Chapters Transcript Atopic Dermatitis -The Old and the New Dr. Siegel discusses atopic dermatitis. Well, good morning everyone and welcome to Early Bird Rounds today. Um, we're so thankful to have you all join us. Today, we have Doctor Liza Siegel who specializes in pediatric dermatology. OK, thanks for having me. Hi everyone. My name is Liza Segal. I'm one of the pediatric dermatologists here at Children's. Um, I started out in pediatrics. I did a year as a hospitalist and I try to use a lot of what I learned and what I didn't know or wish I knew at that time to inform what I included in these talks. Um, OK, for financial disclosures, um, I am starting a clinical trial with ABee hasn't started yet, but um we're hoping to start recruiting soon. OK, so my objectives, um, we'll go through the clinical presentation of atopic dermatitis, how do you diagnose someone with atopic dermatitis. Um, my goal is that you can feel confident in developing a treatment approach for patients with atopic dermatitis, including a basic, um, skin care routine, bathing routine. And then how to use the prescription medicines. And then we'll talk about new and evolving treatments including biologics, some of the new topicals that have come out and how we're using them, um, and then develop strategies to educate families on skin care routine trigger avoidance, um, and adherence to treatment plans. So a little bit about the epidemiology, eczema is the most common chronic skin disease in children. Um, 60% of kids with eczema will present in the first year of life, and then 85% by age 5. So it is possible for eczema to newly present in an older child, but when we see like a 9, 10 year old who's never had eczema presenting with full body eczema, we always think about is there something else going on. And we think about contact dermatitis, is there a new product or something, although it is possible for later. Um, many kids outgrow eczema. Um, I usually say about 5% by age 2, and then those that don't, maybe another half will outgrow by, um, school age, but about 30% will persist into adulthood. Um, the pathogenesis is complex. There's no single cause. There's many pieces of the puzzle, Genetics, skin barrier defects, um, environment bacteria. So because of that, there's no kind of 11 size fits all treatment approach and no single magic cure, unfortunately. So how do you make that diagnosis of eczema? I don't think we always kind of go through a diagnostic algorithm, but it should look like eczema. So the morphology should be consistent with eczema, and we'll talk about um the typical morphology and age-specific patterns you should see, and then there should be a chronic or relaxed. history. So when you're seeing someone for the first time, it can be a little harder to make that diagnosis. And then it should be itchy. So when we see new rashes that kind of look like eczema but they're not itchy at all, that doesn't totally fit. So you kind of also think is this eczema or is it something else? So what is that classic morphology? So in infants, you really come to see that cheek eczema and then it tends to like the extensors, extends your elbows, um, or sorry, yeah, extends your elbows, extends her knees, um, and that facial predominance is really common. Um, again, here's some more of that facial eczema. Um, what I wanted to highlight here was that it tends to spare the nose, just that heavy, um, density of sebaceous glands on the nose kind of helps spare the nose of eczema. So we call it the headlight sign when you see like a very clear nose in the middle of the face of eczema. That can be pretty classic, uh, for eczema there. Um, older children and adolescents is when you start to get into the flexural areas of the arms and legs, um, a lot on the hands too, um, and as it becomes more chronic, can get more like kindified, which is thickened, um, from chronic rubbing scratching. Um, a few other morphologies, so, um, you can see, um, very light canophy eczema as kids get older from chronic scratching, you can see that over there on the right, um, more annular morphologies which can be a little bit tricky, wonder about other annular things like tinnia, and then just one. point, even though we see a lot of diaper rash in kids in general, and kids with eczema, the diaper area tends to be spared. It's very moist in there. It's like a little rainforest environment. It stays nice and moist, and so often you'll see kind of a sharp demarcation there, um, and a clear diaper area. Um, few, um, one other morphology, numbular eczema. Nombular means coin shapes. You can see these very, um, well demarcated round or oval. They're usually thicker plaques of eczema. These can be very stubborn to treat. So when we see a nolar morphology, I'm usually reaching for a stronger steroid. Um, it's also very frequently super infected or colonized with staph. You can see all those little pinpoint hemorrhage. like in the top left there. um, so we are often mixing a mid to high potency topical steroid like triamcinolone or an older kid memetazone with newuricin and having them treat together because there's often staph in these plaques and then if it's what we think is widespread infection, then we're getting a culture and doing oral antibiotics, but even for like a single plaque that doesn't look that bad, mixing with new piercing can help. OK, so, um, kind of moving on from the morphology, developing a framework for treating atopic dermatitis. So, Um, I like to think about, so when I