Infectious Disease: Maui Derm 2019 Highlights

Matthew Zirwas, MD

In this session, Matt J. Zirwas, MD discussed the challenges of managing a range of contact dermatitis dilemmas, including:

  • When to patch test and when to treat empirically
  • Non-allergenic topicals
  • Low allergenicity personal care products
  • Allergen updates
  • The explosion of contact dermatitis from essential oils
  • Fragrances
  • Change in which formaldehyde releasers are most common
  • New or up-and-coming allergens, including long lasting nail polish, glucosides, and ammonium persulfate
  • Effects of L-histidine supplementation in atopic dermatitis
  • Oral management of xerotic dermatitis

 

Powered by JCAD

Atopic Dermatitis: Maui Derm 2019 Highlights

Dramatic advances in our understanding of the immunology and pathogenesis of atopic dermatitis (AD) has resulted in the development of new and novel topical and systemic therapies. MauiDerm’s experts discussed new findings regarding the pathogenesis and comorbidities of AD. The spectrum of old and new topical therapies, such as crisaborole, and systemic therapies, including emerging biologic therapies, were discussed.

Andrew Blauvelt, MD

Andrew Blauvelt, MD, MBA, presented attendees with an update on the AD pipeline. Dr. Blauvelt reviewed recent research on biologics such as tralokinumab, an anti-IL-13 monoclonal antibody (mAb), lebrikizumab, an anti-IL-13 mAb, and nemolizumab, an anti-IL-31 receptor A mAb. Dr. Blauvelt discussed other studies on monoclonal antibodies for AD targeting IL-5, IL-22, TSLP, IL-17C, IL-1alpha, IL-33, and OX40.  In addition, Dr. Blauvelt discussed research on the JAK1 Blockers Baricitinib, upadactinib, and PF-04965842. Additional potential therapies discussed include ASN002, ZPL-389, and apremilast. Dr. Blauvelt also covered new topical drugs for AD, including JAK inhibitors, PDE4 inhibitors, and tapinarof.

Eric Simpson, MD, MCR

Eric Simpson, MD, MCR

Eric Simpson, MD, MCR, provided an update on dupilumab. Topics discussed by Dr. Simpson include:

  • When to use systemic therapy
  • What to tell patients to expect with systemic therapy
  • Are there patients who should not be put on dupilumab?
  • Should we check labs?
  • How to treat dupilumab conjunctivitis
  • How to treat facial resistance or flares
  • How long will patients stay on dupilumab?
  • Tapering
  • Other uses for dupilumab
  • Combination treatment
  • Vaccination

Lawrence Eichenfield, MD

Lawrence F. Eichenfield, MD, provided attendees with an update on pediatric AD.

Dr. Eichenfield began by reviewing the typical timeline for AD development and different disease trajectories for the distinct AD phenotypes, noting there is still much work to be done on phenotyping. He went on to review practical recommendations for the evolving therapeutic landscape and the algorithm for incorporating new therapies. Dr. Eichenfield also discussed recent research on topicals for pediatric AD and counseled attendees on an effective approach to infected AD. In addition, topical microbiome transplants and topical bacterial probiotics were discussed. Dr. Eichenfield finished his presentation with other ways to improve care and additional interesting articles from the literature.
Powered by JCAD

New Drugs, New Devices

By Ted Rosen, MD

The year 2017 saw many new drugs and devices introduced that show considerable promise for dermatology patients. A fast round-up of what was approved in 2017 (including one December 2016 entry) appears in Table 1.

Table 1.

