Atopic dermatitis (AD) is one of the most common skin diseases. It appears in almost one quarter of newborns and infants and it is not uncommon to ameliorate with age. Especially the itching of the reddened and usually dry and scaly skin poses a common burden for children suffering from AD and their families. We asked Peter Springmann, pediatrician, allergist and one of our regular clinical investigators his view on atopic dermatitis, the impact on affected families and the current available treatment regimes.
Mr. Springmann, do you see many children with AD in your practice?
In 1980 I opened a pediatric practice with a special focus on the diagnosis and treatment of atopic dermatitis.
The disease has a high prevalence of 10-15% during infancy. While the infant eczema tends to disappear, the prognosis for those with severe recurrent disease and onset after 2 years of age is less favorable with the likelihood of continued recurrent symptoms.
What is the symptom AD patients most commonly suffer from?
At the center of the disease burden is the severe itching (pruritus), which begins in early infancy with skin areas that are highly irritated by constant scratching and often superinfected. A typical itch-scratch cycle develops, which must be interrupted by avoiding trigger factors and appropriate therapeutic measures in order to achieve a better course, avoiding frequent recurrences and chronification.
When does itching occur more frequently? What triggers or intensifies it?
The common basis of the disease is the impaired skin barrier, accompanied by an impairment of skin hydration. In individual cases it is necessary to find out which trigger factors play a role, as there are allergies (food, inhalation allergens, rarely contact allergens), and numerous environmental factors (skin irritants, sweating, clothing condition, washing habits, climate, microbial factors, psyche, stress). The less of these factors affect the skin, the better the course of the disease.
What are the most effective therapies against pruritus?
The most effective therapy against pruritus is a stage (acute, subacute, chronic) and severity-adapted treatment of the skin with topical preparations. In Germany we have a step therapy plan (severity 1-4). The basis of treatment in all degrees of severity is therapy with hydrating and moisturizing topical preparations. In each case, the individual tolerance of these preparations must be tested and the fat/water ratio must be adjusted according to the stage.
From stage 2 onwards, topical glucocorticoids with a high therapeutic index (effect/side-effect ratio) are used in addition to the basic therapy. Topical immunomodulators, calcineurin inhibitors can also be used in addition to or instead of glucocorticoids depending on age and effectiveness.
Particularly in children, a very careful risk-benefit analysis of topical therapy with these therapeutics is necessary, especially in severe and chronic courses with the need for high dosage, to avoid severe side effects such as skin atrophy and growth retardation.
Are other therapeutic approaches being researched?
Transition why finding new treatment approaches for AD is so important (from systemic to topical/local application to reduce side effects).
For some time now, there has been a treatment option for severe, predominantly allergy-triggered atopic dermatitis (elevated total IgE) with an anti-IgE preparation. This preparation must be regularly injected subcutaneously and has a high disease-reducing efficacy. Irrespective of the allergy status, another very effective therapy with a monoclonal antibody against Interleukin 4-receptor α has recently been made available in Germany from the age of 6 years. This is also used subcutaneously. in regular intervals.
Thank you very much for this interview!
Itching that scratch: Inducing and measuring itch and itch-reduction
Atopic dermatitis is a very common and important cause for pruritus, but far from the only one. Other inflammatory skin conditions such as psoriasis and prurigo nodularis, immune disordears such as allergic uticaria and diabetes but also everyday occurrences such as dry skin, sweating and insect bites can cause itching. To approach pruritus in a clinical test setting, several approaches exist that we at proderm can utilize to show the efficacy of consumer care products, topical pharmaceuticals or medical devices in alleviating pruritus.
One approach in clinical tests is to rely on the existing conditions causing pruritus, e.g. in patients suffering from atopic dermatitis. Other, more standardized methods allow us to induce pruritus in an experimental setting tailored to the product in question. Some ways to elicit itching are shown in this table.
|Mechanical Stimulation||Chemical stimulation||Electrical stimulation||Thermal stimulation||Other|
von Frey filaments
Histamine-induced itch (iontophoresis, Skin prick)Non-histaminergic itch (cowhage spicules)
|Neurometer at a frequency of 5, 250 and 2,000||Thermo Sensory Analyzer|| |
UV- induced itchExaggerated – Eczema Surfactant
Inducing itch is one thing, but measuring it is another! A multitude of measurement scales for self-reported itch exist, some of which we routinely and successfully employ at proderm. Rating scales usually ask the patient to indicate their itch level on simple numerical scales (e.g. rating itch from one to ten), verbal scales (ranging from "low itch" to "very severe itch") or on a so called visual analog scale (VAS), where the patient can rate their itch level on a continuous line between "no itch" and "worst imaginable itch". A slightly different approach is for the patient to assess their change in itch level, where the scale is used to indicate whether itching is getting better or worse. An example is shown in the following
Itching for more: New therapies for atopic dermatitis
We discussed the options for new scientific approaches to revolutionary therapies of atopic dermatitis with our regular clinical investigator, Dr. Brigitte Stephan and she weighed in on the current developments in new AD therapies. In this section a case study related to insect bites is also available.
Itching for your product
See a typical example of a claims support test for a consumer care product that claims to alleviate pruritus in individuals with atopic dermatitis and watch the according webinar on demand.