management of atopic dermatitis
DESCRIPTION
Management of atopic dermatitis 2011TRANSCRIPT
Management of Atopic dermatitis
Sasikarn Suesirisawad, M.D.
O AD is a chronic relapsing inflammatory skin disease
O AD associated with local infiltration of Th 2 that
secrete IL-4, IL-5, IL-13, IL-31
O More than 50% develop asthma
O 75% develop AR
O Complex interrelationship of genetic,
environmental, immunologic, and epidermal factor
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1893-1999
EpidemiologyO Affects 15-30% of children, 2-10% of adult
O 60% begin during the first yr
O 45% begin within the first 6 mo
O 85% begin before 5 yrs
O Up to 70%: spontaneous remission before adolescence
O Predisposed to developing AR/asthma later in childhood .. “Atopic march”
NJEM 2008;358:1483-94
Epidemiology O E merges in 1st month of life, while its prevalen
ce decreases by age.
O Girls more often suffer from AD than boys ... but until age of 6, both sexes are affected equally.
O Increase exposure to allergen & decline in BF were reason for increasing of AD.
Williams H.C.: Is the prevalence of atopic dermatitis increasing?. Clin Exp Dermatol 1992; 17:385-391
O Childhood eczema found correlation with increased socioeconomic class
Williams H.C., Strachan D.P., Hay R.J.: Childhood eczema: disease of the advantaged?. Br Med J 1994; 308:1132-1135
Pediatr Allergy Immunol 2010:21:1028-1035
Risk factor in development of AD
Genetic host factors
O Gene encoding epidermal or other epithelial
structural proteins
Loss of function mutations of
epidermal barrier protein filaggrin (FLG)
Transepidermal water loss (hallmark)
& penetration of environmental allergens
N Engl J Med 2008;358:1483-94
Risk factor in development of AD
Genetic host factors
• Gene encoding major elements of immune system:Gene encoding major elements of immune system:
3q21, 1q21, 16q, 17q25, 20p, 3p26 regulation of IgE synthesis
- Exaggerated T cell responses: imbalance between Th1 & Th2
- Reduced skin innate immune response:
human B defensins, cathelicidin, dermcidin
(antimicrobial peptide)
N Engl J Med 2008;358:1483-94
Risk factor in development of AD
Environmental factorsO Food allergens (egg, milk, wheat, soy)
OAssociate to infantile AD
ORelated to disease severityO Aeroallergens (pets, mites, pollen)
OExacerbation AD in older children
N Engl J Med 2008;358:1483-94
Risk factor in development of AD
Other factorsOther factorsO Weather conditions or humidityO Skin irritants : soap, detergentO Infections : S. aureus, M. furfur, HSVO Emotional stress
Persistent or worsening disease
N Engl J Med 2008;358:1483-94.
Acute ADO Intensely pruritic, erythematous papule
associated with excoriations, vesiculation, and serous exudate
Thomas Bieber. NEJM 2008; 358:1483-94
Histology: Spongiotic area within the epidermis
Chronic ADO May have all skin type, Dry skinO Lichenification … Thickening of skin with
accentuated surface markings and fibrotic papules
Thomas Bieber. NEJM 2008; 358:1483-94
Hyperplastic of epidermis with hyperkeratosis
Color Textbook of Pediatric Dermatology, 4th Edition.
Infantile type Childhood type Adult type
Face, scalp, trunk, extensor surfaces
of extremities
Flexural folds of ext(antecubital, popliteal fossa)
neck, ankles
Upper arms, back, wrists, hands,
fingers, feet, toes
Conventional TherapiesO Identification and elimination of
exacerbating factors (irritants, proven allergens)
OAddressing psychological aspectsOEducationOHydrationOMoisturizersOTopical corticosteroidsOTopical calcineurin inhibitorsOAnti-infective therapyOAnti-pruritic therapy
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1 893-1999
Goal •Efficient short-term control of acute symptoms•Flare prevention•Avoidance side effects
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1 893-1999
Irritative substances
Allergens ( food and inhalant)
Infectious microorganisms Staphylococcus aureus Malassezia furfur
Exacerbating factor in AD
Irritants O A lowered threshold of irritant responsiveness.
O Detergents, soaps, chemicals, pollutants, abrasive
materials, extreme of temperature and humidity
O Cleansers with minimal defatting activity and
neural pH.
O New clothing should be laundered before it is worn
to reduce formaldehyde and chemicals.
