Atopic dermatitis advances multifacted

New York - Treating pediatric atopic dermatitis (AD) effectively can involve both newer treatments, such as calcineurin inhibitors and TNF agonists, as well as new twists on existing treatments, according to Lisa A. Beck, M.D.

"Patients perceive existing AD treatments as inadequate," says Dr. Beck, associate professor of dermatology and medicine at Johns Hopkins Asthma and Allergy Center, Baltimore, Md.

Treatments, effects

Dr. Beck points out that side effects noted by respondents included burning and dryness (29 percent and 23 percent, respectively), while 57 percent reported that AD impacts their daily activities. The survey was sponsored by the National Eczema Association for Science and Education (NEASE).

Among existing treatments, Dr. Beck says Class III steroids are safe when used twice daily for up to four weeks in infants as young as 3 months (Friedlander SA, Herbert AA, Allen DB. J Am Acad Dermatol. 2002 Mar;46(3):387-393). Furthermore, she observes, intermittent (twice to four times weekly) steroid use can indeed prevent relapses (Hanifin J, Gupta AK, Rajagopalan R. Br J Dermatol. 2002 Sep;147(3):528-537.).

As for ceramide-containing moisturizers, she says that presently, only one, TriCeram (Osmotics Corp.), has been shown to be beneficial for patients with AD. Many other ceramide-containing moisturizers are now available, including Impruv (Stiefel Labs), Ceratopic (SkinMedica) and CeraVe (Coria Laboratories Inc.).

"Because AD patients are thought to be lacking in ceramide, which is not only important for barrier function, but probably also for fighting cutaneous infections, it is logical to consider using this group of compounds," Dr. Beck says.

Occlusion can aid in absorption of such products, as well as topical steroids, while also increasing hydration, cooling skin temperature and decreasing trauma from scratching.

Dr. Beck recommends that physicians address the likelihood of Staphylococcus aureus colonizations in AD patients.

"Because more than 90 percent of AD patients are colonized with S. aureus, and 30 percent to 50 percent of staph isolates produce toxins, one should consider antibacterial soaps such as Lever 2000, Bactroban ointment (GlaxoSmithKline) and perhaps bleach baths" using one-quarter cup bleach per tub of water. In more dramatic cases even prescribing oral antibiotics might be necessary, Dr. Beck says.

Improving treatment efficacy

It might also be possible to improve treatment efficacy while minimizing adverse events by using combination treatments, she says. Examples include topical immunomodulators (TIMs), namely Protopic (Astellas) or Elidel (Novartis), combined with topical steroids. Phototherapy that combines PUVA with either UVB or methotrexate is also an option.

Additionally, Dr. Beck says that instead of PUVA (wavelength 315 nm to 400 nm with S-methoxypsoralen given one to two hours before UVA phototherapy) or UVB (290 nm to 315 nm), dermatologists could substitute narrow band UVB (311 nm) or UVA1 (340 nm), both of which are used more commonly in Europe than in the United States.

"Although psoralens are not Food and Drug Administration (FDA)-approved for use in children," she adds, "most dermatologists will treat children with these drugs."

Newer therapies

Commonly used newer therapies for AD include the leukotriene antagonists Singulair (Merck) and Zyflo (Abbott), Dr. Beck says. The former antagonizes the actions of LTC4, LTD4 and LTE4; the latter, LTB4 as well.

However, Dr. Beck says, "Concerns over liver toxicity and four times daily dosing have limited the use of Zyflo, which soon will be remarketed by Critical Therapeutics and will likely be available in a twice-daily dosing frequency by 2007."

The topical calcineurin inhibitors tacrolimus and pimecrolimus, on the other hand, both inhibit T lymphocyte cell activation and the release of several cytokines.