Drug Brand Approval Date Indication/Area What’s New
Crisaborole Eucrisa® 12/14/16 Atopic dermatitis Good safety data, no limit on therapy duration, safe for use on face and eyelids, etc.
Dupilumab Dupixent® 3/28/17 For moderate-to-severe atopic dermatitis, approved for adults only, minimal adverse events
Guselkumab Tremfya® 7/13/17 Psoriasis Superior to adalimumab for achieving PASI75, PASI90, and PASI100 (44% achieved PASI100 at 24 weeks)
Brodalumab Siliq® 2/15/17 Similar results as guselkumab
Blue Control Device

 

 7/13/17 Wearable blue light for psoriasis
Delafoxaciin Baxdela® 6/19/17 Antibiotic Fluorinated quinolone, wide spectrum
Ozenoxacin Xepi® 12/14/17 Non-fluorinated quinolone, cream for impetigo
Oxymetazoline Rhofade® 1/19/17 For persistent facial erythema of rosacea
Benznidazole Not branded 8/29/17 Chagas disease Oral agent to treat tropical disease
Avelumab Bavencio® 3/23/17 Merkel cell carcinoma New treatment for aggressive neuroendocrine cancer
Pembrolizumab Keytruda® 3/14/17 Hodgkin lymphoma Expanded indication for adult and pediatric Hodgkin lymphoma
H202 40% Eskata® 12/17/17 Seborrheic keratosis Topical solution, 40% solution most effective, 41.3% of lesions clear or near-clear
HZ/su Vaccine Shingrix® 10/20/17 Shingles vaccine May be more effective than current vaccine
Dignicap Cooling Cap 7/3/2017 Chemotherapy-induced alopecia 70% of chemotherapy patients expected to lose all of their hair retained at least 50% of scalp hair
DermaPACE device 12/28/17 Diabetic ulcers 48% of patients had >90% healing at 20 weeks

Note that trademarks and registered trademarks are the property of their respective owners.

 

The “libraries” of therapeutic options for many conditions are being expanded, such as the treatments for atopic dermatitis, psoriasis, and cutaneous cancers. With the wealth of new options comes the need to learn how to best deploy these new drugs and devices for use in our patients. A few highlights follow.

Crisaborole

Atopic dermatitis can be a lifelong condition and one that distresses patients by its appearance as well as by itching. Crisaborole, a nonsteroidal phosphodiesterase-4 (PDE-4) inhibitor, is indicated for patients with atopic dermatitis of at least two years duration. There is no skin atrophy, so it may be safely used on the face, eyelids, skin folds, and external genital areas. It is to be used twice a day and there is no limit on how long therapy may persist.1 See Figure 1 for atopic dermatitis patients treated with crisaborole by the author.

Atopic Dermatitis Crisaborole

Figure 1. Monotherapeutic regimen with crisaborole in an adult woman with atopic dermatitis.

 

Dupilumab

Dupilumab is indicated for moderate to severe atopic dermatitis in adults; it is a monoclonal antibody that works against subunit 4Rα of the interleukin (IL)-4 and IL-13 receptors. It reduced pruritus markedly compared to placebo and the once-weekly and twice-weekly regimens provided about equal effectiveness.2

Avelumab

Avelumab is an anti-programmed cell death (PD)-ligand (L)1 immunotherapeutic agent that has been approved for use in pediatric (≥ 12 years) and adult patients with metastatic Merkel cell carcinoma, an aggressive neuroendocrine cancer with high morbidity and mortality rates. Complete response occurred in 10/88 patients in a phase II trial and 19/88 had partial responses with median overall survival rates of 12.9 months.3

Cemiplimab

This anti-PD-L1 monoclonal antibody is used to treat unresectable locally advanced or metastatic cutaneous squamous cell carcinoma. It is not yet approved but early results hold great promise as the objective response rate in phase I was 46.1%. A phase II pivotal study is currently enrolling. The most commonly reported side effects are fatigue, arthralgia, and nausea.4

Important Trends in 2017

  • The armamentarium of agents is building up, giving us more choices and likely improving treatment for patients
  • Many drugs are now being tested against active comparators—these head-to-head studies provide relevant and valuable clinical information (such as the study that showed guselkumab was superior to adalimumab in achieving PASI75, PASI90, and PASI100)
  • Indications may expand, for example, guselkumab is being investigated now for its potential utility in treating psoriatic arthritis

 