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition
Irritants O Changing detergent to a milder one, liquid are
morepreferred than a powder one, extra rinse cycle
O Occlusive clothing should be avoided, cotton should be used.
O Temperature should be temperate to minimize sweating.
O Swimming is well tolerated, shower and use mild soap to remove chlorine.
O Non-sensitizing sunscreen should be used to avoid sunburn.
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition
Fabienne Rance. Ped AI 2008;19:279-84
Environmental risk factors for early infantile atopic dermatitis
O Purpose: To evaluate influence of various environmental risk factors for early infantile AD.
O Population: 2048 mother–child pairs from Taiwan in 2003.
O Method: Information on environmental risk factors for infant gathered by questionnaire were available from 1760 infants at 6 months of age.
O Result: 118 of 1760 (6.7%) were AD. After adjusting for confounding factor, fungi on walls [OR 2.14 (95% CI 1.41–3.22)] and frequent use of microwave oven at home [aOR 1.71 (95% CI 1.13–2.58)] increased risk of early infantile AD.
O Conclude: Fungi are especially important in humid climate as in Taiwan and The hazards of microwave use should be paid more attention.
Pediatr Allergy Immunol 2007: 18: 441–447
Pediatr Allergy Immunol 2007: 18: 441–447
AeroallergensO HDM, animal danders, pollens
O In 1940s, Tuft et al. demonstrated that AD patient who underwent bronchoprovocation of HDM extract developed cutaneous lesions after inhalation to dust mites
O Study with patch testing have shown that direct contact with inhalant allergens can also result in eczematous lesions
O Respiratory and direct contact may be important in the induction and exacerbation of AD
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1 893-1999
- Double blind controlled trial of effect o f
HDM allergen avoidance on AD
Tan et al. -1996 347 1518Lancet ; :
Patient 48 patients (24 adults; mean age 30, 24 children mean age 10) Positive skin test (>= 2mm than NSS) to aeroallergens
Intervention
Goretex bedcovers, benzyltannate spray for carpets and a high-filtration vacuum cleaner
(6 month)
Compare Cotton bedcovers, water spray, conventional domestic vacuum cleaner
Outcome -Der p1 concentration (ng/m2)
-Eczema severity score
-Surface area score
Tan et al. -1996 347 1518Lancet ; :
p=0.002
**
12.6 4.2
p=0.006
Psychosocial factorsO Relaxation, behavioural modification,
biofeedback may all be benefit
O Massage therapy can be adjunct treatment for AD
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition
Hydration O Atopic dry skin and decreased ceramide
level enhanced transepidermal water loss and reduced water binding capacity
O Soak affected area or bath for 10 minutes in warm water and apply occlusive agent to retain absorbed water
O Bleach bath with dilute sodium hypochlorite recommended to reduce skin infection
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th editionImokawa G.et al:J Invest Dermatol 1991; 96:523-526
HydrationO Hand and foot dermatitis treated by soaking limb
in basin.
O It is essential to use occlusive preparation within few minute after hydration skin to prevent evaporation.
O Bathing may remove allergens from skin and reduce colonization by S. aureus.
O Balneotherapy in acidic hot spring shown to help refractory AD
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th editionKubota K.et al: Acta Derm Venereol 1997; 77:452-454.
“Soak and seal” MethodOSoak the affected area for
approximately 10 minutes in warm water
OSeal an occlusive agent to retain the absorbed water within a few minutes (for prevent evaporation which is damage to the epidermis)
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1 893-1999
An. Bras. Dermatol. vol.82 no.1 Rio de Janeiro Jan./Feb. 2007
Breaking the cycle: how I manage difficult ADBreaking the cycle: how I manage difficult AD
Wet wrapWet wrap
Pediatrics 2008;122;812-824
Wet dressing
O Wet-wrap dressings reduce pruritus and inflammation by cooling skin, act as barrier to trauma associated with scratching, improve penetration of steroid.
O Severe AD showed significant improvement after 1 week of treatment using tubular bandages applied over diluted topical steroid.
Wolkerstorfer A.: De Waard van der Spek FB, et al. Efficacy and safety of wet-wrap dressings in children with severe atopic dermatitis: influence of corticosteroid dilution. Br J Dermatol 2000; 143:999-1004. Boguniewicz M: Conventional therapy. Immunol Allergy Clinics North Am 2002; 22:107-124.
