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Atopic dermatitis can have a severe impact on the quality of life for young patients and their parents. Schoolchildren with atopic dermatitis experience marked sleep disruption and, according to studies monitoring their sleep patterns, have been shown to scratch often and wake frequently throughout the night. The resulting daytime sleepiness and sedation can lead to higher rates of school absenteeism and lower IQ test results. Further, in some children, stigma associated with the disease is associated with low self-esteem and psychological disturbances. In a contest in which children were asked to draw pictures of how the disease makes them feel, one child wrote, “My eczema makes me feel like I have been alienated,” and drew a picture of himself as an alien isolated from other children on a playground.
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Parents of children with moderate to severe atopic dermatitis tend to have more psychosocial stressors, poorer work performance, and less social support. They often report feeling responsible for the disease and may seek dietary or environmental solutions and cures. Unfortunately these parents encounter myths about treating atopic dermatitis and need to be educated about standard therapies and newer approaches that lead to better treatment outcomes. Treatment for children with atopic dermatitis includes appropriate medical management and, if indicated, psychological intervention.
A leading myth about atopic dermatitis is that daily bathing exacerbates the condition. Although bathing for long periods in hot water will dry out skin and worsen eczema, a 5- or 10-minute bath or shower in warm water, followed by blot drying and then applying topical medications and moisturizer, can provide relief.
In addition, studies show that daily bathing debrides the skin of Staphylococcus aureus, which aggravates atopic dermatitis in many children. Studies also indicate that bathing hydrates the skin, enhancing the penetration of topical medication. Daily bathing is also psychologically beneficial for older children, providing them with the feeling of cleanliness.
Emolliation, or moisturization, is vital in the care of children with atopic dermatitis. Creams and ointments are more effective than lotions. Parents should consider replacing thick creams and ointments with lighter-weight lotions during summer, because heavy products may cause prickly heat in infants and toddlers, especially in humid climates. Also, parents may mistake heat rash for eczema and apply more cream or ointment, worsening the condition.
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Creams and ointments are effective in dry climates during fall and winter. Under these conditions, parents should apply emollients to the child’s skin throughout the day and after bathing. Emollients can also be applied over topical medications. Aquaphor ointment (Beiersdorf, Inc.) is suitable for use in fall and winter. It is well tolerated, has a good safety profile, and patients are unlikely to develop an allergy to it. Unlike most other petrolatum-based emollients, Aquaphor is water soluble. Eucerin cream (Beiersdorf, Inc.) and Cetaphil cream (Galderma Laboratories) are also useful in spring and summer when light emolliation is appropriate. In addition to these, many other effective emollients are available.
Newer products such as TriCeram (Osmotics) and CeraVe (Coria Laboratories) are also efficacious because they replace the ceramides normally found in the skin barrier. Less expensive alternatives include vegetable oil and petrolatum.
Topical steroids are most effective in reducing inflammation in children with atopic dermatitis. However, a recent study of 200 patients and their families indicated that three of four parents have safety concerns about topical corticosteroid use for themselves and their children. One in four parents reported that they would not comply with physician recommendations because of perceived risks of steroid-induced thinning skin, malabsorption, and adverse effects on growth and development.
Clinicians treating children with atopic dermatitis must teach parents that topical steroids are safe when used properly. Low-strength preparations are not effective for moderate to severe disease and lead to prolonged use when the desired effect is not achieved. Stronger preparations used less frequently produce a better response.
Topical steroid ointments are most efficacious because they are more potent than creams. Ointments are usually applied twice daily and tapered as the dermatitis subsides. Parents should consult the physician, however, if the dermatitis does not subside after two to three weeks.
A low-strength topical steroid such as alclometasone diproplonate ointment or desonide ointment is suitable for use on the face and fold areas where more product can be absorbed and where there is a higher risk of adverse effects such as striae. Prolonged periorbital treatment with topical steroids increases the risk of glaucoma or cataracts and should be avoided in the eye area.
Moderate-strength topical steroids such as triamcinolone and fluocinolone are first-line therapy options for treating the body and limbs. Stronger topical steroids including fluocinonide ointment and mometasone ointment can be used for nonfacial and nonfold areas such as wrists, ankles, and knees.
Another misconception about the treatment of atopic dermatitis in children questions the usefulness of antihistamines. It is critical that physicians break the itch-scratch cycle and prevent secondary infection, and antihistamines are beneficial because they decrease itch and can increase nighttime sedation.
