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Philippine Dermatological Society

Officers & Board of Trustees

PresidentVice President

SecretaryTreasurer

Board Members

Immediate Past President

Rm. 1015 Front Tower, Cathedral Heights Complex, St. Lukes Medical Center, E. Rodriguez Sr. Ave, Quezon CityEmail: pds@pacific.net.ph Website: http://www.pds.org.ph Tel/Fax No.: 727-7309 Fax No.: 932-9269

Francisca C. Roa, MDEvangeline B. Handog MDMa. Lorna F. Frez, MDMa. Teresita Gabriel MD

Benjamin Bince, MDMarcellano Cruz MDMa. Juiet Macarayo MDArnelfa Paliza MDGeorgina Pastorfide MDCarmela Veronica Reyes MDLilian Villafuerte MD

Amelia V. Tianco, MD

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Guidelines of Care for Atopic Dermatitis

I. Definition Atopic Dermatitis (AD) is a chronic and

recurrent inflammatory dermatologic problem marked by severe pruritus causing excoriations, erosions, lichenification and susceptibility to skin infections. The distribution of the lesions are age-related, and a family / personal history of atopy, asthma or allergic rhinoconjunctivitis is elicited. AD has no biological marker.

II.Rationale A. Scope AD is a disease causing great burden on the qual-

ity of life of the patient and family alike. This familial disease has a genetic predisposition and environmentally influenced expression.

B. issue Recognizing AD relies on good patient history

(includes family history) and a thorough physical examination especially that of the skin.

III.Diagnosticcriteria A. Clinical 1. Major Characteristics: a. Pruritus b. Typical Morphology & Distribution 1) Eczematous dermatitis 2) Flexural lichenification or linearity in

adults 3) Facial & extensor involvement in infants 4) Any of these patterns or combination

of patterns can appear in both adults & children

c. Chronic or chronically relapsing dermatitis d. Personal or family history of atopy (asthma, allergic rhinoconjunctivitis, atopic dermatitis, contact urticaria) 2. Other Characteristics a. Xerosis b. Ichtyosis/ palmar hyperlinearity in adults c. Early age of onset d. Cutaneous colonization and/or overt

infections 1) Staphylococcus aureus 2) Herpes simplex virus 3) Warts 4) Molluscum 5) Others e. Nonspecific hand and/or foot dermatitis,

increased susceptibility to irritant contact dermatitis

f. Nipple eczema g. Cheilitis h. Recurrent conjunctivitis i. Infraorbital fold

j. Keratoconus k. Anterior subcapsular cataracts l. Orbital darkening m. Facial pallor / facial erythema n. Erythroderma o. Pityriasis alba p. Anterior neck folds q. Perifollicular accentuation r. White dermographism / delayed blanch s. Impaired cell-mediated immunity t. Other B. Diagnostic/ConfirmatoryTests 1. Uncomplicated AD with definite clinical

characteristics: none required 2. For definitive diagnosis or complicating factors a. Hematological 1) Complete blood count a) Differential count b) Total count for eosinophilia b. Immunologic Testing 1) Complement levels 2) Serum IgE c. Smears for infective agents 1) Tzanck test 2) KOH preparation d. Cultures 1) Bacterial (with antibiotic sensitivity) 2) Viral 3) Fungal e. Skin biopsy f. Patch test g. Radioallergosorbent tests may be

appropriate in special cases h. Scratch / prick / intradermal tests i. Food elimination j. Psychological evaluation: AD tends to

flare during periods of psychic stress (anxi-ety, depression, anger, embar-rassment, shame, resentment). If factors cannot be adequately evaluated and treated by the dermatologist, psycho-logical evaluation and care, including testing, may be of value and should be considered.

iV. Recommendations Goal: Management is individualized to improve

the quality of life of the patient allowing optimal productive daily activities. The aim is to hydrate the skin, reduce inflammation, prevent the itch and eruption of the lesions and relieve sleep disturbance.

1. Prevention / Modulation of trigger factors a. Patient Comprehension and avoidance of

trigger factors 1) Skin care products that cause skin

irritation or dryness a) Soaps

Prepared by: Maria Victoria C. Dizon, MD

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(1) Germicidal / fragrant (2) Non-moisturized (3) Shower gels / bubble baths (4) Fabric softeners (5) Harsh detergents b) Fabrics (1) Rough (2) Occlusive 2) Environment a) Excessive heat (ill-ventilated rooms,

summer months) b) Extreme cold (air-conditioned

rooms) c) Exposure to known allergens (in

gested, inhaled, contactants like herb concoctions)

3) Emotional stress 4) Strenuous physical activities 5) Hygienic practices a) Improper bathing practices

(1) Frequency of bathing – too fre-quent bathing or prolonged water exposure dries out the skin.

