March/April 2019 - Faces of Dermatology

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Advances in Dermatology Managing Pediatric Atopic Dermatitis (Continued from page 21)

used for hands, wrists or ankles. Physicians should reassure families that wearing the damp clothes will not lead to a respiratory illness in the winter. Pruritus, the Itch that Rashes

Scratching and rubbing damage the skin barrier. Fortunately, repairing the barrier dramatically improves the itch, which is often the most difficult symptom to treat. Parents should keep their child’s nails trimmed short, cover their hands at night with socks or gloves, and dress them in long sleeves or pants while focusing on skin directed therapy. If itch is disturbing sleep, physicians can prescribe sedating antihistamines for bedtime to decrease overnight scratching. While antihistamines do not treat the itch, they are useful in assisting in less disturbed sleep for a week or two while skin heals. For daytime, non-sedating antihistamines can be utilized for children with allergic rhinitis or other triggers, but do not work for AD itch, as the itch is not directly histamine driven.8 Bleach Baths

Bleach baths are now widely recommended for pediatric AD treatment.10 A common recipe is approximately ¼-⅓ cup of regular household bleach to a standard bathtub filled to drainage holes, which is about 40 gallons of water. Regular household bleach recently increased in concentration from 6% to 8.25% so many older recipes recommended ½ cup. This level of diluted bleach is safe for brief contact with eyes and mouths, and can be likened to a chlorinated swimming pool. However, to reduce any risk of harm, remind parents to never apply bleach directly to the child’s skin because it can cause a chemical burn.9 Treating Infection and Other Triggers

Infection can be a trigger for flares of AD. But prescribing oral antibiotics for every flare is not consistent with pediatric principles of antibiotic stewardship or the American Board of Internal Medicine or American Academy of Dermatology “Choosing Wisely” campaigns.11 22

March/April 2019

If a flare occurs, the patient should start skin directed therapy that includes wet wraps. But, if there are still small open areas after 48 hours or if the patient is not improving, they may require treatment with oral antibiotics. Cephalexin is a frequently utilized antibiotic as it has adequate coverage of gram positive bacteria, specifically Methicillin-sensitive Staphylococcus aureus (MSSA) and Streptococcus. Even in patients with a history of Methicillin-resistant Staphylococcus aureus (MRSA), MSSA is still often the culprit with AD flares, so cultures should be taken at initiation of skin directed therapy. These cultures can help guide appropriate oral antibiotic therapy. Other common triggers include change of seasons, new more humid or dry environment, stress, airborne allergens, fragrances, and skin infections. Of note, AD is rarely directly related to food allergy. An expert panel sponsored by the National Institute of Allergy and Infectious Diseases, one of the National Institutes of Health, recommends testing only for milk, egg, peanut, wheat and soy allergy in children under 5 years of age with moderate to severe AD, only if the child has persistent AD in spite of optimized management and topical therapy; or if the patient has a reliable history of an immediate reaction after ingestion of a specific food. The panel specifically recommended against avoiding potential allergenic foods as a means of controlling AD.12 If certain foods appear to exacerbate a child’s dermatitis, refer them to an allergist for appropriate testing. Education

There is not a single cause and there is not a known cure for this chronic disease. It is important to educate caregivers and patients on this point. In addition, treatments may need to be adjusted over time and so follow-up visits over time are helpful. There continues to be promising advances in AD therapy, like crisaborale, which is a new non-steroid topical, and dupilumab, which is a new biologic. However, such medications are typically not required to manage mild to moderate AD in children. The approaches listed in

this article, “soak and seal,” bleach baths and wet wraps are simple, affordable and effective tools that all physicians can confidently share with their patients. Dr. Sarah Asch is a Pediatric Dermatologist who is triple board certified in Pediatrics, Dermatology and Pediatric Dermatology. She is accepting new patients at HealthPartners and Park Nicollet Medical Groups, where she practices full-time Pediatric Dermatology. References: 1. Wolter S, Price HN. Atopic Dermatitis. Pediatr Clin North Am. 2014 Apr;61(2):241–60. 2. Kvenshagen, B., Jacobsen, M. & Halvorsen, R. Atopic dermatitis in premature and term children. Arch. Dis. Child. 94, 202–205 (2009). 3. Margolis, J. S., Abuabara, K., Bilker, W., Hoffstad, O. & Margolis, D. J. Persistence of mild to moderate atopic dermatitis. JAMA Dermatol. 150, 593–600 (2014). 4. Silverberg, J. I. & Hanifin, J. M. Adult eczema prevalence and associations with asthma and other health and demographic factors: A US population–based study. J. Allergy Clin. Immunol. 132, 1132–1138 (2013). 5. Ng SY, Begum S, Chong SY. Pediatr Dermatol. Does Order of Application of Emollient and Topical Corticosteroids Make a Difference in the Severity of Atopic Eczema in Children? 2016 Mar-Apr;33(2):160-4. 6. Eichenfield LF, Boguniewicz M, Simpson EL, Russell JJ, Block JK, Feldman SR, et al. Translating Atopic Dermatitis Management Guidelines Into Practice for Primary Care Providers. Pediatrics. 2015 Sep;136(3):554-65. 7. Dabade TS, Davis DMR, Wetter DA, Hand JL, McEvoy MT, Pittelkow MR, et al. Wet dressing therapy in conjunction with topical corticosteroids is effective for rapid control of severe pediatric atopic dermatitis: Experience with 218 patients over 30 years at Mayo Clinic. J Am Acad Dermatol. 2012 Jul;67(1):100–6. 8. Sidbury R, Davis DM, Cohen DE, Cordoro KM, Berger TG, Bergman JN, et al. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014 Aug;71(2):327–49. 9. Lang C, Cox M. Pediatric cutaneous bleach burns. Child Abuse Negl. 2013 Jul;37(7):485–8. 10. Sidbury R, Tom WL, Bergman JN, Cooper KD, Silverman RA, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: Section 4. Prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol. 2014 Dec;71(6):1218–33. 11. Coldiron, B. M. & Fischoff, R. M. American Academy of Dermatology Choosing Wisely List: Helping dermatologists and their patients make smart decisions about their care and treatment. J. Am. Acad. Dermatol. 69, 1002 (2013). 12. Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel. J Allergy Clin Immunol. 126(6):S1–58.


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