Reports

This report is based on medical evidence presented at sanctioned medical congress, from peer reviewed literature or opinion provided by a qualified healthcare practitioner. The consumption of the information contained within this report is intended for qualified Canadian healthcare practitioners only.

PRIORITY PRESS - 88th Canadian Paediatric Society Annual Conference

Québec City, Québec / June 15-18, 2011

Chief Medical Editor: Dr. Léna Coïc, Montréal, Québec

Education is the most important tool physicians have in their armamentarium when treating children and adolescents with eczema (atopic dermatitis). Among the first lessons that patients need to learn is that eczema can be controlled but not eradicated. “We have to get the concept across that the better we control the eczema, the easier it will be to maintain that control in the long term. We’ve got to try and stop the flare before it happens,” Dr. James Bergman, Clinical Assistant Professor of Dermatology, University of British Columbia, Vancouver, told delegates here at the CPS. Physicians also need to better convey the idea that some topical steroids are mild while others are very potent and that it can be to the patient’s detriment if they use a steroid that is not sufficiently potent.

“The other concept that patients have to be educated about is percentage,” Dr. Bergman continued. Patients believe that a steroid such as hydrocortisone 2.5% has to be stronger than clobetasol propionate 0.05% when in fact, the first is a Class 7 steroid (least potent of all) and the latter a Class 1 steroid (superpotent).

Dr. Bergman added, “Many patients want you to use steroids as a last resort—they know they work—but they are concerned about side effects (SEs).” In fact, according to a Food and Drug Administration (FDA) market survey, SEs from steroids occur a mean of 169 days after onset of use, “so you have to use steroids for a long time before these reactions are reported,” he told delegates. The SEs being reported are often with potent combinations of agents and they frequently involve events such as local irritation or dyspigmentation, which cannot be attributed to the steroid. “Used appropriately, the risk of systemic and local SEs from topical steroids is quite rare,” Dr. Bergman emphasized. Most patients also use their medication only when the disease flares and then they will use it for a day.

“What you have to say is, if you treat the flare earlier—at the very first sign of itch or erythema—you can use less of the medication and you will get your eczema under control,” Dr. Bergman suggested. He also revealed that he tells patients that he wants them off the medication more often than they are on; if that is not happening, “they have to come back to see me.” Physicians should demonstrate how much medication patients need to apply and to make sure they apply enough to be therapeutic. And because compliance typically falls after each patient visit and improves prior to a repeat visit, “getting patients to see you every week will improve compliance and subsequent disease control,” he stated.

Alternative Eczema Treatments

Among the alternative treatments for eczema is what Dr. Bergman refers to as a “swimming pool” bath. Many patients with eczema are chronically infected with Staphylococcus aureus and several studies have found that bleach baths decrease colonization of S. aureus. The formula is simple: 1 tablespoon of bleach for each gallon of water. Children sit in the bath for 5 to 10 minutes, and then parents must apply both moisturizer and their medication. “For patients who are recurrently infected, these baths can help,” he noted.

Another alternative to topical steroids are topical barrier repair emulsions. “We know that there is immune dysregulation in eczema and research is increasingly showing there is also skin barrier dysfunction,” Dr. Bergman explained. Environmental triggers can disrupt the skin barrier and when the barrier is disrupted, microbes, irritants and allergens penetrate the skin and the skin itself loses water. “This in turn causes inflammation and inflammation causes further barrier disruption, itching and worsening eczema so it feeds into itself,” Dr. Bergman observed.

Several barrier therapeutics now exist, one of which is a ceramide-dominant, physiologic lipid-based topical barrier repair emulsion (EpiCeram). In one study comparing the emulsion to fluticasone propionate 0.05% cream, Sugarman and Parish (J Drugs Dermatol 2009;8(12):1106-11) reported that at 14 days, the mean reduction in Severity Scoring for Atopic Dermatitis (SCORAD) scores was significantly greater in the fluticasone-treated group. However, at 28 days, there was no difference between the emulsion group and the steroid group.

In a subsequent study (J Clin Aesthet Dermatol 2011;43(3):34-40), 207 patients with mild to moderate atopic dermatitis (AD) were given the same emulsion for 3 weeks, with an option to use another AD medication if their AD was not adequately controlled by the emulsion alone. Seventy-one per cent of participants completed the study using only the emulsion. At week 3, 54% of all patients were clear or almost clear and were considered a treatment success. There were no differences in success rates between those who used the emulsion alone and those who used additional AD treatment, although a greater proportion of patients with mild AD achieved success (62%) than those with moderate disease (46%). Approximately three-quarters of both patients and investigators reported they were satisfied with the treatment and both pruritus and quality of life (QoL) improved during the study.

“I think this category of medication is an extra tool that you can use in your tool belt for eczema, especially if patients are afraid of steroids and want to have other alternatives,” Dr. Bergman observed.

Head Lice and Bed Bugs

Dr. Danielle Marcoux, Clinical Associate Professor of Paediatrics, CHU Sainte-Justine, Université de Montréal, Québec, noted that both pyrethrin- and permethrin-based agents are neurotoxic to lice and are widely used to treat head lice today. However, as she also pointed out, widespread use of these neurotoxic pediculicides has led to resistance. In an effort to determine resistance rates among head lice in Canada, Dr. Marcoux and colleagues collected head lice from infested patients from Ontario, Québec and British Columbia and analyzed them for the resistance allele. Of the head louse population analyzed, 97.1% were found to have a resistant allele, Dr. Marcoux reported to CPS delegates, which could explain some of the treatment failures seen with these pediculicides.

As an alternative, a pediculicide containing dimeticone 92% (NYDA, approved in 17 countries) was found to be approximately 97% effective against head lice and 100% effective on eggs in a study of 145 children (Trop Med Int Health 2007;12(suppl 1):178-9). Dimeticone has long been used in cosmetics such as lipstick, and consequently there are few concerns about potential toxicity.

With what is essentially a super-charged hair dryer that dessicates the lice, a study carried out in the US (Goates et al. Pediatrics 2006;118(5):1962-70) found that the device killed 80 to 98% of the eggs and it has been approved for the treatment of lice by the FDA. Dr. Marcoux also explained that human hair grows at about 1 cm a month. Since nits are fixed by the female at the base of the hair, “when nits are more than 1.5 to 2 cm away from the scalp, they are dead or empty and you can reassure teachers that there is nothing left in these nits and they are not contagious,” Dr. Marcoux told CPS delegates.

She also addressed the growing problem of bedbug outbreaks in hotels and homes alike. To combat these unwelcome guests, Dr. Marcoux offered the following “Sleep Rules”:

• Survey sheets for dark brown or red spots. • Lift and look for hiding places (mattresses, spring, bed frame, nightstand). • Elevate suitcases and other items on a rack away from the bed and the wall. • Examine suitcases when repacking and at home. • Call a professional exterminator if bedbugs are detected and expect repeat visits.

Summary

Eczema is a common dermatological problem that requires ongoing therapy to control inflammation and keep the skin barrier intact. Topical steroids are the mainstay for the treatment of eczema but newer topicals that repair skin barrier disruption have been shown to improve eczema control and QoL. Novel therapies are also welcome for the treatment of head lice as resistance to traditional pediculicides would now appear to be widespread, even in Canada.

Note: At press time, the 92% dimeticone solution was not approved for use in Canada.