Session 1 Atopic Dermatitis Dermatology LC 1.2

Atopic Dermatitis

1. Atopic Dermatitis Didactic Webinar Thursday May 4, 2017 Bringing Basic Dermatology Care to the Pediatric Medical Home 1.2 A PPOC/CHICO Learning Community & Integration Program © 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected]

2. We have no financial relationships with commercial entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients relevant to the content we are planning, developing, presenting, or evaluating. Disclosure © 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected]

3. Glenn Focht, MD Medical Director Pediatric Physicians’ Organization at Children’s Karen R. Barnett, MD, FAAP LC  Medical Director Pediatric Physicians’ Organization at Children’s © 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected] Madeleine Kuhn, MPH CHICO Program Manager Faculty Stephen E. Gellis , MD Program Director, Dermatology Boston Children’s Hospital   Sadaf Hussain, MD Dermatology Boston Children’s Hospita l Sophie Delano, MD Dermatology Boston Children’s Hospita l Tope Osineye, MBBS MPH Practice Consultant Pediatric Physicians’ Organization at Children’s Alex Lorenzo QI Program Coordinator Pediatric Physicians’ Organization at Children’s

4. Graphs are only commercial payers and only practices in the PPOC

5. Learning Community Schedule Date Content Thursday, May 4, 2017 Atopic Dermatitis Thursday, June 1, 2017 Acne Thursday, June 29, 2017 Q&A (Optional and open to past and current participants) Thursday, August 24, 2017 Warts, Molluscum , Hives Thursday, September 28,2017 Q&A (Optional and open to past and current participants Thursday, October 26, 2017 Wrap-up Didactic Webinars: 7:30am – 9:00am Q&A: 7:30am – 8:30am © 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected]

6. Materials stored on Blackboard childrens.blackboard.com and are posted one day after each session. Materials on Blackboard include: Syllabus Schedule Slides Handout Videos Session recordings Surveys (MOC/CME) Questions email course director: Madeleine Kuhn at [email protected] Course Structure © 2015 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected] 4 Didactic Webinars . Didactic webinars are online sessions in which a specialist in dermatology and primary care lead is present to discuss anatomy and lead case discussions. Coursework : Qstream One Pre- and Post process map for one of the areas of study (Acne, Atopic Dermatitis, Warts/ Molluscum /Hives) per practice Case reviews of past dermatology visits per practice After every session you will receive a follow-up email with the recording, course handouts and CME/MOC Survey

7. Physician Boston Children’s Hospital designates this live activity for a maximum of 20.00 AMA PRA Category 1 Credits ™. Physicians should claim only credit commensurate with the extent of their participation in this activity. Boston Children’s Hospital approves this course for 20 ABP MOC Part IV credits Nurse Boston Children’s Hospital designates this activity for 10.00 contact hours for nurses. Nurse should only claim credit commensurate with the extent of their participation in the activity. Course Credits © 2015 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected]

8. Key Features of Atopic Dermatitis Pruritus Comes and goes Early age onset Characteristic locations

9. Atopic Dermatitis Background Prevalence increasing with 15-29% children affected Onset usually at 3-6 months of age; 90% develop before age 5 years 1 st manifestation of the “atopic march” Genetic and environmental factors

10. Case Scenario One

11. Collecting the Patient’s History

12. History HPI: Onset Location Symptoms (itching/sleeping problems) Bathing Habits Frequency Duration Water temperature Soap Moisturizing Treatments tried PMH: skin infections, seasonal allergies, asthma, food allergies FH: atopy ROS: growing/feeding well, diarrhea, bloody stools

13. Case Scenario 2 6 year old with history of intermittent, itchy rash that began around age 6 months. It is worse in the winter. She bathes once daily for 20 minutes with Johnson and Johnson's cleanser and moisturizes with baby lotion .

14. Physical Examination General: well-appearing, appropriate size-for-age, non-dysmorphic Full skin examination Rough, red ( hyperpigmented ), plaques Classic distribution (varies by age) Evidence of infection (pustules, abscesses, impetiginized areas, punched out areas) Pictures are placeholders for correct imagery

15. Distribution of AD by Age Infant (birth-2 years) Face (cheeks), scalp, ears Extensor extremities Seborrheic dermatitis overlap Childhood (2 years-puberty) Face (cheeks) Flexural extremities Teenager-Adult Localized flexural extremities Hands, dorsum feet

16. Physical Examination: Other Considerations Classic features/location-confirmation Evidence of infection Distribution that affects my management-topical strength (skin thickness/site) Clues to exacerbators - airborne allergens, irritants (saliva, wet wipes)

17. Case Scenario 3 A 16 year-old with known atopic dermatitis presents with worsening skin lesions in the popliteal fossae. He feels well but the areas are itchy and sore. What would be your treatment plan?

