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Atopic Dermatitis (1 of 13)

Atopic Dermatitis (1 of 13)

Atopic (1 of 13)

1 Patient presents w/ skin manifestations suggestive of

2 DIAGNOSIS No ALTERNATIVE Do history & physical exam DIAGNOSIS confirm atopic dermatitis?

Yes

Patient suff ers from acute fl are-up Patient suff ers from disease of pruritus & inflammation persistence or frequent recurrences

ACUTE FLAREUP TREATMENT MAINTENANCE TREATMENT A Non-pharmacological therapy A Non-pharmacological therapy • Patient/caregiver education • Same as acute fl are-up • Avoidance of trigger factors • Investigate precipitating factors of each fl are-up • Skin care • Phototherapy* - Bathing B Pharmacological therapy - Moisturizers/emollients Start at earliest sign of local recurrence: - Wet dressing • Calcineurin inhibitor (topical) B Pharmacological therapy or Any one of the following agents: Long-term: • (topical) • Calcineurin inhibitor (topical), combined w/ • Calcineurin inhibitor (topical) • (topical), intermittent use If skin infection is present: If skin infection is present: • Appropriate antibiotics, antifungals, • Antibiotics, antifungals, antivirals (oral &/or topical) antivirals (oral &/or topical) Symptomatic relief of pruritus: Symptomatic relief of pruritus: • Antihistamine (oral) • Antihistamine (oral) MIMS • • Continue Expert referral is recommended • non- Psychotherapeutic/ pharmacological psychopharmacological options therapy may be combined w/ the therapies EVALUATION listed below • Discontinue Yes No Disease A topical Non-pharmacological therapy remission (Severe • Continue therapy above corticosteroid &/ Refractory • Phototherapy or calcineurin Atopic B inhibitor Dermatitis) Pharmacological therapy • Potent corticosteroids (topical) © • Systemic corticosteroids • Systemic immunosuppressants

*May be considered in patients >6 years of age w/ Scoring of Atopic Dermatitis (SCORAD) score of 25-50. Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS.

B22 © MIMS Pediatrics 2020 ATOPIC DERMATITIS • • • • • Pathophysiologic Features: • • • • • • • • w/: present usually <2 years Infants &Symptoms Signs • forAtopic Dermatitis Criteria WorkingUnited Kingdom Diagnostic Party • • • • have (must ≥3) Criteria Minor • • • • • have (must ≥3) Criteria Major Hanifi ofAtopic Dermatitis forDiagnosis Criteria n &Rajka • • Common causes include allergens such as food, soaps, detergents, inhalant allergens detergents, &skininfections include soaps, allergens causes Common food, such as furfur Staphylococcus aureus/epidermidis by &Malassezia caused Susceptibility toinfections &protein formation inlipidmetabolism skinduetoabnormalities dry producing ofskinbarrier Lack IgEproduction Increased 20%inheterozygous twins) (80%inmonozygousHeredity twins,  them isskincharacteristic &infections makes toirritation susceptible - excessskin absorb than more water adultskin &lose water faster mature atInfant’s ofage &wouldonlyfully 1styear at thus barrier least epidermal their adeveloping skinhas afflOne ofthe common most skindiseases &children adults icting both “atopic toas referred Also eczema” adulthood in orstart persist butcan mation &childhood, &exudation that commonly infancy early during presents chronicA familial, relapsing infl skin,w/infl dry intense by itching, characterized skindisease ammatory am- - Diaper area isusually notaff Diaper area ected - &lichenifi scaling redness, Papules, cation - mayA smallnumber ofinfants present eruptions w/generalized sleep during Infant oragitated restless may be - oncheeks plaques red oozing, create scaling, will Continued scratching orwashing characteristic &patient be can sparing may areas Perioral present inthese w/nolesions &perinasal - - &/orchin Usually cheeks foundonthe facial - areas dry Patient commonly scaling, w/red, presents ofinflSigns the during 3rdammation month usuallydevelop oflife ofage when <2years inpatients old started ≥4years &symptoms Signs - oratopic dermatitis ina1st-degree orallergic of asthma relative rhinitis, Personal old if<4years history - 12months the skinwithin last ofdry History - - - Itchy skincondition ≥3ofthe plus following: accentuation whitedermatographism, perifollicular nipple eczema, dermatitis, hand&foot keratosis pilaris, palms, skin,ichthyosis, hyperlinear dry age Early ofonset, Others: cataracts anterior keratoconus, subcapsular reactivity, IgE, elevated impaired cell-mediated immunity, infections, Susceptibility to cutaneous Complications: skin-test immediate skinirritants environmentalTriggers: factors, emotional factors, Foods, anterior folds recurrent neck conjunctivitis, (Dennie-Morgan folds),cheilitis, folds infraorbital darkening, infraorbital Facial Facial features: patches, pallor, hypopigmented erythema, facial atopic dermatitis allergic rhinitis, ofatopy -asthma, Personal history orfamily -chronicDermatitis orchronically relapsing Facial involvement &extensor &children ininfants Typical &distribution morphology Pruritus clinically useful Notvery - emotional stress chemicals, irritating Eg aeroallergens, foods, - Investigate exacerbating factors &physical exam onpatient history isbased Diagnosis ©infections tosecondary skin,eventually leading onthe &perioral lips &crusting oozing licking mayLip inscaling, result months old <18 Flexural involvement forinfants surfaces &extensor oronthe fossa) cheeks (eg &popliteal antecubital <18 months old Visible fl forinfants exural dermatitis surfaces w/involvement &extensor oronthe cheeks ofskincreases Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing 1 Atopic Dermatitis(2of13) ATOPIC DERMATITIS ATOPIC 2 DIAGNOSIS

