Optimizing Treatment of Pediatric Atopic Dermatitis - Episode 5
Lawrence Eichenfield, MD: Why don’t we transition over to treatments, and the current landscape of treatment. We’re going to discuss both traditional, nonpharmacological treatments and skin care, and then we’ll go on to our population, moderate to severe patients, and then on to some of our newer stomach medicines, and then we’ll come back to topical again. Peter, maybe you can lead off. One of the nonpharmacological approaches to management. What kind of lifestyle modifications should be made by patients, or families, to help manage AD [atopic dermatitis] symptoms and signs?
Peter Lio, MD: This is 1 of my favorite areas. I’m very interested in this, and we could go on and on about this because there’s so much here, but let’s start with the basics. The simplest measuring stick is to first make sure there’s not an obvious trigger that’s contributing. That could be certain types of fabrics, that could be a pet licking the kid’s skin, it could be an environment where somebody is smoking or there are other allergies or irritants present. If we can reduce those or remove those, for the mildest patients that might be enough. The next step up is getting a good regimen in terms of bathing and moisturization. From my way of thinking, we’re trying to support the barrier and strengthen it, very gently and nonpharmacologically. That includes a daily bath. There’s an interesting story about bathing less frequently, bathing more frequently, but most of us have come to the conclusion or at least settled on the idea that frequent baths or daily baths are probably good when we use a gentle cleanser and moisturize right after. We’re washing off allergens, irritants, and maybe even some microbes like staph that we don’t want on the skin. Then we can seal the water in the skin, get that ultrahydrated state, and put on a layer of that protectant, which gives them a barrier.
Those are some very basic things. Of course, families often jump right to food and dietary changes, which is a whole different discussion. But I can say, just to get to the punchline, in my honest opinion, over many years of looking at it—and I think we’d all agree—food usually is not the cause of the patient group we’re talking about here. The patients who are lucky enough to have food-induced eczematous dermatosis, or maybe a contact dermatitis that’s manifesting through the diet, usually look a little different and are weeded out a little differently. We know that this doesn’t mean there aren’t food allergies. There’s a huge amount of food allergy in this patient population, but of course that’s different. The patient who’s going to anaphylaxis from a peanut—that is real and serious and affects a huge proportion of these atopic dermatitis patients, but that’s not the cause of their eczema. We know they are not cheating, because they’d be in the ICU [intensive care unit]. We know that’s not the issue, so I try to redirect from that.
Lawrence Eichenfield, MD: That’s reasonable. When we’re discussing the research aspect of atopic dermis, I don’t know if the immunology of food may influence the development of atopic dermatitis. That is, does diet influence the initial setup? That’s a very different question. That’s a big question mark. That’s a different question, this aspect of avoiding foods as an intervention. One of the interesting things when they did the big peanut allergy LEAP study, and they did skin tests on kids and randomized them to peanut versus no peanut, there was a big set of patients who were skin positive for peanut, but not with a really big wheel. Half those patients were randomized to get peanut, and the impact on their excellent course from that was nothing. It didn’t impact the overall course of what happened to their eczema over time. That whole concept of funding and allergen to avoid the impact of eczema sometimes matters, but it doesn’t commonly matter.
Transcript Edited for Clarity