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Peeling Back the Layers: A Best-Practice Approach to Managing Atopic Dermatitis

http://tiny.cc/AANPadhandoutHandouts for this presentation may be found at: and

This activity sponsored by an educational grant from Pfizer Inc.

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Faculty

MARGARET BOBONICH, DNP, FNP-C, DCNP, FAANP Assistant Professor, Case Western Reserve

University Schools of M edicine & NursingUniversity Hospitals Cleveland M edical CenterDepartm ent of Derm atologyCleveland, Ohio

Susan Tofte, BSN, MS, FNP-CAssistant Professor of DermatologySchool of MedicineOregon Health & Science UniversityPortland, Oregon

Peggy Vernon, RN, MA, CPNP, DCNP, FAANPOwner, Creekside Skin Care Centennial, Colorado

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Faculty DisclosuresMargaret Bobonich, DNP, FNP-C, DCNP, FAANP

Speakers’ Bureaus, psoriasis: AbbVie, Lilly USA, Novartis, UCS?

Susan Tofte, MS, BSN, FNP-C

Advisory Board, psoriasis: Celgene, NovartisAdvisory Board, AD: Regeneron/SanofiConsultant, AD: Pfizer

Peggy Vernon, RN, MA, CPNP, DCNP, FAANP+None

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LEARNING OBJECTIVES

Integrate a patient-centered, best-practice approach to educate patient/parent on AD disease management.

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Recognize Atopic Dermatitis and classify severity according to most recent guidelines

Select the best individualized treatment(s) based on classification of severity

Atopic Dermatitis (AD)• Chronic, relapsing inflammatory skin disease• Persistent pruritus, erythema, erosions, lichenfication• Flares/exacerbations• Compromised skin barrier• Increased risk for infections• May precede allergies, asthma, and allergic rhinitis

Eichenfield LF, et al. J Am Acad Dermatol. 2014;70(2):338-51.

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Prevalence in ChildrenMost common skin disease in children

Affects 15–20% of children (10.7% in U.S.)

AD commonly presents before 5 years of age

◦ Highest incidence occurring between 3 and 6 months of age

◦ 60% of patients develop disease in first year of life

◦ 90% within first 5 years of life

Eichenfield LF, et al. J Am Acad Dermatol. 2014;70(2):338-51; Kay J, et al. J Am Acad Dermatol. 1994; 30:35–39; Silverberg JI, et al. J Invest Dermatol. 2015;135:56-66. Avena-Woods C. Am J Manag Care. 2017;23:S115-S123.

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Prevalence of AdultsAD more common in adults in the United States than previously recognized

1–3% of adults worldwide (7.2% in the U.S.)

◦ Prevalence higher in female gender and higher lever education (n=27,157)

70% onset AD during childhood have remission before adolescence

10–30% continue to have symptoms into adulthood

16.8% of adults onset after adolescence

Silverberg JI, et al. J Allergy Clin Immunol. 2013;132:1132-8. Silverberg JI, et al. J Invest Dermatol. 2015;135:56-66. Avena-Woods C. Am J Manag Care. 2017;23:S115-S123.

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PathophysiologyMultifactorial

Intrinsic

Extrinsic

Silverberg NB, et al. Cutis. 2015;96(6):359-361. Cork MJ, et al. J Allergy Clin Immunol. 2006; 118:3–21.

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Genetic

Filaggrin (FLG) gene mutation◦ 30% of European-descent patients with AD

◦ FLG develops profilaggrin protein in epiderm is; provides natural m oisturizing factor and builds stronger skin barrier

Family history◦ 70% with fam ily history of AD or other com m on atopic diseases (e.g., asthm a or allergic rhinitis)

◦ M aternal history m ay be m ore predictive

◦ BUT not necessary for diagnosis

Eichenfield LF, et al. J Am Acad Dermatol. 2014;70:338-51; Palmer CN, et al. Nat Genet. 2006;38(4):441-6; Kantor R, et al. Expert Rev Clin Immunol. 2017;13:15-26; Ruiz RG, et al. Clin Exp Allergy. 1992;22:762-766; Wen HJ, et al. Br J Dermatol. 2009; 161:1166–1172.

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Epidermal Barrier DysfunctionSkin-barrier factors◦ Levels of transepidermal water loss (TEWL) correlate with AD severity ◦ Lipid abnormalities◦ Decreased ceramides◦ Overactive PDE4◦ Increased risk for infection by pathogenic microbes

What can penetrate the skin barrier?◦ High-molecular-weight allergens in pollens◦ Dust-mite particles◦ Microbes and allergens

Kantor R, et al. Expert Rev Clin Immunol. 2017;13:15-26; Schauber J, et al. J Allergy Clin Immunol. 2008;122:261-266; Sicherer SC, et al. J Allergy Clin Immunol. 2009;123:319-327.

