Diagnosing and Treating Atopic Dermatitis: What Practitioners Should Know

Allergic diseases are among the most common chronic illnesses in the United States. In fact, more than 50 million people in the United States live with allergic diseases like atopic dermatitis (AD), according to Anthony J. Mancini, MD, FAAP, FAAD, of Ann & Robert H. Lurie Children’s Hospital of Chicago, and the Northwestern University Feinberg School of Medicine in Chicago, Illinois.

Commonly known as eczema, AD is the most prevalent chronic skin disease among young children, affecting 10% to 20% of children compared with 1% to 3% of adults. Typically, 60% of AD cases in young children begin during the first year of life, and 85% of cases begin by age 5 years.
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Consultant360 spoke with Dr Mancini, who recently presented “Atopic Dermatitis Update” on September 18 and 19, 2017, at the American Academy of Pediatrics (AAP) 2017 National Conference & Exhibition in Chicago.

Symptoms of AD: The Seen and the Unseen

Infants and young children with AD present with several characteristic symptoms, including pruritus and eczematous changes typically affecting areas like the face, neck, and extensor extremities. Symptoms can be acute, subacute, or chronic and, depending on severity, can interfere with the patients’ overall quality of life.

Sleep disturbances are common in children with AD, affecting nearly 60% to 80% of patients. In addition, children with AD may experience social isolation, poor self-esteem, frequent absences from school, impaired academic performance, and strain within the family unit.

The presence of emerging comorbidities can worsen the burden of AD. Various conditions including attention-deficit/hyperactivity disorder (ADHD), depression, anxiety, oppositional defiant disorder (ODD), obesity, and hypertension are all emerging comorbidities among children with AD.

Patients with AD also have an increased risk for developing bacterial and viral skin infections, Dr Mancini added, including Staphylococcus aureus, warts, molluscum contagiosum, and herpes virus infections.

Factors That Can Complicate a Diagnosis

Certain factors can sometimes complicate a diagnosis, including the presence of conditions with clinical features that are similar to those of AD. Differential diagnoses for AD include allergic contact dermatitis, and certain nutritional, metabolic, or immunologic conditions. Practitioners should consider these if patients are at the more severe end of the spectrum and/or do not respond to appropriate therapy, Dr Mancini noted.

Current Treatment Methods and Standards of Care

Treatment for pediatric AD can vary based on the severity of the condition. Children with mild AD may note symptom improvement with dry skin care including the daily application of moisturizers, while patients with moderate to severe AD will likely benefit more from topical anti-inflammatory agents (including corticosteroids, calcineurin inhibitors, or topical PDE4 inhibitors).  Some patients may also require antihistamine agents (especially when the sleep cycle is disrupted) and/or antimicrobial therapies.

When utilized as directed, most traditional therapies for AD are safe and well-tolerated. Side effects such as striae, cutaneous atrophy, and telangiectasias can occur with prolonged use of topical corticosteroids, but are quite rare when used appropriately.

For those with severe or recalcitrant AD who do not experience symptom improvement with topical treatment alone, phototherapy or systemic agents may be appropriate alternatives.

Clinical Applications: Implementation into Your Practice

In his presentation, Dr Mancini noted several points that practitioners should consider in treating pediatric AD.

First, aggressive treatment with topical steroids helps reduce inflammation and, when applied as directed, typically leads to faster symptom improvement with less medication needed (as compared to “under-treatment” with weak agents).

“Pediatric providers may be hesitant [to treat inflammation aggressively] because of concerns about cutaneous side effects or systemic absorption, especially in younger infants and toddlers,” Dr. Mancini noted. “When utilized as directed, these medications are quite safe and well-tolerated.”

Patients’ overall quality of life and specific comorbidities should also be addressed, as these factors can exacerbate the burden of AD for both the patient and the family.

Furthermore, patients with moderate to severe AD and a history of frequent, recurrent infections may benefit from sodium hypochlorite (bleach) treatment. A known disinfectant and antimicrobial agent, sodium hypochlorite can help decrease disease severity and the need for oral antibiotics among patients with moderate to severe disease.

Dr Mancini regularly utilizes oral antihistamines for patients with AD, primarily for their benefit with regard to sleep. However, their use for AD remains somewhat controversial.

“There are no controlled studies which really document the benefit of oral antihistamines on the itch of atopic dermatitis,” Dr Mancini said. “However, practitioners who treat AD patients on a regular basis, myself included, often use them for itch and, more importantly, to help restore the sleep cycle.”

Early emolliation in infants with a higher risk for AD has also shown promise in 2 prospective controlled trials, Dr Mancini noted. In each trial, infants at high-risk for AD who had received regular  application of emollients or moisturizers demonstrated a significantly reduced risk of developing AD, compared with infants who were not treated with them.

For more information on the clinical guidelines for diagnosing, managing, and treating AD, visit the American Academy of Dermatology’s Practice Management Center.

—Christina Vogt

Reference:

Mancini AJ. Atopic dermatitis update. Presented at: American Academy of Pediatrics National Conference & Exhibition; September 16-19, 2017. Chicago, IL. https://www.eventscribe.net/2017/aapexperience/agenda.asp?h=Full%20Schedule&BCFO=P%7CG.