B23 MIMS © MIMS Pediatrics 2020 ATOPIC DERMATITIS • • • • Severity Disease • • • w/: present usually ≥12 years Adolescents • • • • w/: present usually 2-12 years Children &Symptoms (Cont’d)Signs • • • • All Irritants Avoidance ofTriggerFactors • • • • • • Patient/Caregiver Education Severe Moderate W/ areas of dry skin,frequent ofdry W/areas Moderate Mild W/ areas of dry skin,infrequent ofdry W/areas Mild Eczema Area & Severity Index [EASI], Patient Oriented Eczema Measure [POEM]) Patient [POEM]) Eczema Oriented Measure Index[EASI], Eczema &Severity Area usingdiff assessed may be also Severity erent (eg ofAtopic methods Scoring scoring [SCORAD], Dermatitis orskininfections eczema forsevere May require hospitalization complications atopic orinfectious dermatitis presentOcular insevere may be also A holistic approach may be applied when assessing severity ofdisease severity A holisticapproach when applied may assessing be papules &plaques erythematous Dry, scaling, Pattern ofinflammation inachild isthe 2-12 years sameas Resurgence ofinfl ammation that puberty near recurs Constant scratching may toexcoriations orhyperpigmentation lead ofhypo- &eventual areas Papules that quickly change then toplaques lichenifi when scratched ed &ankles wrists fossae, &popliteal antecubital neck, toinvolve May eg progress more areas - contained may be to1or2areas Rash Inflammation inthe fl fossae) antecubital ankles, wrists, (eg neck, exural areas Household fluids (meats, juicesfromfreshfruits) Occupational irritants Disinfectants (swimmingpoolchlorine) - - Lipid solvents(soaps,detergents) Use ofcottonglovesatnighttolimitscratching Keep fingernails trimmedshort - Explain potentialsideeffects of medicationswhenusedoverextendedperiodsoftime Educate thepatientaboutgoodskincarepractices(egbathing,hydration&use ofmoisturizers) Teach thepatient/caregiverhowtomonitordiseaseprogression&whenseek medical help Emphasizethatatopic dermatitistendstoimproveovertime - Discuss thechronicnatureofatopicdermatitis,exacerbatingfactors&appropriate treatment options Severity completely fromclothes When washing,useliquidinsteadofpowder detergent,&doanotherrinsecycletoremovedetergent New clothesshouldbelaunderedbefore wearingtodecreaselevelsofformaldehyde&otherchemicalsadded unaffected areas Patient/caregiver should beinstructedtoapplytopical thinly to skinlesionsonly&emollientsover persistent infections thickening; complicated often by excoriationwithout &skin w/or erythema intensely pruritic, skin, (>20%)ofdry areas Extensive excoriation &skinthickening w/orwithout redness pruritus, © redness of areas w/orwithout pruritus A NON-PHARMACOLOGICAL THERAPY Skin 2 Atopic Dermatitis(3of13) DIAGNOSIS (CONT’D)

