New Approach to Treating Children's Rashes Urged

Eczema, an itchy rash that affects large numbers of infants and children, should be treated in a new way, according to a new paper outlining best treatments for the disease.

The new approach urges physicians to focus on giving patients the best possible long-term management of eczema, also known as atopic dermatitis, using a combination of older and newer types of treatment.

Previous management of the disease focused on treating acute attacks with short courses of corticosteroid creams. Now, a team of doctors co-led by a University of Michigan dermatologist say that new medications, known as calcineurin inhibitors, should be used to help relieve symptoms over the long term. The new medicated creams turn off specific inflammatory cells in the skin that cause the redness and broken skin that are the hallmarks of eczema in young children.

In a paper published today in the May issue of the British Journal of Dermatology, the team describes a new approach to treatment that was adopted at the 2nd International Consensus Conference on Atopic Dermatitis by experts from 10 countries in Europe and the Americas. The conference was sponsored by a grant from Novartis Pharmaceuticals, which makes a calcineurin inhibitor medication.

U-M Health System dermatologist Charles Ellis, M.D., co-author of the new paper, explained that safety concerns have led to restrictions on the intensity and duration of topical corticosteroid use, especially in children and on delicate areas such as the face, neck and skin folds. As a result, many patients endure their eczema's pain and itching aided only by standard over-the-counter lotions.

"A new consensus approach is needed to ensure patients can get the best treatment, including the new therapies such as topical calcineurin inhibitors, and see how these might be used in a coordinated way to improve long-term symptom control while minimizing safety concerns," says Ellis, professor and associate chair of the Department of Dermatology at the University of Michigan Medical School.

Ellis and his fellow clinicians concluded that:* safe, effective therapy is needed for long-term maintenance of atopic dermatitis in patients of all ages* topical corticosteroids are effective, but provoke concerns over their safety for long-term use * the new class of topical calcineurin inhibitors may offer a solution to these concerns by providing a safe and effective treatment for the long-term control of atopic dermatitis. These drugs are non-steroid, selective cytokine inhibitors that do not cause the skin atrophy, blood vessel growth, glaucoma or growth retardation associated with corticosteroids

The Consensus Conference resulted in a comprehensive treatment algorithm that considers how all the key treatments for atopic dermatitis, including emollients (lotions), topical corticosteroids, topical calcineurin inhibitors, phototherapy and oral cyclosporine, can be used to greatest effect at the various stages of the condition.

"All of these treatments have an important place in the effective management of atopic dermatitis. But we should be using new and emerging therapies to complement our more traditional approaches," points out Ellis' co-chair, Thomas Luger, from the Department of Dermatology at the University of Munster, Germany.

"For example, topical calcineurin inhibitors could be used for maintenance therapy because they have been shown both to prevent disease progression and to reduce the incidence of flares. Calcineurin inhibitors could be used at the first signs and symptoms of atopic dermatitis and be used for as long as these persist, while corticosteroids could be reserved for the treatment of severe exacerbations," he adds.

Atopic dermatitis affects 10 percent to 15 percent of children under five years of age in developed countries, and its prevalence is rising. It is a chronic disease characterized by intense itching and recurrent flares. At present, there is no cure.

The ICCAD II framework defines the key aims of treatment as:* reduce acute signs and symptoms* prevent or reduce recurrences* provide long-term management by preventing flares* modify the course of the disease

Ellis welcomes the comprehensive approach of the new treatment concept in treating all stages of atopic dermatitis. "This can be a very distressing and debilitating condition for patients and their families. In the past we have tended to focus on reactive treatment for relapses and we may not have paid enough attention to long-term maintenance treatment aimed at preventing recurrences and flares," he says.

"These new guidelines remind us that we have a lot of highly effective treatments at our disposal to help all our patients whatever the severity of their disease," he adds.

The guidelines recommend:

* continuing use of emollients and education, with trigger avoidance and other adjunctive therapy as appropriate* topical corticosteroids or topical calcineurin inhibitors for acute control of itching and inflammation* for maintenance therapy (persistent disease and/or frequent recurrences), calcineurin inhibitors to prevent disease progression, and intermittent use of topical corticosteroids* for severe refractory disease -- phototherapy, potent topical steroids, oral cyclosporine, methotrexate, oral corticosteroids, azathioprine, and other therapies

Reference: British Journal of Dermatology 2003; 148 (Suppl. 63): 3--10.