribed g/week
Creamy – Rich cream – Greasy – Very Greasy

16. 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

17. 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)

18. 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

19. Induction of remission
Tang et al JACI 2014
Systematic review 26 trials
Induction of remission
Maintenance therapy
Weekend treatment

20. Adherence

21. 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

22. Calcineurin inhibitors
Tacrolimus and pimecrolimus
Approved in
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

23. 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

24. 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

25. Questions?