Guidelines on the Management of Atopic Dermatitis ... - Dermatology

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In adults with head and neck dermatitis a positive ImmunoCAP assay to Malassezia species may be useful as such patients may benefit from treatment with oral anti-yeast treatment. 1,2 Patch tests involve formal patch testing to diagnose superimposed allergic contact dermatitis, e.g. in adult patients with chronic hand dermatitis. The aetiology of the continuing dermatitis is elucidated. 1 Formal patch tests are also useful for deteriorating dermatitis that is being intensively treated. The patient may have an allergic contact dermatitis to one of the components of the current topical treatment. 1 The Atopy Patch Test (APT) is used to diagnose type IV hypersensitivity reactions and is used to determine food and aeroallergen triggers for dermatitis. It is a specialised, timeconsuming procedure that is highly specific. but has lower levels of sensitivity. 6 It is not often used in adults with atopic dermatitis. 1,2,5,6 If immunodeficiency is suspected with atopic dermatitis, tests like HTLV-1, HIV, immunoglobulin subtypes, T and B cell numbers and functions will need to be done. If secondary bacterial infections are suspected, pus swabs will be necessary. For suspected herpes infection a Tzanck smear, an immunofluorescence slide test or electron microscopy will give a quick confirmation. 1 References 1. Friedmann PS, Arden-Jones MR, Holden CA. Atopic Dermatitis. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook‟s Textbook of Dermatology. 8th ed. West Sussex: Wiley Blackwell Publishers; 2010.P.24.27-24.28 2. Katsarou A, Armenaka MC. Atopic dermatitis in older patients: particular points. J Eur Acad Dermatol Venereol 2011;25(1):12-8 3. M. Amarasekera. Immunoglobulin E in health and disease. Asia Pac Allergy 2011; 1(1):12-5 4. Čelakovská J, Ettlerová K, Ettler K, Vaněčková J. Egg allergy in patients over 14 years old suffering from atopic eczema. Int J Dermatol 2011;50(7):811-8 5. Suh KY. Food Allergy and Atopic Dermatitis: Separating Fact from Fiction. Semin Cutan Med Surg 2010;29(2):72-8 6. Čelakovská J, Ettlerová K, Ettler K, Vaněčková J. Atopy patch test in diagnosis of food allergy to egg in adult patients suffering from atopic eczema. Three case reports. Acta Medica (Hradec Kralove) 2011;54(1):29-35 7. Bath-Hextall F, Delamere FM, Williams HC. Dietary exclusion for improving established atopic eczema in adults and children: systematic review. Allergy 2009;64(2):258-64 Prevention of atopic dermatitis Prevention of atopic dermatitis, next to a cure for the condition, would be first prize for practitioners treating and researching this condition. Many exciting strategies for prevention are being investigated, but need further research. Our existing advice has not met with much progress in the last decade of investigation. Primary prevention Attempts to provide allergen-free diets to pregnant mothers, so popular in the early 1990s, have failed to prevent the development of allergy or atopic dermatitis. Food allergen avoidance during pregnancy and early life is unhelpful; in fact, it may even promote atopy. 1 Allergen avoidance in breastfeeding mothers (avoiding potentially allergenic foods), even in the case of high-risk infants, is unhelpful. 2 [1+;A] Cigarette exposure is now
conclusively linked to atopic aetiology and it is a major factor in cause of flares of dermatitis. 3,4 [1-;B] Whilst all components of the “hygiene hypothesis” may contribute to a rising prevalence of allergic disorders, it must be remembered that they are epidemiologically linked to atopy, but would certainly not be important or useful in individual families. Such factors include birth by vaginal delivery, living on a farm, reduced consumption of antibiotics in infants, living in less hygienic circumstances, day-care attendance and living within the context of more siblings. 5 The current role of probiotic supplementation is unclear. [1++; 0] Unfortunately, there are studies supporting benefit of probiotics in prevention, 6,7,8 and studies that fail to support benefit. 