Recalcitrant AD in children

San Francisco

- Most patients with atopic dermatitis (AD) will respond to conventional therapies, such as basic skincare and avoidance of prevocational factors; topical corticosteroids and calcineurin inhibitors; antibiotics for infection and oral antihistamines.

However, the problem is finding effective treatment for those who do not respond to or do not stay controlled by conventional approaches, says Seth J. Orlow, M.D., Ph.D., professor and chairman of the department of dermatology at New York University Medical Center, New York.

Antimibcrobial therapy plays a limited role in AD management in select patients, Dr. Orlow says.

There are many systemic immunomodulatory therapy choices available for treating recalcitrant AD, but there is much room for improvement, he says.

According to Dr. Orlow, treatment of recalcitrant AD should always include plans for long-term control rather than merely "crisis management."

"Get them under control," Dr. Orlow says, "then get them better."

Staphyloccocus aureus is highly prevalent in atopic dermatitis, and colonization of bacteria may correlate with severity of the disease. Further, S. aureus makes a toxin that can directly stimulate T cells and lead to inflammation.

To reduce colonization, mupirocin may be added to topical steroids. Mucipirocin may be effective in some patients, although it is "grossly overused," Dr. Orlow says.

Clinical study

In a multicenter double-blinded study trial of hydrocortisone butyrate ointment plus mucerin or vehicle, bacteria were isolatede from 70 to 75 percent of lesions versus 33 to 35 percent of non-lesional skin. The only difference between experimental and control groups was seen in severe cases at day 7. There was no difference seen in mild-to-moderate cases or by days 14 and 28 (Gong, Br J Dermatol 2006, 155:680-687).

Oral corticosteroids

Oral corticosteroids are recognized as generally effective, although there have been few clinical trials, Dr. Orlow says.

In one study, oral beclomethasone stabilized disease in 10 out of 14 patients, and 70 percent had decreased linear growth by four weeks [Aylett et al Acta Derm Venerol Suppl (1992) 176:123.]

Oral beclomethasone is an effective short-term "crisis management" approach, but is associated with recurrence of AD.

IV therapy

Clinicians should consider pulsed intravenous corticosteroids, such as prednisone 2 mg/kg per day, for children with severe AD. Although such treatments are generally effective, severe adverse events are possible.Cyclosporin A is an effective choice for achieving control of severe pediatric AD. Begin with 5 mg/kg per day, then taper the dose by 100 mg every other week, Dr. Orlow says.

Side effects include immune suppression, hypertension, hypertrichosis, gingival hypertrophy and others.

There are case reports of efficacy with tacrolimus, Dr. Orlow says. However, the side effect profile is similar to cyclosporine A.

Whatever the treatment plan, Dr. Orlow says, it should include plans for long-term control of this chronic disease. DT