18. Atopic Dermatitis Treatment: Pathogenesis-Directed Primary problem in AD is an impaired skin barrier (e.g., filaggrin mutations) Water escapes the skin (dryness) Irritants, allergens and microbes easily enter the skin ( inflammation -redness, itchiness, serous drainage or impetiginization ) Immune system “sees” more and reacts more If the skin isn’t hydrated it isn’t able to block irritants and microbes from “slipping through the cracks” and causing an infection.

19. Treatment 2 Steps to Treat Effectively: Resolve existent inflammation (acute flare) AND reinforce the skin barrier (maintenance)

20. Skin Care Bathe 5-10 minutes with warm, NOT hot, water once every other day Sensitive skin soaps : Dove sensitive skin bar soap, Cetaphil cleanser, Vanicream soap Moisturize twice daily every day Ointments: Hydrolatum , V aseline, A quaphor Creams: CeraVe cream, Cetaphil cream, Aveeno cream, Eucerin cream, Vanicream *do not use lotions as they are minimally effective (too thin) *avoid “organic” products or ones containing fragrance, plant derivatives (calendula, cocamidylpropyl betaine )

21. Treating the Inflammation Topical steroids 1 st line *Systemic corticosteroids are not indicated For itch: sedating antihistamines: diphenhydramine or hydroxyzine po (0.5-2mg/kg/dose)

22. Topical Steroids Low Potency Cost / all are covered by insurance and all are generic Hydrocortisone 2.5% ointment $5.00 - $20.00 Desonide 0.05% ointment $13.00 -$25.00 Triamcinolone 0.025% ointment $4.00

23. Topical Steroids Very High-Potency: (if needed, consider derm eval ) clobetasol , halobetasol , desoximetasone Mid-Potency Cost / Coverage Fluocin o LONE 0.025% ointment $20 - $40 has a generic and brand version and is covered by insurance Triamcinolone 0.1% ointment $4.00 Is generic and is covered by insurance High-Potency Cost / Coverage Mometasone 0.1% ointment $6-$20 may be covered by insurance Fluocino NIDE 0.025 % ointment may be covered by insurance

24. Topical Steroid (Contd.)

25. Topical Calcineurin Inhibitors Thin-skinned areas, periocular disease Maintenance therapy Safety data does not suggest any malignancy risk Prior authorization may be required Tend to be costly and not all are generic

26. Eucrisa ( Crisaborole 2%) Ointment FDA Approval December 2016 PDE-4 inhibitor Ages 2+ mild-to-moderate atopic dermatitis Side effects: hypersensitivity, stinging/burning/pain 1522 participants from 2-79 years Clear/almost clear: 32.8% vs. 25.4% (placebo); 31% vs. 18% (placebo) Utility-yet to be determined

27. Complications Infections Bacterial Perform a bacterial culture for identification and sensitivities Cephalexin po or clindamycin po Bleach baths 2-3 times per week for maintenance (also helps with Inflammation) Herpes Simplex Virus Coxsackie Virus Molluscum Eczema herpeticum requires emergent dermatologic treatment

28. http://www.wider.es/casosclinicos/index.php/eczema-coxsackium-causado-por-coxsackievirus-a6-caso-600/

29. Treatment Cases

30. Algorithm Adapted from Perman M, Yan A. Getting 'ADEPT' at Atopic Dermatitis. Dermped.org . 1:1 (2012)

31. Algorithm Continued

32. How would you treat? Questions Based on the Algorithm Is this atopic dermatitis? Infection? Mild/Mod/Severe (thick or thin plaques)? Thin skinned area? Affecting sleep? Triggers?

33. WebEx Questions You will get the first 4 questions of each case. They are multiple choice and most are yes or no. You will have a total of 30 seconds to answer the 4 questions on each case. Once you have submitted your answers, the speaker will go over the right answers and see how the group did.  If you don't have the question feature you can write your answers in the chat box or listen along.  If you have technical issues during this portion, email the course directors after the course.   

34. Case 1 Is this atopic dermatitis? Infection? Mild/Mod/Severe? Thin Skin? Affecting Sleep? Triggers? YES NO MILD YES YES; SALIVA, FOOD, WIPES NO How would you treat? Plan: Sensitive skin care Low potency- desonide 0.05% ointment BID x1-2 weeks Thick layer of vaseline , hydrolatum , aquaphor before meals, before naps, before bedtime Antibiotics and antihistamines are not necessary

35. Case 2 Is this atopic dermatitis? Infection? Mild/Mod Severe? Thin Skin? Affecting Sleep? Triggers? YES NO MOD NO ? YES How would you treat? Plan: Sensitive skin care Mid-potency- fluocinolone 0.025 ointment BID x2-3 weeks Avoid fragrances and chemicals Antibiotics are not necessary Hydroxyzine 0.5mg/kg/dose at bedtime

36. Case 3: Is this atopic dermatitis? Infection? Mild/Mod/Severe? Thin Skin? Affecting Sleep? Triggers? YES NO; culture if not sure Mild-Mod NO NONE APPARENT YES Patient has history of skin infection. How would you treat? Plan: Sensitive skin care Mid-potency-triamcinolone 0.1 ointment BID x2 weeks Bleach baths 2-3 times per week Hydroxyzine 0.5mg/kg/dose at bedtime