References

  1. Paller AS, Tom WL, Lebwohl MG, et al. Efficacy and safety of crisaborole ointment, a novel, nonsteroidal phosphodiesterase 4 (PDE4) inhibitor for the topical treatment of atopic dermatitis (AD) in children and adults. Journal of the American Academy of Dermatology. 2016;75(3):494-503.e494.
  2. Beck LA, Thaci D, Hamilton JD, et al. Dupilumab treatment in adults with moderate-to-severe atopic dermatitis. The New England journal of medicine. 2014;371(2):130-139.
  3. Joseph J, Zobniw C, Davis J, Anderson J, Trinh VA. Avelumab: A Review of Its Application in Metastatic Merkel Cell Carcinoma. The Annals of pharmacotherapy. 2018:1060028018768809.
  4. Kaplon H, Reichert JM. Antibodies to watch in 2018. mAbs. 2018;10(2):183-203.

 

Atopic Dermatitis: Epidemiology & Beyond

By Jonathan I. Silverberg, MD, PhD, MPH

The global prevalence of atopic dermatitis (AD) has been estimated at about 15% to 20% in pediatric and 1% to 10% of adult populations. The prevalence has increased in the past few decades in many regions.

Atopic Dermatitis Prevalence

Figure 1. Reported prevalence rates of AD vary between adults and children and, for pediatric patients, are higher in developing nations than the industrialized world

It was thought that AD prevalence has increased primarily in the developed world, but it is not possible to draw clear lines of demarcation.1 Sometimes national variations can be striking and seem to defy explanation.

For example, among pediatric patients in the age range of 6 to 7 years, the prevalence of AD was, from lowest to highest, 0.9% in India and 22.5% in Ecuador.2 Among older children (aged 13 to 14), prevalence was lower in China, Asia-Pacific, the Middle East, India, and parts of Latin America but higher in some parts of Africa, Northern and Eastern Europe, and Oceania.2 The prevalence rates for AD vary broadly by developed versus developing nation and are higher for children than adults, see Figure 1.

Factors that may help to explain the global variations in AD prevalence:

  • Genetic factors
  • Environmental factors
  • Microbial exposures
  • Immune dysfunction
  • Definitions of AD, eczema, diagnostic criteria3

Most cases of childhood AD start in in the first five years of life. Approximately, 20-50% of childhood AD persists into adulthood.4 However, adult onset AD is quite common, with one in four adults with AD report adult-onset of their disease.5

Emerging data suggest that family structure may play a role in AD rates. Using multivariable logistic regression and adjusting for socio-demographic factors, it was found that US children from single-adult households, families with a mother but no father present, families with unmarried mothers, and families with non-biological fathers had increased odds of developing AD.6 Other risk factors for AD include cigarette smoking and exposure to second-hand smoke.7 Moreover, both adults and children with AD have higher rates of mental health symptoms, such as depression and anxiety.8,9

AD is characterized by a dysregulation of the immune system and a disruption in the skin’s barrier function. These conditions may set the stage for AD-associated comorbidities. Some of these comorbidities may be interrelated and their exact association with AD may not be yet entirely elucidated.10

  • Cutaneous infections, including extra-cutaneous infections (such as sepsis)
  • Disturbed sleep, sleep inefficiency, fatigue
  • Cardiovascular conditions, such as atherosclerosis, myocardial infarction, congestive heart failure
  • Cerebrovascular disorders, including stroke
  • Obesity
  • Hypertension
  • Hyperlipidemia
  • Diabetes type II

The burden of AD is not trivial. Patients experience severe and sometimes relentless pruritus, may have skin pain11 experience sleep and mental health disturbances, and suffer from an unsightly rash that may cause embarrassment and social isolation. Most AD patients (88%) report the daily presence of itchy skin and 69% report that the itchiness lasts at least 12 hours a day. Fifty percent of AD patients report pain accompanies pruritus and 69% describe the itchiness as being severe or unbearable. Most AD patients (90%) report that their AD disrupts sleep at least one night per week.12-14

AD is a highly prevalent condition associated with serious comorbidities, a high disease burden, and great costs to the healthcare system.

