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Friday General Session

What’sNewinEczemaManagement:PracticePearlsfortheFamilyPhysician

LuciaZ.Diaz,MDAssistant Professor, Department of Internal Medicine and Pediatrics Dell Medical School, University of Texas at Austin Austin, Texas EducationalObjectivesBy completing this educational activity, the participant should be better able to:

1. Recognize the clinical features and characteristic age distribution patterns of Atopic Dermatitis.

2. Describe the role of skin barrier dysfunction, immune dysregulation, and environmental factors in the pathogenesis of Atopic Dermatitis.

3. Individualize Atopic Dermatitis management regimens according to age, location, disease severity, response to treatment, and quality of life concerns.

4. Implement educational strategies to communicate the safe and appropriate use of skin-directed therapies to individuals with mild to moderate Atopic Dermatitis.

SpeakerDisclosure Dr. Diaz has disclosed that she has no actual or potential conflict of interest in relation to this topic. SupporterDisclosureThis CME activity is supported by an educational grant from Pfizer. It has been planned and produced by the North Carolina Academy of Family Physicians and Spire Learning with TAFP strictly as an accredited continuing medical education activity.

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Off-Label Statement

The faculty will discuss non–FDA-approved or investigational agents for the treatment of atopic dermatitis (eczema), including apremilast, anti-IL-31, fezakinumab, lebrikizumab, OPA-154062, roflumilast, SB011, tofacitinib ointment, tralokinumab, and ustekinumab.

Participants should appraise the information presented critically and are encouraged to consult appropriate resources for any product or device mentioned in this activity.

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Learning ObjectivesAt the conclusion of this live activity, family physicians should be better able to:

Recognize the clinical features and characteristic age distribution patterns of AD

Describe the role of skin barrier dysfunction, immune dysregulation, and environmental factors in the pathogenesis of AD

Individualize AD management regimens according to age, location, disease severity, response to treatment, and QoL concerns

Educate patients and families about the safe and appropriate use of skin-directed therapies for the treatment of AD

AD, atopic dermatitis; QoL, quality of life. 8

Worldwide Prevalence of AD

The Pharmaceutical Journal. https://www.pharmaceutical-journal.com/news-and-analysis/infographics/atopic-dermatitis-emerging-and-current-treatments/20202373.article. Accessed January 24, 2019. 9

Epidemiology of AD

> 50 million Americans suffer from

allergic diseases1

1. CDC. https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/allergies.html. Accessed January 24, 2019.2. Leung DY, et al. J Clin Invest. 2004;113:651-657.3. Boguniewicz M, et al. Ann Allergy Asthma Immunol. 2018;120:10-22.4. Ellis CN, et al. Semin Cutan Med Surg. 2012;31(3 Suppl):S18-S22. 10

Lifetime prevalence of AD is

10%-20%in children

1%-3%in adults2

Can persist into adulthood

10%-30%4

First year Age 5

60% 85%3Onset

typically within

Burden of Disease

1. Zuberbier T. J Allergy Clin Immunol. 2006;118:226-232.2. Simpson EL, et al. J Am Acad Dermatol. 2016;74(3):491-498.3. National Eczema Association 2016 Caregiver Survey. https://nationaleczema.org/in-your-words-survey-series/. Accessed January 24, 2019.4. Kruse L. Paper presented at: 42nd Annual Society for Pediatric Dermatology Meeting; July 14-17, 2016; Minneapolis, MN. 11

An average of 9 flares Itching2

87%

experience itching daily

Itching lasts

≥ 18 hours in~42% of patients

Poor quality of sleep

• Sleep disturbances 3 or more days a week, affecting the entire family’s sleep3

• Children with moderate disease wake up an average of 36 times per night, negatively impacting mental health and growth rates4

per year, each lasting

15 days1

Burden of Disease (Cont.)