talk to families about what's going on with eczema, I think about there's, there's two things going on. The skin is dry and it's inflamed. So we have to develop a good dry skincare, gentle skincare regimen to treat the dryness, and then we need medicines to treat the inflammation. When the inflammation is gone, you still continue this dry skincare regimen because that's what's gonna help prevent new flares. OK, so bathing. Um, bathing is a little bit controversial in eczema, so parents have always have a lot of questions about bathing. Um, I, in the past, it was taught that kids with eczema should minimize bathing because it dries out the skin. This is partially true, so long baths with hot water can be drying. However, a short bath with um Lukewarm water can be hydrating for the skin and it can wash off any potential irritants that are sitting on the skin. It could be irritating. So I think that most families can figure out what bathing frequency works best for them, but I tell them no more than once a day, no less than once per week, um, because the optimal bathing frequency really isn't clear. But when they do bathe, the the warm, the water should be lukewarm, use minimal bland fragrance-free soap, and it should keep it short, 5, no more than 10 minutes. Um, it's really what you do after the bath. It's very important. So it's that water evaporating off of the skin that can be very dry. So right when they get out, you want a pat dry and then immediately lock in that moisture, um, with an emollient. And if they need prescription medicine, medicines go on first and then seal everything in um with a moisturizer. Um, what soaps we recommend, um, really, what kind of getting started, I usually just recommend a land fragrance-free soap. There is a chemical called cocaidy propylbeta that a lot of kids with eczema are either sensitive or um allergic to. And so some when we get into a little bit more wondering if the soap is irritating, we'll recommend soaps without that um ingredient and Suday gentle cleanser does not have it, so that's often one of our go to's Danna cream soap and then Trader Joe's oatmeal and honey bar soap um for older kids, the honey. Um, emollients. So, um, I usually try to avoid lotions. So anything that's thin enough to travel up a tube and out a spout is often very thin and not as moisturizing as a cream, ointment, or oil. Um, but the tolerability matters. So you, you know, babies don't mind being greasy and covered in gasoline and oils, but older kids as they're going to school often don't want to be greasy. So it's important, you know, and not a one size fits all with moisturizing, but figuring out what is actually to. on their skin, what feels good on their skin, and what they're willing to do. And sometimes that's a lighter cream during the day and then a thicker emollient at night, but in general, the efficacy is ointments and oils more effective than creams, which are more effective than um lotions. Um, when choosing brands, there are many, many, many on the market. I might the easiest recommendation is that you really can't go wrong with a 100% petrolatum, um, plain Vaseline or generic Vaseline, um. Aquaphor is very similar. It's a little bit easier to spread, goes on maybe a little more elegantly. It does contain lanolin, which not everyone, but it is possible to have an allergy to lanolin. So just important to know there is one extra ingredient in that product. Um, for families who prefer oils, um, I usually recommend 100% extra virgin coconut oil or jojoba oil. Oil and then for um kids who or families who prefer creams, cream, errave Eucerin are just a few of the many creams out there, but you do want to kind of at least tell families when they're looking at labels, you know, cost is important. They might want to get the generic or store brand, but just to look for fragrance-free and actually look for kind of fragrance on the ingredients list. Um, can emollients prevent eczema? So the short answer is no. Um, there was a study in 2014 that came to the conclusion that early use of emollients, starting in infancy can help prevent eczema. And I told my sister, who had a newborn at the time, cover him in Vaseline starting from day one every day. Um, but then since then, and she was like, really? That's really annoying and spoken as a person who didn't have a kid yet. It's like, just do it. Um, so since then, studies have found this not to be true. It can lead to increased skin infections, and we certainly see malaria or heat rash from excessive Vaseline use. So we don't recommend this. Um, you know, not every baby needs to be covered in emollients, Aquaphor, Vaseline starting from day one after birth, but you want to moisturize when you see dry skin and kinda treat what you see. Um, swimming and sunscreen, we always get a lot of questions about that. For kids with eczema, swimming is fine, and for some kids, chlorine may help. So we have kind of different cohorts of kids, some who are, uh, some are flares who, it's like the sun, the heat, the sweat, the sunscreen, grass, all. Irritants on their skin, they tend to flare in the summer, and then other kids, they get better in the summer. They say chlorine, you know, when they're in the pool every day, their eczema looks great and they make you worse in the winter cause it's so dry. Um, so I tell them swimming is fine. Um, if swimming makes them itchy. Just do like a rinse after swimming if there's a shower nearby, just a quick rinse to get things off and