(2) Use of abrasives (scrub cloths, loofahs, pumice stones)

2. Therapy a. Topical 1) Anti-inflammatory agents a) Corticosteroids: mid to high strength steroids after bathing may be used for brief periods, low strength steroids for maintenance. Certain vehicles may act as irritants, so alternative products or com-

pounded preparations may be indicated. b) Tar preparation c) Phototherapy (1) UVA (with or without psoralen) (2) UVB (3) Goeckerman and/or Ingram d) Antibiotics: for localized sites (1) Mupirocin (2) Fusidic acid e) Moisturizers / Emollients: applied

within 3 minutes from bathing. f) Immunomodulators (1) Tacrolimus (FK506) (2) Pimecrolimus (ASM 981) g) Therapeutic baths, compresses, cleansers (1) Tars (2) Emollients / moisturizing soaps (3) Colloidals (4) Skin cleansers 2) Oral / Systemic a) Antihistamines – single or multiple (1) Hydroxyzine hydrochloride (2) Chlorpheneramine maleate (3) Cetirizine (4) Other b) Antibiotics c) Corticosteroids (rarely) d) Immunotherapy

(1) Cyclosporine (2) Mycophenolate mofetil (3) Methotrexate (4) Azathioprine (5) Interferon-alpha and -gamma (6) Other e) Ketotifen (a mast cell stabilizer) 3) Dietary a) Elimination diet b) Supplements c) Other 4) Hyposensitization 5) Others may include but are not limited to

the following: a) Occupational and / or psychological

counseling b) Bed rest c) Psychotherapy 6) Hospitalization when indicated

V. Supportingevidence See References.

Vi. Disclaimer Despite strict adherence to these guidelines, a

complete cure of atopic patients will not be ensured. Patient management is individualized and deciding on the management solely depends on the physician.

References:1. Absolon CM, Cottrell D, Eldridge SM, Glover MT.

Psychological disturbance in atopic eczema: the extent of the problem in school-aged children. Br J Dermatol 1997; 137: 241-45.

2. Coleman R, Trembath R, Harper JI. Genetic studies of atopy and atopic dermatitis. Br J Dermatol 1997; 136. 1-5.

3. Dorner W, Baylock KW, et al. Guidelines of care for atopic dermatitis. J Am Acad Dermatol 1992; 26: 485- 8.

4. Eichenfield LF, Lucky AW, Boguniewicz M, et al. Safety and efficacy of pimecrolimus (ASM 981) cream 1% in the treatment of mild and moderate atopic dermatitis in children and adolescents. J Am Acad Dermatol 2002; 46: 495-504.

5. Hanifin JM, Chan S. Biochemical and immunologic mechanisms in atopic dermatitis: new targets for emerging therapies. J Am Acad Dermatol 1999; 41: 72-7.

6. Harper JI, Ahmed I, Barclay G, et al. Cyclosporin for severe childhood atopic dermatitis: short course versus continuous therapy. Br J Dermatol 2000; 142: 52-8.

7. Krafchik BR. Diagnosis and management of atopic dermatitis. Dermatol Ther 1997: 2;18-28.

8. Leent EJM, Gräber M, Thurston M, et al. Effectiveness of the ascomycin macrolactam SDZ ASM 981 in the topical treatment of atopic dermatitis. Arch Dermatol 1998; 134: 805-9. :127

10. Leung DYM, Soter NA. Cellular and immunologic mechanisms in atopic dermatitis. J Am Acad Dermatol 2001; 44: S1-12.

11. Neuber K, Schwartz L, Itschert G, Tom Dieck A. Treatment of atopic eczema with oral mycophenolate mofetil. Br. J Dermatol 2000: 143: 385-391.

12. Paller AS, Eichenfield LF, Leung DYM, et al. A 12-week study of tacrolimus ointment for the treatment of atopic dermatitis in pediatric patients. J Am Acad Dermatol 2001; 44: S47-57.

13. Ramsay CA, Savole JM, Gilbert M, et al. The treatment of atopic dermatitis with topical fusidic acid and hydrocortisone acetate. J Eur Acad Dermatol Venerol 1995; 7: S15-S22.

14. Ricci G, Patrizi A, Specchia F, et al. Effect of house dust mite avoidance measures in children with atopic dermatitis. Br J Dermatol 2000; 143: 379-384.