Most pediatric dermatologists recommend hydroxyzine, with low doses during the day and higher, more sedating doses of approximately 1.0 mg/kg at bedtime. In my experience, cetirizine is the most effective of the nonsedating antihistamines for daytime treatment of older children. Other nonsedating antihistamines for daytime treatment include loratadine and fexofenadine, but they may not be as effective as cetirizine. Cyproheptadine has a good anti-itch profile but is a potent appetite stimulant. Doxepin, 5 mg at bedtime for children between age 2 and 6 years and 10 mg for children older than 6 years, is useful for the most resistant atopic dermatitis, but this is an off-label use for this medication.
S. aureus is often thought to be unrelated to atopic dermatitis, but up to 80% of children with atopic dermatitis have S. aureus colonization compared with approximately 10% to 15% of the general population.
Antibiotic treatment for infection should be considered for patients with moderate to severe disease, although treatment should be weighed against the potential for antibiotic resistance, especially with the increase in community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections. Seven to 10 days for treatment of mild infection is usually sufficient. Cephalexin is a good first-line therapeutic agent. Dicloxacillin tablets are a good choice for older children and clindamycin for patients with resistant organisms such as community-acquired MRSA. In areas with a high prevalence of MRSA, clindamycin may be the first choice. It should be strongly considered if cephalexin or dicloxacillin fail. Amoxicillin and macrolide antibiotics have unreliable degrees of efficacy, although newer macrolides, such as azithromycin and clarithromycin, are alternatives for patients allergic to penicillin or cephalosporin.
Another myth is that food allergy is a common cause of atopic dermatitis, although food is a trigger in only 20% to 30% of children with moderate to severe atopic dermatitis. Often, atopic dermatitis does not improve after diet modification. Parents should consult a pediatric allergist before indiscriminately eliminating foods from the child’s diet.
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Physicians should consider food allergy in patients with moderate to severe disease, recalcitrant atopic dermatitis, a reliable history of exacerbation by certain foods, or severe ongoing disease through teenage years or early adulthood. Eggs, nuts, milk, soy, wheat, or fish trigger most allergic reactions in the subset of patients who have food allergy (Figure). Most reactions are outgrown, except those to nuts and fish.
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There are conflicting data on preventing atopic dermatitis through diet restriction for breast-feeding mothers. The benefits of breast-feeding, however, seem to far outweigh the risk of sensitization. Some studies show that breast-feeding might reduce the incidence of atopic dermatitis in infants with a family history of atopy. Other investigators recommend nutritional consultation and modification of the mother’s diet to restrict the highly allergenic foods if there is a strong family history of atopic diseases.
Also, although controversial, there is evidence that partially and extensively hydrolyzed infant formulas may suppress antigenic responses and diminish atopy manifestations.
A better understanding of the pathogenesis of atopic dermatitis has lead to newer treatment approaches such as topical calcineurin inhibitors. These nonsteroidal topical immunomodulators include tacrolimus and pimecrolimus and were developed as an alternative to topical corticosteroids. Their development was exciting, considering the limitations of traditional therapies, including tachyphylaxis that may occur with corticosteroids, the potential for adverse effects with topical and oral corticosteroid therapies, and steroid phobia.
Calcineurin inhibitors are steroid-free and are advantageous for treatment near the eyes. Striae, atrophy, telangiectasia, and systemic immunosuppression associated with steroid medications usually do not occur when these topical drugs are used as directed, although they may cause transient burning or stinging in the first week of use. Calcineurin inhibitors may be less efficacious for moderate or severe disease, and the long-term safety of these agents has recently been questioned. In February 2005, the FDA convened a pediatric advisory committee to assess the risk of lymphoma with topical calcineurin inhibitors. Although oncology specialists found no biologic plausibility of an increased cancer risk from pimecrolimus and tacrolimus and pointed out that the presentations of the lymphomas were not consistent with the typical EBV-associated, B-cell presentations seen in the setting of immune suppression, the FDA added a boxed warning and medication guide. The indications were also modified to clearly read that topical calcineurin inhibitors are indicated as second-line therapy for the short-term and noncontinuous chronic treatment of atopic dermatitis and are not recommended for children younger than the age of 2 years. The clinical trials for these agents addressed pharmacokinetic parameters, vaccination responses, and delayed hypersensitivity response, and showed no evidence of immunosuppression. Also, there was no increased risk of systemic infections, but manufacturers of these agents continue to monitor for possible adverse events and long-term safety.
Clinicians and parents can also consider alternative modes of therapy such as naturopathic remedies, Chinese herbal medicines, and behavioral and hypnotherapy approaches. These treatments have been successful for some patients with atopic dermatitis.
