Atopic Dermatitis In-Depth - Twitter summary from 2014 #ACAAI meeting

"Atopic Dermatitis In-Depth" with Peter Lio and Mark Boguniewicz:

Dr Lio is a dermatologist from Chicago who is especially interested in AD. “Many allergists feel abandoned by the dermatologists in the care of severe atopic dermatitis”. Dr Lio says as a dermatologist, he is an 'externist' rather than an internist.

In darker skin types, it can be difficult to appreciate erythroderma. Comprehensive goal of AD care: Moisturization, Antibiotics, Antipruritics and anti-inflammatories.


Dr Lio discussed the importance of filaggrin - barrier and moisturization roles. Keratinocytes differentiated in presence of IL4 and IL13 have significantly less filaggrin to the point it is a functional deficiency.

Dr Boguniewicz: NJ screens for 5 most common filaggrin mutations, mainly in European background, but over 30 mutations described. Insurance often doesn't want to cover filaggrin mutation testing. Exam for 'hyperlinear palms' is the poor man's test for filaggrin mutation. Hyperlinear palms via @Docallergy

The typical filaggrin patient has early onset, severe, persistent AD with increase in allergic sensitization and increased risk of asthma.

Allergic (atopic) march (click here to enlarge the image). Allergic (Atopic) March refers to the natural history or typical progression of allergic diseases that often begin early in life. These include atopic dermatitis (eczema), food allergy, allergic rhinitis (hay fever) and asthma.


More moisturizer = less eczema! Most of the very expensive moisturizers are really no better than cheaper products like petroleum jelly. During day, Dr Lio recommends creams (more cosmetically elegant and moisturizing) and then soak and seal at night (with petroleum jelly).

There is some concerns about shea butter with tree nut allergy but no data to show it cross-reacts. Dr Lio recommends virgin coconut oil and sunflower oil. The coconut oil also has antibacterial properties. But he recommends them with other medications. Sunflower oil first, then medications and then petroleum jelly on top for night regimen. Moisturizer tips: If the patients complains that cream is cold, then float in bath tub to warm it up. If cream feels too hot, then keep in fridge (not freezer).

Atopic Dermatitis Treatment - Illustrated (click to enlarge the image).

Bleach baths

Dr Lio likes bleach baths. Dr Lio uses 1/4-1/2 cup bleach in full bath tub for his patients. Here is Lio's slide on bleach bath recs #ACAAI

Anti-inflammatory therapy

Anti-inflammatory component is probably the most important part of the treatment regimen. Dr Lio feels that steroid ointments are generally preferred. Pearl: If patient says the eczema "comes right back after we stop" then steroid potency is probably too low.

Dr Lio prefers steroid ointments over creams because there are less additives in ointments and it helps with barrier function. Dr Boguniewicz agrees steroid ointments are bettert creams but notes that patients who are "outdoorsy" can get in trouble with dirt and sweating.

Protopic/Elidel problems: cancer scare (Dr Lio discounts the risk) and costs (but they should be going generic soon). Once eczema is clear, then use tacrolimus twice weekly because the skin is NEVER normal even when it looks OK.

“Eczema Boot Camp”

Dr Lio does Eczema Boot Camp: QD - 10-min dilute bleach bath, topical therapy (TAC), emollient application and then wet wraps. Eczema boot camp lasts 3-5 days - if not better after one week then, Dr Lio has patients call him. Wet wraps on for 2 hours at least, Dr Lio recommends to sleep in it if they can tolerate it.

Eczema Action Plan

Dr Lio uses an "Eczema Action Plan" and feels this is the single most important education he does - empowers patients. Dr Lio's website has lots of resources -- Here is Lio's "Eczema Action Plan"

Dr Bowdish: This was perhaps the single most mind-blowing session that I attended at this #ACAAI. These recs will improve my practice.

Atopic Dermatitis (Eczema) Action Plan by National Jewish Health:


60-70% of patients get improvement with phototherapy, but it's a hassle (three times weekly) and expensive (but generally well covered).

Severe cases

Dr Lio discourages prednisone bursts or tapers, instead he prefers cyclosporine for severe patients, it acts quickly and 80-90% clear in 1 month. Dr Lio does 5mg/kg/day of modified cyclosporine, generally taper off in 3 months - monitor BP, BUN/Cr, CBC, LFTs, Uric Acid. Dr Boguniewicz feels kids tolerate cyclosporine much better than adults - less HTN and other ADRs. Other immunosuppressants for SEVERE patients: Azathioprine (Imuran), Mycophenolate (CellCept).

Dr Lio uses full dose cyclosporine, and if doing great then adds full dose CellCept for 1mo, then weans cyclosporine over 1-2 mos, and then off. Dr Lio doesn't use methotrexate but Dr Boguniewicz has patients he works with that do.

Eczema mimickers

Eczema mimickers (ie Wiskott-Aldrich) are extremely rare but you have think about other causes too. Think about these rare zebras if you also have immunodeficiency (WAS) or autoimmunity (IPEX). DOCK8 are the tough ones. However, even they have severe viral infections.

PPV of SPT or sIgE to foods in eczema isn't great, it's more of a fishing expedition and probably more helpful if negative. Dr Boguniewicz: Food challenges in eczema patients are, umm, challenging. The majority of food allergy in eczema is an issue with patients aged 5 years or younger.

Handouts for this (W-23) and other workshops can be found here

This is a Twitter summary from 2014 #ACAAI meeting. The post is a part of series. See the rest here:

The Twitter summary was made possible by @MatthewBowdish and @DrAnneEllis

Several allergists did a great job posting updates from the 2014 meeting of the #ACAAI. I used the website “All My Tweets” to review the tweets. For comparison, here are the tweets from previous #ACAAI meetings (scroll down the page for the past years):

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