DERMATOLOGY: Multiple modalities for treating atopic dermatitis

Management of atopic dermatitis is always a topic of key interest for pediatricians because of the prevalence of this dermatologic disorder, its chronic nature, and its negative impact on quality of life. In his presentation “Update on Atopic Dermatitis,” Fred Ghali, MD, provided a therapeutic update on appropriate treating plans.

Ghali reminded clinicians that topical corticosteroids remain the cornerstone of treatment for this inflammatory skin disease. When clinicians treat atopic dermatitis, their choice of a topical corticosteroid should take into account the severity and location of involved skin. However, to optimize safety, patients and their families must be told that the corticosteroid is not an all-in-one anti-inflammatory/moisturizer, and once a satisfactory response is achieved, the steroid regimen should be adjusted to intermittent use.

Topical calcineurin inhibitor (TCI) treatment offers another modality for controlling inflammation. Accumulating data support the safety of TCIs with judicious use. Nevertheless, the prescribing information for these products still features a black box warning and pediatricians are advised to adhere to the labeling and prescribe a TCI as second-line therapy for short-term and noncontinuous treatment.

Recent discoveries on the role of epidermal barrier dysfunction in the pathogenesis of atopic dermatitis have provided a foundation for the development of barrier repair moisturizer products containing ceramide and other lipids. While useful in theory and in clinical experience, Ghali noted there remains little evidence establishing these products as superior to more traditional moisturizers.

Secondary staphylococcal infections continue to present a therapeutic challenge in managing atopic dermatitis. Pediatricians should be aware of the most recent clinical practice guidelines from the Infectious Diseases Society of America on treatment of methicillin-resistant Staphylococcus aureus infections, but also be knowledgeable about the use of dilute bleach baths and products containing sodium hypochlorite as a means for minimizing skin colonization with S aureus. Patients with severe atopic dermatitis refractory to the aforementioned standard treatments may be candidates for systemic immunosuppressive therapy. However, in many cases, brief use of wet wrap therapy may augment the effects of a topical corticosteroid and mitigate the need for potent systemic medications.

Fred Ghali, MD, FAAP, is clinical associate professor of dermatology at the University of Texas Southwestern Medical School and Baylor Medical Center, Dallas.

This discussion on atopic dermatitis (aka, eczema) is timely with its prevalence in early childhood approaching 20% in industrialized countries and the peak season for eczema in North America fast approaching. Fortunately, science has caught up to atopic dermatitis, so bench research has finally provided us with a better understanding of the pathogenesis and management of the complex disorder.

Most children with atopic dermatitis present with mild to moderate disease that can be readily managed in the pediatric office. Early diagnosis is critical but may be elusive. The clinician must recognize the recurrent and persistent clinical findings and the clinical patterns that evolve with increasing age, from a predilection for involvement of the face and all exposed areas in infants; extensor extremity involvement in preschoolers; flexural disease in school-aged children; and hand and foot involvement in adolescents. Associated findings including ichthyosis vulgaris, keratosis pilaris, prurigo nodularis, pityriasis alba, eyelid folds, and an atopic family history may provide clues.

Once the diagnosis is established, the primary care provider must outline a reasonable personalized treatment plan including recognition and avoidance of triggers, irritants, and allergens; aggressive maintenance of general skin integrity with protective clothing, emollients, and gentle cleansing agents; and the judicious use of anti-inflammatory agents including topical steroids and topical calcineurin inhibitors. What better person to design a plan that takes into account the special sensitivities of patients than the primary care clinician working in the medical home model? Ghali addresses all these issues and provides guidelines for when to ask for help from your friendly neighborhood dermatologist or pediatric dermatologist.  

Finally, stay tuned for a formal clinical report on atopic dermatitis from the AAP that should be published later this year.

Bernard A. Cohen, MD, is director, Pediatric Dermatology and Cutaneous Laser Center, and associate professor of pediatrics and dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland. He also is a physician contributing editor for Contemporary Pediatrics.