15. Ruzicka T, Assmann T, Homey B. Tacrolimus: The drug for the turn of the millenium? Arch Dermatol 1999; 135: 574-580.

16. Tofte SJ, Hanifin JM. Current management and therapy of atopic dermatitis. J Am Acad Dermatol 2001; 44: S13-6.

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Drugs Mentioned in the Treatment GuidelineThis index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing information of these drugs can be found in PPD reference systems.

TopicalCorticosteroidsBetamethasone Betnovate Betnovate Scalp Diprolene Diprosone Steroderm Valezone Bethamethasone/ Clioquinol Betnovate-C Diproform Betamethasone/ Clotrimazole Clotrasone Betamethasone/ Fusidic acid FucicortBetamethasone/ Gentamicin DiprogentaBetamethasone/ Gentamicin/

Clotrimazole Triderm Betamethasone/ Gentamicin/

Tolnaftate/ Clioquinol Quadriderm

Quadrotopic Cream Betamethasone/ Neomycin Sulfate Betnovate-N Betamethasone/ Salicylic acid Diprosalic Clobetasol Clobenate Clobederm Dermovate Dermovate Scalp Clobetasol/ Neomycin/ Nystatin

Clobederm-N Dermovate NN Desonide Desowen

Sterax Dexamethasone/ Neomycin

sulfate Decilone Cream SteraxDiflucortolone Nerisona/ Nerisona ForteFluocinolone Aplosyn/Aplosyn HP Synalar/Synalar HP Syntopic Fluocinolone/ Clioquinol

Aplosyn CFluocinolone/ Neomycin sulfate

Aplosyn N Neo-Synalar 10/Neo-Synalar 25

Fluocinonide Lidemol Lidex

Fluocinonide/ Neomycin sulfate/ Gramcidin/ Nystatin

Lidex NGN Fluticasone

Cutivate Fluocortolone Ultralan Hydrocortisone Cortizan Efficort Lacticare-HC Lotion Hydrocortisone/ Miconazole

nitrate Daktacort Hydrocortisone/ Oxytetracycline

Terra-Cortril TopicalMometasone furoate

Elica Elocon

Methylprednisolone aceponate Advantan Triamcinolone acetonide Kenacort A 0.1%

TopicalAntibioticsGentamicin sulfate Bactiderm Ointment Garamycin 0.1% Cream/

OintmentMupirocin BactrobanNitrofurazone Drugmaker's Biotech

Nitrofurazone FuracinFusidate Na Fucidin Intertulle/Ointment/

Cream Fusoderm 2% OintmentKeratoplastics PolytarTopicalImmunomodulatorPimecrolimus ElidelTacrolimus ProtopicEmollients,Demulcents&Protectants

Cetaphil Dermablend Cleansing milk Johnson's Baby Double

Protection Powder Johnson's Baby Lotion

Rich & Creamy Johnson's Baby Oil w/ Aloe

Vera and Vitamin E Johnson's Baby Sorbolene

Cream Wash Johnson's Baby Top to Toe

Wash Lactacyd Liquid Lacticare Nutraderm Nutraplus Oilatum Bar/ Gel/ Plus PhysiogelPetroleum jelly

Apollo Petroleum Jelly Zinc oxide/ Benzoic acid/

Salicylic acid/ Sulfur Bioderm Ointment

Zinc oxide/ Calamine Calmoseptine OintmentZinc oxide/ Econazole nitrate Pevaryl HP

AntihistaminesChlorphenamine maleate Antamin Barominic Chlor-trimeton Clormetamine Drugmaker's Biotech

Chlorphenamine Hargenan Synestal UL ChlorphenamineChlorphenoxamine

hydrochloride SystralCetirizine

Virlix Zinex ZyrtecClemastine Tavegyl TavistDesloratadine

Aerius Diphenhydramine

Alertuss Am-Europharma Diphenhydramine

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Benadryl Dramelin Drugmaker's Biotech Diphenhydramine

Hizon Diphenhydramine Inj Pharex Diphenhydramine

Hydroxyzine Iterax

Levocetirizine Xyzal

Loratadine Claritin Loradex

OralAntibiotics Amoxicillin

Aldemox Amoxil Amusa Athenalyn Axmel Bacihexal

Cartrimox Cilfam

Clearamox Daisamox DLI Amoxicillin Drugmaker's Biotech Amoxicillin Eleomox Emilex