Moisturizers and occlusives
O Use of effective emollient combine with hydration help to preserve stratum corneum barrier and decrease need for topical steroid.
O Lotion contain more water than cream and may be more drying because of evaporation effect.
O Vaseline is effective occlusive when use to seal in water after bathing.
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1 893-1999
Process of moisturizers
O Repairing skin barrier
O Transiently increase water in stratum corneum
O Decrease transepidermal water loss
O Restoring lipid barriers’ ability to attract, hold and redistribute water
Lynde CW. Skin Therapy Lett 2001;6:3-6Kraft JN, et al Skin Therapy Lett 2005;10:1-8
Effect of a new moisturizing lotion on immediate and cumulative skin hydration:
Two randomized, intra-individual, vehicle and comparator-controlled studies
O Patient: Female ≥ 18 yr with very dry skin on legs. O Intervention: Cetaphil Daily Advance (CDA lotion),
Epidrat ultra hydrating lotion (E lotion), Physiogel lotion (P lotion), Physiogel AI cream (PAI cream)
O Compare: Non-treated control O Outcome: CDA lotion induced significantly greater
hydration than nontreated control (p < 0.001), induced skin hydration up to 3 days treatment cessation and improvement in skin dryness score up to 7 days after treatment cessation (p < 0.05)
Journal of Dermatological Treatment. 2011; 22: 221–225
Patient 173 infants, moderate to severe AD, SCORAD Index 20-70
Intervention
Exomega lotion (containing water, petrolatum, Shea butter, Evening primrose oil, glycerin, paraffin oil, niacinamide, butylene glycol, benzoic acid, carbomer oat extracts)
Compare Placebo
Outcome Primary Outcome: Amounts of use of high potency (0.1% Locatop) and moderate potency topical steroids cream (Locapred)
Secondary Outcome: SCORAD index
- The Steroid Sparing Effect of an Emollient Therapy in Infants with Atopic Dermatitis
G GGG GGG et al. 2 0 0 7 ;2 1 4 : 617
G GGG GGG et al. 2 0 0 7 ;2 1 4 : 617
P<0.05
P=0.722
* P<0.0005 **P<0.0001
Corticosteroid O Reduce inflammation and pruritus are
effective both acute and chronic AD.
O Side effect are thinning of skin, telangiectasia, bruising, hypopigmentation, acne, striae, secondary infection.
O Perioral dermatitis can occur with use of topical steroid on face.
O High-potency topical steroid may lead to atrophic changes and systemic side effect.
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition
Stepwise management of patients with AD.Stepwise management of patients with AD.Akdis et al. J ALLERGY CLIN IMMUNOL JULY 2006
Current Medical Research & Opinion Vol. 26, No. 3, 2010, 633–640
Factors affecting systemic absorption
of Topical Steroids
Patient-relatedO AgeO Individual
response to drugO Presence or abse
nce of skin inflammation
David PariserAmerican Journal of Therapeutics 2009; 16: 264 73–
Drug-related
• Concentration • Potency• Extent of BSA involve
d• Duration• Location/ skin thickn
ess• Vehicle• Use of occlusive dres
sings
Pediatric patients: aware of age-appropriate indications
G GGGGG et al. -2006 54115J Am Acad Dermatol ; :GGGGGGG et al. 1 9 9 7 ; 60: -27980
Corticosteroid O Ointments are most occlusive and better
delivery of medication while preventing evaporative losses
O In humid environment, cream may better tolerated than ointments.
O Cream and lotions are less effective and lead to skin dryness and irritation.
O Solution used on scalp and hirsute area
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition
Vehicle: Sequence of potency
Ointment
Cream
Lotion
Gel
Spray
Foam
Maximum
Minimum
Corticosteroid O Finger tip unit (FTU) proposed as applying
topical steroidO Amount of topical medication that extend from
tip to the first joint of index finger
O 1 FTU to cover hand and groinO 2 FTUs for face or footO 3 FTUs for armO 6 FTUs for legO 14 FTUs for trunk
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition
CorticosteroidO Step care approach with mid range or high
potency preparation, followed by low potency preparation.
O Once daily treatment may help adherence to regimen, fluticasone propionate and mometasone.
O Fluticasone, once control of AD with once daily regimen was achieved, long term control could be maintained with twice-weekly, resulted in fewer relapses and less need for topical steroid.