37. Case 4: Is this atopic dermatitis? NO! This is Scabies!!! How would you treat? Plan: Permethrin 5% cream aad.org

38. Case 5: Is this atopic dermatitis? Infection? Mild/Mod/Severe? Thin Skin? Affecting sleep? Triggers? YES YES MOD-SEV NO NO How would you treat?(With evidence of infection, do we treat infection and inflammation at the same tim e?) Plan: Sensitive skin care Bacterial culture; po cephalexin (Maintenance-bleach bath) Med-potency-triamcinolone 0.1 ointment daily x2 weeks (wrap with plastic wrap) NO

39. Case 6: Is this atopic dermatitis? Infection? Mild/Mod/Severe? Thin Skin? Affecting sleep? Triggers? YES NO MILD YES NO Plan: Sensitive skin care Avoid fragrances Low-potency-hydrocortisone 2.5 ointment daily x3-5 days, then switch to protopic ointment BID x2-3 weeks Apply a thick layer of moisturizer to act as a protective layer against contactant YES; FRAGRANCES, AIRBORNE Picture courtesy of Dr. Gellis

40. Case 7: Is this atopic dermatitis? Infection? Mild/Mod/Severe? Triggers? YES but hmmm YES SEVERE HSV How would you treat? Plan: Emergent referral (eczema herpeticum ) Abrupt rash in child with history of eczema and cold sores.

41. When to Refer to Dermatology?

42. Common Questions How can I tell the difference between atopic dermatitis and psoriasis? But I've seen the diaper area involved in children with atopic dermatitis. What is going on? Is it safe to use topical steroids on eczema that looks infected? When should I test for food allergies? Should I be worried about systemic absorption of topical steroids? What about the side effects?

43. Psoriasis Medicinenet.com

44. Common Questions How can I tell the difference between atopic dermatitis and psoriasis? But I've seen the diaper area involved in children with atopic dermatitis. What is going on? Is it safe to use topical steroids on eczema that looks infected? When should I test for food allergies? Should I be worried about systemic absorption of topical steroids? What about the side effects?

45. Seborrheic Diaper Dermatitis Skinsight.org

46. Baby Wipe Contact Dermatitis ( Methylchloroisothiazinolone ) http://pediatrics.aappublications.org/content/133/2/e434

47. Blue Dye Diaper Dermatitis

48. Common Questions How can I tell the difference between atopic dermatitis and psoriasis? But I've seen the diaper area involved in children with atopic dermatitis. What is going on? Is it safe to use topical steroids on eczema that looks infected? When should I test for food allergies? Should I be worried about systemic absorption of topical steroids? What about the side effects?

49. Common Questions How can I tell the difference between atopic dermatitis and psoriasis? But I've seen the diaper area involved in children with atopic dermatitis. What is going on? Is it safe to use topical steroids on eczema that looks infected? When should I test for food allergies? Should I be worried about systemic absorption of topical steroids? What about the side effects?

50. Common Questions How can I tell the difference between atopic dermatitis and psoriasis? But I've seen the diaper area involved in children with atopic dermatitis. What is going on? Is it safe to use topical steroids on eczema that looks infected? When should I test for food allergies? Should I be worried about systemic absorption of topical steroids? What about the side effects?

51. Postinflammatory Pityriasis Hypopigmentation Alba Pediatricsconsultant360.com Dermnetz.org

52. Algorithm © 2015 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected] On Blackboard and in follow-up email after this session

53. © 2015 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected] Coursework You are assigned a team and will receive an email from Qstream to answer 12 questions over 4 weeks. If you get the question right twice the question will retire and you will get a new question.

54. Key Terms “atopic march” Hyperpigmented Evidence of infection (pustules, abscesses, impetiginized areas, punched out areas) Seborrheic dermatitis overlap Xerosis lichenification filaggrin mutations Impetiginization Eczema Herpeticum Eczema coxsackium Molluscum dermatitis Red Flags

55. Learning Community Schedule Date Content Thursday, May 4, 2017 Atopic Dermatitis Thursday, June 1, 2017 Acne Thursday, June 29, 2017 Q&A (Optional and open to past and current participants) Thursday, August 24, 2017 Warts, Molluscum , Hives Thursday, September 28,2017 Q&A (Optional and open to past and current participants Thursday, October 26, 2017 Wrap-up Didactic Webinars: 7:30am – 9:00am Q&A: 7:30am – 8:30am © 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected] Recordings will be sent out in follow-up email

56. Your Feedback Helps Us Succeed! Please take a moment to fill out the session evaluation survey you will receive via email and provide us with your feedback so that we can continue to improve and meet your expectations! Survey is also a CME / MOC requirement © 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected]

57. Thank you!

58. Appendix

59. Atopic Dermatitis: Definition