Infants with severe atopic dermatitis require team approach

Key Points

Farmington, Conn. - The unique needs of infants with severe atopic dermatitis require special attention. As such, says Mary Wu Chang, M.D., associate clinical professor of dermatology and pediatrics, University of Connecticut School of Medicine, "This is not something you can handle in a 15-minute visit."

Children between 1 month and 1 year of age suffer significantly from AD, she says. They typically experience the same itching, sleep disturbance and frustration that older children do, though these factors are under-recognized. Such problems lead to decreased quality of life for the child and his or her family.

What's more, Dr. Chang says a recent study has linked severe AD in early childhood with psychological issues in later childhood (Schmitt J, Chen CM, Apfelbacher C, et al. Allergy. 2011;66(3):404-411). "It's very controversial," she says, "but some postulate that there's a link between AD and attention deficit/hyperactivity disorder (ADHD), for example. However, it's not clear if these problems stem from the chronic sleep disturbance or other issues caused by AD."

Other barriers include the ongoing shortage of pediatric dermatologists and pediatric allergists, as well as the high cost of some treatments and products used for patients with severe AD, she says.

Underlying conditions ID'd

When a red, scaly baby presents, Dr. Chang says, early biopsy can help confirm the presence or absence of underlying conditions such as psoriasis (Leclerc-Mercier S, Bodemer C, Bourdon-Lanoy E, et al. J Cutan Pathol. 2010;37(2):249-255).

In one study involving 51 children with neonatal or pediatric erythroderma, biopsy identified underlying causes - including immunodeficiency, ichthyosis, Netherton syndrome and eczematous or papulosquamous dermatitis - in 45 percent of cases (Pruszkowski A, Bodemer C, Fraitag S, et al. Arch Dermatol. 2000;136(7):875-880). The same study showed a mortality rate of 16 percent in infants with underlying immunodeficiency.

A later study showed that atopic erythroderma typically appears after 1 month of age, not at birth, and that severe erythroderma usually suggests the presence of immunodeficiency or Netherton syndrome (Fraitag S, Bodemer C. Curr Opin Pediatr. 2010;22(4):438-444).

Diagnosis, management

Dr. Chang says her approach to infants with severe AD begins with a thorough patient history and physical exam. The latter includes checking body folds, uncurling fingers and examining the diaper area and diaper contents.

Managing babies with severe AD requires a team that can include a pediatrician, a pediatric immunologist or allergist, a geneticist, a dermatologist, plus parents and a medical professional such as a resident physician, nurse or specifically trained medical assistant, according to Dr. Chang.

"Parents need a lot of support - both moral support and answers to any questions they may have," she says. To meet parents' needs, she recommends designating one such person as their point of contact within a dermatology practice.

To manage the broader team of physicians and other healthcare providers, however, "The dermatologist needs to be the captain, to watch over and organize the team," Dr. Chang says. "We can't just ship children off to an allergist or other specialists and assume they can manage these complex cases."

Treatment for severe AD in infants includes gentle bathing with minimal cleansers, along with minimizing extraneous irritants, allergens and skin treatments, Dr. Chang says. Some products contain "hidden" allergens that one might not expect - such as almond oil in Cetaphil (Galderma), she says.

Safer options include plain petroleum jelly or Vanicream (Pharmaceutical Specialties), according to Dr. Chang. Additionally, she recommends identifying and treating any bacterial, yeast or fungal infections that patients may have.

Some infants will have milk and/or soy allergy or other food intolerance; an allergist may be needed to help determine this.

"Always ask about spit ups, vomiting, diarrhea, gas and abnormal stools. Poor weight gain can also be a clue," Dr. Chang says.

Nursing mothers will need advice regarding their diet, and ongoing monitoring of their baby's response. For formula-fed babies, Dr. Chang, says hypoallergenic formulas include Similac Expert Care Alimentum (Abbott) or Enfamil Nutramigen (Mead Johnson Nutrition). These products are extensively hydrolyzed, which means that their protein chains have been broken down into shorter, easier-to-digest proteins. However, these products can cost up to $30 per can. Some infants will require elemental formulas such as Neocate (Nutricia) and EleCare (Abbott), which are further broken down and even more costly, she says.