9,10,11 The ultimate answer to the probiotic strategy may well depend on actual bacterial strains (not all organisms have equal benefit), dose, viability and timing of intervention. There is insufficient evidence at present to give a clear recommendation. The role of breastfeeding is also unclear. Studies of exclusive breastfeeding are equivocal in their findings. 12,13,14 There is now mounting evidence that the most valuable allergy prevention strategy is four months of exclusive breastfeeding, followed by weaning between four and six months of age, to a diet that incorporates gradual and consistent introduction of a wide range of foods – even those known to be allergenic (cow‟s milk, egg, peanuts, wheat and fish). 15,16 [1++; A] In high-risk infants who cannot be breastfed, there is evidence that hypo-allergenic milk formulae may be beneficial. 17,18 [2+; B] These include partially hydrolysed whey formulae and extensively hydrolysed casein- and whey-based formulae. Where cost is an important consideration, there is one study that has documented the benefit of partially hydrolysed whey milk. 18 There is evidence that omega-3 polyunsaturated fatty acids (n-3 PUFA) supplementation during pregnancy will reduce some food allergy sensitivities, 19 however, this effect was not seen for supplementation of maternal diet during lactation. 19 [2+; C]There is no clear evidence for prevention of atopic dermatitis by supplementing the neonatal or infant diet with n-3 PUFA. 20 Primary Prevention of Atopy: The only practical advice that can be given to the parents of soon-to-be born or newborn high-risk infants is to exclusively breastfeed for the first four months of life and not to smoke during pregnancy or around young children. Secondary prevention – prevention of the atopic march The administration of newer anti-histamines to clearly atopic infants with dermatitis had initially shown some promise in the overall prevention of asthma, but this is no longer the case. The ETAC study found that a sub-set of atopic infants had a reduced prevalence of wheeze after receiving cetirizine 21 . A study of levocetirizine for asthma prevention, however, failed to provide benefit. 22 [2+; B]Specific immunotherapy shows promise, but is clearly impractical unless orally available. 23 Newer immunotherapy vaccines, and especially those that include bacterial products, are showing promise. 23 [3; C]The role of probiotics in secondary or tertiary prevention is unclear. 24 The use of aqueous creams on the skin of newborn infants has been linked to an increased rate of dermatitis in children. 25 [3; B] Tertiary prevention
Page 1 and 2: Guidelines on the
Page 3 and 4: A systematic review of RCTs or a bo
Page 5 and 6: also by phenotyping characterisatio
Page 7 and 8: dermatitis of 0.75 for monozygotic
Page 9 and 10: Breastfeeding Allergen exposure: -
Page 11 and 12: 32. Kolmer H, Platts-Mills TAE. The
Page 13 and 14: documented an increased one-year pr
Page 15 and 16: Food allergy in atopic dermatitis:
Page 17 and 18: Immediate (IgE mediated) hypersensi
Page 19 and 20: approximately 25% of patients will
Page 21 and 22: These criteria are set out as follo
Page 23: 7. Chalmers DA, Todd G, Saxe N, et
Page 27 and 28: 17. Iskedjian M, Szajewska H, Spiel
Page 29 and 30: A more recent review on the use of
Page 31 and 32: Laundry practices Patients are ofte
Page 33 and 34: Psychosocial factors [1+; B] Althou
Page 35 and 36: Emollients are universally recommen
Page 37 and 38: Advise parents or carers of childre
Page 39 and 40: Table 6: The available TCS formulat
Page 41 and 42: In South Africa, tacrolimus is regi
Page 43 and 44: 27. Kyllonen H , Remitz A, Mandelin
Page 45 and 46: In the absence of defined protocols
Page 47 and 48: Adolesc Med. Basel, Karger, 2011;15
Page 49 and 50: A. Phytotherapy Chinese herbal medi
Page 51 and 52: 1. Hughes R, Ward D, Tobin AM, Keeg

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