• Mental health comorbidities1-3

– Anxiety– Depression– Poor self-image– Attention-deficit/hyperactivity disorder (ADHD)– Behavioral or conduct problems

• Of note, in the GINI-plus birth cohort study, even children whose eczema appeared to resolve in the first 1-2 years of life were shown to have persistent emotional and behavioral difficulties at 10 years of age4

1. National Eczema Association 2016 Caregiver Survey. https://nationaleczema.org/in-your-words-survey-series/. Accessed January 24, 2019.2. Simpson EL, et al. J Am Acad Dermatol. 2016;74(3):491-498.3. Yaghmaie P, et al. J Allergy Clin Immunol. 2013;131(2):428-433.4. Schmitt J, et al. J Allergy Clin Immunol. 2010;125(2):404-410. 12

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Diagnostic Features of AD

• Pruritus (itching)• Chronic or relapsing dermatitis that exhibits:– Typical lesion morphology– Age-specific distribution

• Other important features:– Early age of onset– Personal or family history of atopy– Xerosis

American Academy of Dermatology (AAD). J Am Acad Dermatol. 2014;70(2):338-351. 13

What Does AD Look Like?

• Erythematous papules and plaques

• Excoriations

• Xerosis

• Erosions/crusting

• Lichenification

• Dyspigmentation

• Generally spares axillae and groin

Eichenfield LF, et al. Pediatrics. 2015;136(3):554-565.Siegfried EC, et al. J Clin Med. 2015;4(5):884-917.

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Photos courtesy of Anthony J. Mancini, MD

Clinical Features in Darker Skin Types

• Erythema may be difficult to see

• Follicular accentuation

• Hypo- or hyperpigmentation

• Grayish-white skin discoloration (“ashy skin”)

Photos courtesy of Elaine C. Siegfried, MD; Adelaide A. Hebert, MD; and Anthony J. Mancini, MD.Simpson EL, et al. Semin Cutan Med Surg. 2016;35(5S):S84-S88. 15

Lesion Distribution Varies With Age

Adapted from Simpson EL, et al. Semin Cutan Med Surg. 2016;35(5S):S84-S88.Eichenfield LF, et al. Semin Cutan Med Surg. 2017;36(supp2):S36-S38.Kapur S, et al. Allergy Asthma Clin Immunol. 2018;14(Suppl 2):52. 16

Differential Diagnoses (All Ages)

• Seborrheic dermatitis

• Contact dermatitis (allergic and irritant)

• Scabies

• Psoriasis

• Ichthyosis vulgaris

• Tinea corporis

• Keratosis pilaris

• Nutritional deficiencies in young children

• Immune disorders/immunodeficiency

Siegfried EC, et al. J Clin Med. 2015;4(5):884-917. 17

Differential Diagnoses: Considerations in Adolescents and Adults

• Cutaneous T-cell lymphoma (mycosis fungoides or Sézary syndrome)

• HIV-associated dermatoses

• Dermatomyositis

• Graft-versus-host disease

• Lupus erythematosus

• Pemphigus foliaceus

• Drug eruptions

Siegfried EC, et al. J Clin Med. 2015;4(5):884-917. 18

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Seborrheic Dermatitis (Infant)

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Differential Dx

Photos courtesy of Anthony J. Mancini, MD

Scabies

Photos courtesy of Anthony J. Mancini, MD 20

Differential Dx

Psoriasis

Photos courtesy of Anthony J. Mancini, MD 21

Differential DxIchthyosis Vulgaris

Photos courtesy of Anthony J. Mancini, MD 22

Differential Dx

Tinea Corporis

Photos courtesy of Anthony J. Mancini, MD 23

Differential DxKeratosis Pilaris

Photos courtesy of Anthony J. Mancini, MD 24

Differential Dx

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Impetigo

Photos courtesy of Anthony J. Mancini, MD 25

Differential DxAD Pathogenesis Basics

Ig, immunoglobulin; IL, interleukin; PDE-4, phosphodiesterase type 4; TEWL, transepidermal water loss; Th2, T helper 2.1. Eichenfield LF, et al. J Am Acad Dermatol. 2014;70(2):338-351.2. Leung DY, et al. J Clin Invest. 2004;113(5):651-657.3. Simpson EL, et al. Semin Cutan Med Surg. 2016;35(5S):S84-S88.4. Egawa G, et al. J Allergy Clin Immunol. 2016;138(2)350-358.5. Boguniewicz M, et al. Immunol Rev. 2011;242(1):233-246.6. Hanifin JM, et al. J Invest Dermatol. 1996;107(1):51-56.7. Irvine AD, et al. Semin Cutan Med Surg. 2016;35(5 Suppl):S89-S91.8. Silverberg JI, et al. J Invest Dermatol. 2013;133(7):1752-1759. 26

