3 VIETNAM 29APRIL ECZEMA en

Approach to eczema Hugo Van Bever Department of Pediatrics NUHS - Singapore APAPARI workshop, HANOI, April 29, 2017 Eczema in children Atopic dermatitis Constitutional eczema Contact dermatitis Seborrhoeic eczema H C T I - Looks - Sleep - Study activities Onset of AD… ONSET = (soon after birth) bad skin  bad skin microbiome  skin inflammation (allergy not involved) Whole metagenome profiling reveals skin microbiome-dependent susceptibility to atopic dermatitis flare Chng KR, et al (Singapore) These findings provide insights into how the skin microbial community, skin surface microenvironment and immune system cross-modulate each other, escalating the destructive feedback cycle between them that leads to AD flare Nature Microbiology 2016, doi:10.1038/nmicrobiol.2016.106 Singapore studies on FLG FLG null-mutations are associated with: early onset disease increased disease severity increased bacterial flares   REFERENCES: - CAI S.C., CHEN H., KOH W.P., COMMON J.E., VAN BEVER H.P., McLEAN W.H., LANE E.B., GIAM, Y.C., TANG M B “Filaggrin Mutations are Associated with Recurrent Skin Infection in Singaporean Chinese Patients with Atopic Dermatitis.” Br J Dermatol 2011, 1111, 1365   - CHEN H., COMMON J E., BALAKRISHNAN A., BROWN S.J., GOH C.S., CORDELL H.J., SANDILANDS A,, CAMPBELL L.E., KROBOTH K., IRVINE A.D., GOH D.L., TANG M.B., VAN BEVER H.P., GIAM Y.C., McLEAN W.H., LANE E.B “Wide spectrum of filaggrin-null mutations in atopic dermatitis highlights differences between Singaporean Chinese and European populations Br J Dermatol 2011, 165, 106 - 114 Epidemiologic risks for food allergy Lack G JACI, 2008, 121, 1331 Sensitization to food - Prenatally - Through breast milk - Eating – drinking - Transcutaneous (eczema) - Inhaling - smelling Skin prick testing to food allergens in breast-fed young infants with moderate to severe atopic dermatitis Rennick et al Austr J Dermatol 2006, 47, 41-5 - 59 infants - moderate to severe AD - exclusively breast fed - mean age: 6.5 months 54/59 (91.5%) positive SPT !!! Egg Cow’s milk Peanuts Wheat Soy Management of atopic dermatitis = A PACKAGE (involving life style) Treating eczema… “I cannot cure eczema.” “But, I can… - control better - avoid complications - improve QOL.” Management of AD - principles – Holistic Package Life style Safe Treating eczema… … is more than prescribing drugs • Education • Life style Cornerstones of treatment of AD Moisturizers Topical corticosteroids (?) Antiseptics Scarring in AD Moisturizers… • A lot of moisturizers on the market • Some were not the subject of clinical studies • Some compared to placebo (or baseline) • No comparative studies • Doctors  confused! … go for scientific evidence! Moisturizers = cornerstone of treatment  Better knowledge of skin barrier defects  Better moisturizers “Doctor, what is the best moisturizer for my child?” “Ask your child!” Affordable Pleasant Not irritable To avoid… - antibiotics - oral medicines (antihistamines, immunosuppressant) - extensive diets - complex treatments Primary prevention of eczema (cfr  talk on prevention of allergy Bacterial products (to the mother) Early moisturizing (from birth) Breast feeding (4 – months) Early introduction of allergenic food (?) = area of intense research! Immediate Future of AD treatment • Corticosteroid-free treatment • Causal treatment (preventive treatment) - Role of: Early Immunotherapy Skin barrier restoration treatments Others (bacterial products, antiseptics, calcineurin inhibitors, etc…) General conclusion AD is complex, and its treatment should be holistic, involving patient and family Future: corticosteroid-free treatment Treatment: changes in life style (priority!) Focus on life style! … back to nature! Atopic Dermatitis (@ ECZEMA) - Advice: - unravel the underlying mechanisms of each child with eczema -