While the basic daily therapy for atopic dermatitis of bathing and applying lotion as part of the evening bedtime ritual has proven effective, parents react with uncertainty to the use of topical medications such as steroids and calcineurin inhibitors. In her presentation at the annual congress of the Swiss Society of Allergology and Immunology, Lisa Weibel, MD, from the Children’s Hospital Zurich, therefore pointed out the importance of comprehensive information and instruction for parents.
(rs) The prevalence of atopic dermatitis (AD) has increased sharply over the past three decades in industrialized countries, where it affects approximately 20% of all children and up to 10% of adults. The causes of the disease are not fully understood. A decisive role is played by the impaired barrier function of the skin based on a genetic predisposition, which leads to increased skin dryness and susceptibility to pathogenic germs, irritants and allergens. “AD is primarily a skin disease, not an allergic disease,” said Lisa Weibel, MD, head of the Department of Pediatric Dermatology at the Children’s Hospital Zurich, at the annual congress of the Swiss Society of Allergology and Immunology (SGAI/SSAI) in Davos. “The influence of allergens, especially food allergens, on disease is often overestimated.” In infants and young children, allergy tests regarding food should only be performed if they had shown food intolerance or suffered from severe, uncontrolled eczema.
Prevent eczema
Atopic dermatitis is characterized by the repeated occurrence of itching and eczema. The barrier function of the skin is increasingly impaired by scratching, which consequently increases the inflammatory processes as well as the itching. Finally, the risk of secondary bacterial or viral infection increases with the skin erosions. “To avoid such a complication, the first signs must be interpreted correctly and treated promptly,” Dr. Weibel said.
The basic therapy of AD is to perform regular skin cleansing followed by emollients resp. anti-inflammatory creams (steroids) for eczema sites. Overall, there is sparse evidence on the effect of skin cleansing and no clear recommendations are found in current AD treatment guidelines. “Especially in childhood, once a day short (<10 min.), lukewarm bathing or showering in between, ideally with a little bath oil additive and, if necessary, antiseptic wash lotion,” recommends Dr. Weibel. The procedure reduces the number of microbes, loosens crusts, hydrates the skin and promotes the action of emollients after the bath. In case of secondary infection, antiseptic bath or shower additives have proven effective. So-called bleach baths with highly diluted sodium hypochlorite or detergents with added triclosan are also suitable. In addition to the daily bath, the entire body should be creamed once or twice with a moisturizing care cream. For the best effect, the emollients should be applied within ten minutes after the bath.
As Dr. Weibel said, “the daily routine of bathing and creaming proves effective as part of an evening care ritual and promotes good sleep without itching.”
Eczema Management
Anti-inflammatory treatment with topical steroids is inevitable in acute AD. To alleviate parents’ fear of cortisone therapy, comprehensive education about the characteristics of the treatment is essential. In addition, parents should be given clear instructions for treatment at home. A common regimen is interval treatment, in which a steroid is applied to the skin once a day for about two weeks at the beginning, for example, on five of seven days. If the effect is good, steroid administration can then be reduced to three, and in the course to two days per week. “The goal is to have the eczema healed after one week,” Dr. Weibel said. In younger children, topical class II and III steroids are usually sufficient to achieve this goal. In young children with large-surface eczema, a potent steroid (class III) in diluted form (magistral formulation) can be applied temporarily to large areas. In addition, the special formula simplifies the application for parents.
Good treatment results are also obtained with fat-moist compresses or bandages under which diluted steroids are used. If severe eczema cannot be controlled despite adequately prescribed therapy, the supportive involvement of Kispex often proves helpful.
A common problem of AD is secondary infection, especially with Staphylococcus aureus. “In exacerbated cases, peroral antibiotic administration has been shown to be effective,” Dr. Weibel said. However, the accompanying anti-inflammatory treatment with topical steroids and skin cleansing measures is important. Antiviral treatment, for example with intravenous aciclovir, is indicated for acute eczema herpeticum.
Long-term treatment of acute dermatitis
The use of topical calcineurin inhibitors (CI) such as pimecrolimus and tacrolimus, has been particularly successful in long-term therapy and continues to be considered “second-line” therapy for AD.
Treatment with CI is a good alternative in the treatment of mild to moderate-severe AD. This includes both therapy of a relapse and longer-term treatment. Recent studies show efficacy and tolerability in children over a five-year treatment period, during which study participants were followed up. Thereby, the risk of developing lymphoma and carcinoma was not increased in patients treated with topical CI.
“The risks of malignancies mentioned in CI technical information often cause uncertainty among parents and should definitely be addressed,” Dr. Weibel advised. “We have years of broad experience on the tolerability of calineurin inhibitors – including in infants and young children,” the pediatrician and dermatologist said. To date, no single case of malignancy in a child has been described in association with calcineurin inhibitors, he said. Treatment should be avoided if a herpes virus infection or molluscum contagiosum is suspected.
Source: Meda Pharma GmbH Lunch Symposium at the Annual Congress of the Swiss Society of Allergology and Immunology (SGAI/SSAI), March 20-21, 2014, Davos.
DERMATOLOGIE PRAXIS 2014; 24(3): 44-46
