SAN FRANCISCO – Treatment for severe eczema should begin with education rather than first-line agents, according to Dr. Timothy G. Berger.
Data reported within the past year from a Japanese study convinced Dr. Berger to modify his therapeutic ladder for severe eczema, he said.
He now starts with greater patient and parental education before prescribing first-line treatments and checks vitamin D levels in patients with severe eczema and frequent infection. He chooses among systemic immunomodulators based on a recent practice update. And as a last resort, for the most difficult cases, he uses omalizumab or photophoresis, he said.
Dr. Berger described his treatment ladder approach at the annual meeting of the Pacific Dermatologic Association:
• First rung: education. He used to start up the therapeutic ladder by prescribing topical steroids, moisturization, and antihistamines. Data from the Japanese study persuaded him to insert more intensive education before sending patients and parents on their way.
The study randomized the mothers of 59 children with moderate to severe atopic dermatitis to attend a 2-day parental education program about managing the disease or to receive a booklet about the disease and conventional care. Six months later, patients in the education group had "dramatically better scores" on the Scoring Atopic Dermatitis (SCORAD) tool and on measures of itching, sleeplessness, and family impact, said Dr. Berger, professor of clinical dermatology at the University of California, San Francisco.
SCORAD scores improved in the education group from 40 at baseline to 15 after treatment, compared with a change from 42 to 27 in the control group (Pediatr. Dermatol. 2013;30:438-43). Parents in the education group also reported less anxiety about steroid use. The patients ranged in age from 6 months to 6 years.
"I think that education is really critical," Dr. Berger said.
• Second rung: first-line treatments. With this foundation of education, Dr. Berger starts patients on topical steroids, moisturizers, and antihistamines.
• Third rung: checking vitamin D levels. A comparison of 95 patients with atopic dermatitis and 58 control patients in another study found that low levels of vitamin D were no more likely in one group than in the other, but frequent skin infections were more likely in the subgroup of patients with atopic dermatitis and low vitamin D levels compared with patients who had the disease and normal vitamin D levels. Vitamin D supplementation in the patients with atopic dermatitis and low vitamin D levels significantly improved SCORAD scores (J. Am. Acad. Dermatol. 2013;69:238-44).
In that study, more than 80% of patients with atopic dermatitis and levels of 25-hydroxyvitamin D below 30 ng/mL developed skin infections compared with less than 20% of patients with atopic dermatitis whose vitamin D levels were above 30 ng/mL, Dr. Berger said. That 30-ng/mL cutoff is the dividing line between normal and abnormal or "insufficient" vitamin D levels, "which I’m not so sure how to interpret," he said. In general, levels below 20 ng/mL are considered vitamin D deficiency.
Now when Dr. Berger sees a patient with atopic dermatitis and frequent infections, he checks vitamin D and looks for levels that are deficient or even close to 10 ng/mL. These patients improve on vitamin D supplementation, he said. Vitamin D is required to deliver antimicrobial peptides to the skin surface, which is the presumed mechanism by which this helps.
He recently used this strategy in a patient with refractory lupus, frequent skin infections, and low vitamin D, he said. Both her lupus and skin infections improved with vitamin D supplementation.
• Fourth, fifth, and sixth rungs. Next he prescribes soak and smear, the conventional therapy of skin hydration and smearing on of topical corticosteroids. Beyond that, phototherapy and then possibly day treatment with ultraviolet light and application of coal tar remain options on his therapeutic ladder. "Day treatment with tar and light works very well for a patient that doesn’t have bullous pemphigoid," he said.
• Seventh rung: systemic immunomodulators. Guidance for choosing among these agents comes from a recent practice update from the American Academy of Allergy, Asthma, and Immunology; the American College of Allergy, Asthma, and Immunology; and the Joint Council of Allergy, Asthma, and Immunology (J. Allergy Clin. Immunol. 2013;131:295-9).
Cyclosporine works fastest, especially if started at higher doses, the recommendations say, but "my experience is that in older patients, it’s hard to use," Dr. Berger added. Oral tacrolimus also works, according to the Dr. Berger, as well as the guidelines.
Beyond that, methotrexate and azathioprine appear to be equally effective, with approximately 80% of patients responding in 3-6 weeks. Ordering an assay to detect deficiency of the thiopurine methyltransferase enzyme helps avoid toxicity from the drug in some patients. Because one study showed that increasing the dose of methotrexate does not help if the patient fails to respond to 15 mg/wk, Dr. Berger said he tries to get to 15 mg/wk for 4-6 weeks and holds that dose if there’s a response.