Disease Overview

AD can start early, with ~90% of cases presenting by the age of 5. And as a relapsing condition for which there is no cure, many pediatric cases may continue through adulthood.1

Pruritus is the hallmark symptom of atopic dermatitis1

Mechanism of Disease

Atopic dermatitis is a complex disease with genetic, immune, and environmental factors all thought to contribute to chronic inflammation.1

Consider the skin. With AD, the current paradigm suggests skin barrier dysfunction result in an immune response primarily driven by the type 2 inflammatory pathway.1

Inflammatory type 2 cytokines increased in AD include IL-4, IL-5, IL-13, and IL-311

Aggravating factors

Tobacco smoke and pollutants are associated with disease development. Dry weather and hot showers that result in transepidermal water loss, a hallmark of AD, may also exacerbate disease.1

Diagnosis & Management

Given there are no specific diagnostic tests for AD, healthcare professionals must rely on clinical measures to diagnose and assess disease severity and treatment outcomes.2

Two clinical measures recommended by Canadian guidelines are the Physician Global Assessment (PGA) and the Body Surface Area (BSA).2

PGA:
Assesses overall disease severity at a given timepoint on a 5- or 6-point severity scale from clear to very severe disease2

BSA:
A simple measure of percent body surface area involved with atopic dermatitis that does not incorporate disease severity2

Eczema Area and
Severity Index (EASI)

In addition to above measures, physicians should be able to administer the EASI.2

The EASI is a validated tool that measures the disease extent (7-point scale) and severity (four clinical signs; 4-point scale) across four defined body regions. The four clinical signs evaluated are erythema, induration/papulation, exorciation, and lichenification. Scores for each region are then combined for a maximum of 72 points.2

Download a simple EASI calculator here

Therapies for AD include moisturizers, topical corticosteroids, and topical calcineurin inhibitors (TCI).3,4

Considerations

Hydrophilic moisturizers without added fragrances or preservatives are recommended3

Daily bathing in lukewarm water for a maximum of 10 minutes is recommended (evidence is scarce; water may impair skin barrier). Avoid alkaline soaps and ensure to moisturize after3

Protopic Safety Information

Indications and clinical use:
Treatment: Protopic®, both 0.03% and 0.1% for adults and only 0.03% for children aged 2 to 15 years, is indicated as a second-line therapy for short- and long-term intermittent treatment of moderate to severe atopic dermatitis in non-immunocompromised patients, in whom the use of conventional therapies are deemed inadvisable because of potential risks, or who are not adequately responsive to or intolerant of conventional therapies.

Maintenance: Protopic® is also indicated for maintenance therapy to prevent flares and prolong flare-free intervals in patients with moderate to severe atopic dermatitis experiencing a high frequency of flares (i.e., occurring 5 or more times per year) who have had an initial response (i.e., lesions cleared, almost cleared or mildly affected) with up to 6 weeks of treatment with twice-daily Protopic®.

Most serious warning and precautions:
Risk of skin malignancy and lymphoma: Long-term safety of topical calcineurin inhibitors has not been established. Although causal relationship has not been established, rare cases of skin malignancy and lymphoma have been reported in patients treated with topical calcineurin inhibitors, including Protopic® ointment 0.1% and 0.03%. Therefore:

● Continuous long-term use of Protopic® ointment should be avoided and application limited to areas of involvement with atopic dermatitis
● Protopic® ointment is not indicated in children less than 2 years of age. Only 0.03% Protopic® ointment is indicated for use in children 2-15 years of age

Other relevant warnings and precautions:
● Risk of skin burning (burning sensation, stinging, soreness) or pruritus
● Risk of infections
● Avoid use on pre-malignant and malignant skin conditions
● Do not use in immunocompromised adults and children
● Discontinue use in patients who do not improve within 6 weeks of twice-daily treatment
● Risk of lymphadenopathy
● Risk of acute renal failure
● Risk of varicella zoster virus infection (chickenpox or shingles), herpes simplex virus infection or eczema herpeticum
● Minimize or avoid natural or artificial sunlight exposure
● Risk of increased systemic absorption in patients with a skin barrier defect
● Use in pregnant and nursing women

For more information:
Please consult the Product Monograph at https://health-products.canada.ca/dpd-bdpp/index-eng.jsp for more important information relating to adverse reactions, drug interactions, and dosing/administration information which have not been discussed in this piece. The Product Monograph is also available by calling LEO Pharma Medical Information at 1-800-263-4218.

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References:

  1. Kirchhof MG, Landells I, Lynde CW, et al. Approach to the Assessment and Management of Adult Patients With Atopic Dermatitis: A Consensus Document. Section I: Pathophysiology of Atopic Dermatitis and Implications for Systemic Therapy. J Cutan Med Surg 2018;22(1_suppl):6S-9S.
  2. Gooderham MJ, Bissonnette R, Grewal P, et al. Approach to the Assessment and Management of Adult Patients With Atopic Dermatitis: A Consensus Document. Section II: Tools for Assessing the Severity of Atopic Dermatitis. J Cutan Med Surg 2018;22(1_suppl):10S-16S.
  3. Dhadwal G, Albrecht L, Gniadecki R, et al. Approach to the Assessment and Management of Adult Patients With Atopic Dermatitis: A Consensus Document. Section IV: Treatment Options for the Management of Atopic Dermatitis. J Cutan Med Surg 2018;22(1_suppl):21S-29S.
  4. Hong CH, Gooderham MJ, Albrecht L, et al. Approach to the Assessment and Management of Adult Patients With Atopic Dermatitis: A Consensus Document. Section V: Consensus Statements on the Assessment and Management of Adult Patients With Moderate-to-Severe Atopic Dermatitis. J Cutan Med Surg 2018;22(1_suppl):30S-35S.
  5. Hanifin JM, Ling MR, Langley R, Breneman D, Rafal E. Tacrolimus ointment for the treatment of atopic dermatitis in adult patients: part I, efficacy. J Am Acad Dermatol. 2001;44(1 Suppl):S28-38.