This webinar was recorded on Thursday, October 27, 2022
Atopic dermatitis (AD) can present in many forms depending on age, underlying type and color of skin. Join us as we provide an update on AD basics and specifically address the diversity in its presentation.
Speaker:
- Dr. Melinda Rathkopf
Sponsored by the American College of Allergy, Asthma and Immunology
Transcript:
This transcript is automatically generated. While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.
Speaker 1 (00:05)
Atopic dermatitis is a condition that many people live with and work hard to manage. There are so many challenges living with atopic dermatitis or eczema and those are only amplified for people of color. We look forward to today and looking at identifying the factors that influence the treatment of this skin condition. This is Sally Schoessler Director of Education for Allergy and Asthma Network. Today’s Webinar helps Allergy and Asthma Network live out our mission to end the needless death and suffering due to asthma, allergies, and related conditions through outreach, education, advocacy, and research. We are pleased to welcome today’s speaker, Dr. Melinda Rathkopf. You’ll see her on the next slide. Dr. Rathkopf did her pediatric and allergy immunology training in the Air Force, then moved to Alaska where she is currently the Director of the Allergy, Asthma, and Immunology Center of Alaska. She is very active in local and state advocacy and is a past president of the Alaska State Medical Association. She is a fellow of the American College of Allergy, Asthma and Immunology and the American Academy of Allergy, Asthma and Immunology and is the current chair of the College’s TN Committee and on the Advocacy Council.
Speaker 1 (01:24)
Thank you so much for being with us today and thank you for sharing your knowledge and expertise on this important topic. We’re really eager to hear from you. Dr. Rathkopf.
Speaker 2 (01:35)
Thank you. I was very excited when asked to discuss the topic of diversity. You see, I practice here. This is Anchorage, Alaska, and about 40% of the population of Alaska lives in the Anchorage municipality. But they also live in Kosovo in the matt nutskatsu sitting at Valley in Nome and in Barrow. You can see the diversity here in my state. And actually, Alaska is the 12th most diverse state in the United States. A diversity index is defined as the chance that two randomly chosen people in a state will be of a different race in ethnicity. Alaska ranks 63% in their diversity index. The different races encountered just in the Anchorage area include Whites, Alaska Natives, a very diverse Asian population, blacks, Pacific Islanders, and others. Alaska is also challenging when it comes to skin issues because we know that eczema is more prevalent in areas that are colder, drier and use more indoor heating. As I say this, there is snow on the ground, the morning temperature and the teens. And I do have my space heater on. Next to me here, you can see various skin types that I encounter on a regular basis in my practice.
Speaker 2 (03:03)
We have white skin, Alaska native skin, Filipino, Sudanese, African American, Eastern European, and Samoan. Just to show you some of the variety, here is our outline for today’s talk. We’re going to discuss what is a topic dermatitis to include definition and incidence, how it presents not just in various ages, but also in various skin colors. We’re going to talk about the social factors and how they directly affect atopic dermatitis we’ll discuss biological factors and how they can affect presentation. Then we’ll review some basics on atopic dermatitis to include triggers testing, and then we’ll end with treatment discussion I’ll leave you with some resources you can use, along with some references for today’s talk. So what is atopic dermatitis? It’s defined as a non contagious inflammatory skin condition. It’s characterized by intense itching,redness, oozing, and scaly rashes. It’s due to inflammation, and the pattern tends to be acute flare ups on top of chronic inflammation. Atopic dermatitis affects up to 20% of children and up to 3% of adults. The prevalence is increasing, especially in low income countries. It’s more common in Black Americans, especially in children, and studies have shown that Black and Hispanic children tend to develop more severe cases compared to white children.
Speaker 2 (04:45)
So you would think Alaska would be warmer, because here it looks like we’re this little island down by Hawaii. In the Isaac phase three study by Odombo et al. They revealed that over children are affected by atopic dermatitis in many countries, but the prevalence varies greatly throughout the world. In the six to seven years age group, the data showed the prevalence of atopic dermatitis range from zero 9% in India to 22 5% in Ecuador, with new data showing high levels in Asia and Latin America. For the 1314 year old age group, the data showed prevalent values ranging from zero to in China to almost 25% in Colombia, it was prevalent over 15% was found in four of the nine regions studied, including Africa, Latin America, Europe, and Oceania. Many of you may be familiar with the allergic or atopic march. It describes the natural progression of allergic diseases from infancy to adulthood. Atopic dermatitis first appears early in life and often precedes other allergic diseases. It is usually the first step in the atopic march 50% of all those with atopic dermatitis develop other allergic symptoms in the first year of life, and that number goes to 85% before the age of five years.