• Filaggrin gene mutation (in a subset)

• ↑ Skin pH• ↓ Ceramides• ↑ TEWL• ↓ Hydration• ↑ S. aureus colonization• ↑ Allergen sensitization

• Decreased filaggrin protein levels

• Th2 cell activation• ↑ IL-4, IL-5, IL-13

(also IL-17, IL-22, IL-31, others)

• ↑ Serum IgE• ↑ PDE-4 activation• ↑ Allergen sensitization

• Sweat• Heat• Seasonal change• Infection• Stress• Harsh soaps, detergents,

wool• Allergens

Immune Dysregulation4-7 Aggravating Factors7-8Epidermal Barrier Dysfunction1-3

Ceramides ↓

Paller AS, et al. Allergy Clin Immunol. 2017;140:633-643. 27

Treatment Goals

Control itch and skin inflammation

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Improve skin barrier and decrease xerosis

Reduce frequency of flares

Decrease risk of/treat infection

Improve/maintain quality of life

Stepwise Management of AD

Basic treatment:Skin hydration, emollients, avoidance of irritants, identification and addressing of specific trigger factors

Low-mid potency TCS and/or TCI,* TPDE-4*

Mid-high potency TCS and/or TCI,* TPDE-4*

Systemic therapy (eg, CyA, MTX, biologics) or UV therapy

Step 1

Step 2

Step 3

Step 4Recalcitrant, severe AD

Moderate to severe AD

Mild to moderate AD

Dry skin only

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*Over the age of 2 years.CyA, cyclosporine A; MTX, methotrexate; TCI, topical calcineurin inhibitor; TCS, topical corticosteroid; TPDE-4, topical phosphodiesterase-4 inhibitor; UV, ultraviolet.Adapted from Akdis CA, et al. J Allergy Clin Immunol. 2006;118(1):152-169.

Water: Irritant or Therapeutic?

Water irritates skin IF:

• Skin is frequently wet, without immediate application of effective moisturizer

• Moisture evaporates, causing skin barrier to become dry, irritated

Water hydrates skin IF:

• Effective moisturizer is applied and hydration is retained, keeping skin barrier intact and flexible

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Skin Barrier Dysfunction Is Predictive of Future AD

• Cork Babies After Scope Study1,2

– 1903 infants– TEWL measured at day 2, 2/6 months – AD scored at 6/12 months– Day 2 TEWL, highly predictive of AD at 12 months – 2-month TEWL – highly predictive of AD

• Infants in the Babies After Scope Study1,3

– Day 2 TEWL predictive of food allergy at 2 years

1. Paller AS, et al. J Allergy Clin Immunol. 2017;140:633-643.2. Kelleher MM, et al. J Allergy Clin Immunol. 2015;135(4):930-935.3. Kelleher MM, et al. J Allergy Clin Immunol. 2016;137(4):1111-1116. 31

Transcutaneous allergen sensitization?

Is Early Emolliation Effective?