then apply a mole and moisturize regarding the sunscreens. Um, I prefer the, um, physical or mineral sunblocks and so those are the ones with just zinc oxide or titanium dioxide only without all the other chemicals in it, um, just less likely to be irritating through the skin. Those are the ones that are thicker, harder to rub in, get all over everything, um, but I do think that they're um better tolerated. OK. So that's kind of my dry skin care spiel. Um, now moving on to addressing the inflammation. So our most commonly used medicines for inflammation and eczema are topical steroids and topical calciurin inhibitors. We also have some new non-steroidal medicines um that are recently approved in kids that we'll touch on cause even if you're not prescribing them, you may have. Patients who end up on them and just to kind of know how we use them, I think would be helpful. So topical steroids really are the mainstay of therapy and atopic dermatitis, and they are safe when used correctly, um, which requires picking the proper strength for the severe for the age of the child, the severity of the eczema, and the location on the body. So, generally mid to high potency. Flares and then tapering off or to a lower strength or to a top to a um calcium inhibitor and then just emolleans when improved is kind of the regimen that I go to. Um, ointments preferred over creams. They're more potent and creams can burn, so when the skin is very inflamed, um, putting a cream on top can really sting. So the ointments that are, um, Vaseline-based tend to feel better on the inflamed skin. Um, we use a higher potency for thicker skin, so hands, feet, elbows, knees, scalp, lower potency, or a non-steroidal medicine like el or protopic for delicate skin, so face, skin, so, groin. Um, so when thinking about what to prescribe again, I think about age of the patient, location on the body, and body surface area. So age-wise for infants under 6 months and often under 12 months, we do, we don't generally go go higher than the low potency, sometimes mid potency. Um, and toddlers and older children, uh, the mid potency is usually my go to for the body, sometimes, um, a more potent steroid for thicker skin, like hands and feet. Um, low and mid potency steroids, specifically hydrocortisone 2.5 and triamcinolone.1 can be prescribed in a 454 g jar, 1 pound jar, um, because they're Safe to use over larger surface areas. And then once we get into class 3 and certainly class 1 and 2, they're very strong and should only be used in smaller, more focal areas. So for example, regimens you might see are, you know, for a 5 year old, for example, with kind of diffuse eczema and then some stubborn spots, triamcinolone for most areas of the body, lometasone for the thicker spots, more stubborn spots on the. Hands and feet and maybe Elidel for the face or skin folds might be something you see. For a younger child, it might be just hydrocortisone, 2.5% in a jar for everywhere, Elidel for the face if we can get it. Um, it's not FDA approved under 2, so sometimes it can be hard to get covered. So sometimes it's just that 2.5% will go everywhere, um, with maybe a small tube of triamcinolone for some stubborn spots. Um, for the scalp, often, um, is often involved in atopic dermatitis or with some overlap with separate dermatitis. So you can usually use, think about the same potency for the scalp that you would use on the body. You don't have to use what you're using on the face if you're using a lower potency, um, but you have to think about the vehicle. So for babies, probably. Mind just putting an ointment up there, but as kids get more hair, they might want like a solution or an oil depending on the hair type that they have, so it doesn't um change the texture of their hair. So, um, and like an older child or adolescent, we might use memehazone solution or in a, um, patient that prefers oils in their hair, finol. Um, OK, so overall topical steroids are very safe and side effects are rare, um, but there, there are potential side effects that we do talk about and the risk of side effects is higher with the super potent topical steroids when being applied to thin skin. And when large quantities with lots of refills are being prescribed. So, um, there are some reversible and irreversible side effects of seeing kind of vascular blood vessel prominence, atrophy, hypertrachosis, acne that is reversible, but the stria or stretch marks are not. Um, you can rarely see HPA access suppression from absorption. Um, it can occur. When high potency topical steroids like Clobetasol, one study showed, um, Clobetasol administered at a cumulative dose of, um, greater than 50 g per week was being used, they did see a risk of HP access depression. So, you know, when you think about a tube, usually like a 30 to 60 g tube is kind of those like toothpaste size tubes. So that would be like a tube a week, which is a lot of uh clobetasol. Um, this is an example here, um, of Stria. So, um, you can minimize side effects by prescribing the least potent effective steroid. Apply until smooth and then stop. So I usually tell parents about the touch rules. So if you close your eyes and run your fingers over it, if you can feel it, it still needs medicine, and once it's smooth, you stop. Um, I tell them not to apply steroids to normal skin. Um, I don't usually give a time limit. So a lot of patients I see will say, I was prescribed triamcinolone, it works, but they told me I can only use it for 2 weeks, so I stopped