Speaker 2 (06:11)
So what we often see is an infant with skin irritation with eczema, hives, who then becomes an infant, and toddler with multiple food allergies, who then develops seasonal environmental allergies and then goes on to develop asthma. I reassure parents. It doesn’t mean every child with eczema is doomed to get asthma, but when you look at a child with asthma, this is often the pattern they followed. So what do we call it? You’ve already heard me use a couple of different terms. I found this an interesting article by Cancer et al. In 2016 where they did a systematic review of Medline, Mbase, and Lilacs from 1945 to 2016, and they looked for the terms atopic dermatitis, atopic eczema, and multiple other eczemous disorders. They looked at over 330 publication, and a 64% used the term atopic dermatitis. Around 47% use the term eczema, and only seven five used atopic eczema. Atopic dermatitis was the most commonly used term and appears to be increasing in popularity. The authors of this paper recommended given that eczema is a nonspecific term that describes the morphological appearance of several different forms of dermatitis, they strongly suggested the use of a more specific term atopic dermatitis in publications, healthcare clinician, training, and patient education.
Speaker 2 (07:36)
I’ll do my best to stick with atopic dermatitis, so let’s first talk about the presentation based on age. A topic dermatitis typically shows up before the age of five years, but adolescents and adults can develop it. Also, presentation varies in different age groups. Here you see an infant who has more widespread presentation, from the scalp, forehead, cheeks, and chin to the arms and legs. In the toddler and young children age, we typically see it more affected in the flexural areas, so the antecubital and popliteal fossa, also known as the bends of the elbows and knees. We also see it frequently at the ankles and wrist. And again, as discussed, 60% of those with atopic dermatitis experience symptoms by age one, with another 30% by age five. In teens and adults, we see hands, neck and face, including the eyelids, as commonly affected areas. What do we know about atopic dermatitis and skin of color? What are the main issues? We know atopic dermatitis is more common among Blacks, Asians, and specific Pacific Islanders, especially in children. Black and Hispanic children tend to develop more severe cases of atopic dermatitis compared to white children, and they’re more likely to miss school due to their atopic dermatitis.
Speaker 2 (09:05)
We know a type of dermatitis presents differently in different shades of skin of color, and I think we’ll all agree there’s a general lack of diversity in medical education and research on a topic dermatitis. There’s a disproportionate under representation of minority populations in genetic and pharmacogenetic studies of asthma and atopic dermatitis. Severe cases of atopic dermatitis may not be diagnosed or treated adequately in deeply pigmented children. Erythema has always been a defining characteristic of atopic dermatitis when taught, but it may be hard to identify in darker skin tones. In skin of color, it may also present differently. We tend to see more papules with follicular accentuation, we see more like Kenification, we may see prurigo nodularis , and we may see more post inflammatory hypo and hyperpigmentation. Meaning after the acute phase, the skin may be lighter in color than the other skin or darker in color. So here you see how erythema can present in skin of different color. On the far left you see erythema in a darker skin black person, it tends to be more gray, brown or purple, whereas on the far right you see a white child with very red pink erythema.
Speaker 2 (10:36)
In the middle we have an Alaskan child whose skin is in between. Hypopigmentation is often more pronounced in darker skin tones. And here you can see a couple of examples of some hypopigmented patches on the hand, on the arm, and then in the darker individual, the extreme difference in the hypopigmentation around the envelycus license are these thickened areas where you can see the lines and the strategies in the skin. Like on this person’s hand, you may see more plaques and scales, on darker skin, it may stand out more. And as mentioned before, this is Paragonis, where you see more of these little nodules in atopic dermatitis. The World Health Organization defines social determinants of health as the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. So let’s discuss how some of these factors can affect a topic dermatitis. There can be variations in access to care where limited or lack of transportation can result in patients missing or rescheduling their doctors appointments and foregoing or delaying medication. I’ve had patients that have had to take snow machines or dog sleds to get to the airport to then take a plane to get to specialty care.
Speaker 2 (12:16)
Income has a direct effect, and those in poverty can have poorer access to health care and health insurance. Some low income families may live in areas without specialist or may have to skimp on medications and medical care to meet their other basic household needs. People who live in areas with substandard housing may be exposed to more potential eczema triggers, including dust mites and tobacco smoke. And homes without air conditioning could be a problem because heat is a common eczema trigger. There could be education inequality. A lack of knowledge and understanding of the skin condition can lead to problems such as using medications incorrectly or not following through on treatment. And then there can be language and cultural differences. One study showed that people who spoke Spanish as a primary language struggled more to get appropriate health services and to fully understand treatment plans. So where we live, where a person lives, can have a large impact on their access to healthcare, their ability to get to healthcare appointments, and the quality of that care. This can be true for urban as well as rural settings. One of the most significant examples I had of this early on in my time up here is I had been recommending daily bathing for my patients with atopic dermatitis, and it was quite awhile before I realized I didn’t ask if they had running water.
Speaker 2 (13:45)
It is not uncommon in many of our native villages to not have running water, and it wasn’t until an adolescent told me that she had to go into town and go to the washitaria where they had public showers to be able to bathe. A person’s home or neighborhood can also expose them to the allergy triggers as mentioned, like pollution, dust, mold or cockroaches. And access to safe food may be an issue, as many with Eczema have food allergies, and they may live in places without easy access to allergies safe foods that they need to keep them safe. The community in which a person lives can also affect whether the health care they receive is culturally in tune with their own experience. For example, Eczema and black or brown skin can look very different than in white skin. But in some places there are few healthcare providers who have experience diagnosing and treating Eczema and skin of color. Many people with Eczema can’t easily find a doctor or nurse who speaks the same language they do, which makes it hard to communicate about their condition. This can result in doctors prescribing the same treatment to all patients.
