Hot Topics in Pediatric Dermatology

Lian Sorhaindo; Anthony Rossi; Andrew Alexis; Nanette B Silverberg


Expert Rev Dermatol. 2010;5(3):259-267. 

In This Article

Atopic Dermatitis: What's New, What's Not

The session 'Atopic dermatitis: what's new, what's not' was presented by Richard J Antaya from Yale University (CT, USA). Atopic dermatitis (AD) has prevalence in children of approximately 10–17%.[18] It is mild in severity in approximately 85% of cases. Moderate-to-severe AD can cause profound impairment of patient quality of life, comparable with severe chronic illnesses, such as cystic fibrosis and diabetes mellitus. Intractable itching, soreness, skin damage, sleep loss and social stigma are all associated with AD.

The diagnosis of atopic dermatitis is based on the presence of pruritus and eczema with an early age at onset; 80–90% by the age of 5 years. In addition, a personal family history of atopy, as well as xerosis, are criteria for atopic dermatitis. Other secondary criteria include the presence of keratosis pilaris, hyperlinear palms, ichthyosis, infra-auricular fissures, periorbital/ocular changes, such as Dennie–Morgan folds, prurigo lesions and atypical cutaneous vascular responses.

Treatments of atopic dermatitis are multifaceted. The physician should start by explaining the entity to the patient and family, and that atopic dermatitis is called 'the itch that rashes'. The patient and family should be informed of common precipitants of itch in atopic dermatitis, which include: heat and perspiration (96%), wool (91%), emotional stress (81%) and the 'common cold' (36%).[19] Randomized clinical trials support topical corticosteroids, oral cyclosporine, ultraviolet light therapy, topical calcineurin inhibitors and psychological approaches, such as habit-reversal techniques. Bathing in a bathtub is recommended daily, in addition to using moisturizing cleansers, followed by patting dry and applying moisturizer within 3 min of drying. Moisturizers should be the backbone of all treatment regimes. Creams or ointments, not lotions, should be used and applied immediately after bathing and repeated throughout the day. Medical treatment is anchored with topical corticosteroids, starting with the weaker class including nonfluorinated ointments and creams such as hydrocortisone acetate 0.5, 1.0 or 2.5%, and then using the medium-to-high-potency steroids, such as triamcinolone, memetasone and fluticasone ointments, twice a day for 2 weeks when needed. These can also be administered as pulse dosing on the weekends or 3 days per week. It is imperative to keep in mind the body surface area being treated and to dispense an adequate amount. Medications such as triamcinolone ointment come in 454 g jars when a large surface area needs to be covered. The body surface area of a 3–6-month-old patient is roughly equivalent to 4–5 g of the medication, and that of an adult is roughly 20–30 g. Dosing can also be carried out using fingertip units, where two fingertip units equal 1 g. One fingertip unit is enough to cover two adult hands and fingers. Another approach to treatment with topical steroids is the 'soak and smear' technique. This consists of soaking in a bath with plain water for 10–20 min at night, then immediately upon exiting smearing on the topical steroid, usually triamcinolone 0.1% ointment, without drying. In a study of 28 adults with severe chronic recalcitrant dermatitis, 15 of whom had atopic dermatitis, 17 showed complete response, and nine patients showed 90–100% improvement with the soak and smear method. Most improvements occurred in several days to 2 weeks.[20] Antihistamines can also be employed, although no randomized trials have demonstrated efficacy. Hydroxyzine, diphenhydramine, cyproheptadine and doxepin have all been used. Lesions can become impetiginized, for which oral antibiotics can be prescribed. For reduction of Staphylococus aureus overgrowth or colonization, topical application of mupirocin twice a day for 7 days per month to the nares, navel and nails can be carried out in conjunction with bleach baths consisting of 4 ounces of bleach per 25 gallons (tubful) of water, or approximately 2 teaspoons per gallon of water, 2–3 times per week.[21]

When topical corticosteroids are ineffective, there are adverse side effects noted, or the locations affected are not suitable for corticosteroids, such as the intertriginous areas or eyelids, topical calcineurin inhibitors can be started. Topical tacrolimus and pimecrolimus are thought to work by affecting CD4+ lymphocytes and inhibiting transcription of IL-2, IL-3, IL-4, IL-5, GM-CSF, TNF-a and IFN-g, although they are not recommended for children less than 2 years of age and have a black-box warning.


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