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ATOPIC DERMATITIS (AD) FOR FLARES

• Topical corticosteroid (TCS) 1 -2 times daily • Use until inflammatory lesions are significantly improved • “Soak & Smear”: soak for 20 min followed by application of TCS • Wet Wraps: apply TCS, then wet layer (tubular bandage, cotton clothing, etc.), then dry layer • Topical antibiotics are not recommended but oral abx if clinically infected

Treatment of Staphylococcus aureus Colonization in Atopic Dermatitis Decreases Disease Severity Jennifer T. Huang, Melissa Abrams, Brook Tlougan, Alfred Rademaker and Amy S. Paller Pediatrics May 2009, 123 (5) e808-e814; DOI: https://doi.org/10.1542/peds.2008-2217 J Am Acad Dermatol. 2014 Jul;71(1):116-32. doi: 10.1016/j.jaad.2014.03.023. Epub 2014 May 9. Treatment of Staphylococcus aureus Colonization in Atopic Dermatitis Decreases Disease Severity Jennifer T. Huang, Melissa Abrams, Brook Tlougan, Alfred Rademaker and Amy S. Paller Pediatrics May 2009, 123 (5) e808-e814; DOI: https://doi.org/10.1542/peds.2008-2217 J Am Acad Dermatol. 2014 Jul;71(1):116-32. doi: 10.1016/j.jaad.2014.03.023. Epub 2014 May 9. ADVERSE EFFECTS?

• Side effects are low but when overuse occurs, a patient can get purpura, telangiectasia, striae, focal hypertrichosis, and acneiform or rosacea-like eruptions • Risk of hypothalamic-pituitary-adrenal axis suppression is low but increases with prolonged continuous use, especially in individuals receiving corticosteroids concurrently in other forms (inhaled, intranasal, or oral) • If prescribing high potency topical steroids, see people back and don’t give refills • Most patients (~75%), have steroid phobia

• Yo u r 3 5 ye a r-old patient returns and reports her rash has resolved in the AC and popliteal fossa and she is very pleased. However, she inquires what would be the best way to prevent her eczema from returning in these areas so frequently. FOR MAINTENANCE:

• Moisturize with fragrance free thick cream or ointment twice per day. NO LOTIONS. • Use fragrance free non-soap cleanser if possible • For areas prone to recurrence: 1-2 times weekly topical steroid prevents flares • +/- add a topical calcineurin inhibitor: tacrolimus 0.1% ointment or pimecrolimus 1% cream BID 2-3 times per week • SE: stinging, burning • 10 year follow up: no increased risk for infections or cancer • Black box warning • Dilute bleach baths with intranasal mupirocin x 3 months

• Creams, ointments, oils, gels, lotions • Emollients: glycol and glycerol stearate, soy sterols: • Lubricate and soften skin • Occlusive agents: petrolatum, dimethicone, mineral oil • Forms a layer to decrease evaporation of water • Humectants: glycerol, lactic acid, urea • Attract and hold water • Reduction in inflammation and AD severity • Most importantly: Decreases amount of prescription topicals required for disease control • As frequently as needed to prevent xerosis BATHING

• Limited use of fragrance free non-soap cleansers • 5-10 min, once daily, medium temp bath or shower immediately followed by moisturizer • Goal is to not let water evaporate off the skin

https://www.aad.org/skin-care-basics/dermatologists-tips-relieve-dry-skin CASE 3: PSORIASIS

• 43 year-old male presents with PMH of obesity, DM2, and dyslipidemia and a 5 year history of this rash. He ”googled it” and thinks he has psoriasis. He has treated it only with tea tree oil with no improvement. It is itchy at times. He denies any joint pain, swelling, or deformity. This is his exam:

WHICH TOPICAL REGIMEN WOULD YOU START WITH?

• A. Hydrocortisone 2.5% cream twice daily x 14 days • B. Betamethasone 0.05% ointment twice daily x 14 days • C. Tacrolimus 0.1% ointment twice daily x 1 month • D. Calcipotriene 0.005% cream twice daily x 1 month TOPICAL STEROIDS

• Set expectations: ~40—75% improvement (dependent on potency) • Creams, ointments, solutions, foams, shampoos, sprays, oils, gels • Low potency for thin skin, face, intertriginous areas: Example: Hydrocortisone 2.5% • Mid-very high potency for other areas. Examples: triamcinolone 0.1-0.5%, betamethasone 0.05%, or clobetasol 0.05%. • Limit use of highest potency TCS (i.e. clobetasol and halobetasol) to no more than BID for 2-4 weeks and no more than 50 g/week • Gradual reduction once clinical response achieved to avoid rebounding • Understand that adherence to topical medications will be very low

Alan Menter, Neil J. Korman, Craig A. Elmets, Steven R. Feldman, Joel M. Gelfand, Kenneth B. Gordon, Alice Gottlieb, John Y.M. Koo, Mark Lebwohl, Henry W. Lim, Abby S. Van Voorhees, Karl R. Beutner, Reva Bhushan, Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. Journal of the American Academy of Dermatology, Volume 60, Issue 4, 2009 Pages 643-659,ISSN 0190-9622, Alan Menter, Neil J. Korman, Craig A. Elmets, Steven R. Feldman, Joel M. Gelfand, Kenneth B. Gordon, Alice Gottlieb, John Y.M. Koo, Mark Lebwohl, Henry W. Lim, Abby S. Van Voorhees, Karl R. Beutner, Reva Bhushan, Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. Journal of the American Academy of Dermatology, Volume 60, Issue 4, 2009 Pages 643-659,ISSN 0190-9622, VITAMIN D ANALOGS

• Calcipotriol (aka calcipotriene); calcitriol • Cream or solution; ointment • Twice daily to affected areas • Reported SE: transient burning, pruritus, edema, peeling, xerosis, redness • Calcipotriene is inactivated by UVA • Available in combination with betamethasone as an ointment. Combo is more effective than either alone.