B24 MIMS nights; lost school days school lost nights; Signifi ofqualitycant oflife;sleepless disruption frequently disrupted frequently disrupted sleep wellbeing, &psychosocial activities Moderately aff quality oflifeincluding everyday ects changes in psychosocial wellbeing) changes inpsychosocial disturbance mild the during day sleep, &during Minimal impact onquality oflife(some Quality of Life & Social Wellbeing &Social ofLife Quality © MIMS Pediatrics 2020 ATOPIC DERMATITIS 1 Various products are available. Please see prescribing information forspecifiVarious prescribing see are available. Please products c formulations inthe latest MIMS. Bathing • Care Skin • • • • Others • • • • &Aeroallergens Contact Avoidance ofTrigger Factors (Cont’d) • • Wet Dressings • • • • • • Moisturizers • • • • • • Hydration ofskinw/emollients isessential inatopic dermatitis treatment - - factors Psychological cycle) (menstrual Hormones duetosweating losses evaporative may increase sunexposure Prolonged - Consider temperature &humidity duetoheat &perspiration control pruritus toavoid increased - Climate allergens outsuspected forruling are useful results Negative - - - - Foods - mites Dust Human dander (dandruff ofyeast inovergrowth ) resulting Molds dogs) animals(cats, Furry Temporary ofcorticosteroids absorption reported systemic increased - corticosteroids eff w/topical be can Combined cases intreating refractory ective atopic dermatitis inpatients w/moderate-severe severity help reduce Can & disease water loss - common eff as adverse reported folliculitis&impetigo Discomfort, ects - aff orseverely lesions onweeping used May be areas ected used itshouldnotbe stings, If product orfragrances Avoid w/preservatives products dermatitis ofthe presence regardless ofactive possible, as often 2xdailyoras at allover applied least Should be corticosteroids fortopical &other the interventions need pharmacologic decrease Can - Eff ects: liquid paraffi(PEA), glycerin, etc] n, mineral oils, Patient preference inemollients [eg &treatment formula used palmitoylethanolamide determine will area Water-in-oil emollients are preferred the by skin water absorption tobath butdonotincrease added soothing may be Oatmeal products orichthyotic inpatientsSalt baths impetiginized skin w/heavily used may be infections w/frequent bacterial disease formoderate-severe bathsBleach used may Mupirocin w/intranasal be ofhydratedgreater penetration skin Topical of because bathing for 20minutes after toweling applied without dry orsoaking are best medications consider May also usingbath 2minutes the ofbathing oilswithin last - &emollients bathing topicals after isthe “Soak-and-seal” application immediate ofprescribed - 2 baths in1day bath water &“soak-and-seal”Soaking dailyfor10-15minutes orshower usingwarm approach nottoexceed Soap w/ minimal substitutes defatting activity, pH are to low preferredw/ neutral hypoallergenic, fragrance-free, triggers or who have psychological problemstriggers orwhohave psychological &counseling considered inpatients shouldbe evaluation whohavePsychological diffi culty w/emotional &scratching pruritus exacerbation, induce (eg &anger) disease Emotional factors cause anxiety immune &increase activation orallergic toaspecifi reaction therapies &/orw/history toprevious unresponsive & disease c food atopic mayconsidered testing dermatitis allergy in childrenbe w/ moderate-severe <5 years food Limited &measurement ofspecifi (SPT) Skin tests prick food toaparticular sensitization todetermine c IgEare used atopic dermatitis moderate-severe Flaring/occurrence ofatopic dermatitis aspecifi with may elimination warrant inpatients diet c food w/ sofa upholstered avoid airconditioning, humidity by level indoor decrease &curtains, carpeting removeweekly bedroom in hotwater bedding washing & mattresses, Avoidance on pillows encasings of dustmite-proof include use 1 Moisturizers help re-establish & preserve the stratum help Moisturizers corneum re-establish &preserve 1

© A NON-PHARMACOLOGICAL THERAPY (CONT’D) Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Atopic Dermatitis(4of13)