Glamox Globamox Globapen

Harvimox Himox

IHC-Amoxicillin Littmox Macropage

Medimoxil Megamox

Montecil Moxillin Multicare Amoxcillin

Novamox Oramox/Oramox Forte

Pediamox Pharex Amoxicillin

Pharmamox Polymox

Promox RiteMED Amoxicillin

Semoxillin Servimox

Shinamox Sumoxil Teramoxyl Zymoxyl

Amoxicillin/ clavulanic acid Amoclav Augmentin

Natravox Ampicillin

Ampicin Ampin Amplivacil Apamicin Bactimed DLI-Ampicillin Drugmaker's Biotech Ampicillin Excillin

Genaxcin Pensyn Pentrexyl

Polypen Saloxin

Shinapen Azithromycin Zithromax Bacampicillin PenglobeCefaclor Ceclor/Ceclor BID/ Ceclor CD Ceclobid Clorotir Pharex Cefaclor RiteMED Cefaclor XelentCefadroxil Drozid Duracef Cefalexin Asaflex Biogenerics Cefalexin Bloflex Cefalexin-Vamsler Cefalin Capsule/ Drops/

Suspension Ceporex Cidoxine Cromlex Difagen Drugmaker's Biotech Cefalexin

Eliphorin Exel Fensid Fevenil Genflex Gesenal Harvexyl Keflex Lefex Lexum Lyceplix Medoxine Oneflex Oranil

Pectril Pharex Cefalexin RiteMED Cefalexin

Servispor VCP Cefalexin

Xinflex Zeporin Cefatrizine ZanitrinCefdinir Omnicef Cefprozil Procef Cefradine Sedinef Velodyne VelosefCefuroxime Kefox Lifurox Profurex RiteMED Cefuroxime Romicef Shincef Zegen Zinacef ZinnatCiprofloxacin Ciloxan Ciprobay Cipromet Cirok Iprolan Pharex Ciprofloxacin Xipro Zyflox ZalvosClarithromycin Klaricid/ Klaricid OD OnexidClindamycin Biogenerics Clindamycin Clindal Dalacin C HCl/Dalacin C

Palmitate/Dalacin C Phosphate

Inprosyn-HPCloxacillin Biogenerics Cloxacillin

Cloxigen Drugmaker's Biotech Cloxacillin

Encloxil IHC-Cloxacillin Interclox Myrex Cloxacillin

Oxaclen Patriflex Pharex Cloxacillin Prostaphlin-A

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Ritemed Cloxacillin Cotrimoxazole Bacidal Bactille Forte Bactille-TS Bactrim

Bacxal Biogenerics Cotrimoxazole Cotrexel

Cotribase Cotrimoxazole-Vamsler DLI-Cotrimoxazole Doctrimox Drugmaker's Biotech Cotrimoxazole

Fedimed Genoxzole/Genoxzole Forte

Genzaprim/ Genzaprim Forte

Globamox Globec/Globec Forte Gutrisul Intrafort Kathrex Lagatrim Forte Macromed Microbid/Microbid DS Onetrim Pharex Cotrimoxazole Procor

RiteMED Cotrimoxazole Septrin

Servitrim Synerzole Thoprim Trihexal

Trim-S Trimephar Trimetazole/ Trimetazole DS Trizole Suspension

Doxycycline Atrax Doryx Doxicon Doxin Drugmaker's Biotech

Doxycycline Harvellin Servidoxyne Vibramycin Erythromycin Am-Europharma Erythromycin Ditron DLI-Erythromycin Drugmaker's Biotech

Erythromycin

Ery-max Erycar Erycin Erythrocin/Erythrocin DS

Erythrolan Ethiocin Gentrocin Ilosone Pharex Erythromycin RiteMED Erythromycin Romaxin Sefavex Sensomed Erythromycin ServitrocinFlucloxacillin Na StafloxinLevofloxacin Floxel LevoxLincomycin Harvivin Lincocin Moxifloxacin Avelox Ofloxacin Gyros Inoflox Pharex Ofloxacin Qinolon Oxytetracycline Terramycin Roxithromycin Macrol/Macrol Kiddie/ Toddler/OD RulidSultamicillin Unasyn Oral Tetracycline Ritemed Tetracycline

Tetracycline-B Unimycin OralSteroidsBetamethasone Betnelan

Celestamine Celestone

DiprospanBetamethasone/ chlorphenamine

maleate Betneton Dexamethasone Decilone Drenex Oradexon/ Oradexon Forte ScancortinMethylprednisolone Adrena Depo-Medrol

Medrol Solu-Medrol Prednisolone Liquipred Optipred RiteMED Prednisolone Prednisone Drazone Drugmaker's Biotech Prednisone GXI Prednisone Orasone 5/ Orasone 20 Pred 5/10/30 Prednisone Organon Triamcinolone Kenacort Ketotifen

Quomyl Zadec / Zadec SRO Zaditen

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