Photo by Emily Innes-Leroux/The Chronicle
Early treatment of atopic dermatitis (AD) reduces the flaring frequency and intensity of this condition regardless of a patient’s skin colour, said Dr. Leon H. Kircik, during a presentation at the Skin Spectrum Summit in Montreal on May 14, 2016.
Awareness of the triggers of AD is an important part of treatment and prevention, said Dr. Kircik, who spoke about strategies for managing AD in young patients with skin of colour.
Weather is one trigger of AD, and ethnicity can make a difference in terms of how this environmental factor impacts the skin, said Dr. Kircik, clinical associate professor of dermatology at Indiana University School of Medicine and Mount Sinai Medical Center in Louisville, Ky.
“In the case of Caucasian people, cold weather makes the skin of these patients dry and [the condition] worse. It is different for African Americans—their skin tends to get worse in the summer, because sweating make these patients worse,” he said.
The primary treatments for AD are still topical corticosteroids, said Dr. Kircik. “Topical corticosteroids are safe to use as along as we know how to us them and we use them carefully.”
“The second-line treatments for AD are topical immunomodulators,” he said. Oral treatments such as systemic immunotherapy may be beneficial in severe cases of AD.
Skin discolouration, AD
There is some concern about the use of topical corticosteroids causing skin discolouration in skin of colour patients, but that it is rarely the case, noted Dr. Kircik.
“Skin discolouration is much more likely to result from AD itself, because skin inflammation can increase or decrease the amount of pigment in the skin,” he said, adding that skin discolouration resulting from AD will resolve over time, but may take several months.
Another concern regarding the use of topical corticosteroid therapy is steroid phobia among parents or caregivers who have a child with AD, said Dr. Kircik.
“Steroid phobia is a real problem. Sometimes parents say ‘I do not want my kid on steroids,’ and if that is the reason for the fear then you have to sit the parent down and explain to them that the topical steroid is not going to be [ingested]. It is also a good idea to mention that a topical corticosteroid is not testosterone, it is an anti-inflammatory,” he said.
“Alleviating the steroid phobia is important because, for example, if the mother is afraid to put the topical corticosteroid on the kid’s skin then they are not going to use it and it is, therefore, not going to work.”
Topical corticosteroid may inhibit lipid senses
An additional problem of topical corticosteroid is that it may inhibit lipid senses. “When this happens you end up making the patient’s AD worse by disrupting the epidermal barrier,” said Dr. Kircik.
“So, when you treat these patients you have to be mindful of potentially disrupting the epidermal barrier and treat accordingly.”
Use of topical calcineurin inhibitors can be steroid-sparing
The use of pimecrolimus cream and a moisturizer may help reduce the need for topical corticosteroids, said Dr. Kircik, who recommended the following regimen for AD treatment:
Use topical corticosteroids when there is an AD flare;
When the flare is almost clear use pimecrolimus cream;
When AD is clear use a moisturizer such as Cerave;
When the AD symptom starts to flare, use pimecrolimus cream again.
Pimecrolimus 1% cream safe, efficacious
“There is a concern about the use of topical calcineurin inhibitors because there is a black box warning. It should not be used on children younger than two years of age and we have to be cognisant of that,” he said.
He noted that a five-year study published in Pediatrics (Apr. 2015; volume 4 (1)) found that the long term management of mild-to-moderate AD in infants with pimecrolimus 1% cream or topical corticosteroids was safe without any effect on the immune system.
This open-label study involved 2,418 infants who were randomized to pimecrolimus 1% cream (n=1,205; with short-term topical corticosteroids for disease flares) or topical corticosteroids (n=1,213).
Findings revealed that both pimecrolimus 1% cream and topical corticosteroids had a rapid onset of action with >50% of patients achieving treatment success by week 3. After five years, >85% and 95% of patients in each group achieved overall and facial treatment success, respectively.
Data also showed that the pimecrolimus 1% cream group required substantially fewer steroid days than the topical corticosteroids group (seven vs. 178).
“So, pimecrolimus 1% cream has a steroid-sparing effect and the researchers were able to show that it is safe to use on an as needed basis,” said Dr. Kircik.