THE MANAGEMENT OF

PEDIATRIC ATOPIC DERMATITIS

DINA MUKTIARTI
DEPARTMENT OF CHILD HEALTH
FACULTY OF MEDICINE UNIVERSITAS INDONESIA-
CIPTO MANGUNKUSUMO HOSPITAL, JAKARTA

PKB DEP IKA FKUI-RSCM, 29 MAY 2022

TOPICS

• Background
• Update management
• General rule
• Moisturizer
• Topical treatment
• Others
• Summary
BACKGROUND

• Atopic dermatitis is increasing in prevalence worldwide, with

around 20% of children affected.
• In most developed countries are affected by AD, causing a
significant burden on healthcare resources and quality of life.
• Epithelial barrier dysfunction in AD is a significant risk factor for
the development of epicutaneous food sensitization, food allergy,
and other allergic disorders.

Flohr C, Mann J. Allergy 2014; 69: 3–16.

Nguyen GH, et al. Int J Dermatol. 2019; 58:279–82.
Tham EH, et al. Pediatr Allergy Immunol. 2020;31:7–18
Brough HA, et al. Allergy. 2020;00:1–21.
 280 Review Climate change and atopic dermatitis Nguyen, Andersen, and Davis

WORLDWIDE PREVALENCE
Worldwide OF ATOPIC
prevalence of Atopic DERMATITIS
Dermatitis
W Europe
10–14%
Canada
>14%
Japan
4–6%

US
Palembang, 2017 Mediterranean
(4007
4.8%
subjects): AD China
10-14% prevalence in children aged
Africa
9.5% India
6-7 years 0–3%
Columbia based on ISAAC questionnaire
0.9%
was
24.6% equator
Ecuador
4.4% with severe AD was 0.2%.Asia-Pacific
10.2%
22.5%

Australia
>14%

Nguyen GH, et al. Int J Dermatol. 2019; 58:279–82

Figure 1 Worldwide prevalence of atopic dermatitis Alia M, Muktiarti D, et al. Thesis (unpublished)
 Major Criteria (need three or more of the following):
• Pruritus
• Typical morphology and distribution
Facial and extensor involvement in infants and children iii
Flexural lichenification or linearity in adults
• Chronic or chronically relapsing dermatitis
• Personal or family history of atopy (allergic rhinitis, asthma, atopic dermatitis)

ATOPIC Minor Criteria (need three or more of the following):

• Anterior neck folds

DERMATITIS
• Anterior subcapsular cataracts
• Cheilitis
• Course influence by environmental or emotional factors
C Associated atopic stigmata

DIAGNOSIS:
• Dennie-Morgan infraorbital fold
• Early age of onset
• Food intolerance i ii
• Keratoconus

HANIFIN •
•
Ichtyosis, palmar hyperlinearity, or keratosis pilaris
Immediate skin test reactivity
• Intolerance to wool and lipid solvents

RAJKA •
•
•
Itch when sweating
Nipple eczema
Orbital darkening

CRITERIA •
•
•
Perifolicular accentuation
Pityriasis alba
Raised serum IgE
346

• Recurrent conjunctivitis
• Tendency toward cutaneous infections (especially S. aureus and herpes simplex) or
impaired-cell immunity
• Tendency toward nonspecific hand or foot dermatitis
• White dermatographism or delayed blanch
• Xerosis
ATOPIC DERMATITIS DIAGNOSIS:
WILLIAM CRITERIA

¡ An itchy skin condition (or parental report of scratching or dubbing in a child) plus
three or more of the following minor criteria:
1. a history of involvement of skin creases such as folds of elbows, behind the knees,
front of ankles, or around the neck (including cheeks in children under 10 years of
age);
2. a personal history of asthma/hay fever (or a history of atopic disease in first
degree relatives in children under 4 years of age);
3. a history of generally dry skin in the last 12 months;
4. visible flexural atopic dermatitis (or atopic dermatitis involving the
cheeks/forehead and outer limbs in children under 4 years of age); and
5. onset under the age of 2 years
TYPICAL PRESENTATION OF ATOPIC Managing Atopic Dermatitis