Speaker 2 (14:54)
But as we all know, one size does not fit all when it comes to Eczema and people of color. A person’s financial means can have a huge impact on their ability to have their Eczema recognized, treated and managed over the long term. For someone without health insurance, it may be difficult to find a place where their Eczema can be diagnosed and managed. For many people, even the special creams that are commonly recommended to keep Eczema under control are far too expensive for them. So those are a lot of the social factors and how they directly affect patients with atopic dermatitis. Now let’s discuss some of the biological factors. The Ceramide is a component in the stratum cornea of the skin. It is essential for maintaining barrier integrity, and it can differ according to ethnicity and race. Individuals of African ancestry have a lower Ceramide cholesterol ratio than those with white skin or in Asians common loss of function mutations in the Philippine gene have been associated with atopic dermatitis in European population, and a lot of research has gone into this area. This, however, may be less relevant in African American atopic dermatitis patients. Although studies have varied on this conclusion.
Speaker 2 (16:13)
Japanese and Korean patients with atopic dermatitis had higher numbers of certain types of T helper cell the Th 17 and Th 22 cells that cause inflammation than those with European American backgrounds. Comparing African American with European American atopic dermatitis patients, researchers found lower numbers of certain Th 1, Th 17 inflammation causing cells and higher numbers of the Th 2 Th 22 in the affected skin from AfricanAmerican. All of these just point out that there can be genetic and structural biological components in the various skin types, and more research is needed to discover these differences and how to best address them. Let’s go through some of the basics as a review of atopic dermatitis. Atopic dermatitis, as I mentioned, is an inflammatory, chronic skin condition that waxes and wane based on triggers or exposures. These are some common triggers that are found skin irritants, such as soaps, shampoos, detergents or fragrances. Heavy or tight clothing that rubs the area. Chemicals in skin products such as cosmetics. Jewelry that contains nickel. Environmental allergens such as pollens and molds, food allergens, pet, dander, saliva or urine, dust mites, hot and humid temperatures, cold air in the winter which can dry out the skin, viral and bacterial infections, and even the things we use to try to treat those such as antibacterial, ointments, tobacco smoke and stress.
Speaker 2 (17:58)
And in young children. I tell parents it’s not just stress as we think about in older kids and adults, but it can be the stress that their body feels when they’re sick or upset. Often we’ll do testing in atopic dermatitis. Atopic dermatitis is typically a clinical diagnosis, but there are certain tests that can be helpful in identifying allergic triggers that may be contributing, or it may help rule out other skin diseases. Skin prick testing is often used to help identify type one or Ige mediated food allergens and environmental allergens that may be contributing to the skin condition. Patch testing can be used to help identify type four or contact allergies, as we mentioned before, to metals and makeup, maybe Adhesives and other items found in soaps and detergents. Although I do caution trying to do patch testing in skin that is really dry or flared up as you’ll get a higher false positive rate. Sometimes we do blood testing to look at total Ige levels and specific Ige levels to food or environmental allergens. You will see that children with atopic dermatitis often have very elevated Ige levels, which may lead to higher false positive rate with this type of testing, and a skin biopsy may be useful if you’re worried about other skin condition, especially in older kids and adults and want to rule out other things.
Speaker 2 (19:32)
I’m going to talk a little bit more about infants and children and the association with food allergies. Infants and children under the age of five with atopic dermatitis are more likely to have a food allergy than older children and adults with atopic dermatitis. 33% to 63% of young children with moderate to severe atopic dermatitis also have food allergies. The prevalence of food allergies in atopic dermatitis varies by age and severity of the atopic dermatitis, and infants with severe Ad are at a high risk of developing peanut allergy. A large paradigm shift that I’ve had to talk to parents about over the last seven years or so has been in the food allergy atopic dermatitis realm. We used to think that allergies caused atopic dermatitis, although now we know that the atopic dermatitis generally starts before the food allergies or environmental allergies. But it is the presence of the abnormal skin and the barrier damage that leads to increased risk of allergies. So I tell parents the atopic dermatitis comes first, but because of this change in the permeability barrier in the membranes, the child is more likely to end up with allergies, and once allergies have set in, they can be a trigger for atopic dermatitis flare ups or worsening reactions.
Speaker 2 (20:55)
We do, however, see a high rate of food sensitization and a high rate of false positive results on food testing, making this evaluation challenging. Sensitization means presence of IgE, but does not directly necessarily correlate with an allergic reaction or clinical allergy. In recent studies have raised the concern of development of Ige mediated allergy and those who practice food avoidance. So in one publication, 19% of patients with boots triggered eczema atopic dermatitis. But no previous history of an immediate Ige mediated food reaction develop a new immediate reaction following the onset of an elimination diet of that allergen. So let me break that down and clarify that. So here they took children who parents were concerned that their atopic dermatitis was flared by a food, although they had never had a life threatening anaphylactic reaction to that food. They tested them and removed the foods that were positive on testing. On subsequent exposure to that food, they had a much more severe immediate reaction. So you have to warn parents about the risk of pulling out foods unnecessarily. So how do we treat atopic dermatitis? We’re going to talk about trigger avoidance, a good daily skin care plan, or routine topical annoyance.