B25 MIMS © MIMS Pediatrics 2020 ATOPIC DERMATITIS • • • • • • • • • • • Prevention • • • • • • • • Phototherapy • • • • (Topical)Corticosteroids time & under close supervision time &under close  of erapy-resistant may lesions corticosteroid require under potent period topical occlusion forashort used preparations ofhigher potency use shouldfollow inpotency decrease Agradual - Rebound fl preparations are discontinued occur ifhigher abruptly potency can aring potent buteffLeast used shouldbe product ective offl onseverity depend Choice will ofproduct &other (eg oflesions factors distribution humidity)are-up, aff isalso Potency the by vehicle the isformulated in(eg product ected ointment) cream, - Topical corticosteroids are available indiff potent erent mildtovery from potencies compliancegood w/application atopic orworsening dermatitis despite innon-resolving reactions hypersensitivity cause May occasionally followed (eg ondelicate &skinfolds)shouldbe use face, skinareas neck eff toadverse Continuous lead can use thus intensity regarding restrictions recommended &duration of ects, Rapid symptomatic relief ofacutefl &prevention offlare-ups are relapses to prove thisto prove benefit however, mayProbiotics reduce ofatopic the also dermatitis, incidence orseverity more studiesare needed - benefi tobe shown w/hypoallergenic formula milkwas hydrolyzed orfeeding Breastfeeding cial of atopic dermatitis Identification &elimination isthe mainstay factors oftriggering forprevention offl treatment &long-term ares Premature malignant diseases &potential Long-term: cutaneous skinaging - skinpain,pigmentation, itching Short-term: Erythema, - reactions: Adverse cessationRelapse following oftherapy frequently occurs ifw/continued isrecommended skinexam A yearly phototherapy atopic dermatitis patients older refractory than ofage forpediatric 6years whopresent w/severe therapy reserved shouldbe UV dermatitis Photochemotherapy atopic w/Psoralens &UVA severe topatients w/widespread restricted shouldbe Phototherapy &youngchildren ininfants avoided shouldbe isthe initialphototherapy ofchoice UVB profi safety Narrowband duetoits le &availability dermatitis &UVA-1 UVB inatopic &UVA, narrow-band orcombined UVA useful Broad-band UVB be can &UVB - (histamine,prostaglandins) Suppression release ofmediator - number &activity Alteration inleukocyte - Anti-infl mechanisms through activity several &antipruritic ammatory Mildly potent corticosteroids are formaintenance recommended therapy oftime periods short Moderately forthe potent &potent treatment corticosteroids used exacerbation ofclinical shouldbe over 1st-line as Used treatment atopic dermatitis formildtosevere via the histamine-2receptor) via all identifi allergen her food from diet ed allergy,If the patient w/food toeliminate w/atopic the diagnosed mother dermatitis advised isalso shouldbe Enhanced response to agents that increase cyclic adenosine monophosphate adenosine (prostaglandin E toagents cyclic thatEnhanced response increase

© A NON-PHARMACOLOGICAL THERAPY (CONT’D) Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing B PHARMACOLOGICAL THERAPY Atopic Dermatitis(5of13)

B26 MIMS © MIMS Pediatrics 2020 2 &histamine ATOPIC DERMATITIS 1 Various information forspecifi corticosteroids prescribing &immunosuppressants oralantihistamines, see are available. Please c formulations inthe latest MIMS. Skin Infections Skin • Agents Biological Other • • Dupilumab Agents Biological • • Tacrolimus • • Pimecrolimus • • • • • • • • • (Topical) Inhibitors Calcineurin • • • Infections Bacterial • • Tezepelumab, Tofacitinib, Upadacitinib, &Ustekinumab Fezakinumab,include Baricitinib, Nemolizumab, Omalizumab, Rituximab, Mepolizumab, Lebrikizumab, off undergoing as orare currentlyOther biologicals trials clinical used being -label therapy foratopic dermatitis studies clinical involved inseveral Signifi inpatients &quality activity, oflifewere Dupilumab cant given seen improvements indisease symptoms, treatments tolerate totopical treatments &cannot for children systemic oldunresponsive ≥12years  efi for1st-line approved rst human antibody monoclonal treatment atopic dermatitis ofmoderate tosevere children Studies have confi the effirmed ofTacrolimuscacy Well-tolerated corticosteroids topical w/transient in skinburning/irritation 0.03%compared potency tolow - - atopic dermatitis formoderate-severe Indicated corticosteroids use plus topical inlong-term moisturizers typical over advantageous therapeutically tobe shown ithas stages inearly ofdisease, When used fl Prevents insignifi &results are-ups - effcant -sparing forupto12months when used ect day 3ofuse as early as seen relief been Pruritus has - &effiSafety inchildren ofage shown >2years w/mild-moderate atopic dermatitis been has cacy Avoid continuous &avoid inpatients use use w/compromised immune systems tocontrol oftimeusingminimum amount symptoms necessary periods Use onlyforshort Avoid agents the ofthese use inchildren younger than ofage 2years sideeffCommon Transient &pruritus erythema ects: burning, All preparations are ofastandard potency the face, hands&feet oftime,especially periods forextended locations onallbody used May be strength corticosteroids oftopical potency Equated tomedium Helps reduce fl subsequent orrelapses w/intermittentare-ups use - dications toother therapies topical therapySecond-line forpatients w/chronic atopic to,intolerant dermatitis unresponsive orw/contrain- of, of calcineurin Inhibit infl ammatory cytokinetranscriptioninactivatedTcells&otherinfl ammatory cells throughinhibition - lesions infected totreat widespread Usually necessary - Oral therapy resistance ofbacterial risk todecrease avoided shouldbe use Prolonged - Retapamulin forchildren isrecommended ≥9months - Fusidic &Retapamulin acid,Mupirocin, are treatment options - infection secondary totreat mild&localized used May be - Topical therapy infections S aureus iscommonly the oflocalized cause eczematous skin&isoften from cultured toprevent recurrence ofthe groin) (eg infection nose, totreat reservoirs May need anti-infl at starting before treatment infections cleared Clinical shouldbe sites agents ammatory adverse effadverse ects forupto1 year used May be ofeff loss without orother risk non-application-site ininfection increase ectiveness, options 1st&2ndgeneration &Clindamycin are treatment cephalosporins macrolides, Anti-staphylococcal penicillins,