DERMATITIS AT VARIOUS AGES

Figure 1 Typical Presentation of Atopic Dermatitis at Various Ages

Feldman SR, et al. Am Health Drug

Benefits. 2019;12:83-93.
MANAGEMENT OF ATOPIC DERMATITIS –
GENERAL RULE
 Basic therapy avoidance of clinically relevant allergens (encasings, if
diagnosed by allergy tests)

(b) Treatment recommendation for atopic eczema: children

• For every phase, additional therapeutic options should be considered
TREATMENT RECOMMENDATION FOR CHILDREN WITH
• Add antiseptics / antibiotics in cases of superinfection
• Consider compliance and diagnosis, if therapy has insufficient effect

ATOPIC ECZEMA
• Refer to guideline text for restrictions, especially for treatment marked with 1
• Licensed indication are marked with 2, off-label treatment options are marked with 3

SEVERE: Hospitalization, systemic immunosuppression:

SCORAD >50 / or cyclosporine A 3, methotrexate 3, azathioprin 3,
persistent eczema mycophenolate mofetil 1,3

MODERATE: Proactive therapy with topical tacrolimus 2 or class II or

SCORAD 25-50 / or III topical glucocorticosteroids 3, wet wrap therapy, UV
recurrent eczema therapy (UVB 311 nm) 1, psychosomatic counseling,
climate therapy

MILD: Reactive therapy with topical glucocorticosteroids class

SCORAD <25 / or II 2 or depending on local cofactors: topical calcineurin
transient eczema inhibitors 2, antiseptics incl. silver, silver coated textiles

BASELINE: Educational programmes, emollients, bath oils, avoi-

Basic therapy dance of clinically relevant allergens (encasings, if dia-
gnosed by allergy tests)

Wollenberg A, et al. JEADV. 2018; 32: 657–82

Figure 1 Treatment recommendation for adults (a) and children (b) with atopic eczema.
 ACUTE AND
MAINTENANCE
TREATMENTS
FOR ATOPIC
DERMATITIS
ACROSS THE
SPECTRUM OF
DISEASE
SEVERITY

FDA, Food and Drug Administration; TCI, topical calcineurin inhibitor; TCS, topical steroid. aNot an indicated dosage. bFor
FIGURE 2. Step-care management of atopic dermatitis (AD). Acute and maintenance treatments for atopic dermatitis across the
patients aged >2 years with mild-to-moderate AD. cFor adults (aged >18 years) or adolescents (aged 12-17 years) with
spectrum of disease severity. FDA, Food and Drug Administration; TCI, topical calcineurin inhibitor; TCS, topical steroid. aNot an indicated Fishbein AB, et al. J Allergy Clin Immunol Pract.
moderate-to-severe AD not adequately controlled with topical prescription therapies or when those therapies are not
dosage. bFor patients aged !2 years with mild-to-moderate AD. cFor adults (aged !18 years) or adolescents (aged 12-17 years) with 2020;8:91-101.
advisable. dNot FDA- approved for AD. eNot recommended for long-term maintenance.
moderate-to-severe AD not adequately controlled with topical prescription therapies or when those therapies are not advisable. dNot FDA-
BATHING

¡ Bathing is crucial for skin hygiene, and although water is an immediate means of
hydrating the skin, it can act as a drying agent if left to evaporate.
è Therefore, postbath moisturizer use, the so-called soak- and-smear
practice, is generally recommended to reduce this drying effect.
¡ A bath duration of 5-10 minutes once daily is generally recommended.
¡ The use of antiseptics (e.g., chlorhexidine, triclosan and potassium permanganate)
while bathing has not been shown to benefit AD patients.
¡ Use of non-soap cleansers, with low or neutral pH, hypoallergenic, and fragrance free
is recommended.

Cow S, et al.Asia Pac Allergy. 2018;8:e41

LePoidevin LM, et al. Pediatr Dermatol. 2018;1–30
AVOID TRIGGERS

Food
Irritants Aeroallergen
allergens

Infections
MOISTURIZER
MOISTURIZER

¡ Moisturizers come in many formulations, ranging from oils and ointments to lotions
and gels.
¡ Moisturizers are not created with equal component ingredients.
¡ The importance of essential skin barrier repair in atopic dermatitis:
¡ Strengthens the barrier that protects against environmental triggers (e.g., skin
irritants, aeroallergens, dust mites, pet dander).
¡ Decreases moisture loss that perpetuates damage and can provoke inflammatory
processes.
¡ Promotes a healthy microbiome via induction of antimicrobial peptides.
¡ Maintains stratum corneum acidification, which protects against pathogens.
¡ Reduces recurrence of flares when used daily.