Speaker 2 (22:21)
Topical medications and systemic medications. One of the most important things in caring for a topic dermatitis is a routine skincare plan. I tell parents this can be exhausting, you can never take a break. Studies have shown that the quality of life in families who had children with atopic dermatitis can be lower than the quality of life seen in children with diabetes or other chronic medical illnesses. And it’s because the family can never take a break. You can’t be too tired to put on the moisturizer or to bathe the child. And in families with young children with atopic dermatitis, the children don’t sleep well and therefore a family doesn’t sleep. So the good routine skin care plan is made up of moisturizer at least once a day, but can be applied to or even more often. You want to do daily bathing in lukewarm water. 15 to 20 minutes is ideal. I want to briefly discuss bleach baths, cause bleach baths have been recommended and can be an important part of a skincare plan. Parents often get alarmed when you talk about bleach baths, but then I say it’s similar to pool water, it’s chlorinated water.
Speaker 2 (23:39)
It’s especially helpful in children who frequently get secondary infections of their skin and it can cut down on the staph aureus in the skin. There have been some mixed studies on the utility of bleach baths. So I usually tell parents I’m giving them general recommendation that they can try and then decide if it’s helpful for their child. They worry about bleach drying out the skin and if you didn’t immediately follow the bath with heavy moisturizing, it could. You want to avoid harsh soaps and try to opt for dye free and fragrance free skin cleansers. You want to pat the skin dry, trying not to rub too hard. Is that just the mechanism of rubbing the skin can flare it up. And then you want to apply moisturizer. People prefer lotions because they are lighter, but they often burn containing some alcohol and they don’t tend to penetrate as well. Ointments are the best moisturizer to use, followed by creams and then lotions. We talked about soak and smear. So you soak in the bath, you pat dry and then you smear the moisturizer on I’m going to go through wet wrap therapy. So this is wet wrap therapy taken from an inpatient study, so this is very medical, but then we’ll talk about how to apply it more practical to home use.
Speaker 2 (24:57)
So you need your topical medications and moisturizers. You want tap water that is warm, you need a basin for dampening the dressings or the clothing. And you want clean dressing of enough size to cover the involved area. If a child has a heavy involvement of the face, you want wet, clean and gauze bandages and then something to hold them in place, like an expandable orthopedic or surgical neck covering like you see in this picture. For the arms, legs, hands and feet, you want two to three layers of wet cleaning gauze bandages that can be held in place. Or you can use tube socks, cotton gloves, and then for total body use a combination of above or wet pajamas or long underwear and turtleneck shirts covered by pajamas or sweatsuits. Pajamas with feet in them work well for an outer layer. You want to have blankets to prevent chilling, and non sterile gloves if necessary. It often takes two people to do a good wet wrap and you want to explain the procedure. You want to fill the basin with warm water and after 15 to 20 minutes soaking bath for the patient, the child in warm water without additional additives, you pass the skin dry with a towel.
Speaker 2 (26:08)
You can apply the medication to the affected areas and moisturizer to the non affected areas. So here we’re talking about our steroid or non steroidal topicals on the layered up areas and then moisturizer on the rest of the body. You can soak the dressings in warm water and then squeeze out the excess water. The dressing should be wet but not dripping. You want to cover the area with a wet dressing immediately after wrapping and then cover it with a dry material. Start at the feet and move upward and use wet pajamas or long underwear if most of the body surface area is involved. You want to have a warm blanket that you can warm up in the dryer if needed. But don’t overheat the patient in this type of setting. They remove them after two to 4 hours, or they can rewet them if the patient is known or suspected to have an infection. Dispose of the dressings appropriately and then moisturize the entire body after you remove the dressings. For a little more practical use at home, you can just moisten the dressing in warm water until damp. You wrap the moist dressing around the affected area.
Speaker 2 (27:13)
So here you can see using a sleeve like piece of material. I’ll often talk about cutting the arm off of an old pair of cotton pajamas or long jaws or the leg off and creating a sleeve. You put a dry dressing over the wet one and then put on night time clothing and leave them on overnight or at least several hours. So let’s start going through some of the treatments. There are various topical moisturizer on the market for atopic dermatitis. You can get plant derived products such as aloe vera or coconut oil. You can get animal based products such as lanolin or horse oil, but with both of these categories you want to be sure the patient doesn’t have a contact allergy or a contact irritation from plant and animal derived products. We talked about serums as. The lipid molecules found naturally in high concentration in the cell membrane of the cells in the skin, and their major function is to maintain the integrity of the skin barrier to help prevent water loss. Multiple moisturizers contain ceramides and studies have found that the skin of atopic dermatitis patients have lower levels of ceramides. So it sounds like a good idea to replace them in a topical ceramide.