© 1 Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not B Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing PHARMACOLOGICAL THERAPY (CONT’D) Atopic Dermatitis(6of13)

B27 MIMS © MIMS Pediatrics 2020 ATOPIC DERMATITIS 1 Various information forspecifi corticosteroids prescribing &immunosuppressants oralantihistamines, see are available. Please c formulations inthe latest MIMS. Antihistamines • • Fungal Infections • • Viral Infections Systemic Corticosteroids Systemic • • • Infections Skin • • • • • Azathioprine • • Ciclosporin Immunosuppressants Systemic • • • Superfi antifungals ortopical ovale w/systemic treated may be cial dermatophytosis &Pityrosporum inatopic dermatitis isquestionable Role offungi infections Prophylactic herpetic recurrent tosuppress cutaneous oralantiviral agents used may be treatment setting inahospital &may Acyclovir eruption) require systemic (Kaposi’s herpeticum inclusive ofeczema infections varicelliform herpes Patients may secondary develop Topical &may allergic pruritus cause contact antihistamines inrelieving are usuallynothelpful dermatitis urticaria ofpatients inasmallgroup w/associated useful may be they however incontrolling results antihistamines variable have pruritus, Studies shown oforalnon-sedating  at worse night since istypically pruritus at bedtime used are best ey - disturbancedermatographism) &sleep or ifthe patient antihistamines useful may urticaria Oral sedating comorbidities be has (allergic rhinitis, in thiopurine methyltransferase in patients depression marrow & bone defi liver dysfunction myalgia, fatigue, : Nausea, reactions Adverse cient doses tolow patients Most respond - long-term used been &has Safer than Ciclosporin parameters Monitor hematologic &liver function ofmyelotoxicity risk formyelosuppression &test todecrease dose  taken pretreatment shouldbe &whileontreatment levels todetermine (TMPT) methyltransferase iopurine forchildren w/signifi especially disease forsevere/refractory Used impact cant psychosocial isnotjustifi use Long-term &renal dysfunction ofhypertension ofrisks because ed discontinuation tends after Condition toreturn level oftherapy severity at butnotalways the original - Eff disease refractory insevere forshort-term use ective corticosteroid treatment &continuously hydrating the skin chance of reboundUse eff short-term & decrease topical while increasing slowly oral form tapering by ect butreboundImproves fl lesions discontinuation usuallyoccurs upon are-up consideredShould intreatment-resistant only be atopic dermatitis 1 1 © (Cont’d) Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not B 1 Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing PHARMACOLOGICAL THERAPY (CONT’D) 1 Atopic Dermatitis(7of13)

B28 MIMS © MIMS Pediatrics 2020 ATOPIC DERMATITIS 1 Combination the w/other forspecifi latest MIMS emollients see are available. Please c formulations. Lactic acid Liquid soap Liquid acid Lactic hyaluronate) acid (Na Hyaluronic acid) Glycyrrhetic (, acid Glycyrrhetinic Soap; Wash; Glycerin Cream Dimeticone 2-5%Oint, Dexpanthenol fl extr) ower recutita Chamomilla recutita, (Matricaria Chamomile Bar Lotion; Ceramide Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products Lotion Cream; Lotion Cream; Lotion Cream; Cream; Lotion Soln Cream, Wash Shampoo; Cream; Bath oil; placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed Strength &/or Strength &/or Preparations Available Available

© EMOLLIENTS, CLEANSERS&SKINPROTECTIVES Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing • • • • • • • • • • • • • • • • • Atopic Dermatitis(8of13) pruritus, xerosis, &chafi xerosis, pruritus, ng senile skin, atopic dermatitis, Emollient fordry moisturizer Diaper rash, infant hygiene Diaper rash, dermatitis& seborrheic intertrigo, mycosis, pruritus, eczema, dermatitis, intopical Antiseptic For woundhealing better ofdermatoses types various Symptomatic relief of ofdermatoses types various Symptomatic relief of the skin infl disorders of ammatory Treatment ofnon-infective infant/elderly skin skin, allergic dermatitis, sun-damaged skin areas, soap-intoleranthiemalis, ichthyosis, pruritus atopic orinfantile eczema, xerosis, skinareas, sensitive treatmentCleansing fordry &smoothness softness & enhance skinflexibility, skinmoisture Helps increase skin &damaged dry very &protect repair Helps relieve, skin Dry/damaged Diaper rash out &drying scaling lipid content, preventing Stabilizes skinmoisture & drying without scalp skin& sensitive Cleanses skin Sensitive dermatitis &skinrashes to moderate atopic Symptomatic relief ofmild skin Dry/sensitive Dosage Guidelines Indication

