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Early initiation of treatment for atopic dermatitis (AD) offers the best possibility for altering the natural course of the disease, increasing the odds that children might outgrow the problem, according to Elaine Siegfried, M.D., professor of pediatrics in dermatology, Saint Louis University Health Sciences Center, St. Louis.
National report - Early initiation of treatment for atopic dermatitis (AD) offers the best possibility for altering the natural course of the disease, increasing the odds that children might outgrow the problem, according to Elaine Siegfried, M.D., professor of pediatrics in dermatology, Saint Louis University Health Sciences Center, St. Louis.
Eighty percent of cases begin in children younger than age 2, and 95 percent occur in children younger than age 5, so the disease is primarily a pediatric condition, she says. However, many children continue to experience outbreaks of eczema throughout their lives, and there is a recognized adult-onset form of AD.
"There is some suggestion in the literature that the earlier and the better the disease is controlled, the higher the chances that it will improve or even go away as the child ages," Dr. Siegfried says.
There is no way for dermatologists to know which child will outgrow the condition or which will continue to have flare-ups into adulthood, although it has been suggested that children with more severe disease or who have comorbidities tend to suffer into adulthood, according to Dr. Siegfried.
Making an impact
The condition affects every area of the child’s life and causes stress for the entire family. To get some idea of what AD is like, imagine being covered in mosquito bites, suggests Amy Paller, M.D., M.S., professor and chairwoman of dermatology and professor of pediatrics at Northwestern School of Medicine, Chicago. "You would be itchy all the time,” she says.
So in school, children may be less attentive because they tend to be hyperactive, they can’t participate in sports because they can’t tolerate wearing the equipment, and their social interactions may suffer because they feel they look different. Constant irritability leads to lack of sleep, which affects the entire family, according to Dr. Paller.
"I recently saw a patient who is starting the 10th grade. He gets up multiple times a night and wakes up his father to put cream on his back for the itch. And the father gets up and goes to work the next day," Dr. Siegfried says. "This has been going on for his entire life."
Says Kari Martin, M.D., assistant professor of dermatology and pediatrics at the University of Missouri, Columbia, Mo., "The stress on the family is high. There are a lot of doctor visits, so medical costs are high, and it takes time for families to manage the entire skincare regimen that is needed to help their children. It takes a lot of time and it needs to be done every day or the child will relapse."
Standard of care
The mainstay of treatment is still topical corticosteroids, "bland" skincare and diluted bleach baths, with the addition of other therapies as needed, such as topical calcineurin inhibitors (TCIs), pimecrolimus and tacrolimus, antibiotics and phototherapy, according to Dr. Martin.
AD is usually a clinical diagnosis, which means taking a complete medical history and doing a thorough examination that focuses on triggers and comorbidities. Frequent skin infections are common. The diluted bleach baths go a long way in protecting against infection, Dr. Martin adds.
Barrier creams are crucial, and they must be applied after every bath or shower. By far the favorite for dermatologists is petroleum jelly. It's inexpensive, and it forms a good moist barrier and it is free of allergens. Many people have an aversion to the way it feels, however. In those cases, clinicians should suggest thick creams and ointments without perfumes and preservatives, according to Dr. Siegfried.
"We have to develop a regimen that the family will follow," Dr. Paller says.
"Adherence is tough because they have to do it every day," Dr. Martin says. "Even when parents are adherent, the condition waxes and wanes and children have flares. It is hard to stick with it. Usually, they will be good about the regimen after the doctor's visit, and things get better. Then they relax with the intensive regimen and the eczema flares again."
Approaches to treatment
For many pediatric dermatologists, AD comprises 10 percent of the patients, and 90 percent of the time because education is so important. Clinicians should recommend safe products for skincare, including cleansing, moisturizing, sun protection, insect repellant, woundcare, etc., that have the fewest potential allergens and irritants, these experts say.
If children do not improve on the initial regimen, make sure they understand the regimen and are adherent before changing the steroid strength or switching to the TCIs, Dr. Siegfried says.
Phototherapy with ultraviolet B light can be helpful, but it can be difficult to do because parents have to bring the child to the office two to three times a week to be effective.
Wet wraps are useful, and parents can be taught to use these at home. The child soaks in the tub for about 10 minutes then the parent slathers on the barrier cream and topical steroids. The child puts on a sauna suit or wet pajamas for at least 15 minutes. If they have a sauna suit, they can sleep in it, Dr. Martin says.
TCIs can be helpful because they reduce pruritus and erythema. Some dermatologists use them as steroid-sparing medications and others use the TCIs as an adjunct to the corticosteroids. It depends on the child and the severity of the AD, according to Dr. Siegfried.
A promising therapy, REGN668 (interleukin-4R antibody) is being developed by Regeneron and Sanofi. The product will be an antibody to the receptors for interleukin-4 (IL-4) and IL-13. It is in phase 1 trials for AD. However, the studies are being done in adults, not children, so the dermatologists say its use in most AD patients will be limited until more data are known about its effects in children, Dr. Siegfried says.
If the AD is not responding even after tinkering with the regimen, evaluating the adherence and assuring children are avoiding triggers that exacerbate the condition, dermatologists should rethink the diagnosis because other conditions can mimic the disease, all three physicians say.
Disclosures: Dr. Siegried reports she was a consultant for Valeant and Promius. Dr. Paller has financial relationships with many companies, including as a consultant and investigator for Galderma; investigator for Astellas; and consultant for Sanofi/Regeneron. Dr. Martin reports no relevant financial interests.