Address barrier dysfunction in AD with good dry skin care:• Bathe daily (short bath or shower)• Apply emollient/barrier repair product immediately after bathing• Apply emollient after topical medications• May play a role in prevention as well

1. Simpson EL, et al. J Allergy Clin Immunol. 2014;134(4):818-823.2. Horimukai K, et al. J Allergy Clin Immunol. 2014;134(4):824-830. 32

RCT Simpson EL, et al1 Horimukai K, et al2

# of neonates, high AD risk

124 110

Intervention Full-body emollient daily (starting 3 weeks of age) vs no emollient

Moisturizer applied daily for first 32 weeks of life in 58 neonates

Primary outcome Cumulative AD incidence at 6 months

• Cumulative AD/eczema incidence at week 32• Egg white IgE

Results 50% relative risk reduction in AD (emollient arm)

• 32% fewer neonates with AD in emollient arm• No effect on allergic sensitization

“Pathogenesis-Based Therapy” With Emollients/Barrier Repair Agents• Add to the skin “what is missing”• Restore the barrier, maintain hydration• Ceramide-based products:

– Aveeno® Eczema Therapy– CeraVe® cream or lotion– EpiCeram® (prescription only)– Mario Badescu A.H.A & Ceramide Moisturizer

• Filaggrin-based products:– AFAs™ Moisturizer– Cetaphil RestoraDerm®

– Dr.G Filagrin™ Barrier cream or balm– pH Drop Filaggrin product line

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Topical Corticosteroids (TCSs): Benefits and Limitations

• Benefits:– Highly effective at treating inflammation– Rapid onset of action – Multiple potency and delivery vehicles

• Varied potency frequently required per patient

• Limitations:– Product-specific age limits (although often used off-label)– Potential for local and systemic side effects (but rare when used appropriately):

• Local: Striae, telangiectasias, skin atrophy, dyspigmentation, periorificial dermatitis, acne rosacea

• Systemic: HPA axis suppression• Periorbital administration: Cataracts, glaucoma

HPA, hypothalamic-pituitary-adrenal.Eichenfield LF, et al. J Am Acad Dermatol. 2014;71:116-132. Stein SL, et al. JAMA. 2016;315:1510-1511. 34

Best Practices When Using TCSs • Examples of location-appropriate

corticosteroids:– Face/fold areas: Low potency

(e.g., hydrocortisone 2.5%, desonide, alclometasone)

– Trunk/extremities: Mid potency (e.g., fluocinolone, triamcinolone)

– Severe flares (trunk/extremities): High potency (e.g., mometasone, fluocinonide)

• Apply twice daily to actively inflamed areas

• Oral corticosteroids (e.g., prednisone) rarely indicated in the treatment of AD; risks of rebound, side effects

C, cream; F, foam; G, gel; L, lotion; Oi, oil; O, ointment; S, solution.Adapted from Eichenfield LF, et al. J Am Acad Dermatol. 2014;71:116-132. 35

Topical Calcineurin Inhibitors (TCIs) –Benefits

• Extensive clinical trials experience• Nonsteroid alternative

• Good efficacy for mild, moderate, and severe AD• Used for acute AD and maintenance therapy• Little systemic absorption

• Can be applied to face, fold areas, periorbital region, genitals

Eichenfield LF, et al. J Am Acad Dermatol. 2014;71:116-132. Stein SL, et al. JAMA. 2016.315:1510-1511.

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TCIs: Limitations and Potential AEs• Second-line agents1,2

• Not approved for use in children < 2 years of age1,2

• Limited range of vehicles available vs TCS

• Stinging and burning in a subset of patients1,2

• FDA-mandated boxed warning and medication guide– No evidence to date of increased cancer risk in majority of studies, post-

marketing surveillance registries– Recent study of European population databases (JOELLE): increased IRR for

lymphoma (Hodgkin’s in children, CTCL in adults) with tacrolimus vs TCS, and for CTCL with pimecrolimus vs TCS in adults; if low IRs causal small excess risk for individual patients3

AEs, adverse events; CTCL, cutaneous T-cell lymphoma; IR, incidence rate; IRR, incidence rate ratio.1. Eichenfield LF, et al. J Am Acad Dermatol. 2014;71:116-132. 2. Stein SL, et al. JAMA. 2016;315:1510-1511.3. Castellsague J, et al. Clin Epidemiol. 2018;10:299-310. 37

Available TCIs

• Both TCIs were shown to be more effective than vehicle in short-term (3-12 weeks) and long-term studies (up to 12 months) in adults and children with active disease3-8

– Decline in Eczema Area and Severity Index (EASI) score– Decrease in percentage of body surface involved– Reduction in patient-evaluated symptoms and signs of disease

1. US FDA. CDER. Pimecrolimus NDA 021302. Label 03/28/2014.2. US FDA CDER. Tacrolimus NDA 050777. Label 11/04/2011.3. Boguniewicz M, et al. J Allergy Clin Immunol. 1998;102:637-644.4. Eichenfield LF, et al. J Am Acad Dermatol. 2002;46:495-504.