 

References

 

  1. Nutten S. Atopic dermatitis: global epidemiology and risk factors. Annals of nutrition & metabolism. 2015;66 Suppl 1:8-16.
  2. Odhiambo JA, Williams HC, Clayton TO, Robertson CF, Asher MI. Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three. The journal of allergy and clinical immunology. 2009;124(6):1251-1258.e1223.
  3. Dizon MP, Yu AM, Singh RK, et al. Systematic review of atopic dermatitis disease definition in studies using routinely collected health data. The British journal of dermatology. 2018;178(6):1280-1287.
  4. Kim JP, Chao LX, Simpson EL, Silverberg JI. Persistence of atopic dermatitis (AD): A systematic review and meta-analysis Journal of the American Academy of Dermatology, Vol. 75, Issue 4, p681–687.e11. Published online: August 18, 2016
  5. Lee HH, Patel KR, Singam V, et al. A systematic review and meta-analysis of the prevalence and phenotype of adult-onset atopic dermatitis. Journal of the American Academy of Dermatology. Published online: June 1, 2018
  6. McKenzie C, Silverberg JI. Association of family structure with atopic dermatitis in United States children. Journal of the American Academy of Dermatology. 2018.
  7. Kantor R, Dalal P, Cella D, Silverberg JI. Research letter: Impact of pruritus on quality of life—A systematic review. Journal of the American Academy of Dermatology, Vol. 75, Issue 5, p885–886.e4. Published online: August 28, 2016
  8. Yaghmaie P, Koudelka CW, Simpson EL. Mental health comorbidity in patients with atopic dermatitis. The Journal of allergy and clinical immunology. 2013;131(2):428-433.
  9. Yu SH, Silverberg JI. Association between Atopic Dermatitis and Depression in US Adults. The Journal of investigative dermatology. 2015;135(12):3183-3186.
  10. Silverberg JI. Associations between atopic dermatitis and other disorders. F1000Research. 2018;7:303.
  11. Vakharia PP, Chopra R, Sacotte R, et al. Burden of skin pain in atopic dermatitis Annals of Allergy, Asthma & Immunology, Vol. 119, Issue 6, p548–552.e3. Published in issue: December 2017
  12. Simpson EL, Bieber T, Eckert L, et al. Patient burden of moderate to severe atopic dermatitis (AD): Insights from a phase 2b clinical trial of dupilumab in adults. Journal of the American Academy of Dermatology. 2016;74(3):491-498.
  13. Dawn A, Papoiu AD, Chan YH, Rapp SR, Rassette N, Yosipovitch G. Itch characteristics in atopic dermatitis: results of a web-based questionnaire. The British journal of dermatology. 2009;160(3):642-644.
  14. O’Neill JL, Chan YH, Rapp SR, Yosipovitch G. Differences in itch characteristics between psoriasis and atopic dermatitis patients: results of a web-based questionnaire. Acta dermato-venereologica. 2011;91(5):537-540.

 

A real-world study evaluating adequacy of existing systemic treatments for patients with moderate-to-severe atopic dermatitis (AD-QUEST): baseline treatment patterns and unmet needs assessment

A real-world study evaluating adequacy of existing systemic treatments for patients with moderate-to-severe atopic dermatitis (AD-QUEST): baseline treatment patterns and unmet needs assessment

Presenters: Wei W1, Ghorayeb W2, Andria ML3, Walker V4, Chao J3, Schnitzer J2, Kennedy M3, Chen Z3; Belland A4, White J4, Silverberg JI5

Affiliations: 1Formerly of Sanofi, Bridgewater, NJ; 2Sanofi, Bridgewater, NJ; 3Regeneron Pharmaceuticals, Inc., Tarrytown, NY; 4Optum, Eden Prairie, MN; 5Northwestern University Feinberg School of Medicine, Chicago, IL

Objective: To evaluate potential unmet needs in the treatment of moderate-to-severe atopic dermatitis (AD) from a patient perspective.

Methods: Adults with an AD diagnosis in the last five years and a prescription for systemic treatment in the last six months were identified using claims data from Optum Research Database. Patients with self-assessed moderate-to-severe AD were invited to participate in monthly surveys over 12 months about disease signs and symptoms, quality of life (QoL) and AD treatment. We report baseline survey data.

