When a patient fails to respond to treatment for atopic dermatitis, it is important to consider whether nonadherence might be responsible, according to Dr. Lawrence F. Eichenfield.
Dr. Eichenfield, professor of pediatrics and dermatology at the University of California, San Diego, cited a study that found a low level of adherence in children whose use of twice daily triamcinolone ointment was monitored covertly for 8 weeks. Of 26 children who completed the study, the mean rate of adherence was only 32% (J. Am. Acad. Dermatol. 2007;56:211-6).
Dr. Lawrence F. Eichenfield
But the study offered at least one glimmer of hope on improving adherence. Among the children in the study, adherence was substantially higher on or near office-visit days, but rapidly dropped off. Given this finding, more frequent office visits appear to be indicated, Dr. Eichenfield reported at a seminar on women's and pediatric dermatology sponsored by Skin Disease Education Foundation.
Results of other studies suggest that physicians treating atopy should prescribe the simplest possible intervention. They should attend to the psychological and educational needs of patients and their parents. And they should keep therapies short, he said.
He put these lessons into practice when he established the Eczema Center at Rady Children's Hospital in San Diego. Among the most important features of the center is an intensive education component for patients and their families, which Dr. Eichenfield calls "atopic dermatitis school." It is led by a nurse with extensive training and experience in the disorder.
Dr. Eichenfield described the case of a 2-year-old child who had severe inflammatory eczema involving 60%-70% of body surface area with a secondary bacterial infection. The parents were using very small quantities of topical corticosteroids because of fear of possible side effects, and they could not recall the last time their child’s skin had been clear.
Dr. Eichenfield prescribed aggressive topical corticosteroid therapy with wet wraps and a standard course of antibiotics. In atopy school, the family learned not to fear using an appropriate quantity of mid-strength topical corticosteroid. In 2-3 weeks, the child was 90%-95% better and "was easily transitioned to a maintenance regimen of only intermittent prescriptive medicines with excellent disease control over the next 4 months," he said in an interview.
"The intervention wasn't different than what we did before the Eczema Center was established," Dr. Eichenfield added, "But having the dedicated nurse to explain how to do the wet wrap therapy, and providing the opportunity for the parents to explore their questions and concerns about safety with other families in the atopic dermatitis school, made them feel comfortable taking on a regimen that was very effective in treating the disease with a minimum of stronger medicine."
The Eczema Center's Web site includes printable handouts for families and a "Virtual Curriculum," which includes videos on the main topics covered in atopic dermatitis school
Disclosures: Dr. Eichenfield diisclosed serving as a clinical investigator and past consultant for Astellas, Galderma, Johnson & Johnson, Promius, and Stiefel/GSK. He said that neither he nor his family has any equity interest in these companies and no ongoing consultancy relationship, and that the companies had no influence on the content of any of his educational activities.
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