Speaker 2 (28:28)
There’s a category called natural moisturizing factors. These are small molecules that absorb water into the skin and hydrate the skin. Urea, PCA, glutamic acid and other amino acids are some of these examples. They absorb water from the atmosphere and ensure the superficial layers of stratum corneum stay hydrated. You can try to replace antimicrobial peptides. These are called host defense peptides and they’re part of the innate immune system response that we have. The peptides are potent broad spectrum antibiotics also and can demonstrate potential as novel therapeutic agents. They are being studied in topical ameya. EchoTin is an organic osmolyte that is also being studied on skin, with the aim of preventing water loss in dry atopic dermatitis skin through the application of an ointment and containing them. In most studies, however, most moisturizers showed some beneficial effect and there is generally no consistent evidence that one moisturizer is better than the other. The physician recommendation is the primary consideration for what parents will choose when selecting a moisturizer or a moisture, so try to provide an evidence based information about it. Petroleum Jelly your good old vaseline is the cheapest. Although I was made aware by a family, two families in the past month, that there is now a version of Vaseline for infants that actually has added fragrance.
Speaker 2 (29:56)
So make sure they’re not getting added fragrance or colors into their ointment in general. Again, use a fragrance free, dye free, ointment based moisturizer is best. Let’s talk about some topical medication treatment. We’re going to review topical steroids, topical calcium inhibitors, topical PDE-4 inhibitors, and then the new category of JAK inhibitors. And those are covered in this table here. Topical steroids are the most commonly used medications to treat atopic dermatitis. They can relieve it, reduce inflammation, reduce dryness and decrease flare. Ups at lower potency, as you see on the table here, the class seven steroids. They’re available over the county counter. Higher potencies are available by prescription. They can be found as creams, ointments, foams and solutions. So take into account the body area where you’ll be applying them and the social situation you can imagine on a scalp. The patient may not want to put an ointment on the scalp and then have greasy hair where foams and solutions may be better. For scalp, you want to use the lowest possible dose as higher potency has higher levels of thin skinning and pigment changes. And as we showed in pictures before, darker skin can be more susceptible to the hypopigmentation effects of topical steroids.
Speaker 2 (31:32)
Other topical treatments you have topical calcineurin inhibitors, pimecrolimus is cream based and tacrolimus is ointment based. These have the benefit of reducing inflammation, reducing itch, combating dryness and preventing flare ups. The concerns are you may be a little more light and sun sensitive and they can acutely burn when applied and cause increased redness. We typically recommend that families mix it with a low dose topical steroid initially or with vaseline over the first few days. The redness and burning tend to resolve over repeated application over a few days. They do carry an FDA warning regarding an increased risk of cancer, although this was found with high dose of ingested forms of the medication and is not thought to be clinically relevant at the doses used in topical treatment. Crisaborole is a topical PDE-4 inhibitor that targets this molecule to reduce inflammation in the skin. It’s also been shown to reduce swelling similar to the topical calcium inhibitors. However, it can cause burning or stinging at the site. It’s approved for mild to moderate atopic dermatitis. One of the newest categories are the topical JAK inhibitors. Ruxolitinib was recently approved. It blocks the JAK signaling pathway, also known as Janus kinase pathway to decrease inflammation, and it’s approved for mild to moderate atopic dermatitis in patients twelve years of age and older.
Speaker 2 (33:04)
And what about some of the systemic treatments? This will be biologics, oral or injectable steroids, phototherapy and JAK inhibitors, and those can be found in this table here from the Allergy and Asthma Network. So let’s talk about the biologic. Dupilumab is a monoclonal antibody that blocks interleukin four and interleukin 13. It’s approved for children and adults aged six months and older for uncontrolled moderate to severe topic dermatitis. It may be more expensive than other treatments and it may not be covered by insurance. There is an increased risk of eye related side effects. We have seen some increased risk of conjunctivitis in patients onto pillow mouth, although they often see such a dramatic improvement in their skin. And we can treat the eye side effects and it does tend to get better over time. They’ve only ever stopped one patient medication because we could not get the eye side effects under control. Tralokinumab is a monoclonal antibody similar to Dupilumab, but it blocks only interleukin 13. It’s been approved for treatment of moderate to severe a topic dermatitis in adult patients whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable, it has a similar side effect.
Speaker 2 (34:30)
Profile is cephalop. A new category of oral JAK inhibitors has been approved. I have not used either of these products yet, but there are two recently approved abrocitinib. And I’m going to butcher this one. You bet. Upadacitnib. So we’ll just say the two oral JAK inhibitors, they’re an oral tablet. The first one for adults with refractory moderate to serious atopic dermatitis, and the second one is down to twelve months of age, or twelve years excuse me, twelve years of age for moderate to severe to serious atopic dermatitis. They do have some serious side effects that can be associated with them, and that includes infection, cancer risk, low blood cell counts, and high cholesterol levels. Those are rare but serious side effects. Some common but less serious side effects can include nausea, indigestion, diarrhea, and headaches. They do have the advantage of being an oral product, unlike the biologics I showed you that are injectable. Let’s review the treatment issues in skin of color. In general, treatment for atopic dermatitis is the same regardless of skin color. You want to ensure an accurate diagnosis, but that can be harder. As previously discussed, we need to learn how to accurately diagnose and assess severity when Erythema may not be easily recognizable if phototherapy is used as a systemic treatment, studies have shown that higher doses and longer duration may be needed in skin of darker color.
