LAS VEGAS – In the treatment of eczema, the gap between evidence and practice can be broad.
Dermatologists who treat atopic dermatitis confront many challenges – patients may be severely atopic, have a hard time being compliant with therapies, and have frequent recurrences, Dr. Robert Sidbury said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar. “It just is not easy,” he said.
Dr. Robert Sidbury
However, even for challenging patients, physicians should be mindful of evidence-supported treatments and be attentive to practice gaps, said Dr. Sidbury, chief of the division of dermatology at the University of Washington’s Seattle Children’s Hospital.
Though the field is rapidly changing, the American Academy of Dermatology has issued practice guidelines that can help guide clinical treatment decisions, said Dr. Sidbury, who helped develop the AAD guidelines. He noted that prescribers may eventually feel the pain of the practice gap if AMA-driven performance measures are enforced.
At the meeting, Dr. Sidbury discussed areas in which many clinicians may have a practice gap in the treatment of eczema. Topping the list of non–evidence-based eczema care are overuse of steroids, oral antibiotics, and nonsedating antihistamines.
Practice gap: Many clinicians believe that topical steroids are more effective for atopic dermatitis when used twice daily.
Reality: “Randomized, controlled trials and a systematic review suggest that there is no benefit to twice-daily use of steroids,” over once-daily use, Dr. Sidbury said, though he admitted that he’s having a hard time breaking his own longstanding practice habit of prescribing twice- rather than once-daily dosing of topical corticosteroids. He pointed out that Dr. Hywel Williams, the director of the University of Nottingham’s Center of Evidence-Based Dermatology, England, calls this the “lowest-hanging fruit” in terms of cost savings, safety, and convenience to patients.
Practice gap: Unnecessary skin cultures can lead to overuse of systemic antibiotics in atopic dermatitis.
Reality: Colonization with Staphylococcus aureus occurs in more than 90% of adults with atopic dermatitis, but the vast majority of these patients are not infected. “Except for bleach baths in concert with intranasal mupirocin, no topical antistaphylococcal treatment has been shown to be clinically helpful in patients with atopic dermatitis,” Dr. Sidbury said.
“How do we know when eczema is infected? We know it when we see it. You are best served by using your clinical gestalt,” he added. Eczematous skin presents along a continuum, ranging from erythema, scaling, and crusting, to a frankly purulent appearance with clear infection, and clinical presentation and judgment should guide treatment. Barring frank infection, the evidence doesn’t support use of systemic antibiotics (Br J Dermatol. 2010 Jul;163 [1]:12-26).
Practice gap: Many patients with atopic dermatitis receive nonsedating antihistamines for itching.
Reality: There is no evidence that nonsedating antihistamines are beneficial unless the patient has concurrent rhinoconjunctivitis, so data don’t support their use “for the actual itch of eczema,” Dr. Sidbury said. In fact, the AMA-sponsored Physician Consortium for Performance Improvement nearly passed an overuse measure that would have penalized the prescription of nonsedating antihistamines in this setting, he said.
Practice gap: Systemic immunomodulatory therapy is used for pediatric atopic dermatitis, despite the lack of data that provide clear guidance.
Reality: The landscape here is a little more complicated, according to Dr. Sidbury. Among the systemic immunosuppressants, cyclosporine, methotrexate, azathioprine, and mycophenolate have the most evidence backing their use. However, there remains a lack of comparative studies and a lack of studies evaluating these therapies in the pediatric population, he said.
In general, Dr. Sidbury said that systemic therapy for atopic dermatitis is indicated only when control is inadequate despite truly optimized topical care, and the condition is having a “significant negative physical, psychological, or social impact” on the patient. Before beginning these potent systemic therapies, it’s important to assess that the patient and family are truly adherent to the topical treatment regime, and that adjunctive treatments like wet wraps and strict allergen avoidance are being followed. The Food and Drug Administration is beginning to include pediatric patients in clinical trials of systemic therapy for atopic dermatitis, so the quality of data should improve.
If systemic therapy is initiated, some clinical pearls can guide use, he said. Cyclosporine has the quickest onset of action and can be dosed at 3-6 mg/kg per day, divided into twice daily dosing. The maximum dose is 300 mg/day, and the microemulsion form is preferred. Overall, mycophenolate is the best-tolerated immunosuppressive. If methotrexate is chosen, it should be dosed at 0.2-0.7 mg/kg per week; liver function should be checked at 5-7 days after dosing, since methotrexate can cause a transient transaminitis. There are no standard recommendations to guide if or when to do liver biopsy recommendations in children receiving methotrexate. (J Am Acad Dermatol. 2014 Aug;71[2]:327-49).