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SAN DIEGO Parents of children newly diagnosed with atopic dermatitis can be riddled with angst.
Some gravitate to guilt and self-blame, figuring "we did something wrong to our child" or "it must be something we're giving him" that's causing the atopic dermatitis, Dr. Magdalene A. Dohil said at a meeting sponsored by Rady Children's Hospital.
Others believe that baths are bad for their child, and many are frightened to use topical steroids to treat the disease. "They may say things like, 'there are so many creams, we can't remember what goes on and where it goes,'" said Dr. Dohil, a pediatric dermatologist at Rady Children's Hospital, San Diego. "They want a simple and easy cure so they can control the disease."
Many parents find it hard to accept the fact that there is no treatment that completely cures atopic dermatitis. That is why she practices "extreme parent education" from the get-go.
"We have to battle myths and misperceptions," said Dr. Dohil, also of the University of California, San Diego. "We have some good safety data on atopic dermatitis treatments out there. It's just not common knowledge, and they are not that easy to explain."
Patient Resources
Web-based resources she points parents and patients to include The Eczema Center at Rady Children's Hospital (
Management of atopic dermatitis is currently based on the number, location, and intensity of lesions, persistence of disease, frequency of flares, patient age, and quality of life and emotional issues.
Dr. Dohil focused her discussion on topical corticosteroids and topical calcineurin inhibitors. "We have to stress for our patients that this is what it boils down to; this is our primary anti-inflammatory armamentarium right now," she said.
Topical Corticosteroids
Topical corticosteroids have been a mainstay of inflammatory atopic dermatitis treatment for decades. They are also used to manage acute flares and as maintenance therapy.
"We can start as low potency as needed or start high, control, and go back to low potency as needed," she said.
"This is my preference because I feel it gives you that initial trust and compliance if parents see their child getting better. It allows you to taper down and reassure parents that you are no longer at that very potent level of topical steroids," Dr. Dohil added.
The choice of topical corticosteroid is influenced by what prior agents have been used, the age of the patient, severity and localization of dermatitis, formularies, and parental steroid phobia. The anti-inflammatory effects of topical corticosteroids come at a price, Dr. Dohil said, including the potential for skin atrophy, telangiectasia, acne, perioral dermatitis, as well as hypothalamic-pituitary-adrenal axis suppression.
"This really scares parents. We need to take this parent fear factor into account at every step along the way because if you don't, you set yourself up for noncompliance. The eczema's not going to get better. The parents will get confused, and there is so much input from non-health professionals, such as 'this worked for my child. Why don't you try this?' and so on," she said.
Previous research has demonstrated that the anti-inflammatory effects of topical corticosteroids stem from a pathway of transrepression, while its side effects stem from a pathway of transactivation.
"Current research is focusing on trying to separate these two pathways," Dr. Dohil said.
"In the meantime we have great data down to 3 months of age that give us a sense of how safe they are, [and] how long we can use these agents. Most of these studies have run over a period of 4 weeks. I think it's important to share this information with parents, to help them feel comfortable about the treatment," she said.
Topical Calcineurin Inhibitors
The topical calcineurin inhibitors, tacrolimus ointment (Protopic) and pimecrolimus cream (Elidel), are popular second-line treatment options for treatment of moderate to severe disease.
According to labeling information, these agents are indicated in nonimmunocompromised adults and children 2 years of age and older, who have failed to respond adequately to other topical prescription treatments, or when those treatments are not advisable.
After a Food and Drug Administration black box warning was issued in January 2006 related to concerns about skin malignancies and lymphoma from the use of topical calcineurin inhibitors, several case-control studies, long-term registries, ongoing clinical studies, and data safety monitoring boards were launched to continue to assess their safety.
A 10-year study, A Prospective Pediatric Longitudinal Evaluation Study, will examine 8,000 pediatric subjects treated for at least 6 weeks.
Another 10-year trial, The Pediatric Eczema Elective Registry, is an observational parent-report registry designed to assess the risk of malignancies in 5,000 children aged 217 years who were treated with pimecrolimus for at least 6 weeks.
One recent study found that the patients with severe atopic dermatitis were 2.4 times more likely to develop lymphoma, compared with controls. However, use of pimecrolimus and tacrolimus conferred a protective effect, with odds ratios of 0.8 each (J. Invest. Dermatol. 2007;127:80816).