Speaker 2 (36:12)
As the darker skin pigment acts as a UV filter. Patients with skin of color may also experience more post inflammatory hypo and hyperpigmentation, usually related to the higher dose topical steroids monitoring. Response to treatment may also be different in skin of color, since, as mentioned, Erythema appears differently, and most of the standardized scoring methods that are required in studies and required by many insurance companies when using a biologic both take into account the Erysema. So let’s review our take home points. Much of what is currently known about atopic dermatitis has been learned by studying white skin. Health care providers and researchers are acknowledging this and are addressing these gaps to improve knowledge and care of eczema in skin of color. Skin, genetic and immunologic factors that contribute to eczema can differ between racial and ethnic groups, and this can impact prevalence, persistence, and severity of eczema in skin of color. Increasing representation of skin of color in medical education, medical literature, and the healthcare workforce in general, including specialized clinical centers, will improve healthcare for people with skin of color. These are some of the best resources I found in discussing atopic dermatitis. You have the Allergy and Asthma Network, there’s a website, eczema and skin of color.
Speaker 2 (37:48)
And there’s actually a skin of color society addressing these concerns and needs in this, the National Eczema Association. That’s where some of the handouts shown in this talk today came from, and those can be shared with patients. The American College of Allergy, Asthma and Immunology has patient information on skin allergies and eczema. As does the American Academy of Allergy, Asthma and Immunology. These are references used today in this presentation. So I just want to go back to say how excited I was to bring up the topic and discuss it, and I hope you found it worthwhile. We need to take into account the uniqueness of our patients and our patient population and go beyond what we may have learned in our training and keep seeking new education to address the issues of diversity. Thank you for your time today, and we’ll now take any questions.
Speaker 1 (38:55)
Thank you so much, Dr. Ravkov. We do have several questions. Our first one is more of a comment. It’s from a school nurse who says, there are several students in my school who have asthma and atopic dermatitis. This presentation is needed, so I’m glad we’re able to provide that information. Our next question is what research has been done with the Hispanic population?
Speaker 2 (39:22)
There is some I did not specifically come across that just address the Spanish population. There was one reference to Spanish speaking as the primary language having more challenges with healthcare in the healthcare setting. But I did not specifically come across skin of color in the Spanish population. I found most of it was on African and African American skin or Asian skin.
Speaker 1 (39:56)
Okay, our next question is maybe you said this. Sorry if I missed it. I am still seeing patients. Do you ever do double pajamas to bed? First layer damp, outer layer dry?
Speaker 2 (40:08)
Yes. So what I shared with you, there was a very medical, clinical, hospital based regiment. I believe that was actually the regiment from National Jewish, where they actually will have a treatment center that deals with this in the clinical setting. What I typically tell patients is take a pair of old pajamas, preferably 100% cotton, take a pair that still can get on, but maybe a little tight, and you want long sleeve. You went all the way down to the ankle. You do your bath, you do your prescription medication on the flared areas. You do your rest of the body of mullens. You wet those tighter pair of pajamas in the warm water, put those on, and then put a looser fitting dry pair over the top of them and then sleep in that overnight. That’s how I typically tell a patient to take care of it. The challenge can be when it’s on the face, and that’s when I pull out that picture to show if you have a child or even an adult with extensive facial involvement, that’s where the gauze wraps can be helpful. I’ll often talk about while they’re soaking in the tub.
Speaker 2 (41:16)
You can take a hand towel and you can sew it like a little hood. You can make a little hoodie to go over their face or just take washcloths and wet them, but you can do a hood out of a towel. Cut a hole for the mouth and for the eyes, but that can soak in the tub water and then they can wear it while they’re in the tub. Obviously they’re not going to wear that to sleep, so the gauss wrappings can be useful for the face.
Speaker 1 (41:42)
Well, I’m thinking about making like, a superhero mask to wear in the bathtub. Might be kind of fun. Make it a little bit more fun than just a towel, too. Our next question says, I’ve heard some pediatricians recommend the use of an antihistamine such as Zurtech to treat the itchiness associated with atopic dermatitis, as some children tend to itch during the night. Do you recommend this?
Speaker 2 (42:10)
So I do it quite frequently, although the studies are pretty lacking. Probably it’s not thought to be a histaminertric driven itch and they were more effective when we use sedating any histamines, and it was probably more the sedation that helped and help them sleep than the true histamine blocking. So with the newer generation less sedating antihistamines, you’re going to find it less useful. Their tech is a slightly sedating antihistamine. I’ll often use hydroxyzine because it is a little more sedating if the itch is to the point that it’s interfering with sleep. So I’ll often calculate a weight appropriate dose of hydroxyzine. I’ll often try zyrtec because it is once a day it is over the counter, although I think it’s less effective because again, hydroxyzine is slightly more sedating and that’s probably really what’s helping. But I’ll provide families with a weight appropriate dose of the hydroxyzine to use at bedtime, but only if the itch is at the point where it does interfere with sleep. Generally, I say if the acutely flared up child is really itchy, I would throw them in the tub and I would repeat your evening regimen. I would reapply a moisturizer.