Results: Of 6,000 patients invited to participate, 1,485 responded and 801 were eligible for inclusion (mean age: 45 years; female: 72%; Caucasian: 84%; employed: 79%; AD severity [Rajka & Langeland criteria]: moderate 74%, severe 26%). In the 12 months before baseline, 38 percent and 36 percent reported no remission or less than three months remission from AD. In the month before baseline, most reported using topical corticosteroids (64%) or calcineurin inhibitors (8%), some reported using antihistamines (38%), and a few reported using systemic steroids (11%) or immunosuppressants (5%). In the same period over 81 percent reported AD flares (1: 23%; 2: 20%; ?3: 38%), of which, 65 percent and 22 percent had partial or no recovery. Patients experiencing a flare versus those with no flare at baseline reported significantly worse POEM (13.5 vs. 6.2), peak pruritus NRS (worst itch in previous 24 hours: 6.3 vs. 3.5) and DLQI scores (8.6 vs. 3.7), and greater work productivity loss in previous seven days (8.2 vs. 3.4) (all P<0.001).

Conclusion: This suggests that despite standard-of-care treatments, adults with moderate-to-severe AD report disease symptoms, recurrent flares, and impaired QoL, suggesting unmet therapeutic needs.

Funding/Disclosures: Wenhui Wei is a former employee and current stockholder of Sanofi and an employee of Regeneron Pharmaceuticals, Inc. Eric Ghorayeb and James Schnitzer are employees of and stockholders in Sanofi. Michael Andria, Jingdong Chao, Martha Kennedy and Zhen Chen are employees of and stockholders in Regeneron Pharmaceuticals, Inc. Valery Walker, Angela Belland, and John White are employees of Optum, a company that received research funding for the current study. Jonathan Silverberg is a member of an institution that received research funding for the current study. This study was funded by Sanofi and Regeneron Pharmaceuticals, Inc.

An investigator blinded randomized study evaluating hypochlorous acid (HOCl) in the treatment of atopic dermatitis-associated pruritus

An investigator blinded randomized study evaluating hypochlorous acid (HOCl) in the treatment of atopic dermatitis-associated pruritus

Presenters: Berman B, Nestor M

Affiliation: Center for Clinical and Cosmetic Research and University of Miami Miller School of Medicine, Miami, FL

Background/Objective: Hypochlorous acid (HOCl) might potentially reduce pruritus in atopic dermatitis (AD) by its microbicidal qualities, particularly in reducing Staphylococcus aureus, and by its anti-inflammatory qualities that reduce the activities of histamine, leukotriene B4, and interleukin-2, all of which contribute to the pathophysiology of itch. Here, we present the results of a three-day study designed to evaluate the effect of HOCl on pruritus in patients with AD.

Methods: The study was conducted according to the protocol and in compliance with Good Clinical Practice (GCP) and other applicable regulatory requirements. This investigator-blinded, randomized Phase II, 72-hour study investigated the antipruritic effect of HOCl with patients diagnosed with AD. Subjects enrolled had AD as defined by the Hanifin criteria and had scored higher than 2 on an itch severity scale (0–4). Thirty subjects were enrolled, 20 randomized to the treatment group (HOCl), and 10 randomized to the untreated control group. Subjects used a HOCl containing solution BID or PRN for 72 hours and recorded applications in a diary. Subjects randomized to the untreated group received no treatment and were only instructed to come to follow-up visits for study-specific assessments.

The three primary measures used were Participant Global Assessment (PGA), Investigator Global Assessment (IGA), and Visual Analog Scale (VAS) itch score. Adverse events (AEs) and serious adverse events (SAEs) and incidence of local skin reactions leading to discontinuation were recorded as well. Measurements were taken at baseline, 24 hours, and 72 hours post-treatment. Photographs of representative areas of affected skin were taken.