TCI Vehicle Indications

Pimecrolimus (1%)1

Cream Approved for mild to moderate AD (2 years and older)

Tacrolimus (0.03% and 0.1%)2

Ointment Approved for moderate to severe AD (0.03%: 2 years and older; 0.1%: 15 years and older)

5. Ho VC, et al. J Pediatr. 2003;142:155-162.6. Kang S, et al. J Am Acad Dermatol. 2001;44(Suppl):S58-S64.7. Paller A, et al. J Am Acad Dermatol. 2001;44(Suppl):S47-S57.8. El-Batawy MM, et al. J Dermatol Sci. 2009;54:76-87. 38

Crisaborole 2% Ointment• A nonsteroidal, boron-based PDE-4 inhibitor1,2

• Indicated for mild to moderate AD in adults and children ≥ 2 years3

• Benefits3,4

– Reduces inflammation and itching– Maintains skin barrier– Low molecular weight enhances skin penetration– Limited systemic exposure– Favorable safety profile over 48-week study5

• Limitations– Stinging and burning at application site

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1. Hanifin JM, et al. J Invest Dermatol. 1996;107:51-56.2. Jarnagin K et al. J Drugs Dermatol. 2016;15(4):390-396.3. US FDA. CDER. Crisaborole NDA 207695. Label 10/16/2017.4. Tom WL, et al. Pediatr Dermatol. 2016;33(2):150-159.5. Eichenfield LF, et al. Presented at: Winter Clinical Dermatology Conference; January 15-20, 2016; Koloa, HI.

Dupilumab• Human monoclonal IgG antibody targets IL-4Rα; blocks IL-4 and

IL-13 signaling1

• Indicated for patients ≥ 12 years with moderate-to-severe AD; subQ injection every 2 weeks1

• Phase III trials: > 33% of patients achieved significant improvement in AD severity2

• Topical therapies can be combined with dupilumab for additional benefit in adults with refractory AD3

• Associated with potentially serious side effects, requires close monitoring1,4

– Conjunctivitis– Injection-site reactions

SubQ, subcutaneous.1. US FDA. CDER. Dupilumab NDA 761055. Label 03/11/2019.2. Simpson EL, et al. N Engl J Med. 2016;375(24):2335-2348. 40

3. Blauvelt A, et al. Lancet. 2017;389(10086):2287-2303.4. Yang EJ, et al. Pediatrics. 2018;142(4):e20181102.

Dupilumab: Pediatric Studies Underway…

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Emerging Treatments for AD• Topical therapies

– PDE-4 inhibitors (e.g., roflumilast,1 OPA-154062)– Janus kinase inhibitors: tofacitinib ointment3

– Calcineurin inhibitor: SB0114

• Systemic therapies– Apremilast: an oral PDE-4 inhibitor5

– Anti-IL-316

– Ustekinumab, lebrikizumab, tralokinumab, fezakinumab (IL inhibitors)7

• Numerous other potential targets in developmentIL, interleukin.1. ClinicalTrials.gov Identifier: NCT01856764. 2. Hanifin JM, et al. J Am Acad Dermatol. 2016;75(2):297-305. 3. ClinicalTrials.gov Identifier: NCT02001181. 4. ClinicalTrials.gov Identifier: NCT02079688. 5. ClinicalTrials.gov Identifier: NCT02087943. 6. ClinicalTrials.gov Identifier: NCT01614756.7. Yang EJ, et al. Pediatrics. 2018;142(4):e20181102. 42

