2018-19 TOW #24: Atopic dermatitis

With all of this cold, dry sunny weather we’re having, it’s the season for dry skin and flares of atopic dermatitis. (Indeed, one of my daughters is constantly complaining of dry lips right now, and we are trying to forestall lip lickers’ dermatitis, to which she is prone!) This is a great time to review some tools of the trade and recent data.

Key points to review:

  1. Epidemiology: Atopic dermatitis (AD) is one of the most common skin disorders in young children, with a prevalence of 10% to 20% in the first decade of life. It is a chronic illness with multiple etiologies and requires multifaceted treatments. Almost half of children with AD develop it before 1 year of age, and the majority by age 5.
  2. Pathophysiology: Defects in the epidermal barrier function and cutaneous inflammation are 2 hallmarks of AD, which is why we target therapy with emollient barrier agents and anti-inflammatory treatments. Both skin with lesions and without have shown defects in transepidermal water loss, even measured at 2 days of age. Mutations in filaggrin, an important protein in skin barrier function, are predictive of multiple forms of atopy, including atopic dermatitis, food allergies, and asthma.
  3. Topical corticosteroids are the mainstay of therapy for inflammatory skin diseases like AD. They reduce inflammation in the skin by causing vasoconstriction and preventing inflammatory cells from entering the affected area, so they also have an anti-pruritic effect. Potency is actually determined by how much vasoconstriction they cause. For children with rapid flares, a recommendation is short-term bursts of mid- to high-potency topical steroids, typically applied twice daily for 7 to 10 days, then tapering to lower potency daily, then to intermittent application, 2-3 times per week.
  4. Regular use of emollients to prevent drying of the skin is also important in managing AD. Patients should use a dye-free, fragrance-free moisturizer and apply it at least twice per day and after bathing. In practice (and personal experience with my kids), my go-to has been petroleum jelly / white petrolatum (Vaseline). It’s effective, does not sting like other creams/lotions can, and is affordable.
  5. Prevention of AD – yes it’s possible! Data from 2 RCTs, one in the US/UK and one in Japan, has shown that applying moisturizers daily for infants from birth to 6 months can forestall development of eczema among infants who have at least one family member with AD. In a cost analysis, the most cost effective emollient was petrolatum (i.e., Vaseline/petroleum jelly). In the lay press, NYT highlighted these AD prevention studies.
  6. Side effects of topical steroids and calcineurin inhibitor options: Steroid side effects are most problematic when applied to skin without inflammation. Steroids should be applied to affected skin until 3 days after resolution. For those with more severe AD, treatment may continue weekly (or more often) to prevent flares symptoms. Use lower potency especially in the face and groin area where the skin is thinner / more susceptible to damage. Topical calcineurin inhibitors provide another treatment option. They are considered second line therapy for short term and noncontinuous chronic treatment, with improving evidence for safety since the 2006 FDA black box warning.

TOW #16: Acne

One of the great things about general pediatrics is seeing patients of all ages, from newborns to adolescents, often back-to-back in clinic. We covered newborn concerns last week, so this week we’ll review a topic near and dear to adolescents: acne!

Acne is a near ubiquitous experience of adolescence, and one of the more distressing aspects to teens. We are poised to be frontline helping them deal with it. Materials for this week:

Take-home points for this week on acne:

  1. Epidemiology: Acne is the most common skin disorder in the United States, affecting approximately 85% of young people between 12 and 24 years of age. Adolescent acne usually begins with puberty onset, occurring earlier in girls than boys. Most people outgrow it, but 12% of women and 3% of men continue to have clinical acne at 44 years of age.
  2. Pathogenesis: Acne is chronic inflammation of the pilosebaceous unit, which consists of a hair, its associated sebaceous gland, and the opening to the skin surface known as the follicular ostium (“pore”). These are concentrated on the face, back and chest, where acne mostly occurs. Four interrelated processes contribute to acne development: 1) abnormal keratinization obstructing the follicle, 2) androgen stimulation and increased sebum production, 3) secondary inflammation, and 4) proliferation of bacteria. Genetics and environment influence these processes.
  3. Misconceptions of acne causes: For many years, avoiding foods such as chocolate, soft drinks, milk, fatty foods, and ice cream was recommended; however, the literature does not support these restrictions to decrease acne (though warranted for obesity). Dirt or poor hygiene do not cause acne, so frequent face washing does not improve acne and may worsen it through irritation.
  4. Knowing the acne severity grading can help with determining appropriate treatment strategies.
Acne severity grading
Grading
Lesion Type
Distribution
Scarring
Mild
Few to several comedones, few scattered papules
Less than 1/4 of the face, mostly T zone
None
Moderate
Many papules and pustules, variable comedones, 1-2 nodules
Roughly 1/2 face
Few, shallow
Severe
Numerous papules and pustules and nodules; variable comedones; sinus tracts and/or cysts
Face, back, and/or
chest
Moderate to extensive, hypertrophic and/or deep

 

  1. Treatment: Topical agents treat the different causes: retinoids treat keratinization, benzoyl peroxide treats secondary inflammation and bacteria, and topical antibiotics treat bacteria. Topical agents are first line for mild and moderate, while oral agents (antibiotics, oral tretinoin – Accutane, oral contraceptives) are used for severe cases. For mild acne, we often start with a single agent – either a retinoid or benzoyl peroxide (note benzoyl peroxide 5% has been found as good as 10% with less side effects). For mild to moderate, combine agents that address different pathways (retinoid + BP or topical antibiotic). Anticipatory guidance is critical to adherence: topical medications are preventive and require 8 to 12 weeks to assess efficacy. The entire area affected must be treated, not just current lesions, and long-term therapy usually is required. Clinical tip: recently most insurance plans are covering the combination product OTC Differin gel 0.1% instead of tretinoin (Retin-A). Our pharmacists report this product to be similarly effective and better tolerated than tretinoin. Notes on how to order this in Epic.