Results: The mean VAS itch score between the two groups was similar at baseline. Mean change in PGA and IGA scores between baseline and 72 hours both significantly decreased in favor of the HOCl treatment group (PGA: p value=0.128; IGA: p=0.012). The mean itch VAS scores between the treated and untreated groups were significantly different between baseline and 72 hours post-application, with the percent mean change shown to be significantly lower (improved) in the HOCl treated group.

The analysis showed 73.7 percent of the subjects in the HOCl treated and 30.0 percent of the subjects in the untreated group experienced a reduction in itching between baseline and 72 hours after initial application. There were no treatment related discontinuations or SAEs.

Conclusion: This study demonstrated that application of HOCl-containing solution leads to a reduction in itching associated with AD at 24 hours with significantly better results when compared to the untreated cohort at 72 hours.

A Phase IIb dose-ranging efficacy and safety study of tralokinumab in adult patients with moderate-to-severe atopic dermatitis (AD)

A Phase IIb dose-ranging efficacy and safety study of tralokinumab in adult patients with moderate-to-severe atopic dermatitis (AD)

Presenters: Wollenberg A1, Howell MD2, Guttman-Yassky E3, Silverberg JI4, Birrell C5, Kell C5, Ranade K2, Dawson M5, van der Merwe R5

Affiliations: 1Ludwig Maximillian University, Munich, Germany; 2MedImmune, LLC, MD; 3Mount Sinai School of Medicine, NY; 4Northwestern University Feinberg School of Medicine, IL; 5MedImmune, Ltd., Cambridge, UK

Background/Objective: AD is a chronic inflammatory skin disease characterized by increased interleukin (IL)-13 levels. Tralokinumab, an anti-IL-13 monoclonal antibody, has shown efficacy and an acceptable safety profile in patients with severe, uncontrolled asthma driven by the T-helper 2 pathway. Serum dipeptidyl peptidase 4 (DPP-4) has been reported as a predictive marker for tralokinumab in patients with severe asthma. Here, we evaluated whether tralokinumab offers therapeutic benefit to adults with moderate-to-severe AD.

Methods: In this Phase IIb, randomized, placebo-controlled, double-blind study (NCT02347176), patients were randomized 1:1:1:1 to receive tralokinumab 45mg, 150mg, or 300mg, or placebo every two weeks with mid-strength topical corticosteroids (TCS) for 12 weeks. Coprimary endpoints were change from baseline in Eczema Area Severity Index (EASI) and percentage of patients with clear or almost clear Investigator’s Global Assessment (IGA 0/1) at Week 12. Further efficacy, patient-reported outcomes, serum biomarkers, and safety endpoints were assessed.

Results: Overall, 204 patients were randomized. Tralokinumab 300mg treatment significantly reduced EASI scores (adjusted mean [standard error] change from baseline: 15.7 [1.3]; p=0.011) vs. placebo (-10.8 [1.4]) and more patients had IGA 0/1 (26% vs. 12%). Significant improvements were observed in patients who received tralokinumab 300mg versus placebo for Scoring of Atopic Dermatitis (p=0.002), Dermatology Life Quality Index (p=0.006), Pruritus Numeric Rating Scale (p=0.002), EASI75 (p=0.003), and EASI50 (p=0.025). Tralokinumab 300mg significantly reduced the number of Staphylococcus aureus-colonized patients (p=0.015), the concentration of serum immunoglobulin E, periostin, and TARC/CCL17, dose-dependently versus placebo (p<0.001). Patients with increased IL-13 activity (n=102), identified by baseline serum DPP-4 concentrations above median, showed an increased response to tralokinumab 300mg; more patients achieved IGA 0/1 (35% vs. 8%) and EASI75 (52% vs. 13%) than patients receiving placebo. The most frequent adverse events in all groups were nasopharyngitis (17%), upper respiratory tract infection (9%), headache (6%) and AD (6%).

Conclusion: Tralokinumab with TCS was more efficacious than TCS alone and demonstrated clinically relevant efficacy and an acceptable safety profile in patients with moderate-to-severe AD. DPP-4 might become a predictive marker for patients with AD who respond to tralokinumab 300mg, allowing a personalized medicinal approach.

Funding: This study was funded by MedImmune.