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Immunologic FactorsComplex immune dysregulation in AD AD predominance of Th2 cells decrease expression of FLG Associated with gene variants involved in immune pathways

◦ Acute or initial phase T-helper (TH) 2 releases cytokines, causing increased inflammation

◦ IL-4, IL-13, TSLP, and eosinophils ◦ Chronic AD

◦ Th1/Th0 dom inance affects pathways

◦ IFN-γ, IL-12, IL-5, and GM-CSF

Kantor R, et al. Expert Rev Clin Immunol. 2017;13(1):15-26.

GM -CSF, Granulocyte-m acrophage colony-stim ulating factor; IFN-γ, interferon gam m a; IL, interleukin; TSLP, thym ic strom al lym phopoietin

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Environmental and Other Risk FactorsEnvironmental•Climate/seasonal changes•Dust mites, pollen, and pets •Pollution and tobacco smoke•Urban (vs rural) setting

Kantor R, et al. Expert Rev Clin Immunol. 2017;13:15-26.

Risk Factors• Diet—food allergens• Soaps and detergents impair

skin-barrier function• Hand sanitizers

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PresentationFirst signs often present in infancy or early childhood◦ Often precede allergic diseases

Erythema with scale, fissures and erosions, diffuse borders Intense itching, especially at night

Eichenfield LF, et al. J Am Acad Dermatol. 2014;70:338-51.

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Diagnostic Approach to ADDetailed history

Family history

Symptoms (incl. frequency, severity, remission, triggers, etc.)

Therapies—past and current

Clinical presentation◦ Morphology primary and secondary lesions◦ Persistent, intermittent, remission◦ Distribution◦ Pruritus

Recognize and classify AD ◦ Clinical presentation phases

Patient assessment of their pruritus is critical

Eichenfield LF, et al. J Am Acad Dermatol. 2014;70(2):338-51.

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Patterns in Various Age Groups

Scalp, facial, neck, and extensor involvement in infants and childrenCurrent or previous flexural lesions in any age groupSparing of the groin and axillary regionsCommon to have secondary infections

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Significance of PruritusPruritus is the HALLMARK of AD◦ 91% experience itch on a daily basis◦ Per U.S.-based survey, n=304

Most significant symptom affecting quality of life

Can lead to sleep disturbance (falling asleep and staying asleep)◦ Experienced by ~2/3 of patients ◦ Difficulty initiating and maintaining sleep daytime fatigue

• Severe excoriations can result in skin damage◦ Disruption in skin barrier can lead to bacterial infections, most commonly Staphylococcus aureus• Psychosocial effects

Eichenfield LF, et al. J Am Acad Dermatol. 2014;70:338-51; Kabashima K. J Dermatol Sci. 2013;70:3-11; Silverberg JI, et al. J Invest Dermatol. 2015;135:56-66.

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Perinatal Prevention of ADPerinatal focus, given childhood prevalenceBreastfeeding (until at least 3 months of age) Delaying of early introduction of solid foods increases risk factor for ADInfants who cannot be breastfed, use infant formulas with partially hydrolyzed or extensively hydrolyzed formulas (EHF)◦ Alexander et al. show 45% reduction in infantile AD in at-risk infants with partially

hydrolyzed whey formula compared to cow’s milk formula◦ Results from long-term GINI study (n=2252) evidence for allergy-preventive effect of

hydrolyzed infant formulas; risk reduction up to 10 years of age

Kantor R, et al. Expert Rev Clin Immunol. 2017;13:15-26; Alexander DD, et al. J Pediatr Gastroenterol Nutr. 2010;50: 422–430; von Berg A, et al. J Allergy Clin Immunol. 2008;121:1442–1447.

GINI, G e rm an In fan t N u tritio n a l In te rve n tio n S tu d y

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Documenting SeverityMorphology

•Dry scaly

•Weep fissures

•Pustules/vesicle (moist)

•Crust (impetigo)

•Lichenification

•Striae

Frequency

• Persistent, intermittent

• Distribution

• Face, trunk, extremities

• Flexural or Extensor

• Pruritus

• Day/night

• Quality of life: school, work, sleep,

psychosocial

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Avoid Triggers of Exacerbation• Lifestyle modification•Avoid wool. Prefer loose fitting cotton clothing•Caution if pet allergies (i.e., not to sleep in their bed)• Identify and manage triggers known to aggravate condition•Avoidance of known allergens•Consistent use of emollient maintenance therapy•Consistency among caregivers (challenges for split households)•Caution against “steroid phobia”•Avoid overheating or sweating• Try to break itch/scratch cycle with cool packs or tapping gently

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Moisturizers and Emollients•Moisturizers• Refers to a finished product• Add moisture to skin

•Emollients• Refers to a specific ingredient • Reduce water loss from the epidermis• Act as barrier to extrinsic agents

•Humectants• Bonds with water molecules to increase water content

•Occlusive• Provide physical barrier to decrease epidermal water loss

Pearls:• Avoid products with anti-itching agents• Refrigerate moisturizers/emollients for “cooling” effect• Do not use fragranced products from specialty lotion shops