Hebert AA, et al. American J Clin Dermatol. 2020; 21:641–55.

MOISTURIZERS
MECHANISM
OF ACTION

Purnamawati S, et al. Clin Med Res. 2017;15(3-

4):75-87
TRADITIONAL VS BIOACTIVE MOISTURIZER

Traditional Bioactive
¡ Replenish intercellular lipid lamella. ¡ Replenish intercellular lipid lamella.
¡ Decreased transepidermal water ¡ Decreased TEWL.
loss (TEWL). ¡ Upregulate lipid synthesis.
¡ Decrease neurosensory
transmission of itch signals.
¡ Reserve oxidative stress.
¡ Decrease inflammatory cell activity.
¡ Modulate skin microbiota
Chandan N, et al. J Cosmet Dermatol. 2021;00:1–6
PRESCRIPTION EMOLLIENT DEVICES (PEDS) CAN AUGMENT
‘UPSTREAM’ AD TREATMENT OPTIONS

¡ PEDs are a new class of topical agents that specifically target defects in skin barrier
function that are observed in AD.
¡ PEDs are different from over-the-counter emollients, as they contain ingredients that
include antioxidants, anti-inflammatory agents, emollients and humectants..
¡ Approved as medical devices based on the assertion that they serve a structural role
in skin barrier function without any chemical action.

Pigatto PD, Diani M. Dermatol Ther (Heidelb) 2018;8:339–47.

COMPONENTS OF RECENTLY DEVELOPED MOISTURIZER

Chandan N, et al. J Cosmet Dermatol. 2021;00:1–6

 FURFURYL PALMITATE, A POTENT ANTIOXIDANT, IS EFFICACIOUS IN TREATING
AD SYMPTOMS IN CHILDREN

In children with AD
between 3 and 11 years
(N=17)1
• Furfuryl palmitate use was
associated with reduced
intensity of blisters,
erythema, dryness,
desquamation and itching
after 48 hours, 7 and 14 days
after initiation of treatment

Bocchietto E et al. Giornale Italiano Di Dermatologia E Venereologia 2002;137:1–13.

FURFURYL PALMITATE HAS EFFICACY APPROACHING
THAT OF CORTICOSTEROIDS IN PATIENTS WITH AD

When tested against

corticosteroids
¡ Patients with AD on their hands were
prescribed either Furpalmate™-
containing cream (n=20) or topical
corticosteroids (n=20)*

Lauriola MM et al. A Single-center, Randomized, Perspective, Investigator Blinded Controlled Trial To Examine Efficacy
And Safety Of A Furpalmate™ Cream In Comparison To Topical Corticosteroid In Atopic Dermatitis Of Hands Of
Hands Of 40 Adult Patients. In: Poster Session 20th EADV Congress, 20–24 October 2011, Lisbon, Portugal.
 EFFICACY OF FURFURYL PALMITATE IN TREATING AD
Disease Test agent Comparison N Study Treatment Results Year
agent design protocol
Atopic dermatitis and pityriasis ARGG27® Placebo 60 RCT BL BID × 30 days Itching and severity significantly reduced in the AR GG27® group 2012
alba paediatri DB compared with placebo group after 15 and 30 days of treatment
c
patients
Atopic dermatitis (33), irritant Superoxidodismut None 60 CT UL BID × 2 weeks Significant improvement of the inflammatory skin conditions, with 2002
and allergic contact dermatitis ase (SOD), 18 paediatri evident and fast inflammation and eczema reduction in all the
(17), miscellaneous pathologies beta glycyrrethic c investigated pathologies
with an inflammatory cutaneous acid, vitamin E, patients
component and symptomatic alpha bisabolol
manifestations such as eczema or and furfuryl
xerosis (10, including 3 palmitate
seborrheic dermatitis and 2
psoriasis)
Atopic dermatitis (40), Superoxidodismut None 64 adult CT UL BID × 2 weeks Efficacy assessed as good or excellent in most of the cases treated; a 2002
seborrheic dermatitis (30), ase (SOD), 18 and 44 significant reduction in erythema, itching and the presence of blisters
allergic contact dermatitis (13), beta glycyrrethic paediatri is obtained just 48 h after starting to apply the product
irritative and irritative contact acid, vitamin E, c
dermatitis (25) alpha bisabolol patients
and furfuryl
palmitate
Atopic dermatitis Emollient cream Emollient 117 RCT BID × 14 days While the emollient cream containing furfuryl palmitate was 2009
enriched with cream paediatri efficacious to a certain extent, the results were less clinically
furfuryl palmitate c relevant than those observed for the same cream not containing the
patients active ingredient
Pigatto PD, Diani M. Dermatol Ther (Heidelb) 2018;8:339–47.
 Number of participants who experienced improvement :
All moisturisers versus vehicle, placebo or no treatment (no moisturiser)