Wolkerstorfer A. et al: Fluticasone propionate 0.05% cream once daily versus clobetasone butyrate 0.05% cream twice daily in children with atopic dermatitis. J Am Acad Dermatol 1998; 39:226-231. Lebwohl M.: A comparison of once-daily application of mometasone furoate 0.1% cream compared with twice-daily hydrocortisone valerate 0.2% cream in pediatric atopic dermatitis patients who failed to respond to hydrocortisone: Mometasone Furoate Study Group. Int J Dermatol 1999; 38:604-606.
V ariation in T opical Steroid P rescribing Habits
OStep-care approach O Mid-range or high potency to induce
remission followed by quick tapering down to low-potency preparations
OShort-burst treatmentO use short bursts of a potent preparation
followed by a steroid-free “holiday period” of emollient use only until relapse occurs
OMaintenance therapyO When once daily achieved, shifted to twice-
weekly applications to areas that had previously been involved but now appeared normal
GGGGGG GGG et al. GGGGGGGGGG 2008; 122 : -81224Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1 893-1999
CorticosteroidO Topical steroid can decrease S. aureus
colonization
O Allergen-induce immune activation can alter T cell response to glucocorticoid receptor binding affinity.
O Systemic steroid should be avoided in AD.
O Dramatic improvement with systemic steroid associated with flaring of AD after discontinuation.
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition
Tacrolimus and Pimecrolimus are structurally similar
HO
H3COCH3
OH
O
CH3·H2O
CH3
H3CO OCH3
N
OO
O
O
H3C
H3CO
OH
H
H CI
H3COCH3
OH
O
CH3
CH3
H3CO OCH3
N
OO
O
O
H3C
H3C O
OH
H
H
CH3
Pimecrolimus810.48 Da
C43H68CINO11
Tacrolimus822.05 Da
C44H69NO12·H2O
Topical Calcineurin Inhibitors
1. Pimecrolimus cream 1% (≥ 2 yr) (Elidel)
O mild to moderate AD.
2. Tacrolimus ointment 0.1% (adult)
0.03% (≥ 2 yr) (Protopic)O moderate to severe AD.
Topical calcineurin inhibitors complexing with macrophilin-12 and calcium-calmodulin to block dephosphorylation of NF-AT by calcineurin, preventing translocation of NF-AT to the nucleus.CaN, Calcineurin; MP-12, macrophilin-12;NF-ATc, nuclear factor of activated T cells in the cytoplasm;NF-ATn, NF-AT in the nucleus; NF-κB,nuclear factor-kappa B; TCI, topical calcineurin inhibitor.
Topical calcineurin inhibitors complexing with macrophilin-12 and calcium-calmodulin to block dephosphorylation of NF-AT by calcineurin, preventing translocation of NF-AT to the nucleus.CaN, Calcineurin; MP-12, macrophilin-12;NF-ATc, nuclear factor of activated T cells in the cytoplasm;NF-ATn, NF-AT in the nucleus; NF-κB,nuclear factor-kappa B; TCI, topical calcineurin inhibitor.
Journal of the American Academy of Dermatology Volume 53, Issue 1 Suppl (July 2005)
Topical calcineurin inhibitors(TCIs)
O Useful for treatment face and intertriginous area.
O Inhibitory effect on cytokine production
O Application site : Stinging, burning, redness in 10-30% of patient esp in extensive excoriation but mostly transient < 1wk
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1893-1999
O 6-week RCT O Compared twice daily Tx with pimecrolimus 1%
with tacrolimus 0.03% ointment O 141 children ( 2 – 17 yr ) with moderate AD O Pimecrolimus had better local tolerability. O No difference in efficacy Tx, after 6 wks O Pimecrolimus cream 1% had better formulation
attributes and local tolerability than tacrolimus ointment 0.03% while providing similar efficacy and overall safety in pediatric patients with moderate AD.
A randomized investigator-blinded study comparing pimecrolimus cream 1% with tacrolimus ointment 0.03% in the treatment of pediatric patients with
moderate atopic dermatitis
Kempers et a.lJ AM ACAD DERMATOL OCTOBER 2004
Tacrolimus ointment is more effective thanpimecrolimus cream with a similar safety
profile inthe treatment of atopic dermatitis: Results
from3 randomized, comparative studies
O 6-week RCT in 1065 patientsO Compared twice daily Tx with pimecrolimus 1%
cream with tacrolimus ointment 0.03% in 426 children with mild AD; 0.1% in 226 children with moderate to severe AD and in 413 adults with mild to very severe AD.