Video: The Pathogenesis of Atopic Dermatitis

Read more

Crisaborole: New Treatment for Atopic Dermatitis

Crisaborole (EUCRISA) is a novel non-steroidal topical ointment for mild to moderate atopic dermatitis (AD, eczema) that was approved in December of 2016. Topical agents are the mainstay of AD therapy and current guidelines recommend both corticosteroids, and topical calcineurin inhibitors (Eichenfield, 2014).

Agents in both of these classes are effective, but may be limited by application reactions and safety concerns with extended use.  Crisaborole is a phosphodiesterase 4 inhibitor (PDE-4) inhibitor with a mechanism of action that has been described for apremilast (Otezla), the oral drug used to treat psoriasis (Moustafa, 2014).

Two identical, vehicle-controlled, double-blind studies showed that crisaborole was significantly more effective than vehicle in achieving ≥2-grade improvements in Investigator’s Static Global Assessment (ISGA) scores in patients with AD (P<0.05 for both studies).

Crisaborole also provided significantly more rapid relief from itch than vehicle. As you know, this is a very important consideration for patients with AD since itch is generally the most bothersome symptom in this common disease.  In addition, itch typically results in scratching which can promote lesion formation and/or transformation to a chronic lichenified state (Turner, 2014).

The majority of treatment-related adverse events with crisaborole were application site pain, primarily reported as burning or stinging. This pain was the only treatment-related adverse events that occurred in ≥1% of patients (Paller, 2016).  Perhaps the main advantage of crisaborole over available topical therapies is avoidance of the potential long-term risks associated with these agents (Zane, 2016).

References

Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014;71:116-32.

Moustafa F, Feldman SR. A review of phosphodiesterase-inhibition and the potential role for phosphodiesterase 4-inhibitors in clinical dermatology. Dermatol Online J. 2014;20:22608.

Turner MJ, Zhou B. A new itch to scratch for TSLP. Trends Immunol. 2014;35:49-50.

Infectious Disease 2016: Pediatric Infected Atopic Dermatitis

Dr. Sheila Fallon-Friedlander

Dr. Sheila Fallon-Friedlander

Dr. Sheila Fallon-Friedlander

A major aggravating factor associated with atopic dermatitis is the presence of microorganisms on the patient’s skin surface. S aureus and Streptococcus pyogenes can exacerbate chronic skin inflammation. S aureus can colonize the skin or the respiratory tract in healthy patients and become pathogenic under conditions such as skin barrier breakdown and diminished immunity. Atopic dermatitis patients are highly susceptible to staphylococcal skin infections. Studies have shown that between 80% and 100% of patients with atopic dermatitis have nasal or skin colonization by S aureus vs 5% to 30% in individuals without atopic dermatitis. First and second generation cephalosporins are suitable for treatment of patients infected with methicillin-susceptible S aureus and MRSA is best treated with clindamycin and trimethoprim/sulfamethoxazole. Antimicrobial therapy should be tailored on the basis of local resistance patterns. Streptococcal infections may be treated with clindamycin and cephalexin.

Eczema herpeticum, also known as a form of Kaposi varicelliform eruption caused by viral infection, usually with the herpes simplex virus (HSV), is an extensive cutaneous vesicular eruption that arises from pre-existing skin disease, usually atopic dermatitis. Children with atopic dermatitis have a higher risk of developing eczema herpeticum, in which HSV type 1 is the most common pathogen. Patients with this condition may be treated with acyclovir.

Eczema cocksackium may also occur in patients with atopic dermatitis. In one case series, 51% of patients diagnosed with Eczema cocksackium had a history of atopic dermatitis. This enterovirus-associated exanthem is characterized by fever, stomatitis of the oral mucosa, and a vesicular rash affecting the hands, feet, and occasionally the buttocks. About one-third of infants <1 year of age may also present with bullae. Symptoms are strikingly similar to eczema herpeticum caused by HSV type 1. Patients with eczema cocksackium have been successfully treated with wet wrap therapy and low-dose corticosteroids. Bleach baths are also effective for both killing of pathogens and decreasing inflammation.