Cochrane Database of Systematic Reviews 2017, Issue

2. Art. No.: CD012119.
 Change from baseline in itch:
All moisturisers versus vehicle, placebo or no treatment (no moisturiser)

Cochrane Database of Systematic Reviews 2017, Issue

2. Art. No.: CD012119.
 Change in disease severity as assessed by the investigators:
All moisturisers versus vehicle, placebo or no treatment (no moisturiser)

Cochrane Database of Systematic Reviews 2017, Issue

2. Art. No.: CD012119.
 Number of participants experiencing a flare:
All moisturisers versus vehicle, placebo or no treatment (no moisturiser)

Cochrane Database of Systematic Reviews 2017, Issue

2. Art. No.: CD012119.
Karagounis TK, et al. Pediatr Dermatol. 2018;1–7.
TRADITIONAL EMOLLIENTS IN ASIA

¡ In Asia, traditional emollients such as virgin coconut oil are used.

¡ In patients with mild to moderate AD, camellia oil has improved itch and
helped reduce the use of medicated topical ointments.
¡ Olive oil reduced the number of Staphylococcus aureus colonies but
caused erythema and reduced stratum corneum integrity.
¡ Virgin coconut oil improved SCORAD, TEWL and skin capacitance
scores, and reduced S. aureus colonization.

Cow S, et al.Asia Pac Allergy. 2018;8:e41

 Moisturizer

Moisturizer should
be given at least
2x/day after taking
the bath (100-200
gram/week for
children).