B29 MIMS • • • • • • • • • • • • • • Apply required as Use as asoap substitute Use as gentlymassage Apply onaff 8hrly area & ected gentlymassage Apply onaff 8hrly area & ected required as often Use as needed & at night oras shower after ontoMassage skininthe morning diapereach change) (after Apply once needed oras offhair then rinse thoroughly Wash: skin/ wet allover Massage ApplyCream: toaff area ected water w/lukewarm then rinse to wholebody, gently rub for5min Apply Oil: Bath 10-20mLdirectly soap substitute Use as liquid cleanser Use as Bath: Apply 8-12 hrly &/orfortreatment: Moisturizer soap substitute Use as Administration 1 © MIMS Pediatrics 2020 ATOPIC DERMATITIS 1 Combination the w/other forspecifi latest MIMS emollients see are available. Please c formulations. Liquid Liquid paraffi n (Mineral oil) Paraffi n olamine Piroctone isomerate Saccharide parkii extract) parkii (Butyrospermum butterShea Telmesteine Cream; Cream; Telmesteine Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All EMOLLIENTS, CLEANSERS&SKINPROTECTIVES Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed Topical gel gel; 70% 70% Shower Emollient; 63.4% Cream; Bath oil;6% 85% 7.5% Bar; Gel; Shower Gel; Emollient; Cream; Bar; Cream Lotion; OintLotion; Cream; Lotion; WashLotion; Cream; Lotion Preparations Strength &/

© Available Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not or or Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing • • • • • • • • Atopic Dermatitis(9of13) Dosage Guidelines (pruritus hiemalis) (pruritus winter psoriasis, geriatric therapy, chronic eczema, w/ dermatitis, skinassociated dry xerosis, Treatment forichthyosis, skin Itchy, dry, sensitive irritated, process which enhances the healing moist skinenvironment maintaining skinby waxy Helps manage dry &relieve ichthyosis psoriasis, eczema, dermatitis, tochronic skin secondary Symptomatic relief ofdry soft &supple soft moisture the which makes skin ofreplenishment & need skinin &soothes Nourishes metalloproteinase collagenase, elastase, eg enzymes harmful Reduces damage epithelial skinfrom Protects process beneficial tothe healing environment, which is maintaining amoistskin skinby dry, waxy Relieves Indication

B30 MIMS • • • • • • • • • • • Rinse offRinse  gently. &massage en rub aff whileskiniswet. area ected Apply tothe whole Shower: bath aff for used be also can area; ected Wet Emollient: in skin&rub inwell &rub area ApplyCream: onto aff ected dry of oiltoremain onthe skin.Pat excessively athin toallow film rinsing from Refrain area. little aff water &cleanse ected WorkBar: lather uparich w/a bath water. for10-20min Soak to8-inch Add 1-3capful Bath: or rub onto skin or rub wet Add tobath water Emollient: required as often inwell. &rub Usearea as ApplyCream: tothe aff ected as needed Apply toaff 8hrly area or ected needed especially after shower after especially needed Apply as often 12hrly oras Apply 24hrly Apply needed 8-24hrly oras 1 (CONT’D) Administration © MIMS Pediatrics 2020 ATOPIC DERMATITIS 1 Combination the w/other forspecifi latest MIMS emollients see are available. Please c formulations. Dupilumab Urea iai Oint Vitamin A Vitamin E Lotion; Lotion; Vitamin E extract) seed (Grape extract seed Vitis vinifera icoie7.5%,10%, oxide Zinc Drug Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All EMOLLIENTS, CLEANSERS&SKINPROTECTIVES Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed every other wk every 300mgSC dose: Maintenance sites in2diff300 mgSCeach erent inj as consecutively administered 600mgSC dose: Initial ≥12 yr, ≥60kg: other wk every 200mgSC dose: Maintenance sites in2diff200 mgSCeach erent inj as consecutively administered 400mgSC dose: Initial ≥12 yr, <60kg: Preparations Lotion Cream; 10%, 20% Cream; OintCream; Lotion Cream; powd TopicalOint; 200 mg/g 40%, Cream; 310 mg/g 32%, Strength &/