O Significantly more patients treated with tacrolimus had almost or completely cleared AD (43 vs 31 %)
O Tacrolimus ointment is more effective and has a faster onset of action than pimecrolimus cream; their safety profiles are similar.
Paller et alJ AM ACAD DERMATOL MAY 2005.
Paller et alJ AM ACAD DERMATOL MAY 2005.
O Patient: Adult and pediatric (n = 347) with ADO Intervention: Tacrolimus ointment 0.03%O Compare: Pimecrolimus cream 1%; O Control: -O Outcome: EASI at the end of study, tacrolimus
ointment was significantly more effective than pimecrolimus cream (p = 0.0002). Frequency of adverse events was comparable between treatment groups (24.0% for tacrolimus ointment vs. 25.6% for pimecrolimus cream)
Safety and Efficacy of Tacrolimus Ointment Versus Pimecrolimus Cream in the
Treatment of Patients with AD Previously Treated with Corticosteroids
Robert S.et al. Acta Derm Venereol 2010; 90: 58–64
Robert S.et al. Acta Derm Venereol 2010; 90: 58–64
In a Public Health Advisory issued March 10, 2005, FDA recommended physicians
to consider:
O Use TCIs only as second-line therapy in unresponsive to or intolerant of other Tx
O Avoid use of TCIs in < 2 yrs ; found higher rates of URI in < 2 yrs treated with pimecrolimus
O Use TCIs only for short periods of time and use minimum amount necessary to control symptoms; avoid continuous use
O Avoid use TCIs in compromised immune systems
FDA issued warnings about possible link between TCIs and cancer 2006 placed "black box"
O Animal studies in mice, rats, monkeys have increased risk of lymphoma and skin cancers with TCIs
O 2004, FDA received 29 reports of cancers in adults and children treated with TCIs; half were lymphomas and other half were cutaneous tumors
Current Medical Research & Opinion Vol. 26, No. 3, 2010, 633–640
Tar preparationsO Tar inhibit influx of proinflammatory cells
and in expression od adhesion molecules in response to epicutaneous allergen challenge.
O Tar preparation used with topical steroid in chronic AD may reduce need for more potent steroid preparation.
O Tar shampoos are often beneficial for scalp involvement.
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1893-1999
Paghdal KV - J Am Acad Dermatol - 01-AUG-2009; 61(2): 294-302
Adverse effects of Tar Adverse effects of Tar Preparations.Preparations.
O Avoid using Tar in inflamed skin because it may result in skin irritation.
O photosensitivity reactionsO pustular folliculitis.
Rare
Microbial agentO Lipophilic yeast M. sympodialis and
superficial dermatophyte T. rebrum associated with elevated with specific IgE levels in AD, clinical improvement after antifungal therapy
Boguniewicz M., SchmiGrendelmeier P., Leung D.Y.M.: Atopic dermatitis. J Allergy Clin Immunol 2006; 118:40-43.
O S. aureus are superantigen result in persistent inflammation or exacerbation of AD
Leung: Presence of IgE antibodies to staphylococcal exotoxins on the skin of patients with atopic dermatitis: evidence
for a new group of allergens. J Clin Invest 1993; 92:1374 O More than half of AD had S. aureus culture
from skin.
Antiinfective therapyO Systemic ATB may necessary to treat AD
when secondary infection with S. aureus is present.
O Penicillin or first or second generation cephalosporins for 7-10 days are usually effective.
O Maintenance ATB therapy should be avoided, because it may result in colonization by methicillin-resistant organisms.
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition
Antiinfective therapyO Topical ATB mupirocin (Bactroban) may be
effective for treating localized involvement.
O Twice-daily treatment for 5 days with nasal preparation of mupirocin may reduce nasal carriage of S. aureus.
O Daily bathing with antimicrobial soap 1.5% triclocarban reduces in S. aureus colonization and greater improvement than placebo soap.
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition
Bleach baths O Sodium hypochlorite 6% solution (liquid
chlorine bleach) has activity against S. aureus
including MRSA.
O Lukewarm water, soak in the bath for 5 to 10
min.
O Rinse with fresh water, pat themselves dry
O Immediately apply an emollient and/or
prescribed medications.
O The baths are taken two times per week.Krakowski AC et al. Management of atopic dermatitis in the pediatric population. Pediatrics 2008; 122:812.