Cow group
eatment S, et al. Asiainjection
Pac Allergy.
site2018;8:e41
reaction. Three to 5% of dupilumab-treated
LePoidevin
0, or 2 grades LM, et al. Pediatr Dermatol. 2018;1–30
subjects developed conjunctivitis, as compared to 1% in
oup (18–25%). the placebo group. A third phase 3 study consisted of a
TOPICAL TREATMENT
 Steroid Classes and Their Formulations. children and adults but for shorter treatment periods.
Class/Generic Name Formulation Mayba and Gooderham
However, longer term therapy with mid-potency steroids
may be necessary to treat chronic lesions involving the trunk
Class 1: Very high potency and extremities. Ultra-high and high-potency steroids are
Betamethasone dipropionate 0.05% G O (diprolene) indicated for short-term treatment of lichenified areas in
Clobetasol 0.05% C F G L O S adults.38
Diflorasone diacetate 0.05% O Table 2. Topical Calcineurin Inhibitors Available for the
For the application of TCSs, a general rule of thumb sug- affected areas
Topical Calcineurin Inhibitors
Halobetasol propionate 0.05% C O gests that therapy should be initiated with the lowest potency
Class 2: High potency Treatment of Atopic Dermatitis, Their Formulations and
agent that will sufficiently control the disease. However, this parameters w
Amcinonide 0.1% O
Betamethasone dipropionate 0.05% C (diprolene)
Strengths, and Indications for Use.
should be balanced to avoid prolonged use of an agent of
effects. Com51
insufficient potency. For acute flares, TCS application is rec-
Desoximetasone 0.05% G, 0.25% C O
Fluocinonide 0.05% C G O S
ommended daily until the inflammatory lesions are con-
Agent Formulation/Strength Indication pruritus, skin
Topical Corticosteroids
Halcinonide 0.1% C
trolled, for up to several weeks at a time.23 Higher potency
51
Mometasone furoate 0.1% O agents should be used for relatively brief periods (less than 2
weeks of everyday use for class 1 agents), followed by
headache. T
Class 3: High potency Tacrolimus 0.03% O (ages 2+)
switching to lower potency TCSs or other agents for mainte-
Moderate/severe TCI use in th
Amcinonide 0.1% C L
Betamethasone dipropionate 0.05% C (nondiprolene) 0.1% O (ages 15+)
nance after the initial flare is controlled.38 atopic dermatitis
Betamethasone valerate 0.1% O In situations where AD lesion severity must be quickly ing at the app
Pimecrolimus 1% C (ages 2+)
reduced, wet-wrap therapy (WWT) has been shown to be Mild/moderate
Desoximetasone
Diflorasone diacetate
0.05% C
0.05% C useful in the setting of significant flares and recalcitrant dis-
atopic dermatitis
days of contin
ease.23 A topical agent, such as a TCS, is applied and first
Fluticasone propionate
Halcinonide
0.005% O
0.1% O S covered by a wetted layer of gauze followed by a dry second/
It has bee
Triamcinolone
Class 4: Mid-potency
0.1% O outside layer. InAbbreviations: C, cream;
more generalised disease, O, ointment.
clothing prepared
in a similar way can be used instead. This helps occlude the
0.1% is supe
Betamethasone valerate 0.12% F topical agent for increased penetration, while also decreasing reducing the
Topical Phosphodiesterase
or inhaled). Overall, TCSs have4a good
Inhibitors
Fluocinolone acetonide 0.025% O water loss and providing a physical barrier against scratch-
Flurandrenolide 0.05% O ing. The wrap can be worn up to 24 hours at a time, for up 47
intranasally, safety
to efficacy and
Hydrocortisone valerate 0.2% O 2 weeks.43 It should be noted that when using mid- to high- 52
Mometasone furoate 0.1% C 45
profile, and currently there is no indication for monitoring
potency TCSs, care should be taken to avoid the possibility profile.
Triamcinolone 0.1% C
PDE4 side
•of systemic expressed in inflammatory cells,
of hypothalamic-pituitary-adrenal (HPA) axis suppression, 23
Class 5: Mid-potency
Betamethasone dipropionate 0.05% L
effects for patients with AD using TCSs.
although short courses of WWT have not been associated
with prolonged adrenal suppression.44 TCSs can cause cuta-
Betamethasone valerate
Fluocinolone acetonide
0.1% C
0.025% C including AD.
neous side effects, including purpura, telangiectasia, striae,
focal hypertrichosis, and acneiform or rosacea-like erup-
Medical Th
Fluticasone propionate 0.05% C