• 0.1% or 0.05% gel, cream • Applied once daily • ~50% improved by 50% • SE: local irritation is very common. • To decrease irritation: Use cream > gel, leave on for only 30-60 min, combine with moisturizer, alternate days of use, apply with TCS • Preg category X

Weinstein GD, Koo JY, Krueger GG, Lebwohl MG, Lowe NJ, Menter MA, et al. Tazarotene cream in the treatment of psoriasis: two multicenter, double-blind, randomized, vehicle- controlled studies of the safety and efficacy of tazarotene creams 0.05% and 0.1% applied once daily for 12 weeks. J Am Acad Dermatol 2003;48:760-7. Alan Menter, Neil J. Korman, Craig A. Elmets, Steven R. Feldman, Joel M. Gelfand, Kenneth B. Gordon, Alice Gottlieb, John Y.M. Koo, Mark Lebwohl, Henry W. Lim, Abby S. Van Voorhees, Karl R. Beutner, Reva Bhushan, Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. Journal of the American Academy of Dermatology, Volume 60, Issue 4, 2009 Pages 643-659,ISSN 0190-9622, TOPICAL CALCINEURIN INHIBITORS

• Tacrolimus 0.1% and pimecrolimus • Valuable mainly in use on the facial and intertriginous PsO • Tacrolimus 0.1% RCT: 65% clear/almost clear with 8 weeks BID on facial/intertriginous PsO

Lebwohl M, Freeman AK, Chapman MS, Feldman SR, Hartle JE, Henning A. Tacrolimus ointment is effective for facial and intertriginous psoriasis. J Am Acad Dermatol 2004;51: 723-30.

• Accepted as a adjunctive therapeutic to pharmaceuticals • Placebo/vehicle response is 15-47% • Applied 1-3 times daily

Nast A, Kopp IB, Augustin M, Banditt KB, Boehncke WH, Follmann M, et al. Evidence-based (S3) guidelines for the treatment of psoriasis vulgaris. J Dtsch Dermatol Ges 2007;(5 Suppl 3);1-119. COMPARISON STUDIES

• Vitamin D analogs vs To p i c a l s t e ro i d s • Both have similar efficacies alone, but vit D analogs have slower onset of action but tend to yield longer disease free periods • Calcipotriol is more irritating than TCS • Tazarotene vs medium potency TCS • Equal efficacy after 12 weeks. Tazarotene had longer disease free periods • Tazarotene + medium potency TCS vs calcipotriene • Tazarotene + medium potency TCS had more improvement

Kragballe K, Gjertsen BT, De Hoop D, Karlsmark T, van de Kerkhof PC, Larko O, et al. Double-blind, right/left comparison of calcipotriol and betamethasone valerate in treatment of psoriasis vulgaris. Lancet 1991;337:193-6. Lebwohl M, Ast E, Callen JP, Cullen SI, Hong SR, Kulp-Shorten CL, et al. Once-daily tazarotene gel versus twice-daily fluocin- onide cream in the treatment of plaque psoriasis. J Am Acad Dermatol 1998;38:705-11. Guenther LC, Poulin YP, Pariser DM. A comparison of tazarotene 0.1% gel once daily plus mometasone furoate 0.1% cream once daily versus calcipotriene 0.005% ointment Menter et al 659 twice daily in the treatment of plaque psoriasis. Clin Ther

REFERENCES

1. Guidelines of care for the management of acne vulgaris. Zaenglein, Andrea L. et al. Journal of the American Academy of Dermatology, Volume 74, Issue 5, 945 - 973.e33

2. J Am Acad Dermatol. 2014 Jul;71(1):116-32. doi: 10.1016/j.jaad.2014.03.023. Epub 2014 May 9.

3. Alan Menter, Neil J. Korman, Craig A. Elmets, Steven R. Feldman, Joel M. Gelfand, Kenneth B. Gordon, Alice Gottlieb, John Y.M. Koo, Mark Lebwohl, Henry W. Lim, Abby S. Van Voorhees, Karl R. Beutner, Reva Bhushan, Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. Journal of the American Academy of Dermatology, Volume 60, Issue 4, 2009 Pages 643-659,ISSN 0190-9622,

4. Kragballe K, Gjertsen BT, De Hoop D, Karlsmark T, van de Kerkhof PC, Larko O, et al. Double-blind, right/left comparison of calcipotriol and betamethasone valerate in treatment of psoriasis vulgaris. Lancet 1991;337:193-6.

5. Lebwohl M, Ast E, Callen JP, Cullen SI, Hong SR, Kulp-Shorten CL, et al. Once-daily tazarotene gel versus twice-daily fluocin- onide cream in the treatment of plaque psoriasis. J Am Acad Dermatol 1998;38:705-11.

6. Guenther LC, Poulin YP, Pariser DM. A comparison of azarotene 0.1% gel once daily plus mometasone furoate 0.1% cream once daily versus calcipotriene 0.005% ointment . Clic Ther

7. Nast A, Kopp IB, Augustin M, Banditt KB, Boehncke WH, Follmann M, et al. Evidence-based (S3) guidelines for the treatment of psoriasis vulgaris. J Dtsch Dermatol Ges 2007;(5 Suppl 3);1-119.