© Available Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not or Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage Atopic Dermatitis(10of13) • • • • • • • • Dosage Guidelines pruritus) , irritant conditions (eg xerosis, skin or excessive dry Emollient forhyperkeratotic wounds & dry skin wounds &dry small sunburn, burns, chafiDiaper rash, minor ng, Dry skin Dry Protects impaired skinbarrier Protects activity scavenging antioxidant &free-radical w/its healing Promotes & slight excoriation ineczema &protects Soothes wounds &burns non-infected skin irritations, ofminor healing Promotes contactdirect w/the skin coming from intowetness preventing by diaper rash Prevention &treatment of IMMUNOLOGICAL Indication

B31 MIMS • • Instructions Special • Reactions Adverse prior toinitiationprior oftreatment Treat patients w/pre-existing helminth infection impairment renal impairment, hepatic severe asthma, Use w/ caution inpatients w/helminth infections, redness) facial headache, eosinophilia, Other eff blepharitis); pruritus, (oral herpes, ects eff (conjunctivitis, eye allergic conjunctivitis, ects effLocal (inj Ophthalmologic sitereaction); ect • • • • • required aff 8-12hrly area &as ected Apply into &rub the sparingly Apply 8-12hrly Apply needed as Apply 24hrly Apply needed as Remarks 1 (CONT’D) Administration © MIMS Pediatrics 2020 ATOPIC DERMATITIS arlms0.03%,0.1% Tacrolimus 1% cream Pimecrolimus Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed oint Available © Strength Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing OTHER DERMATOLOGICALS areas to the aff ected oint 12-24 hrly 0.03% or0.1% Apply ≥16 yr: areas the aff ected 12-24 hrly to 0.03% oint Apply 2-15 yr: Apply 12 hrly ≥2 yr: Atopic Dermatitis(11of13) Dosage Guidelines Dosage

B32 MIMS • • • • • Instructions Special • • • • Reactions Adverse • Application • • • • • • Instructions Special • • • Reactions Adverse • Application artificial sunlight Patients oravoid shouldminimize natural or w/occlusive dressing used Should notbe ofatopic& symptoms dermatitis Continue treatment ofsigns clearing for1 wkafter applicationbefore ofTacrolimus cleared shouldbe infections cutaneous Clinical infections viral ofacutecutaneous notapply toareas Do studyphotocarcinogenicity to skintumor formation inanimal time shortened inhumans, than used Higher dose discontinuedbe Tacrolimus cause, &ifnoclear investigated should If lymphadenopathy the shouldbe cause occurs, infections &viral common:Less Bacterial w/continued use usually decreases effLocal which pruritus stinging, Burning, ects: & completely Apply athin layer toaff ingently skin&rub ected artificial sunlight Patients oravoid shouldminimize natural or w/occlusive dressing used Should not be re-evaluated patientIf noimprovement shouldbe 6 wk, within persist &symptoms signs continued longas as of atopic dermatitis toprevent fl & are-up at 1stsign used treatment, shouldbe In long-term discontinue Pimecrolimus clears until infection appropriately. notresolve, does Ifinfection treated shouldbe infections &fungal Bacterial infections viral ofacutecutaneous notapply toareas Do studyphotocarcinogenicity to skintumor formation inanimal time shortened inhumans, than used Higher dose infections &viral common:Less Bacterial itching) (egreactions erythema, irritation, w/ continued application use, site usually decreases effLocal sensation ofwarmth which Burning, ects: & completely Apply athin layer toaff ingently skin&rub ected Remarks © MIMS Pediatrics 2020 ATOPIC DERMATITIS caproate 0.05%cream, Fluocortolone/ acetonide acetonide valerate Difl ucortolone (Desoxymetasone) valerate dipropionate Betamethasone 0.1%cream, dipropionate Potent III) (Group propionate Very Potent IV) (Group Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed cream 0.25%/0.25% lotion, oint 0.2% cream gel, oint 0.025% cream, oint 0.01% cream, Apply 6-12 hrly 0.025% cream fatty oint oint, 0.1% cream, oint 0.25% cream, 0.05% gel soln lotion, oint, Apply 24 hrly 0.1% cream, 0.06% cream 0.05% cream 0.025% cream Apply 12 hrly 0.025% cream soln oint, 0.064% cream, soln oint, 0.05% cream, lotion, oint © application gel, scalp oint, 0.05% cream, Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Available Strength Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing TOPICAL CORTICOSTEROIDS Atopic Dermatitis(12of13) Dosage Guidelines Apply 8-24 hrly Apply 8-12 hrly Apply 8-24 hrly Apply 8-24 hrly Apply 8-24 hrly Apply 8-24 hrly Apply 8-24 hrly Apply 8-24 hrly Apply 8-12 hrly Apply 12-24 hrly Dosage