•Medical Therapy—Topical CalcineurininInhibitors

tions. The most concerning of these effects, however, is skin
Flurandrenolide
Hydrocortisone butyrate
0.05% C
0.1% C Crisaborole was approved
atrophy, which can occur with any TCS, but more so in December
higher potency agents with occlusion, on thinner skin and in
TCIs and TC
Hydrocortisone valerate 0.2% C Traditionally
Class 6: Low potency
Alcometasone dipropionate 0.05% C O
2016
Topical for theinhibitors
calcineurin treatment(TCIs)ofincluding
mild to
older patients.45 TCSs may also exacerbate preexisting or
coexisting dermatoses, such as rosacea, perioral dermatitis,
tacrolimus
a 4- to 7-day
and pimecrolimus are invaluable second-line agents to TCSs.
and tinea infections.38 Some patients can develop allergic
Betamethasone valerate
Desonide
Fluocinolone acetonide
0.1% L
0.05% C L O
0.01% C S
moderate AD for
in the
patients >treatment
2 yearsof old
contact dermatitis/type IV hypersensitivity to TCSs or other
They are both approved short-term
ingredients in their formulations, such as propylene glycol active lowed by app
Class 7: Low potency and preservatives.23 In the event the patient’s lesions fail to
AD lesions and tacrolimus also for chronic maintenance delay the on
Hydrocortisone acetate 0.5% C L O, 1% C O F C,respond
cream; F, foam;
or worsen with TCSG, application,
gel; L, lotion; O, ointment;
patch testing should S, solution.
Hydrocortisone hydrochloride 0.25% C L, 0.5% C L O be done to determine if the allergen 31 is the TCS itself or a
treatment. TCIs inhibit the transcription of proinflamma- increasing ev
S, 1% C L O S, 2% L, component of the vehicle.46 Although documented in sys-
2.5% C L O S
tory cytokine genes, such as IL-2, which are dependent on
temic corticosteroid use, the association between TCSs and to control the
Mayba JN, Gooderham MJ. J Cutan Med Surg.2017;21:227-36.
the development of cataracts and glaucoma is not clear.
 GUIDE TO SITE-BASED TOPICAL THERAPIES FOR AD
patients,105,106 so physicians often
fear long-term TCS effects such as
skin atrophy, striae development, or
systemic effects. This has resulted
in an increased use of second-line
treatments, such as the topical
calcineurin inhibitors (TCIs) tacrolimus
and pimecrolimus, in the management
of pediatric AD.107 However, TCIs are
associated with increased rates of
burning sensations and pruritus and
have higher costs, with no additional
benefit over TCSs with respect to long-
term safety or efficacy.101 Thus, TCSs,
when used appropriately, are a safe
and effective first-line option for the
treatment of pediatric AD.82,108

As the underlying mechanisms of

AD have become better understood,
new topical therapies have been
developed for AD, most notably
crisaborole. Crisaborole is a topical Yang EJ, et al. Pediatrics. 2018;142:e20181102
TOPICAL CORTICOSTEROID

¡ TCS is recommended for short-term use because of potential side effects.

¡ Twice daily application for not more than 3 weeks is effective in most patients
¡ The right choice of topical formulation ensures better treatment outcome.
¡ Lotion and gel should be used in acute eczema with exudation and blisters, and to
hairy regions.
¡ Ointment is used for thick, dry areas, and to palms and soles.
¡ Cream can be used on all areas.

Cow S, et al. Asia Pac Allergy. 2018;8:e41

 Time to relapse; children; all severities

Number of participants with one or more relapses; all

severities; split by age
Weekend therapy versus no topical
corticosteroid (TCS)/ reactive
application

Cochrane Database of Systematic Reviews 2022, Issue 3. Art. No.: CD013356.

OTHERS
WET WRAP THERAPY

¡ A treatment modality using layers of bandages,

cotton clothing, or gauze over or together with
topical medication.
¡ WWT is well tolerated in eczema treatment
due to the cooling, antiinflammatory, and
antipruritic properties on the skin.
¡ Itch is reduced by cooling through
vasoconstriction.
¡ WWT increases skin hydration and
decreases TEWL.
¡ WWT protects the skin as a barrier against
external irritants and allergens.
Fig. 2. (A) Supplies for WWT. (B) Topical steroids applied to affected lesions. (C) Wet socks to
Nicol NH, Boguniewicz M. Immunol Allergy Clin N Am. 2017;37:123–39
eczema of extremities. (D) Wet pajamas to eczema of trunk. (E) Dry layer applied over wet
INTERNATIONAL GUIDELINES ON WWT FOR AD

• Wet wrap therapy can be implemented for recalcitrant AD and flares.

• The U.S. guidelines recommend the wrap be worn for several hours (up to 24)
depending on the patient's tolerance.
• The British, Italian, European, and Polish guidelines stated that daily WWT with
TCS application should be limited to 14 days, whereas the Singaporean
guidelines recommend limiting it to 7 days.
• Each supporting guideline warns against possible increase in TCS absorption
with WWT.

LePoidevin LM, et al. Pediatr Dermatol. 2019;36:36–65.

ANTIPRURITIC THERAPY

¡ Antipruritic therapy in AE is multidimensional treating the symptom

itself.
¡ Multiple contributing factors:
¡ Dry skin
¡ Inflammation
¡ Related scratch lesions.
è several general measures should be
recommended
 Cochrane Trusted evidence.
Informed decisions.
 
