Highlights of Society for Pediatric Dermatology Annual Meeting

July 13-16, 2005; San Diego, California

Brandie J. Roberts, MD


October 11, 2005

In This Article

Recent Trends in Atopic Dermatitis

Lawrence F. Eichenfield, MD,[1] Clinical Professor of Pediatrics and Medicine (Dermatology) at Children's Hospital San Diego and the University of California, San Diego, presented an update on clinical aspects of atopic dermatitis (AD), including management trends and data supporting its increasing incidence.

AD is thought to arise from an interaction of environmental and genetic factors. Although a family history of atopy is a strong risk factor for the development of AD, many researchers speculate that environmental factors are responsible for the increasing prevalence of AD. In one study, the prevalence of AD in the United States was estimated to be 17.2%,[2] and the prevalence in Westernized countries is known to be higher than that in non-Westernized countries, independent of ethnicity.[3] Several hypotheses may explain this phenomenon, including the "hygiene theory," which hypothesizes that decreased exposure to various pathogens at an early age deprives the developing immune system and contributes to the development of allergic disease.

It is known that food and environmental allergies are more common in patients with AD than in the general population.[4] What is less clear is the role that these allergies play in the exacerbation of AD. Given the high prevalence of allergies in this patient population and their unclear clinical relevance, Dr. Eichenfield emphasized the importance of patient selection when considering allergy testing. Allergy testing, which may include radioallergosorbent testing and/or referral to an allergist, may be useful when patients are difficult to control or maintain with standard therapy or when an allergy is suspected on the basis of a patient's history and pattern of flares.

Care of dry skin, including mild soaps and emollients, is the mainstay of AD treatment. Because allowing moisture to evaporate off the skin results in xerosis, frequent bathing has traditionally been discouraged. This notion has recently been challenged, because it has also been observed that the application of emollients immediately after bathing can "seal in" the moisture. Dr. Eichenfield presented recent studies that compared the effects of applying an emollient after bathing with the effects of applying an emollient without bathing first.

Dr. Eichenfield underscored the importance of emollients by asking the audience 2 questions: "What product, when used at the first signs and symptoms of dermatitis, allowed 30% to 35% of infants and children to go 6 months without using a corticosteroid or experiencing a flare?" and "What product, when used for moderate to severe AD in children, allowed 27% of these children to be at least 50% improved after 12 weeks of therapy?" The answer to both questions is the same and may surprise you: an emollient. These are the data from the vehicle arms of 2 similar studies, and they emphasize the importance of emollients alone in the management of AD.

Fresh in the minds of many dermatologists and pediatricians is the February 2005 Pediatric Advisory Committee's warning on the possible risk for cancer from the topical use of the calcineurin inhibitors pimecrolimus and tacrolimus. The concern stems from the known risk of malignancy with the systemic use of these drugs, along with the increasing use of these topical medications, especially in children younger than 2 years of age. Dr. Eichenfield presented data from human and animal studies. There is no evidence of systemic immunosuppression from the topical application of pimecrolimus cream or tacrolimus ointment, and reports of malignancies are not increased in patients using these medications compared with expected rates in the general population. However, this controversy forces us to reevaluate the place of these medications in our practices. Ongoing studies by Dr. Eichenfield and others in the field of pediatric dermatology are seeking to determine optimal combination regimens of topical steroids and topical calcineurin inhibitors in order to spare the use of and decrease the risk for side effects of both medications.


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