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Wet Wraps

• Wet wraps prevent scratching and promote moisture retention

• Use with emollients or a TCS• Taper from TCS to Vaseline

• Sporadically or frequently (during acute flares)

• Extensive or localized• Absorption toxicity risk is minimal

Sladden MJ, et al. Clin Exp Dermatol. 2005;30(4):454-455.Krakowski AC, et al. Pediatrics. 2008;122(4):812-824.Hindley D, et al. Arch Dis Child. 2006;91(2):164-168.Dabade TS, et al. J Am Acad Dermatol. 2012;67(1):100-106. 43

Colonization With Staphylococcus aureus

• Carriage common in nares/subungual areas• Worsens disease status

• Renders disease harder to control

• Patients do not have to be infected to be adversely impacted by S. aureus

• Skin that is colonized: A trigger for disease flares

Boguniewicz M, et al. J Allergy Clin Immunol. 2010;125:4-13.44

Bleach Therapy

• Sodium hypochlorite has disinfectant and antimicrobial properties

• Bleach baths/intranasal mupirocin shown to: – Improve disease severity in patients with moderate to severe AD– Minimize antibiotic use

• When is bleach therapy indicated?– Moderate to severe AD– Frequent infection/antibiotic use

Huang JT, et al. Pediatrics. 2009;123:e808-e814.Eichenfield LF, et al. J Am Acad Dermatol. 2014;71:116-132.Kedzierska A, et al. Br J Dermatol. 2008;159(6):1290-1299. Lever R, et al. Br J Dermatol. 1988;119(2):189-196. 45

Bleach Therapy Delivery Options

• Clorox bleach – 6% sodium hypochlorite (newer formulas 8.25%)– 1/8-1/2 cup bleach in full tub; soak 10-15 min, TIW

• CLn wash – OTC cleanser with sodium hypochlorite (0.006%); good option for older kids and teens (www.clnwash.com)

• Levicyn – Rx antipruritic gel and spray gel with hypochlorous acid/water– Broad antimicrobial activity– Indicated for burning and itching of dermatoses, pain of burns

Rx, prescription; TIW, three times a week. 46

Oral Antihistamines in AD

• Some controversy, but many use them, especially for sleep

• Hydroxyzine most commonly used sedating antihistamine at bedtime

*Available over-the-counter.Sidbury R, et al. J Am Acad Dermatol. 2014;71:116-132.

Agent Vehicle Properties

Diphenhydramine* Oral Sedating antihistamine

Hydroxyzine Oral Sedating antihistamine

Doxepin Oral Sedating antihistamine

Cetirizine* Oral Nonsedating antihistamine

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Maintenance Therapies for AD• Liberal and frequent application of moisturizers to reduce

dryness and itching, prevent flares• Warm baths/showers (< 5 min) using non-soap cleansers

or mild soaps• Antiseptic measures– Dilute bleach baths, if indicated

• Trigger avoidance, when feasible• Intermittent application of TCSs or TCIs to prevent flares

(“hot zones”)

Eichenfield LF, et al. J Am Acad Dermatol. 2014;71:116-132. Boguniewicz M, et al. Ann Allergy Asthma Immunol. 2018;120:10-22.Kirkup ME, et al. J Dermatolog Treat. 2003;14(3):141-148.Breneman D, et al. J Am Acad Dermatol. 2008;58(6):990-999. 48

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Customizing Patient Treatment Plans• Written treatment plan increases likelihood of adherence

• Tailor treatment plan based on:– Age– Locations of disease– Previous treatment success/failures– Patient/caregiver preferences

• Identify/eliminate triggers, if possible

• Address quality-of-life issues (e.g., sleep disruption, co-sleeping)

• Provide basic skin care instructions (e.g., bathing, emollients)– Moisturize frequently throughout the day– Topical medications do not take the place of moisturizers– Continue maintenance therapies, even if skin “appears” healthy

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When to Test for Food Allergies

• Food allergy testing should be considered when:– Moderate to severe AD is persistent despite optimal

management– Reliable history of anaphylaxis or immediate reaction after

ingestion of a specific food

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• Early referral in the case of severe, persistent disease• Otherwise, refer if the patient is not responding to conservative

measures and standard treatment modalities

Specialist Referral

Case Presentation

• 5-month-old female who developed an eczematous rash on her cheeks at about 3 months of age, and more recently has had involvement of her neck and outer aspects of upper extremities. She has not had any open or weeping lesions.

