LA JOLLA, CALIF. How has your sleep been? When's the last time your skin was totally clear? Those are the two questions Dr. Lawrence F. Eichenfield asks his atopic dermatitis patients.
"It's amazing how families don't tell you about sleep disturbance unless you ask," he said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "At least 20% of families say they've lost sleep because of their child's scratching. … I view sleep disturbance as a marker for out-of-control disease."
Another way to gauge the severity of disease is to ask patients or their parents when the last time the patient's skin was totally clear as well as asking how the skin has been over time, so that you can assess the skin between office visits.
He also makes it a point to ask about the quantity and use of topical corticosteroids and other medications. "I want to know if they're using 30 g, 50 g, or even 90 g of medication a month so I can let them know whether I'm worried about the quantity of use or not," said Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children's Hospital and the University of California, San Diego.
The first phase of treating atopic dermatitis is what he termed "induction therapy," or getting the disease under control. He recommends a course of topical corticosteroids for 13 weeks, "depending on how bad it is" as a first line of treatment. Three products have received Food and Drug Administration approval for use in patients as young as 3 months of age: desonide nonethanolic foam (Verdeso, Stiefel Laboratories Inc.), desonide aqueous gel (Desonate, SkinMedica Inc.), and fluocinolone acetonide oil (Derma-Smoothe, Hill Dermaceuticals Inc.).
"Generally, we use 'strength as needed' to get the disease under control," said Dr. Eichenfield, who was involved in clinical studies of the topical agents but has no financial interest in their manufacturers.
Another option is generic topical corticosteroids. "It's nice that I can send my patients to Wal-Mart or Target and for $4 they can get 80 g of triamcinolone 0.1% ointment," he commented.
Using wet wrapsan intensive therapy applying steroids under hydrated gauze wraps, covered by dry wrapsfor 34 days yields the same results as using topical corticosteroids for 23 weeks, he said.
Dr. Eichenfield uses topical calcineurin inhibitors (TCIs) as second-line agents in patients with persistent or frequently recurrent atopic dermatitis. He noted that use of TCIs has dropped about 50% since the FDA issued a black box warning in 2005 concerning the potential for oncogenesis.
"There have been no further data confirming any true risk associated with the use of these medicines topically," he noted. "There have been multiple negative studies showing generally very low blood levels of these topical agents when used appropriately."
The second phase in treating atopic dermatitis is maintenance therapy. With severe cases, Dr. Eichenfield prefers clearly defined regimens; in some patients this may be intermittent topical corticosteroids, in others TCIs intermittently or daily, and in some a mixture of corticosteroids, TCIs, and nonsteroidal barrier creams.
The last phase in treatment is "stepped maintenance," in which the agent or agents are decreased as tolerated. "That is the time to step backward in frequency of application of medications," he advised. "A slow withdrawal of medications allows you to titrate how little is needed to keep the skin in good shape, the patient not itchy, and the family sleeping through the night."
Dr. Eichenfield disclosed that he has been a clinical investigator in trials conducted by Amgen Inc., Astellas Pharma Inc., Ferndale Laboratories Inc., Galderma Laboratories, Graceway Pharmaceuticals, Hill Dermaceuticals Inc., Johnson & Johnson, Novartis Pharmaceuticals Corp., and Medicis Pharmaceutical Corp. He stated that he has no relevant financial interest in any of the companies.
'I want to knowif they're using30 g, 50 g, or even 90 g of medication a month.' DR. EICHENFIELD