A separate case-control study of patients with inflammatory dermatitis found that those who used pimecrolimus and tacrolimus had almost a 50% reduction in the risk of developing nonmelanoma skin cancer (Dermatology 2007;214:28995).
The odds ratio of association for nonmelanoma skin cancer decreased as the number of tubes used and the potency of the agent increased. "There was no clear explanation for this," Dr. Dohil said. "There's still a lot of discussion going on."
She added that studies of the blood levels of topical calcineurin inhibitors indicate that they "appear to be negligible when used appropriately."
In clinical practice these agents are commonly used for the face and genital area and for other so-called hot spots with high risk of atrophy.
They are often used in patients with concerns about steroids due to quantity of use in delicate locations, need for constant or near constant therapy, or in those with an adverse event history such as striae or systemic effects.
"Many people feel that topical calcineurin inhibitors can help patients experience a longer flare-free interval and then further transition from this maintenance treatment to maybe just a topical moisturizer if you give enough time for the skin to settle down," Dr. Dohil said.
Dr. Dohil disclosed that the department at Rady has received grant and research support from Hill Pharmaceuticals. She has also received honoraria from Medicis and Dermik.
Many parents find it hard to accept the fact that there is no treatment that completely cures atopic dermatitis. DR. DOHIL
SAN DIEGO Parents of children newly diagnosed with atopic dermatitis can be riddled with angst.
Some gravitate to guilt and self-blame, figuring "we did something wrong to our child" or "it must be something we're giving him" that's causing the atopic dermatitis, Dr. Magdalene A. Dohil said at a meeting sponsored by Rady Children's Hospital.
Others believe that baths are bad for their child, and many are frightened to use topical steroids to treat the disease. "They may say things like, 'there are so many creams, we can't remember what goes on and where it goes,'" said Dr. Dohil, a pediatric dermatologist at Rady Children's Hospital, San Diego. "They want a simple and easy cure so they can control the disease."
Many parents find it hard to accept the fact that there is no treatment that completely cures atopic dermatitis. That is why she practices "extreme parent education" from the get-go.
"We have to battle myths and misperceptions," said Dr. Dohil, also of the University of California, San Diego. "We have some good safety data on atopic dermatitis treatments out there. It's just not common knowledge, and they are not that easy to explain."
Patient Resources
Web-based resources she points parents and patients to include The Eczema Center at Rady Children's Hospital (
Management of atopic dermatitis is currently based on the number, location, and intensity of lesions, persistence of disease, frequency of flares, patient age, and quality of life and emotional issues.
Dr. Dohil focused her discussion on topical corticosteroids and topical calcineurin inhibitors. "We have to stress for our patients that this is what it boils down to; this is our primary anti-inflammatory armamentarium right now," she said.
Topical Corticosteroids
Topical corticosteroids have been a mainstay of inflammatory atopic dermatitis treatment for decades. They are also used to manage acute flares and as maintenance therapy.
"We can start as low potency as needed or start high, control, and go back to low potency as needed," she said.
"This is my preference because I feel it gives you that initial trust and compliance if parents see their child getting better. It allows you to taper down and reassure parents that you are no longer at that very potent level of topical steroids," Dr. Dohil added.
The choice of topical corticosteroid is influenced by what prior agents have been used, the age of the patient, severity and localization of dermatitis, formularies, and parental steroid phobia. The anti-inflammatory effects of topical corticosteroids come at a price, Dr. Dohil said, including the potential for skin atrophy, telangiectasia, acne, perioral dermatitis, as well as hypothalamic-pituitary-adrenal axis suppression.
"This really scares parents. We need to take this parent fear factor into account at every step along the way because if you don't, you set yourself up for noncompliance. The eczema's not going to get better. The parents will get confused, and there is so much input from non-health professionals, such as 'this worked for my child. Why don't you try this?' and so on," she said.
Previous research has demonstrated that the anti-inflammatory effects of topical corticosteroids stem from a pathway of transrepression, while its side effects stem from a pathway of transactivation.
"Current research is focusing on trying to separate these two pathways," Dr. Dohil said.
