ATOPIC DERMATITIS/ECZEMA

What is atopic dermatitis?
Atopic dermatitis (AD) is an itchy, inflammatory skin condition that occurs primarily in infants and children. This common disorder is characterized by recurring episodes of intense itching and multiple lesions with redness, swelling, and scaly erosions. It is often associated with a personal or family history of hay fever or asthma.

What causes atopic dermatitis?
The cause of atopic dermatitis is unknown but it is thought to involve a complex interaction between an individualís susceptibility genes, their environment, defects in skin barrier function, and systemic and local immune responses. Research on the pathophysiology of atopic dermatitis has focused primarily on immunological mechanisms; however recent genetic studies have shown the potential role of filaggrin and epithelial barrier defects in the pathophysiology of atopic dermatitis. Filaggrin is a protein that facilitates differentiation of the epidermis and formation of the skin barrier. Recent research suggests that loss-of-function genetic variants in the gene encoding filaggrin are strong predisposing factors for atopic dermatitis.

How does it present?
In infants, the disease classically involves the face, neck, and extensor surfaces of the extremities; in adolescents and adults, thickened skin and papules in the popliteal and antecubital fossae are the more common presentation.

Is it common?
In the United States and United Kingdom, surveys have documented a prevalence of about 17% in children, with the vast majority of these AD cases being mild in intensity.

Are there treatments for atopic dermatitis?
Treatment for eczema includes topical medications and oral antihistamines to reduce inflammation and itching. A mild skin care routine using a gentle cleanser and moisturizing cream is helpful in reducing dry skin and to restore the skin barrier. Perfumed soaps, harsh laundry detergents and fabric softeners should be avoided. Bathing should be kept to a minimum amount of time in only warm water. Avoid hot showers.

What therapies do you recommend?
Topical corticosteroids are the mainstay of therapy for AD flare-ups. Once the acute disease is controlled, emollients and proper bathing can often help restore the skin barrier and prevent relapses. Emollients and proper skin care, including avoidance of irritants, are keys to maintaining remission, but periodic use of topical steroids is often required to sustain such remissions. Guidelines by the American Academy of Asthma, Allergy, and Immunology have also recently recommended low-potency topical steroids for use in maintenance therapy, a recognition both of the recurring nature of this disease and of the persistent immunologic abnormality that likely resides even in the normal-appearing skin of many individuals with a history of AD.

I have heard that topical steroids are not safe to use, is this true?
Yes and no. While intermittent use of corticosteroids has long been recognized as the overall standard of care for flares of AD, there is a potential for complications including skin atrophy, striae, and telangiectasias. There can also be very rare systemic adverse events including suppression of the hypothalamic-pituitary-adrenal [HPA] axis and growth retardation. All of these facts guide the selection and use of corticosteroid products for individual patients. In particular, decisions regarding corticosteroid potency, formulation, duration of use, and frequency of application are often driven by consideration of the patientís age and the location and severity of the dermatitis. Lower potency corticosteroids, for example, are often used on the face to avoid skin thinning. Always use the products as directed by Dr. Weiss and his team and review the package insert of all prescriptions both for instructions on use and important safety information.

What about new therapies for atopic dermatitis?
Recently, two non-steroidal anti-inflammatory therapies for the treatment of AD have been introduced: pimecrolimus (Elidel™) and tacrolimus (Protopic™). They both inhibit calcineurin to reduce inflammation and have proven very effective in managing the disease. However, both are not without their own adverse effects and the FDA has recently warned of the potential long-term safety concern for malignancy (e.g., skin and lymphoma). Discuss the benefits and risks of these products with Dr. Weiss and his team. To learn more about these products visit www.elidel.com and www.protopic.com.