peds ezcema part 2 Flashcards
when are wet wraps used
for areas liquenified and not healing
when using a wet wrap, when should it be applied
bath, drug, then moisturizer, then wet wrap
why are wet wraps used?
they can increase the penetration of the steroid, decrease the itch, and prevent scratching
soothe the skin and itch
explain how wet wraps should be applied and for how long
wet layer of cotton (old cotton shirts or cotton bed sheets), and then dry layer of cloth/gauze
keep in place 3-8 hours
can use overnight for up to 1 week or 24-72 hours if changing every 3-8 hrs
when may CS side effects be more pronounced?
if applied to thin skin like face/neck/groin
name some skin-related side effects of topical CS
acne
perioral dermatitis (if used near mouth)
hypopigmentation
rosacea
cutaneous atropy (striae, thinning, telangectasia – like spider veins)
what are some adverse effects if topical CS are applied near the eyes
cataracts
glaucoma
intraocular HTN
name 3 VERY RARE systemic adverse effects of CS
adrenal suppression
growth retardation
reduced bone density
when is there a risk of flare relapse?
if the steroid is ABRUPTLY discontinued
TRUE OR FALSE
CS tends to be more effective then calcineurin inhibitors
FALSE —- efficacy is same
TCIs are _____ agents.
how do they work?
immunosuppressive
suppress T cell activation and cytokine production
how often are TCIS applied
like CS - BID
true or false
TCIs are immunosuppressives
true
how long do TCIs take to work
within 3 days of starting
Tacrolimus 0.1% ointment
who is it FDA approved for
children greater than or equal to 16 and adults with mod-sev AD
tacrolimus 0.03% ointment
pimecrolimus 1% cream
who is it FDA approved for?
children greater than or equal to 2 and adults with mild-moderate AD
which is more effective - pimecrolimus or tacrolimus?
tacrolimus
name some adverse effects of TCIs and how to avoid them
localized burning and stinging — to reduce, can pre treat with topical CS
roseacea, contact dermatitis
as mentioned, burning and stinging is an adverse effect of TCIS
is it worse for tacrolimus or pimecrolimus
tacrolimus
as mentioned, TCIs and Cs’s have the same efficacy
what is an advantage of TCI over CS?
they cause less skin atrophy and ocular AE
name 3 disadvantages of TCIs
more expensive
burning and stinging
BBW: malignancy
WHY are topical TCIs like tacrolimus 0.1% not indicated in patients younger than 2?
they tend to absorb more drugs through the skin, and these drugs have a black box warning of possible development of skin cancer and lymphoma
TCIs are ________ line therapy for AD
2nd line - when others not effective or tolerated
what is it considered if children younger than 2 use TCIs?
considered off label
what to counsel pts on getting TCI
apply with SPF-30 (reduce cancer risk)
use smallest amount needed for shortest period of time -AVOID continuous use
TCIs should be avoided in ____ persons
immunocompromised
because they suppress T cells
true or false
TCIs are intended for long term treatment of milk-moderate AD
FALSE - short term
should not be used continuoisly
typically used for mod-severe – but can be milkd-mod (lower doses)
besides CS and TCI what is another treatment for AD flares
topical PDE4 inhibitors
name a topical PDE4 inhibitor
Crisaborole
who is indicated for treatment with crisaborole
treat mild-moderate flares of AD in infants greater than or equal to 3 months!!!
when TCS/TCI cannot be used or is not effective
how does crisaborole work in managins AD flares
decreases cytokine production by inhibiting PDE4
true or false
crisaborole is applied twice a day
true
how long does crisaborole take to work?
compare to TCS/TCI
AROUND 8 DAYS AFTER STARTING
TCS/TCI is 3 days
name some adverse effects of crisaborole
burning and stinging at the application site
after the flare has been cleared, what is the treatment for preventing relapses?
state treatment for both topical CS and TCI
corticosteroids - apply to previously affected area ONCE DAILY twice a week for 2 consecutive days
up to 16 weeks
TCI - once daily, 2-3 times a week for 10-12 MONTHS
phototherapy is a ____ agent for severe, refractory AD
systemic
what is a disadvantage of using phototherapy?
how does it work?