 
Library Better health. Cochrane Database of Systematic Reviews

[Intervention Review]

Oral H1 antihistamines as ‘add-on’ therapy to topical treatment for

eczema

Uwe Matterne1, Merle Margarete Böhmer1, Elke Weisshaar2, Aldrin Jupiter2, Ben Carter3, Christian J Apfelbacher1

1Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany. 2Department
of Clinical Social Medicine, Heidelberg University Hospital, Heidelberg, Germany. 3Biostatistics and Health Informatics, King's College
London; Institute of Psychiatry, Psychology & Neuroscience, London, UK

Contact address: Christian J Apfelbacher, Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg,
Regensburg, Germany. christian.apfelbacher@klinik.uni-regensburg.de, capfelbacher@gmail.com.

Editorial group: Cochrane Skin Group

Publication status and date: New, published in Issue 1, 2019.

Citation: Matterne U, Böhmer MM, Weisshaar E, Jupiter A, Carter B, Apfelbacher CJ. Oral H1 antihistamines as ‘add-on’
therapy to topical treatment for eczema. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD012167. DOI:
10.1002/14651858.CD012167.pub2.

Copyright © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

Background
The symptoms of eczema can lead to sleeplessness and fatigue and may have a substantial impact on quality of life. Use of oral H1 an-
Matterne U, et al. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD012167. DOI: 10.1002/14651858.CD012167.pub2.
tihistamines (H1 AH) as adjuvant therapy alongside topical agents is based on the idea that combining the anti-inflammatory effects of
RECOMMENDATIONS

• Topical corticosteroids are recommended to control pruritus in the initial phase of

AD exacerbation. (1a,A)
• Topical calcineurin inhibitors are recommended to control pruritus in AD until
clearance of eczema. (1a,A)
• There is not enough evidence to support the general use of both first- and second-
generation H1R antihistamines for the treatment of pruritus in AD.
• These may be tried for the treatment of pruritus in AD patients, if standard
treatment with TCS and emollients is not sufficient. (1b, A)
• Long-term use of sedative antihistamines in childhood may affect sleep quality and is
therefore not recommended. (-,D)
Wollenberg A, et al. JEADV. 2018; 32: 657–82
SYSTEMIC THERAPY FOR TREATMENT OF MODERATE-TO-SEVERE AD
Corticosteroid Cyclosporine A Methotrexate Azathioprine Mycophenolic acid
Starting dose Variable 5 mg/kg/day 5 mg/week 50 mg/day MMF: 1000-2000
children Prednisolone 0.2- mg/day; EC-MPA:
0.5 mg/kg/ day 1440 mg/day
Maintenance dose As little as possible 2.5-3 mg/kg/day Increase 2.5-5 2-3 mg/kg/day MMF: 2000 mg/day;
children mg/week until EC-MPA: 1440
effect mg/day
Time for response Days 2 weeks 12 weeks 8-12 weeks 12 weeks
Adverse effects Diabetes, Nephrotoxicity, Liver dysfunction, Gastrointestinal Gastrointestinal
hypertension, hypertension, gastrointestinal disturbances, liver disturbances, fatigue,
gastric ulcer, tremors, headache, complaints, dysfunction and liver dysfunction,
osteoporosis, paresthesia, hematological leucopenia hematological
glaucoma, and nausea, diarrhea, abnormalities, abnormalities, flu-like
Cushing syndrome myalgia, pulmonary toxicity, syndrome
hyperkalemia, etc fatigue, headache
Laboratory control Blood count, blood Blood count, Blood count, liver Leukocyte count,
glucose Monoclonal antibody:
creatinine, urea, enzymes liver enzymes
cholesterol,
Dupilumab (blocks IL-4 related to IL-13 signaling).
triglycerides,
electrolytes
Time for relapsing Days <2 weeks > 12 weeks > 12 weeks > 12 weeks
Giavina-Bianchi M, Giavina-Bianchi P. Archivum Immunologiae et Therapiae Experimentalis.2019;67:69–78.
 75