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Probiotics, the potentially beneficial healthy gut microflora, may also play a role in the prevention of atopic diseases, including atopic dermatitis. Studies show that Lactobacillus rhamnosus GG given to mothers prenatally and during lactation may be associated with a decreased incidence of atopic dermatitis in their children at 2 and 4 years of age. The mechanism of action is not entirely clear, but the hypothesis is that a deficiency of gut microflora in children with atopic dermatitis impairs development of immune responses and a normal mucosal barrier. A disrupted barrier may increase antigen transport and sensitization in the first few months. Probiotics as treatment for established disease are less clear, and they have been studied mostly for their role in prevention. I do not routinely recommend probiotics to patients at this time, but physicians should monitor this area of research.
Prescription emollients such as MimyX (Stiefel Laboratories, Inc.), Atopiclair (Chester Valley Pharmaceuticals) and EpiCeram (Ceragenix Pharmaceuticals) are products in a new class of FDA–approved (as “medical devices”) treatments that help restore skin barrier function. They are indicated for relief of burning, itching and pain associated with dermatoses.
Education and the wide array of treatment options for children with atopic dermatitis can make management of the disease less stressful and enhance quality of life for patients and their parents.
Selected References
- Chamlin SL, Frieden IJ, Williams ML, Chren MM. Effects of atopic dermatitis on young American children and their families. Pediatrics. 2004;114:607-611.
- Chamlin SL, Mattson CL, Frieden IJ, et al. The price of pruritus: sleep disturbance and cosleeping in atopic dermatitis. Arch Pediatr Adolesc Med. 2005;159:745-750.
- Chan YH, Shek LP, Aw M, Quak SH, Lee BW. Use of hypoallergenic formula in the prevention of atopic disease among Asian children. J Paediatr Child Health. 2002;38:84-88.
- Chandra RK, Puri S, Hamed A. Influence of maternal diet during lactation and use of formula feeds on development of atopic eczema in high risk infants. BMJ. 1989;299:228-230.
- Charman CR, Morris AD, Williams HC. Topical corticosteroid phobia in patients with atopic eczema. Br J Dermatol. 2000;142:931-936.
- Gdalevich M, Mimouni D, David M, Mimouni M. Breast-feeding and the onset of atopic dermatitis in childhood: A systematic review and meta-analysis of prospective studies. J Am Acad Dermatol. 2001;45:520-527.
- Kalliomaki M, Salminen S, Arvilommi H, Kero P, Koskinen P, Isolauri E. Probiotics in primary prevention of atopic disease: A randomised placebo-controlled trial. Lancet. 2001;357:1076-1079.
- Kalliomaki M, Salminen S, Poussa T, Arvilommi H, Isolauri E. Probiotics and prevention of atopic disease: 4-year follow-up of a randomised placebo-controlled trial. Lancet. 2003;361:1869-1871.
- Kelsay K. Management of sleep disturbances associated with atopic dermatitis. J Allergy Clin Immunol. 2006;118:198-210.
- Lewis-Jones S. Quality of life and childhood atopic dermatitis: The misery of living with childhood eczema. Int J Clin Pract. 2006;60:984-992.
- Ogden NS, Bielory L. Probiotics: A complementary approach in the treatment and prevention of pediatric atopic disease. Curr Opin Allergy Clin Immunol. 2005;5:179-184.
- Rautava S, Kalliomaki M, Isolauri E. Probiotics during pregnancy and breast-feeding might confer immunomodulatory protection against atopic disease in the infant. J Allergy Clin Immunol. 2002;109:119-121.
- Reuveni H, Chapnick G, Tal A, Tarasiuk A. Sleep fragmentation in children with atopic dermatitis. Arch Pediatr Adolesc Med. 1999;153:249-253.
- Stores G, Burrows A, Crawford C. Physiological sleep disturbance in children with atopic dermatitis: A case control study. Pediatr Dermatol. 1998;15:264-268.
- Szajewska H, Mrukowicz JZ, Stoinska B, Prochowska A. Extensively and partially hydrolysed preterm formulas in the prevention of allergic diseases in preterm infants: A randomized, double-blind trial. Acta Paediatr. 2004;93:1159-1165.
Anthony J. Mancini, MD, is associate professor of pediatrics and dermatology at Northwestern University Feinberg School of Medicine and head of the division of pediatric dermatology at Children’s Memorial Hospital in Chicago.
[Introduction]
[The epidemiology of atopic dermatitis in children: Incidence, causes and control]
[The treatment of atopic dermatitis in children: A review of therapeutic options]
[Clinical insight: Case management for children with atopic dermatitis]
[Panel Discussion]