and I came right back. So I don't usually have a time limit. Um, I say use it until smooth, but the caveat that if you are treating for like 3 weeks and you're not seeing any improvement, let me know because that tells me, OK, this isn't the right medicine or there's something else going on, maybe an infection, but If you're treating for 2 weeks and it's 75% better, keep going, get it smooth and clear and then stop. Um, systemic steroids. So really a minimal role for systemic steroids and atopic dermatitis. You'll rarely see dermatologists prescribe them for eczema. They do help, but then the eczema will flare right back the second they're stopped. Um, we'll sometimes use them in allergic contact dermatitis because there's a clear trigger that has been pulled away and then you need to calm down the inflammation. But with atopic dermatitis, you haven't changed the pathophysiology of what's going on, so they're just gonna flare right back up. Um. If a patient with atopic dermatitis is taking steroids for another indication, which is very relevant, a lot of these patients have asthma. They should be aware that their eczema may flare when the steroids are stopped. So sometimes we'll tell families if you go on prednisone for an asthma flare, you know, you might want to amp up your topical regimen while you're on it because it can kind of trigger a flare once they finish the steroids. What do you do when your regimen is not working? You prescribe this new regimen, you feel good about it. A few months later, the family calls and says it's not working. So, when I ask, are they applying enough? Are they applying it every day, twice a day? Are they continuing until smooth or are they kind of spot treating? Sometimes I use the analogy of a forest fire. So if you throw a little bits of water on it here and there, it's really not gonna do anything. You wanna fully put it out and then sometimes even treat a few days beyond clear cause they say it could be simmering under the surface a little bit. So you really get it clear before you stop the medicine. Um, and if you have a hard time figuring out how much, how often they're applying it, have them bring in the tube and you know, have you refilled this since you picked up the 30 g tube 3 months ago? If not, and that's all they have, they're certainly not using it twice a day every day. Um, we were asked how long does the tube last if they said they have refilled it. I can also give you a sense of how much they're using. Is the steroid. The appropriate strength. So, if you prescribed hydrocortisone, 2.5% for 1 year old with eczema and most areas cleared, but there's a few that are being stubborn and not clearing, then you think, OK, well, we're, we're halfway there, but let's send a small tube of triamcinolone for those stubborn spots. Are there signs of infection, or is there bleeding, crusting, scabbing, pustules, oozing, then you need to address that. They need a culture and antibiotics. And then, are the topicals just not cutting it and then we have to think about do they need a systemic medication. Um, how much medicine should you prescribe? So I will usually prescribe anywhere from a 60 g tube to a 450 g tub for a a mid to low potency steroid, and then for a high potency steroid, usually just a small 30 g tube. Um, I never use this chart, but it can be helpful to get a sense of how much medicine patients need. So one finger tub unit, the length. Of an adult fingertip, um, is enough medicine for a thin layer to cover two adult hands, and that's 0.5 g of medicine. So if you're ever curious, you could kind of look at this chart and it could tell you how many grams they need, but often the 15 g tube that they were sent home from the ER with is not gonna last them more than like 2 weeks if they were there for a severe flare. So they're gonna need refills quickly. Um, wet wraps is a way to provide, um, to apply topical steroids under occlusion, um, to increase efficacy. So typically this is something we'll recommend for a severe flare for a very stubborn area. Um, maximum usually 5 days at a time. So the concept that you're applying the steroid to damp skin or to skin and then covering with a damp fabric. Um, this can be a damp washcloth if it's just a small area, just like wet wraps for the hands or if it's for more diffuse eczema, we'll say like wet PJs, um. Socks, gloves, if the hands are involved, um, and then dry clothing, clothing on top so they don't get cold or gonna wrap them with a blanket, let them just kinda hang out, watch something. Um, this can be for severe flares. It's kind of what we call it kind of like a skin treatment that they'll do for a short amount of time. They can help get over like a really tough spot that they're in. Um, you wouldn't want to do this for more than 5 days because they are going, you're gonna have increased absorption, um, but something that some families will do for 4 years. The drool dilemma. Um, so a big piece of the cheek and chin eczema we see in infants and toddlers is irritant dermatitis. So, saliva foods, so many irritants come in contact with the face of an infant and toddler and can lead to this dermatitis. I reassure families that this is not a food allergy and that they will outgrow it. I think managing facial dermatitis is very similar to managing a diaper rash. Um, there's so many Irritants coming in contact with this very delicate skin that it's going to get inflamed and then it's very hard to clear it because those irritants are