• Her pediatrician prescribed hydrocortisone 2.5% cream, but her parents are concerned about using a topical steroid. They are wondering about allergic triggers.

Photo courtesy of Anthony J. Mancini, MD

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Treatment GuidelinesMild Atopic Dermatitis

• Basic skin care (hydration and moisturizer)• Avoid irritants (and known allergens)• TCSs

– Use lower strength in thin-skin areas (face, axillae, genital areas) and for mild eczema anywhere on the body

Clinical Pearl: Choose correct vehicle and dispense correct amount• TCIs

– Pimecrolimus cream indicated for ages 2 years and older for mild to moderate AD; if parents concerned about TCSs can consider, but disclose that it is off-label

• Crisaborole ointment indicated for mild to moderate AD in children 2 years and older; another steroid-free option, also off-label in this patient

• Sedating antihistamine may help with itch and sleep disruption• Discuss atopic diathesis and possible allergies but appropriate to treat first

and assess response to therapies (unless clear-cut indication for allergy referral)52

Case Presentation• 12-year-old female with onset of

eczema in early childhood. Over the years, it has involved her head and neck, trunk, and flexural aspects of her upper and lower extremities. She has had infrequent superficial skin infections.

• On exam: Moderate patches of eczema involving face (including eyelids), neck, and flexural aspects of all 4 extremities with lichenification. Several areas with crusting.

• Parents want to discuss TCI options

Photo courtesy of Anthony J. Mancini, MD 53

Treatment GuidelinesModerate Atopic Dermatitis• Basic skin care (hydration and moisturizer)• Avoid irritants (and known allergens)• TCSs

– Use lower strength in thin-skin areas (face, axillae, genital areas)– Use mid-potency for trunk and extremities– Caution with TCSs in periorbital locations

• TCIs– Pimecrolimus indicated for ages 2 years and older for mild to moderate AD– Tacrolimus ointment indicated for ages 2 years and older for moderate to severe AD (0.03% for ages 2-15 years;

0.1% for > 15 years)– Discuss potential indications (especially around eyes), boxed warning

• Crisaborole ointment indicated for mild to moderate AD in ages 2 years and older• Sedating antihistamine for sleep disruption/nocturnal pruritus• Nonsedating antihistamine may help in patients with allergic triggers, better for daytime (school)• Dilute bleach baths

– 1/8-1/2 cup of bleach in a full bathtub (about 40 gallons) of water– Soak 5 to 10 minutes 2-3 times/weekly

• Oral antibiotic for bacterial infection (usually MSSA; consider MRSA if history or suggestive clinical findings)

54MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-susceptible Staphylococcus aureus.

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Patient/Parent Education

• Chronic disease, prone to flares and remissions

• Importance of dry skin care and maintenance use of emollients/barrier-repair agents

• Treat acute flares aggressively

• Recognize/treat infection, and attempt to prevent (bleach) when indicated

• Optimize sleep, consider antihistamines for this and control of pruritus

• Escalate therapy if response suboptimal (and good adherence)

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Take-Home Messages• Most patients with mild to moderate AD can be managed by the

primary care physician

• AD impacts the entire family’s QoL, not just the patient’s

• Need to educate patients and caregivers about the disease, provide a written action plan, and review/modify PRN at follow-up

• Address itch-scratch cycle, sleep disturbance, behavioral associations

• Underlying skin inflammation is always present, even when the skin appears normal – treat with the appropriate agents and consider maintenance anti-inflammatory therapy

• Patient adherence is critical to AD management

• Consistent skin care can reduce flare-ups56

Questions?

Thank You

Please complete the post-assessment and evaluationlocated in your meeting handout.

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Notes