Speaker 1 (43:24)
Thank you so much. Someone’s just making a comment that says I currently have discoloration on chin and it’s spreading underneath on my African American skin.
Speaker 2 (43:33)
That’s probably one of the biggest challenges, is the hypopigmentation. It can be both from the treatment and the disease process and in some individuals it’s darker and in some it’s lighter, and in some individuals they have both darker and lighter. So both the hypo and the hyperpigmentation can be a problem.
Speaker 1 (43:52)
Such challenges someone is asking the question, as asthma could be seasonal, can atopic dermatitis present seasonally as a trigger by pollen or mold?
Speaker 2 (44:04)
Yes, it can. That’s a great question. What’s interesting is when I see infants and toddlers, most of them do not have seasonal allergies. They’ve not lived through enough pollen seasons to have seasonal allergies. So if I hear of onset of atopic dermatitis in early infancy, I look more at the possibility of what they could have no allergies and be non allergic. They could have food allergies are the most common. And then we look at indoor allergens like dust mite and pest. If I hear about Muon said after a few years of age, and especially with seasonal variation, I definitely look at pollen allergies. What we’ll often hear about is outside in the grass, rolling around in the grass or going out barefoot and breaking out on their feet. I’ll often have children wear socks even when they’re outside playing in the grass, even if they don’t want their shoes on. They want to be like the other kids going around barefoot, but they often don’t have to wear their socks in the grass because they flare up in the grass.
Speaker 1 (45:02)
Thank you for that. Our next question starts with saying that this is a wonderful presentation, but the question to follow that is any data on humidification of air, like a humidifier by the bedside at night?
Speaker 2 (45:15)
So it’s really challenging as an allergist about how I recommend humidification as a pediatrician. When I practice general pediatrics, I used to recommend humidifiers regularly, although adding moisture to the air and therefore adding it potentially to their skin can be helpful. It’s a fine line. Too much humidity and dampness can lead to increased mold and dust mites. So it all depends. I did finally add humidity into my home with a humidifier when I moved to Alaska. When I grew up in the deep south. In first practice in the south, we did not have to do that because we had such high humidity naturally. So it really depends. If I had someone with mold or dust mite allergy, I tell them to ensure that they keep the humidity below 30% to 40% in the home and make sure if you’re using a humidifier that you empty it out regularly, let it completely dry out and clean it regularly.
Speaker 1 (46:10)
Oh, thank you so much. Our next question says, what have you seen as the treatment course length for Dupixant for atopic dermatitis? My son has been on it now for two plus years and has improved a lot. But it is still present.
Speaker 2 (46:26)
Yes, and I don’t think there’s a good answer for that. I appreciate your anecdote. I was actually talking to that with a parent today. You know, now that it’s approved down to six months of age, it can be started earlier, but then, of course, we all have a little bit of reservation about then how long is this person going to be on it? And when we talk about atopic dermatitis in general, it does get better over time. So the majority of patients do improve over time, not everyone. And we can have adult and onset, as we mentioned, but for a disease that naturally could improve over time, how do you know when you can stop a medication that’s working? We see this in other disease processes also. So I don’t think we have a good answer for that question. And I do picks and again, you’re not completely carrying, you’re just treating, so you’ll see less involvement. Often we’ll approach patients who have been doing really well for sustained periods of time about spacing it out. So do we space it out? You know, most children with Duxipent are on every two weeks, some are every four, depending on the weight of the child.
Speaker 2 (47:35)
So you may consider slowly spacing it out and seeing. So there’s not a really good answer to that. I know many who have been on it for a few years already also, but I also know some who’ve stopped it, some who flare, and some who have still done okay even after stopping it.
Speaker 1 (47:54)
Thank you very much. Our next question is we hear a lot about introducing peanut into a child’s diet early, but if atopic dermatitis is present, should peanut still be introduced early?
Speaker 2 (48:06)
Very good question, and I have an entire lecture on food allergies and atopic dermatitis, an early introduction of food. But just to try to quickly answer this all came about with the Leap study in 2015, the publication Leap Study where an observation had been made that children in Israel who are fed peanut early in life had less incident of peanut allergies than children in the UK. Where they tended to wait till a little bit later in life like we did in the US. Generally after three years of age. So they did a study where they took children who were at risk of a peanut allergy and they define that as in presence of a topic, dermatitis or presence of an egg allergy or both. And they randomized them to get peanut introduced early in life as an infant versus waiting. And it was very protective to introduce peanut early. However, as I mentioned in this talk, there’s a risk of peanut allergy with atopic dermatitis. So although we recommend early introduction, if your child has atopic dermatitis already, especially moderate to severe or has an egg allergy, I recommend you discuss it with their provider and they may need to be evaluated by an allergist before considering introduction of that food.