still there. Um, so the mainstay of treatment is barrier cream. Uh, lots and lots of Vaseline or Aquaphor applying to the face, often to act as a barrier between food, saliva, other irritants so they don't come in direct contact with the skin, and then low potency steroids, usually hydrocortisone 2.5% or non-steroid, uh, twice a day. OK. Um, moving on from topical steroids to our, um, Non-steroid anti-inflammatory medicines, um, most commonly that we use are the topical calcium urine inhibitors, which are tacrolimus and porolimus. Both are FDA approved for children under the age over the age of 2. tacrolimus comes in two strengths, 0.03% for kids under 16 and 0.1% approved for kids over 16. There is a black box warning on the label for both medicines due to potential cancer risk. This is due to animal studies where animals swallowed large amounts of medicine over long periods of time and achieved significant blood levels of the drugs and developed lymphomas. Uh, since then, there was a large study showing no. Risk of cancer and the black box this morning has been removed in Canada. It has not been removed here yet. Um, I do talk about it with families because the pharmacist is going to tell them they're gonna see it on the box, but I tell them I think these are very safe. We use them in patients with cancer. I put them on my own kids and usually people are reassured by that. Um, they are a great choice. So where do you use them? Um, face other areas of delicate skin. I tell families this is a medicine you can use twice a day. You don't have, you can stop, you can keep going until the eczema is better. You don't have to worry about a time limit, um, and really we don't see side effects other than sometimes they can burn or sting a little bit if the skin is inflamed, um. So, um, if, if it burns or stains, sometimes they'll need like a few days of a topical steroid to really to calm down the inflammation a little bit so it's not so inflamed, and then they can tolerate the topical calcium inhibitor or they can put a cold compress on after they apply or use a fan or put the medicine in the refrigerator. It can also help. Um, so in addition to using it in um areas of thin skin, you can also use it as a maintenance regimen. So for kids who, you have this history of like, yup, the triamcinolone or memetazone or hydrocortisone clears it, but the second I stop, it comes right back and I try to taper off and just the next day it comes back. Sometimes you can say, OK, do Elidel daily there, even when it's clear to prevent that eczema. And then maybe you just need it a couple of times a week and that's kind of your, and I let families kind of experiment with that. Um, it's a very safe medicine and they might just need it a couple times a week um to help prevent the flares and then if they do get a flare, then you step up to the topical steroid. Um, OK. A few other medicines that I'll go through, um, so crisaberol or Eresa, this is a PDE4 inhibitor, FDA approved for atopic dermatitis, also in kids over the age of 2. We haven't seen much success with this medicines and studies have not been that impressive with a very modest improvement when compared to Vehicle and it does burn and sting with applications. So I don't prescribe this very often. I'll really only prescribe it in patients where um the parents are resistant to use the calcineurin inhibitor because of the black box warning or if a topical calcium inhibitor is not covered by their insurance, and I wanna have some sort of non-steroid option, but we don't use this a whole lot. Topical refluulla is a newly improved PD4 inhibitor. Um, this is approved in kids over the age of 6. It's nice cause it's once daily dosing, um, and it's well tolerated, and they haven't seen the burning and stinging that we'll see with rosabr. Um, and there was a 22 times improvement compared to vehicle, um, but the downside is it's hard to get covered by insurance. Um, so I do try prescribing this a lot and it gets bounced back to me a lot too. Uh, topical alitinib is a topical jack inhibitor being used in dermatology for atopic dermatitis and vitiligo. Um, it's FDA approved for both indications for kids 12 and up, um, currently being studied down to age 2 with about, um, with pretty good efficacy in the studies, 50% of patients achieving clear, almost clear compared to 15% with vehicle. And then, um, to pin her off cream, it's an aero hydrocarbon receptor agonist, hot off the press, now FDA approved and kids over the age of 2, around 45% had treatment success compared to 15% with vehicle. Again, just hard to get covered by insurance, but I think all of these you'll start seeing more and more as um. Kind of time goes by and hopefully we can start getting them approved. OK, moving on to systemic therapy, so, um, we start to think about systemic for patients who cannot be adequately controlled with safe quantities of topical medicines, we start thinking, OK, we have to move on to another step. So phototherapy, not really a systemic, but also not really a topical, so I included it here and then the immunosuppressants, biologics, and CAC inhibitors. So phototherapy is a really nice option for families who want to avoid a systemic medication but need better control. So who are really hesitant to do injections or pills, but we're just not getting where we need to be with topicals. It's challenging logistically, so it needs to be done, usually 2, sometimes 3 times a week. Adults often will come to the office for