Severe Atopic Dermatitis - 2018 WSAAI update

This is a Twitter summary from the 2018 WSAAI meeting. This summary was compiled from the tweets posted by @MatthewBowdish, an allergist/immunologist, who attended the 2018 Western Society of Allergy, Asthma and Immunology (WSAAI) meeting. The tweets were labeled #WSAAI. The text was edited and modified by me.

Jon Hanifin on Treatment of Severe Atopic Dermatitis: Important to recognize that atopic dermatitis is a chronic disease - brief therapies fail.

In the management of AD, prevention is the primary goal, for that we use topical agents (steroids, calcineurin inhib, PDE4 inhibitors), systemic drugs (cyclosporine, MTX, azathioprine) and emerging drugs (dupilumab, JAK inhibitors, etc).

Early correction of skin barrier dysfunction may prevent or delay development of atopic dermatitis.

Emollient for primary prevention of AD reduced AD by 50%
in 22 high risk neonates (started petrolatum-based cream daily at 1 week of age to all body surfaces ex scalp & diaper area)- JAAD 2010.

Skin microbiome transplants may protect against S aureus effects on AD skin (Nakatsuji Sci Trans Med 2017, William & Gallo JID 2017;137). Microbiome transplants in AD:

Atopic dermatitis maintenance (click to enlarge the image).

One week remittive regimen for AD:

Why does AD management fail?

1. Conservative TCS dosing - put out the fire!
2. Failing to pre-hydrate
3. Starting & stopping TCS rather than taper and maintain on BIW dose
4. Prolonged ABX therapy (5 day limit)

Maintaining AD Remission:

1. Taper TCS: goal is twice weekly
2. In between: stabilizers like moisturizers (petrolatum, creams, never lotions), calcineurin and PDE4 inhibitors
3. UV light

You have to be mindful of applying emollient over TCS or TCI - can dilute the steroid and reduce desired effect.

Topical calcineurin inhibitors are effective anti-inflammatories...TO FOLLOW corticosteroids. Topical calcineurin inhibitors are safe for prolonged use (Margolis et all JAMA Derm 2015).

Extracellular pathways under investigation in AD:

Qualifying for Dupilumab Therapy:

1. Severe, chronic, extensive AD
2. Failure to clear & maintain with topical steroids and calcineurin inhibitors
3. Unresponsiveness or CI to prolonged cyclosporine therapy

Other AD Therapies in Development:

In 1379 patients, 1:1:1 injections of dupilumab qwk, q2wk or placebo qwk. At 16 weeks, 38% clear/almost clear with dupilumab vs 10% placebo.

JAK Inhibitors in AD Treatment:

Dr. Winder Gill @winder_gill: From this month’s @AnnalsAllergy - A management plan for #AtopicDermatitis. This issue has a number of great articles on #AD!!

Dr. Hanifin discussed "Diseases that mimic Atopic Dermatitis".

Atopic dermatitis is a chronic skin inflammation with severe itching with early age of onset, often associated with IgE antibodies. From 1915-2006, AD was thought of primarily as an allergic disease. Since 2006, we now think of AD as a skin disease involving barrier defects which predispose to allergic sensitization.

Some conditions that may mimic AD: hand eczemas, facial rashes, scalp dermatitis, cutaneous lymphoma, hyperIgE/DOCK8, dermatomyositis.

Other genetic associations with barrier defects, eczema and atopy:

1. Peeling skin disease
2. Claudin-1/tight junction defect
3. Netherton's
4. SPRR3 defect

Chronic eczematous conditions in aging other than AD:

-xerotic dermatitis
-drug eruptions
-dermatophytids - body's reaction to a dermatophyte (fungal) infection and is a skin eruption that appears on an area of the body that is not the area where the infection first began.
-cutaneous lymphoma

Periorbital dermatitis

Evaluating ocular eczemas: consider allergic contact dermatitis, stop all OTC and ophthalmologic topics/drops...and nail lacquer. Also, discuss seasonality & aeroallergens.

For ocular eczema, use adequate topical steroids (mid-potent/potent bid x3 days, then biw, then TCIs) as conservatism can be deleterious: There can be far more damage from rubbing including corneal abrasions, keratoconus and even cataracts.

Possible diagnostic procedures in AD: contact allergy patch testing, skin biopsy if atypical, Staph culture (?MRSa), KOH/fungal culture, total serum IgE and allergen skin prick tests.

61% of those with AD have hand eczema.

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