B33 MIMS • • • • Instructions Special • • • Reactions Adverse • • • • • Application - eff ects Mildly potent agents rarely side will cause Intermittent therapy isusuallypreferable to - used onfaceorintertriginousareas) sideeffcause for<3mth (except ifused ects if Moderately potent &potent agents rarely will patients ofage <1 yr Very in potent agents used shouldnot be areas face &intertriginous Mildly potentpreparationsarepreferredfor - Absorption is more likely when used over over ismore likely when Absorption used - thin by &/orraw isincreased Absorption - syndrome retardation, &Cushing’s hypertension growth suppression, pituitary-adrenal-axis cause can Systemic eff through the Absorption skin ects: irreversible telangiectasia&striaeatrophica hypopigmentation which reversible, may be acneat siteofapplication, dermatitis, contact ofunderlying infection, worsening stoppingtreatment, after restored may notbe effLocal ects: inningofskinwhich may or reactions of adverse  emore potent the agent, the more chance improves the preparations condition as potency weaker w/ 3 wk)following agents isfor1-2 wk(max highpotency ofvery use Recommended 2x the offl size at adulthand (approx 500 mg)issuffi1 FTU cient tocover tip ofadultindexfinger to1stcrease be measuredbyfi nger tipunit(FTU)whichis Length ofcream/ointsqueezedfromtubecan totreat chronic conditions used been Every other day orweekend application has offeet forpalmsorsoles necessary may be More frequent administration agents. most 12-24 hrly applications are for recommended large areasaretreated if long-term continuoustherapyespecially Intermittent therapyisusuallypreferable to long-term continuouslong-term therapy very large &inchildren areas very orocclusion areas skin, intertriginous Remarks © MIMS Pediatrics 2020 ATOPIC DERMATITIS propionate Potent III)(Cont’d) (Group rdiooe05 ra Apply 8-24 hrly 0.5%cream PotentMildly I) (Group acetonide butyrate 0.02%oint butyrate Apply 12-24 hrly dipropionate 0.25%cream PotentModerately II) (Group furoate Apply 12-24 hrly aceponate 0.05%cream aceponate Hydrocortisone Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed 0.005% oint 0.05% cream © 2.5% lotion cream, oint 1% lotion, 0.5% cream 0.02% cream 0.2% cream lotion scalp lotion, oint, 0.1% cream, soln oint, Apply 12-24 hrly 0.1% cream, 0.1% cream lotion, oint 0.05% cream, oint 0.05% cream, oint 0.05% cream, lotion, oint fatty gel, oint, 0.1% cream, oint 0.1% cream, Apply 12-24 hrly 0.127% cream Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Available Strength Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing TOPICAL CORTICOSTEROIDS(CONT’D) Please see the end of this section for the reference list. reference the for section this of end the see Please Atopic Dermatitis(13of13) Dosage Guidelines Apply 12-24 hrly Apply 6-12 hrly Apply 6-12 hrly Apply 6-12 hrly Apply 8-12 hrly Apply 6-12 hrly 6 hrly Apply upto Apply 8-12 hrly Apply 24 hrly Apply 24 hrly Dosage

B34 MIMS • • • • Instructions Special • • • Reactions Adverse • • • • • Application Intermittent therapy isusuallypreferable - eff ects Mildly potent agents rarely side will cause Intermittent therapy isusuallypreferable - areas) onface orintertriginous used sideeffcause for<3mth (except ifused ects if Moderately potent &potent agents rarely will patients ofage <1 yr Very in potent agents used shouldnot be areas face &intertriginous Mildly potent preparations are for preferred - Absorption is more likely when used over over ismore likely when Absorption used - thin by &/orraw isincreased Absorption - &Cushing’shypertension syndrome retardation, growth suppression, pituitary-adrenal-axis cause skin can Systemic eff through the Absorption ects: atrophica striae & telangiectasia irreversible reversible, be application, hypopigmentation which may acneat contact siteof infection, dermatitis, treatment, ofunderlying worsening stopping after restored may notbe effLocal ects: inningofskinwhich may or reactions of adverse  emore potent the agent, the more chance condition improves the preparations as potency weaker w/ 3 wk)following agents isfor1-2 wk(max highpotency ofvery use Recommended 2x the offl size at adulthand (approx 500 mg)issuffi1 FTU cient tocover crease which is tip ofadultindexfinger to1st fi by measured be can nger tipunit(FTU) tube from ofcream/ointLength squeezed totreat chronic conditions used been Every other day orweekend application has offeet or soles forpalms administration necessary may be More frequent agents. for most 12-24 hrly applications are recommended if large are treated areas continuousto long-term therapy especially to long-term continuousto long-term therapy very large &inchildren areas very orocclusion areas skin, intertriginous Remarks © MIMS Pediatrics 2020

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