this. You know, it's quick. They're in the machine for minutes. They'll do it on their way to work or, you know, the phototherapy offices open earlier on their lunch break, but for kids, it's just not practical when they're in school to be brought in several times a week. It's just really challenging. Um, so we often try to get a light unit for home, the cost can be prohibitive. So we try and sometimes insurance will cover it, sometimes they won't, um. The other downside is that the skin is quite inflamed. It can hurt. It can feel really hot or stinging on the skin. Um, upside is that you have not shown increases of skin cancer with narrow band UVB, so that's a big question families ask a lot and um that has not been a concern, um, but it can help with the inflammation and once they get good control, you can kind of taper down or take the summers off and just get light on some sunlight on the skin, um, so it's something that we will talk about. Um, and then the traditional immunosuppressants, so, um, the ones we use for eczema are methotrexate and cyclosporin. We're certainly using them less now that we have the biologics and Jack inhibitors, but we do still use them. Um, methotrexate is a slower onset of action, so cyclosporin is sometimes chosen when we want to get someone better immediately. Um, but the downside of cyclosporin is there's limits on how long patients can be on it. So usually 1 to 2 years, so it's not a great long-term solution. Usually when I'm putting someone on cyclosporin, I'm also, I'm already thinking about how am I gonna get them off, like what's my next step, because this isn't good for long term versus methotrexate, we will use long term. Um, it does require frequent lab monitoring. So for families that are kids who are needle phobic and don't want to do pick at shots, these, these medicines sound very appealing, but with the drawback of, OK, but then you're checking blood work every 3 months, which is a needle, and I think more challenging, you have to go to the lab and versus just like a um subQ injection. So something to think about, something we talk about, um, but we're definitely using them less now. Um, biologics, uh, so the ones that are FDA approved to treat ectopic dermatitis are dilumab, which is an IL-4-13 inhibitor, and then, um, these two new IL-13 inhibitors, um, triloquiumab and levacuzumab. Um, so dupilimab is approved down to 6 months of age. It's dosed as a subcutaneous injection every 2 to 4 weeks, and the dosing depends on the age of the patient and the weight. Um, you can see improvement as early as 2 weeks after starting with the maximum benefit expected by 24 weeks. Um, I think of them as being very safe. They're not as broadly immunosuppressive as the traditional immunosuppressants. Um, it does affect the allergic arm of the immune system which can put patients at higher risk for parasite infections. So I just tell them, you know, be extra careful and careful if you go camping, don't drink the water, and if the child is having increased pruritus, you know, full body itching came out of the blue with an unknown cause, that's when you would consider testing for a parasite infection. Um, vaccines on dilliumab is, um, a hot topic. So, um, live vaccines specifically. So participants in the Duilliumab trial were not allowed to receive live vaccines, and that resulted in a package and start recommending patients avoid live vaccines, and this started to become very relevant when the FDA approval went down to 6 months of age, um, starting to think about particularly those like 4 or 5 year old MMR, um. The vaccines, um, when I see like a 3 or 4 year old that I want to start to fix it. Um, so there was a Delphi consensus recommendation from the American College of Allergy, Asthma and Immunology. It came out last year and they said that the avail available literature suggests that live vaccines are, are safe and effective because they were able to look at many patients that got them. Accidentally, they didn't know that they weren't supposed to avoid them, so they were finding that there were actually many patients out there who were on who got vaccines and that it was safe and the vaccine was so effective. So I will talk about this now with families. I'll let them know this is on the package and so that they're supposed to avoid it, that we have, you know, data and recommendations showing that we do think that this is safe, but I think it's important for families to know, um, if they, or and I tell them to talk to the pediatrician about it. And if either there or the pediatrician does not feel comfortable giving live vaccines while on it, then I'll have them, so I don't. Say, OK, then just skip your vaccines or I'll sign a letter saying you, I will have them take a break from the medicine. So basically, um, if the injections are monthly, they would get their shot 4 weeks later, skip the shot. And then a month later, get the, and then get the vaccine and then a month later resume, so we kind of have 2 months off of medicine. OK. Inhibitors. Lastly, um, so we have, um, two DAC inhibitors FDA approved for each topic dermatitis, and catacitinib and Aroitinib, um, approved for patients age 12 and up. Um, studies show that these are at least as efficacious as the injectable biologics or maybe more, um, with the advantage is that it's an oral agent. Taken once daily and they do have very fast results. So, um, for families or for um patients who are feeling hesitant about injections, it's another