TOW #28: Atopic dermatitis

With all of the cold, dry sunny weather we have had, it's the season for dry skin and flares of atopic dermatitis. (Currently we are treating lip lickers’ dermatitis for my 5 yr old, so I can relate!) This is a great time to review some tools of the trade and recent data.

Key points to review:

  1. Epidemiology: Atopic dermatitis (AD) is one of the most common skin disorders in young children, with a prevalence of 10% to 20% in the first decade of life. It is a chronic illness with multiple etiologies and requires multifaceted treatments.
  2. Pathophysiology: Defects in the epidermal barrier function and cutaneous inflammation are 2 hallmarks of AD, which is why we target therapy with barrier agents and antiinflammatory treatments.
  3. Topical corticosteroids are the mainstay of therapy for inflammatory skin diseases like AD. They reduce inflammation in the skin by causing vasoconstriction and preventing inflammatory cells from entering the affected area, so they also have an anti-pruritic effect. Potency is actually determined by how much vasoconstriction they cause. For children with rapid flares, a recommendation is short-term bursts of mid- to high-potency topical steroids, typically applied twice daily for 7 to 10 days, then tapering to lower potency daily, then to intermittent application, 2-3 times per week.
  4. Regular use of emollients to prevent drying of the skin is also important in managing AD. Patients should use a dye-free, fragrance-free moisturizer and apply it at least twice per day and after bathing. In practice (and personal experience with my kids), my go-to has been petroleum jelly / white petrolatum (Vaseline). It's effective, does not sting like other creams/lotions can, and is affordable. I was intrigued with recent data showing that applying moisturizers regularly for infants could forestall development of eczema. Most cost effective was petroleum jelly.
  5. Side effects of topical steroids: Steroid side effects are most problematic when applied to skin without inflammation-apply steroids to affected skin that it is red or inflamed, typically not more than 2 weeks at a time (however, in clinical practice, this may be adjusted for those with more severe AD, or another option may be switching to topical calcineurin inhibitors). Use lower potency especially in the face and groin area where the skin is thinner / more susceptible to damage.

TOW #43: Acne

So, this week, it’s time to talk about zits! Acne is a near ubiquitous experience of adolescence, and one of the more distressing aspects to teens. We are poised to really be in the frontline for helping teens dealing with acne and it’s important for us to really know causes and treatment. Materials for this week:

Take-home points for this week on acne:

  1. Epidemiology: Acne is the most common skin disorder in the United States, affecting approximately 85% of young people between 12 and 24 years of age. Adolescent acne usually begins with puberty onset, occurring earlier in girls than boys. Most people outgrow it, but 12% of women and 3% of men continue to have clinical acne until 44 years of age.
  2. Pathogenesis: Acne is chronic inflammation of the pilosebaceous unit, which consists of a hair, its associated sebaceous gland, and the opening to the skin surface known as the follicular ostium ("pore"). These are concentrated on the face, back and chest, where acne mostly occurs. Four interrelated processes contribute to acne development: 1) abnormal keratinization with obstruction of the follicle, 2) androgen stimulation and increased sebum production, 3) secondary inflammation, and 4) proliferation of bacteria. Genetics and environment influence these processes.
  3. Misconceptions of acne causes: For many years, avoiding foods such as chocolate, soft drinks, milk, fatty foods, and ice cream was recommended; however, the literature does not support these restrictions to decrease acne (though warranted for obesity). Dirt or poor hygiene do not cause acne, so frequent face washing does not improve acne and may worsen it through irritation.
  4. Knowing the acne severity grading can help with determining appropriate treatment strategies.

Acne severity grading

Grading
Lesion Type
Distribution
Scarring
Mild
Few to several comedones, few scattered papules
Less than 1/4 of the face, mostly T zone
None
Moderate
Many papules and pustules, variable comedones, 1-2 nodules 
Roughly 1/2 face
Few, shallow
Severe
Numerous papules and pustules and nodules; variable comedones; sinus tracts and/or cysts
Face, back, and/or
chest
Moderate to extensive, hypertrophic and/or deep

 

  1. Treatment: Topical agents treat the different causes: retinoids treat keratinization, benzoyl peroxide treats secondary inflammation and bacteria, and topical antibiotics also treat bacteria. Topical agents are first line for mild and moderate, while oral agents (antibiotics, oral tretinoin – Accutane, oral contraceptives) are used for severe. For mild acne, we often start with a single agent – either a retinoid or benzoyl peroxide (5% has been found as good as 10% with less side effects). For mild to moderate, combine agents that address different pathways (retinoid + BP or topical antibiotic). Anticipatory guidance is critical to adherence: topical medications are preventive and require 8 to 12 weeks to assess efficacy. The entire area affected must be treated, not just current lesions, and long-term therapy usually is required.