Mechanism of PruritusO Neuropeptides, proteases, kinins, cytokines induce
itching.
O IL-31 (produced by T cells) : - strongly pruritogen - up-regulated by exposure to staphylococcal exotoxins in vitro.
N Engl J Med 2008;358:1483-94.
Antipruritic agentsO Systemic antihistamine and anxiolytics may
be most useful through their tranquilizing and sedative effects
O TCA doxeptin: both H1 and H2 receptor binding affinity as well as long half life.
O Second-generation antihistamine: effective in treating pruritus, modest clinical benefit
O Cyclosporin A: decrease transcription of proinflammatory cytokines
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1893-1999
HospitalizationO Erythroderma
O Toxic
O Remove Pts from environmental allergen or stressor
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1893-1999
Systemic immunomodulatory therapies
O CyclosporineO Recombinant human Interferon-gammaO AzathioprineO Mycophenolate mofetilO Phototherapy
Cyclosporin AO Cyclosprin A (5MKD) using either intermittent
or continuous treatment show no significant differences between two approaches.
O Severe AD treated with cyclosporin A, 5MKD for 6 wks, monitored until relapse and treated with second 6 wks course. Subset of Pts get clinical benefit.
Harper J.I.et al: Br J Dermatol 2000; 142:52-58.
Phototherapy and photochemotherapy
O UV light: modality for chronic AD.
O High dose UVA1: decrease dermal IgE-binding cells, down regulating proinflammatory cytokines or inducing apoptosis in skin-infiltrating CD4+ T cells.
O Photochemotherapy with oral methoxypsoralen therapy followed by UVA may be indicated in severe AD.
Hanifin J.M., Cooper K.D., Ho V.C., et al: J Am Acad Dermatol 2004; 50:391-404.
Clinical Efficacy of Blue Light Full Body Irradiation as
Treatment Option for Severe Atopic Dermatitis
O Patient: 36 pts with severe, chronic AD resisting long term disease control with local corticosteroids
O Intervention: 1 cycle of 5 consecutive blue light-irradiations (28.9 J/cm2).Patients were instructed to ask for treatment upon disease exacerbation despite interval therapy with topical corticosteroids
O Compare: -
O Outcome: The majority of pts noted first improvements after 2–3 cycles. EASI score was improved by 41% and 54% after 3 and 6 months
. Becker.D et al. Plos One.2011;6(6):e20566. Epub 2011 Jun 8.
*=p≤0.05***=p≤0.02
**p≤0.005
***p≤0.002
Recombinant human IFN-ɣ
O IFN-ɣ suppresses IgE synthesis and inhibit Th2 cell function.
O rhIFN-ɣ reduced severity and decrease total circulating eosinophil in AD.
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1893-1999
AzathioprineO Affect purine nucleotide synthesis and
metabolism.
O Side effect: myelosuppression, hepatotoxicity, GI disturbance, susceptible for infection, skin cancer.
O Onset of action is slow, benefit may not be apparent for several month after treatment.
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1893-1999
O Allergen desensitizationO Intravenous gammaglobulinO Omalizumab O Antifungal therapyO Traditional Chinese herbal therapyO ProbioticsO Essential fatty acidsO Leukotriene receptor antagonists
• Prevention– Delayed solid food introduction
• No protective effect was seen by delaying the introduction of solid food after 4 month.
• Avoidance of soybean, nuts, and cocoa in first 6 months , did have protective effect in the nonintervention cohort.
• AAP recommend for delayed beyond 4 month of life– Probiotics
• The evidence for the use of probiotics for treatment of AD is lacking, however, there does appear to be benefit to the use of prenatal probiotics for prevention of AD.
OEnvironmental and behavioral modificationO Unfavorable indoor climate, HDM exposureO Zinc : decrease plasma level found in ADO Vitamin D : induces expression of protective
antimicrobial peptidesO Contact allergiesO Food –induced eczemaO Education O Skin care and emollient
Conventional TherapiesO Identification and elimination of
exacerbating factors (irritants, proven allergens)
OAddressing psychological aspectsOEducationOHydrationOMoisturizersOTopical corticosteroidsOTopical calcineurin inhibitorsOAnti-infective therapyOAnti-pruritic therapy
Mark Boguniewicz, Donald Leung.Middleton’s Allergy 7’th edition 1 893-1999