option um of an oral medicine. They're easy to stop and start, so some people are talking about, you know, could you use them seasonally if they, you know, do really well in the summer and then flare in the winter or vice versa, could you do them for kind of short periods, couple of months for a flare, um, or something like that? Something to think about. OK, um, bacteria and other infections. I think it's an important point, um, to always think about in your atopic dermatitis patients who are not getting better, who are flaring, having increased crusting, always think about infection. So, first bacterial infections, so staph, colonization. It is very common in atopic dermatitis and superinfection is also very common with both staph and strep. So clinical signs um that suggest infection, crusting, erosions or pustules, and I always tell that to families, new eczema patients I see, if you ever see oozing, bleeding, crusting, scabbing, that it's not just because they scratch really hard and give themselves a scab, let me know that could be a sign of infection. So Treating that infection often helps decrease the severity of the dermatitis and helps the skin heal. Um, mild infection may clear with just um topical steroids alone or topical steroids and um a topical antibiotic, but severe infections or widespread infections often require oral antibiotics. So, um, when treating infected atopic dermatitis, an important point is that you do need to continue treating the underlying dermatitis. So I think sometimes people wonder, well, if the skin's infected, I shouldn't put steroid on top of infected skin, but you should. So keep putting that triamcinolone on there while they're taking their Keflex or using the nuclein because if you stop treating the inflammation, um, it's gonna be very hard to control the infection and um the the flare. Um, you can often use topical antibiotics which is a small crusted or eroded area. Often I'll include that or add that into the regimen shortly after the first visit of if you ever see an open area, erosion, a crust, something they scratch open, just start putting the piercing on it right away because if you just think of all of that eczema being colonized with staph, one open little erosion, they scratch something open, that stuff, it's just gonna be very um easy for it to get infected. So I'll have them just start me piercing right away. Um, when we are, when we do see a patient who looks to have widespread infection, I'll usually take a culture and start antibiotics right away. Um, usually Keflex or if they're inpatient A unless there's a history of MRSA, um, but I do like getting that culture, so if the infection is not responding, you can tailor antibiotics or then you can see in the future if they get reinfected, you know what they've grown before. Um, bleach baths, uh, dilute bleach baths, um, are something we commonly use for eczema. It can help with pruritis and may help reduce infections. So, um, we give the families a recipe and I usually say, give this a try. It, it seems to help with itching, um, or it may decrease the frequency of infections, you can continue it. Some families are like, I hated that and I say, OK, great, you don't have to keep doing it. Um, so if they're using like a, a regular size bathtub, a 1/4 cup of bleach, and the tub of water, um, or if they're using like a baby tub, just a tablespoon. Um, so for about 1015 minutes, I tell them it's very safe. It's like swimming in a swimming pool. I, you know, don't say dump it on their face, but if it gets on their face, it's fine, it's safe, and then just give them a little rinse, have them stand up after and rinse them off. Um, may, it may minimize infection, um, decrease disease severity, or decrease pruritus. There's also some newer um sodium hypochlorite products. Um, so there's sprays with hypochlorous acid, there's CLN wash, boshi wash. So for um older kids, teenagers who are showering, they don't wanna take a bleach bath, um, they can use these antibacterial washes. Um, so 7 year old, 7, I should say month old, um, with a history of, um, mild to moderate atopic dermatitis, it's flaring. You see these punched out erosions, um, in hands, so this is a patient, um, with eczema hepaticum. So this is, um, those monomorphic erosions are very classic for eczema herpeticum. There's not many things that can make perfect circles like that. Um, so that should always raise your antenna for eczema herpeticum, um. Eczema coccacium can definitely be a mimic and sometimes it can be hard to tell. These children are usually more unwell, um, not feeling well, maybe febrile, um, so we'll usually, and they can often be super infected with bacteria too. So sometimes they're super crusty on top like this space here might also have staph or strep in there, so often we're swabbing for bacteria and HSVVZB um. And starting a cycle until we get um a PCR result back. Um, and if there's any eyelid involvement, um, getting ophthalmology involved as well. Um, in comparison to eczema coxsackin, it can definitely be confusing. Um, we've all been fooled. Um, you'll usually see some classic hand foot mouth lesions, um, in addition to the punched out erosions in the eczema. Um, typically, these kids are a little more well appearing compared to eczema herpetic but it can be hard to tell, um, and they're usually gonna get swabbed for, um, HSV too if there's any, um, questions. OK, so to summarize, um, this is a treatment letter. It was published in the Journal