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Lotions: 70% water, 30% oil

Creams: equal parts oil and water

Ointments: 80% oil, 20% water

Avoid fragrances, parabens, and dyes

Apply after bath◦ AAD recommends applying moisturizer (free of additives and fragrances) after every bath

Pearls:◦ Generic white petrolatum (cheap, free of fragrances, dyes & preservative,

available everywhere)

◦ Make emollient use fun after bath, “soak and smear”

Lotions, Creams, Ointments

American Academy of Dermatology. Atopic dermatitis clinical guideline.

https://www.aad.org/practicecenter/quality/clinical-guidelines/atopic-dermatitis; Sidbury R, et al. J Am Acad Dermatol. 2014;71(2):327-49.

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Daily Skin Care to Control and Prevent FlareDaily tub soaks BID if severe◦ 10 minutes in lukewarm water & pat dry◦ Pearl: Very helpful to loosen scale or crust

Apply prescribed mediations to affected areasMoisturize entire body after bathing◦ Apply to damp skin immediately [3-minute rule] after removing from tub

Bleach baths weekly ◦ ¼ cup bleach to a tub of water◦ Soak 10 minutes◦ Rinse before removing from tub◦ Mixed reviews—per Chopra et al. 2017 study: although bleach baths are effective to decrease AD severity,

they do not appear to be more effected than water baths.Wet-wrap therapy for moderate to severe AD◦ Decreases water loss during flares; cools skin; increases moisture; helps as scratching barrier

Chopra R, et al. Ann Allergy Asthma Immunol. 2017;119:435-440. Sidbury R, et al. J Am Acad Dermatol. 2014;71(2):327-49.

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Daily Skin Care continuedNail care

◦ Trim

◦ Keep clean

Best practices for management of infection◦ Systemic and topical antibiotics

◦ Mupirocin, sometimes intranasal, accessorial, peroneal, umbilicus

Pearl: ◦ For children, consider mupirocin under nails if repeated skin infections

Rangel SM, et al. Clin Dermatol. 2018;36:641-647.

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Tips to Address PruritusWear loose clothing

Avoid wool

Avoid overheating or sweating

If itchy, apply cool packs or tapping instead of scratching

Use of antihistamines

◦ Evidence of decreasing itch◦ Sedating vs non-sedating◦ Decrease some comorbidities vs itch

He A, et al. J Am Acad Dermatol. 2018;79:92-96.

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Treatment Course• Combination of TCS and moisturizing (use of creamy or greasy emollients),

preventing heat and sweating; reducing psychological stresses Mild AD

• Topical therapy with TCS in combination with topical immunomudulators• May require phototherapy or systemic immunomodulating drugs

Moderate AD

• Refer to dermatology specialist for management systemic immunosuppressant agents and biologic therapySevere AD

TCS, topical corticosteroid

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Pharmacotherapeutics—Topical CorticosteroidsWhen lifestyle modifications and emollients are not effective:

First-line therapy TCS, baring effectiveness of non-pharmaceutical treatment and emollients

Treats active inflammation and itch, for all agesReduces inflammation for a duration of one or two weeksApproved for chronic AD in pediatricsCourse: ◦ Proactive, intermittent use as maintenance therapy (1–2 times/wk)◦ Overuse can result in flare ups

Monitor for cutaneous side effects during long-term, potent steroid useAddress patient fears of TCS use to improve adherence

American Academy of Dermatology. Atopic dermatitis clinical guideline. https://www.aad.org/practicecenter/quality/clinical-guidelines/atopic-dermatitis; Sidbury R, et al. J Am Acad Dermatol. 2014;71(2):327-49.

TCS, T o p ica l co rtico ste ro id s

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Shared Decision Making SDM shown to improve adherence and leads to better outcomesClinician puts patients in either of 2 groups based on patient history, physical exam, and previous treatments

◦ Mild-to-moderate◦ Moderate-to-severe patients

Patient evaluates various treatments for the type of severityFactors to consider:

◦ Benefits◦ Risks◦ Side effects◦ How treatment is applied, ◦ Duration of therapy ◦ Cost

Patient asked to agree or disagree to a series of statements to determine best treatment to fit patients lifestyle

Blaiss MS, et al. Ann Allergy Asthma Immunol. 2018. pii: S1081-1206:30710-5. [Epub ahead of print]

SDM , Shared Decision M aking

This will make a nice handout

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Accurate diagnosis and prompt treatment Identify and manage triggers known to exacerbate their AD Prescribe evidenced-based therapy individualized for patients and disease severityEducate patients and caregivers about novel AD treatmentsImprove adherence & outcomes through shared decision-makingNew studies, survey, research needed to address new prevalence data, changing prescribing patterns, and additional contributing factors (e.g., presenteeism) On the horizon: targeted biologic therapies, combination therapy, and TCS

TCS, Topical corticosteroids

Take-home Summary

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