takes a LOT of treatments, and done 3x a week
has anti inflammatory effecs, dec cytokine production, and antimicrobial effects by decreasing staph colonization
in what age is phototherapy avoided
children and young adults - bc skin cancer risk
what are some AE of phototherapy
skin erythema and pain, itching, malignancies, premature skin aging
____ may be used as bridge therapy from systemic and back to topical once the pt improves
phototherapy
when are SYSTEMIC corticosteroids used for AD?
for exacerbations that havent responded to topical therapy
why are systemic corticosteroids not recommended to be taken long term
toxicity
rebound flares – when you come off you may flare up
what is allergen specific immune therapy
can be used in AD when the allergen is identified – but risk of anaphyalxis
what is cyclosporine A
a systemic agent for refractory (keeps coming back) AD
how does cyclosporine A work as a systemic agent for refractory AD
suppresses inflammatory cytokine gene transcription in T cells
what are some AE of cyclosporine A
GI
headache
hephrotixic
dont use more than 1 year - malignancy concern
name 3 systemic agents that inhibit murine synthesis
azathioprine
mycophenolate
methotrexate
what is interferon gamma
systemic agent used in refractory AD
down regulates helper T cell function — but causes flu like msyptoms
what is an issue with systemic agents for refractory AD
they take a long time to work and have a lot of adverse effects
name 1 monoclonal antibody and 3 JAK inhibitors that are biologics and can be used in AD
monoclonal – dupilumab
JAK inhibitors - baricitinib
abrocitinib
upadacitinib
biologic therapies are specific to the _________ of AD
pathophysiology
explain the MOA of bupilumab (dupixent)
inhibits signaling of IL4 and IL13 tH2 cytokine pathways
in what age/severity is dupilumab indicated for
children greater than or equal to 6 months
moderate to severe AD - when other therapies not effective or cant be used
dupilumab is usually administered with what?
a topical corticosteroid – response may be improved
what is the approximate onset of action of dupilumab?
compare this to the other systemic agents
2-3 weeks
other systemics are much longer at aorund 14 weeks
does dupilumab have good efficacy?
yes
63-82&
explain how dupixent works to help AD pts
downregulate inflamm mediators
upregulation of genes involved with barrier
reduction in skin infection
downregulation of markers of epidermal proliferation
name some adverse effects of dupilumab
GI upset
injection site reactions
conjunctivitis/blepharitis/dry eye
oral herpes
facial edema
skin papilloma
as mentioned, dupilumab can cause facial edema
it is unresponsive to what meds? it is responsive to what meds? what may the edema be due to?
unresponsive to topical anti inflammatories
may be due to malassezia (fungus)
may be responsive to anti fungals or decrease dose or dicontinue dupilumab
name 3 advantages of JAK inhibitors over biologics
given by mouth
predictable pharmacokinetics
less immunogenicity (ability to cause an immune response)
JAK inhibitors are indicated for what patients?
who have not had disease control with topical and/or phototherapy
generic for rinvoq
What class is it?
JAK inhibitor
upadacitinib
upadacitinib is FDA approved for what age and what population?
12 years old and older and adults
refractory moderate-severe AD that is unresponsive to systemic medications
compare the efficacy of dupulimab and upadacitinib
upadacitinib has lower efficacy than the injectable
upadacitinib should not be co administered with what
other JAK inhibitors (like tofacitinib)
any immunosuppressant
DMARDS (adalimumab, infliximab)
name some AE of upadacitinib (rinvoq)
NVD
increased risk of infection and tb activation
retinal detachment
dec WBC
malignancy risk
Abrocitinib (cibinqo) is FDA approved for what age and population
greater than 12 years and adults
refractory, mod-severe AD that is unresponsive to oral and systemic
abrocitinib should not be coadministered with what
other JAK inhibitors
any immunosuppressant
DMARDS
Major AE of abrocitinib
risk for CV event, thrombosis
what is a drug that may benefit pts in controlling AD?
probiotics
name 3 oils that can be used topically for AD
olive oil
coconut oil
sunflower seed oil
of the 3 oils, for which is there a concern of contact dermatitis
olive oil
_______ is at the heart of AD therapy
EDUCATION