of Allergy, Asthma and Immunology with a proposed treatment for ectopic dermatitis. Um, I've added a few things to kind of add some of the newer treatments, but I think it's, I like kind of the overall structure and that basic management. on the left, um, focuses on skin care and trigger avoidance, and then as severity increases, you continue that basic management. Um, you add maybe an antiseptic management like urine, bleach bath, CLN wash, and then topical steroids, BID PRN for flares. Um, for moderate severity, you could think about adding a calcium neuron inhibitor, or I would say you can even add that if they're mild, if they have facial involvement, um, or you could expand that to include some of the other topicals, newer topicals that we've discussed, which can be used for flares or daily as maintenance areas that frequently flare, and then for severe cases, you're gonna think about systemic medicines or um uh therapy. And then down here, just if not resolved in within like a week or two, you're gonna think about, you know, is there an infection? Is there something else going on. Um, a lot of parents of kids with eczema will ask about food allergies. So we know about the atopic triad. Up to 35% of kids with moderate to severe eczema will have food allergies, but the food allergies are not causing the eczema. So, um, Families will often ask, you know, if they just have flaring eczema or early onset eczema, should we see an allergist? Is there a food, you know, and sometimes it can be help, oftentimes it can be helpful to get um allergy input on the eczema or if they do have an underlying food allergy, but it's not a food that's causing the eczema. If they have a food allergy, you're gonna see other signs of food allergy. And if they have hives in their body is reacting to that, it could certainly make the eczema flare, but it's not the underlying cause and often we'll see families who are eliminating so many things out of their kids' diet, and that's gonna cure their eczema, and that's often just not the case. Um, to, um, in terms of peanut allergies, so, um, exposure to peanut antigen in dust through an impaired skin barrier and inflamed skin is a possible route for peanut sensitization and peanut allergy, and so it is recommended um to decrease the risk of peanut allergy to make sure they're sensitizing to the gut, which I'm sure you guys all know about, um, leading to the recommendation of early uh peanut introduction. OK, so, um, parent education, so just always, you know, in any setting, um, I always try to remember that parents remember about less than 50% of what they were told in the office. So we always really try to utilize the ABS, make things very clear, what you do as your daily regimen, what do you do when things are flaring. I try to always make sure I write on the tubes for the prescription, not just like use BID, but this is used twice a day for the most severe areas of eczema on my hands and feet. Use twice a day for eczema on the face so that it's on the tube, it's also on their handout and bringing patients back frequently because often when you see a new eczema visit, you bring them back in a month. There's something you can tweak about that regimen or something that they, you know, weren't doing as prescribed and you can make um make a big impact there. Also, these regimens are complicated. I try to simplify. I try not to have more than 3 creams at a time. Um, and just understanding and, you know, acknowledging with families, this is really hard. Like I can barely get Aquaphor in my kids' cheeks twice a day. It's just hard to do these things that you don't like it, they run away from you. And so when I see um a child back and their eczema is under really good control, I really applaud the families. Like, wow, this is really, you've been doing a lot of work. I can see the work you're doing. You're so much better and they're like, yeah, it's a full-time job. And so I think they really appreciate being acknowledged. Um, and then just a little plug for these handouts. These are free, available to anyone on the Society for Pediatric Dermatology website. You just Google um SPD dermatology handouts and we have all of these um reviewed by multiple pediatric dermatologists for many diagnoses, um, that you can, you can download them, um. Into this like printable version and then there's also like an EMR friendly version that puts in a Word document so you can copy and paste it and make um ABS handouts about it and um there's just a lot of great diagnosis there. Um there's if you just want a sunscreen handout, just about moles, how to look at your skin, things like that, very common um things in primary care. Um, and then the national, I just want to include this as my last slide. This is um from the National Eczema Foundation, um, published messages from patients living with eczema, what they wanted people to know. Um, the itch is bad, it's painful. They want people to know that they can't catch it. Um, so I hope this lecture was helpful, that you can feel more confident treating patients with opic dermatitis. Please. Refer if you have concerns, we're always happy to see um these patients. If you can't get your patients in, feel free to send emails, epic messages. We're always, you know, I know we're very full, but we always wanna help too, and so, um, we'll find a way to get them in. So thank you. That's all I have. Created by Presenters Liza Siegel, MD Dermatology, Pediatric Dermatology View full profile