"In the meantime we have great data down to 3 months of age that give us a sense of how safe they are, [and] how long we can use these agents. Most of these studies have run over a period of 4 weeks. I think it's important to share this information with parents, to help them feel comfortable about the treatment," she said.
Topical Calcineurin Inhibitors
The topical calcineurin inhibitors, tacrolimus ointment (Protopic) and pimecrolimus cream (Elidel), are popular second-line treatment options for treatment of moderate to severe disease.
According to labeling information, these agents are indicated in nonimmunocompromised adults and children 2 years of age and older, who have failed to respond adequately to other topical prescription treatments, or when those treatments are not advisable.
After a Food and Drug Administration black box warning was issued in January 2006 related to concerns about skin malignancies and lymphoma from the use of topical calcineurin inhibitors, several case-control studies, long-term registries, ongoing clinical studies, and data safety monitoring boards were launched to continue to assess their safety.
A 10-year study, A Prospective Pediatric Longitudinal Evaluation Study, will examine 8,000 pediatric subjects treated for at least 6 weeks.
Another 10-year trial, The Pediatric Eczema Elective Registry, is an observational parent-report registry designed to assess the risk of malignancies in 5,000 children aged 217 years who were treated with pimecrolimus for at least 6 weeks.
One recent study found that the patients with severe atopic dermatitis were 2.4 times more likely to develop lymphoma, compared with controls. However, use of pimecrolimus and tacrolimus conferred a protective effect, with odds ratios of 0.8 each (J. Invest. Dermatol. 2007;127:80816).
A separate case-control study of patients with inflammatory dermatitis found that those who used pimecrolimus and tacrolimus had almost a 50% reduction in the risk of developing nonmelanoma skin cancer (Dermatology 2007;214:28995).
The odds ratio of association for nonmelanoma skin cancer decreased as the number of tubes used and the potency of the agent increased. "There was no clear explanation for this," Dr. Dohil said. "There's still a lot of discussion going on."
She added that studies of the blood levels of topical calcineurin inhibitors indicate that they "appear to be negligible when used appropriately."
In clinical practice these agents are commonly used for the face and genital area and for other so-called hot spots with high risk of atrophy.
They are often used in patients with concerns about steroids due to quantity of use in delicate locations, need for constant or near constant therapy, or in those with an adverse event history such as striae or systemic effects.
"Many people feel that topical calcineurin inhibitors can help patients experience a longer flare-free interval and then further transition from this maintenance treatment to maybe just a topical moisturizer if you give enough time for the skin to settle down," Dr. Dohil said.
Dr. Dohil disclosed that the department at Rady has received grant and research support from Hill Pharmaceuticals. She has also received honoraria from Medicis and Dermik.
Many parents find it hard to accept the fact that there is no treatment that completely cures atopic dermatitis. DR. DOHIL
SAN DIEGO Parents of children newly diagnosed with atopic dermatitis can be riddled with angst.
Some gravitate to guilt and self-blame, figuring "we did something wrong to our child" or "it must be something we're giving him" that's causing the atopic dermatitis, Dr. Magdalene A. Dohil said at a meeting sponsored by Rady Children's Hospital.
Others believe that baths are bad for their child, and many are frightened to use topical steroids to treat the disease. "They may say things like, 'there are so many creams, we can't remember what goes on and where it goes,'" said Dr. Dohil, a pediatric dermatologist at Rady Children's Hospital, San Diego. "They want a simple and easy cure so they can control the disease."
Many parents find it hard to accept the fact that there is no treatment that completely cures atopic dermatitis. That is why she practices "extreme parent education" from the get-go.
"We have to battle myths and misperceptions," said Dr. Dohil, also of the University of California, San Diego. "We have some good safety data on atopic dermatitis treatments out there. It's just not common knowledge, and they are not that easy to explain."
Patient Resources
Web-based resources she points parents and patients to include The Eczema Center at Rady Children's Hospital (
Management of atopic dermatitis is currently based on the number, location, and intensity of lesions, persistence of disease, frequency of flares, patient age, and quality of life and emotional issues.
Dr. Dohil focused her discussion on topical corticosteroids and topical calcineurin inhibitors. "We have to stress for our patients that this is what it boils down to; this is our primary anti-inflammatory armamentarium right now," she said.