Speaker 1 (49:24)
Thank you so much. Our next question is do you find that breastfeeding decreases the chances of children developing eczema?
Speaker 2 (49:32)
That’s a good question, and I am not sure off the top of my head if the studies have shown that specifically, we know breastfeeding is very beneficial to the mom and the child and offers some great immune benefits. We know that allergens can be passed through maternal breast milk and there have never been any consistent studies to show ways of preventing development related to breastfeeding or food avoidance in mom or in the child. Studies that have shown potentially delaying or preventing atopic dermatitis include decreasing the water loss in the skin. So there was a study that looked at aggressive moisutrizing at a very, very early age. So as soon as the baby’s born, you want to lube them up and keep them well moisturized and prevent the skin from drying out. They also showed early aggressive use of topical steroids in infants with eczema decreased the risk of development of allergies. But I don’t want to quote tell you wrong. I don’t know specifically breastfeeding related to atopic dermatitis.
Speaker 1 (50:39)
Okay, thank you. Someone says that you mentioned about your other lecture on food allergies and early introduction of food. They’re wondering if that’s available anywhere to watch or read.
Speaker 2 (50:51)
No, I gave it for a CME medical conference up here in Alaska. We hold an annual meeting called itching Wheezing and Sneezing in Alaska, and it was given as part of that talk.
Speaker 1 (51:03)
Well, that sounds like that might be another webinar for another day. Our next question is, should people with atopic dermatitis avoid any vaccines?
Speaker 2 (51:16)
No, there’s no evidence that I know of childhood vaccinations that are contributing or lead to the development of atopic dermatitis. And we know that they do obviously cut down on vaccine preventable diseases. And, you know, with atopic dermatitis, you already have a little bit of an immune defect, if you want to put it that way, because our greatest immune organ is our skin. Our greatest barrier to the outside world is our skin. So we want to keep our skin as healthy as possible, but we also want to do whatever other measures we can do to try to prevent preventable diseases.
Speaker 1 (51:56)
Thank you so much. Another question we have that just came in is, do you recommend avocado oil to moisturize with?
Speaker 2 (52:04)
I’m always hesitant to have oils that are plant derived or animal derived. So if a parent were telling me they were using avocado oil, I would just say is it seemed to irritate the skin, is it worsening it? And if no, then I continue it. I grew up in the Deep South in first practice there, and so Crisco was frequently used, which is an animal based lard product, was used on the skin as a moisturizer. I definitely think coconut oil use certain commercial products have soy in them, they have oat in them. So it really just depends. You can see contact reactions when moisturizers have food in them, food products in them. I do see some lanolin sensitivity. So lanolin is wool alcohol, and that is found frequently in certain moisturizers have that in them. So in general, I try to recommend a lanolin free, plant free, animal product free moisturizer in general, although I would not have any problem if someone was using avocado oil and it worked for them.
Speaker 1 (53:12)
And would it be more a better idea to use it as an adult rather than a child?
Speaker 2 (53:19)
Not necessarily. I mean, I think you can have contact sensitization. I guess the interesting question, and I’m posing a question to myself that I don’t know the answer to is could the person potentially become allergic to avocado because they’re using avocado on broken down skin. There was a study quite a few years ago trying to look at what increased the risk of peanut allergy and it was skincare products containing peanut oil, which we did not see commonly in the US. I think this was a UK study. And so you could see that they were adding peanut to the skin on broken down skin and there was an increased risk. I have seen here in our native population, well oil from the blubber from the whale can contribute. And we had a patient present where they had a contact reaction to whale oil applied to the skin and they were actually allergic to whale and seal meat.
Speaker 1 (54:14)
That’s so interesting. There are so many interesting things that are a part of this discussion and we thank you so much for being here with us today and working through a lot of these questions with us. So, Dr. Rathkopf, thank you so much for being with us today.
Speaker 2 (54:30)
Thank you. I’d like to just let our listeners.
Speaker 1 (54:33)
Know we’re glad you could be with us today as well. And at this time, please download the certificate attendance from the handouts pane on your control panel. If you have any difficulties, don’t hesitate to email us using the link in your emails. Please join us for our next Advances in Allergy and Asthma webinar as we look at the concerns surrounding chronic cough. This webinar will be on November 17 at 04:00 p.m. Eastern Time. You can register for this webinar on our [email protected]. Scroll to the bottom of our homepage to webinars. You can also view our recorded webinars on this page of our website. So please visit our website for quality guidelines based resources on allergy and asthma. Also access important medical information on allergies and asthma from our partners, the American College of Allergy, Asthma and Immunology at Allergy and Asthma relief.org. Thank you once again for joining us today. Please stay online for two to three minutes to complete the evaluation survey. This is Sally Schoessler for the staff at Allergy and Asthma network. Thank you for joining us as we shared important information on a topic dermatitis, and we look forward to having you join us next time on Advances in Allergy and Asthma.
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