SKIN INFECTION IN AD
75

r atopic diseases (food al-

ased risk for EH [23•]. EH
(EC). This condition can also present with extensive vesicles
and skin breakdown. However, EC is not life-threatening and
Bacterial infection Viral infection Fungal infection
pes simplex virus (HSV). can be managed following standard treatments for AD. EC is
de presence of vesicles, clinically significant in that it may be a differential diagnosis

• Majority of skin • Major infectious • Malassezia

agic crusts. The skin may of EH. In some EC patients, the signs of hand-foot-mouth
may be widespread (Fig. 2) disease may be present. In others, a predilection of EC lesions
considered in AD patients on the buttock areas may be distinct, since these are not com-
do not respond to systemic
isseminated vesicles with
n more serious complica-
mon areas for AD.
infection is caused complication of AD colonization drives
and meningitis. HSV ex-
ertheless, EH only affects
Management and Therapeutic Approaches
by S. aureus, is eczema inflammation in AD
immunological and genet-
tients more susceptible to
Preventive management of infectious complications in AD
primarily involves control of AD flares. To prevent AD flares,
patients should avoid irritants and allergens that may trigger
followed by S. herpeticum. in a subset of
ents can present with
as eczema coxsackium
AD, including soaps and detergents with fragrances. Wool
clothing can also be a significant irritant for AD patients. In pyogenes or a • Characteristics: patients who
atopic diseases (food al-
sed risk for EH [23•]. EH
(EC). This condition can also present with extensive vesicles
and skin breakdown. However, EC is not life-threatening and
mixture of both S. presence of vesicles, typically have
pes simplex virus (HSV).
e presence of vesicles,
gic crusts. The skin may
can be managed following standard treatments for AD. EC is
clinically significant in that it may be a differential diagnosis
of EH. In some EC patients, the signs of hand-foot-mouth
aureus and S. punched-out dermatitis in the
ay be widespread (Fig. 2)
considered in AD patients
disease may be present. In others, a predilection of EC lesions
on the buttock areas may be distinct, since these are not com- pyogenes. erosions, or areas with a high
density of
o not respond to systemic mon areas for AD.
sseminated vesicles with
n more serious complica- • Characteristics: hemorrhagic crusts,
and meningitis. HSV ex-
ertheless, EH only affects
mmunological and genet-
Management and Therapeutic Approaches
weeping, honey- pruritic or painful, sebaceous glands
(e.g., head, neck,
Preventive management of infectious complications in AD
ients more susceptible to primarily involves control of AD flares. To prevent AD flares,
patients should avoid irritants and allergens that may trigger colored crusts, and • and lesions may be
ents can present with
as eczema coxsackium
AD, including soaps and detergents with fragrances. Wool
clothing can also be a significant irritant for AD patients. In
pustules widespread. and upper chest and
back)

Chan G, Ong PY. Curr Dermatol Reports.2019;8:73–9

 Concern for skin
infection in AD

MANAGEMENT OF
Minor: consider
topical antibiotic for
5-7 days
More severe or
widespread BACTERIAL
INFECTIONS IN
ATOPIC
Outpatient or without overt sign of Signs of deep skin and soft
If unresponsive deep tissue infections (e.g. cellulitis
or abscess)
tissue infection or systemic signs
of infection DERMATITIS

Consider hospitalization and

Consider beta lactam empiric coverage for MRSA,
antibiotics consider wound culture for
antibiotics susceptibility

Chan G, Ong PY. Curr Dermatol Reports.2019;8:73–9

EPICUTANEOUS SENSITIZATION IN ATOPIC DERMATITIS
AND INTERVENTION STRATEGIES
THAM eT Al. |       9

Tham EH, et al. Pediatr Allergy Immunol. 2020;31:7–18

SUMMARY

• Skin barrier abnormalities have been suggested to play an essential role in

initiation of early atopic dermatitis.
• Comprehensive management of AD including emollients, anti-
inflammatory therapy, systemic therapy (if needed), prevent and manage
skin infection, avoidance of irritants/allergens and education.
• Restoring the skin barrier and treating atopic dermatitis would have
beneficial effects on prevention of further allergic diseases.
THANK YOU