Topical Corticosteroids
Topical corticosteroids have been a mainstay of inflammatory atopic dermatitis treatment for decades. They are also used to manage acute flares and as maintenance therapy.
"We can start as low potency as needed or start high, control, and go back to low potency as needed," she said.
"This is my preference because I feel it gives you that initial trust and compliance if parents see their child getting better. It allows you to taper down and reassure parents that you are no longer at that very potent level of topical steroids," Dr. Dohil added.
The choice of topical corticosteroid is influenced by what prior agents have been used, the age of the patient, severity and localization of dermatitis, formularies, and parental steroid phobia. The anti-inflammatory effects of topical corticosteroids come at a price, Dr. Dohil said, including the potential for skin atrophy, telangiectasia, acne, perioral dermatitis, as well as hypothalamic-pituitary-adrenal axis suppression.
"This really scares parents. We need to take this parent fear factor into account at every step along the way because if you don't, you set yourself up for noncompliance. The eczema's not going to get better. The parents will get confused, and there is so much input from non-health professionals, such as 'this worked for my child. Why don't you try this?' and so on," she said.
Previous research has demonstrated that the anti-inflammatory effects of topical corticosteroids stem from a pathway of transrepression, while its side effects stem from a pathway of transactivation.
"Current research is focusing on trying to separate these two pathways," Dr. Dohil said.
"In the meantime we have great data down to 3 months of age that give us a sense of how safe they are, [and] how long we can use these agents. Most of these studies have run over a period of 4 weeks. I think it's important to share this information with parents, to help them feel comfortable about the treatment," she said.
Topical Calcineurin Inhibitors
The topical calcineurin inhibitors, tacrolimus ointment (Protopic) and pimecrolimus cream (Elidel), are popular second-line treatment options for treatment of moderate to severe disease.
According to labeling information, these agents are indicated in nonimmunocompromised adults and children 2 years of age and older, who have failed to respond adequately to other topical prescription treatments, or when those treatments are not advisable.
After a Food and Drug Administration black box warning was issued in January 2006 related to concerns about skin malignancies and lymphoma from the use of topical calcineurin inhibitors, several case-control studies, long-term registries, ongoing clinical studies, and data safety monitoring boards were launched to continue to assess their safety.
A 10-year study, A Prospective Pediatric Longitudinal Evaluation Study, will examine 8,000 pediatric subjects treated for at least 6 weeks.
Another 10-year trial, The Pediatric Eczema Elective Registry, is an observational parent-report registry designed to assess the risk of malignancies in 5,000 children aged 217 years who were treated with pimecrolimus for at least 6 weeks.
One recent study found that the patients with severe atopic dermatitis were 2.4 times more likely to develop lymphoma, compared with controls. However, use of pimecrolimus and tacrolimus conferred a protective effect, with odds ratios of 0.8 each (J. Invest. Dermatol. 2007;127:80816).
A separate case-control study of patients with inflammatory dermatitis found that those who used pimecrolimus and tacrolimus had almost a 50% reduction in the risk of developing nonmelanoma skin cancer (Dermatology 2007;214:28995).
The odds ratio of association for nonmelanoma skin cancer decreased as the number of tubes used and the potency of the agent increased. "There was no clear explanation for this," Dr. Dohil said. "There's still a lot of discussion going on."
She added that studies of the blood levels of topical calcineurin inhibitors indicate that they "appear to be negligible when used appropriately."
In clinical practice these agents are commonly used for the face and genital area and for other so-called hot spots with high risk of atrophy.
They are often used in patients with concerns about steroids due to quantity of use in delicate locations, need for constant or near constant therapy, or in those with an adverse event history such as striae or systemic effects.
"Many people feel that topical calcineurin inhibitors can help patients experience a longer flare-free interval and then further transition from this maintenance treatment to maybe just a topical moisturizer if you give enough time for the skin to settle down," Dr. Dohil said.
Dr. Dohil disclosed that the department at Rady has received grant and research support from Hill Pharmaceuticals. She has also received honoraria from Medicis and Dermik.
Many parents find it hard to accept the fact that there is no treatment that completely cures atopic dermatitis. DR. DOHIL