LA JOLLA, CALIF. — How has your sleep been? When last was your skin 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 about it,” he said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. “I view sleep disturbance as a marker for out-of-control disease.”
Another way to gauge the severity of disease is to ask when the last time the patient's skin was totally clear, as well as asking how the skin has been over time.
The first phase of treating atopic dermatitis is what he termed “induction therapy.” He recommends a course of topical corticosteroids for 1–3 weeks, depending on severity, as a first line of treatment.
Three products have received Food and Drug Administration approval for use in patients aged as young as 3 months: 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 the drugs' manufacturers.
Generic topical corticosteroids, such as triamcinolone 0.1% ointment, are a “cost-effective, short-term intervention for diffuse atopic dermatitis.” Using wet wraps—an intensive therapy applying steroids under hydrated gauze wraps, covered by dry wraps—for 3–4 days yields the same results as using topical corticosteroids for 2–3 weeks.
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's 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.”
The second phase is maintenance therapy. With severe cases, clearly defined regimens are preferable; in some 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 is “stepped maintenance,” in which the agent or agents are decreased as tolerated.
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 said that he has no relevant interest in any of the companies.