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Introduction
Atopic dermatitis is a chronic inflammatory disease of the skin primarily seen in the pediatric age group Characterized by dry skin, pruritus, erythema, edema, scaling, excoriations, oozing, lichenification Increasing prevalence, rising costs Together with asthma and allergic rhinitis forms part of the atopic triad
Pediatric Subcommittee of the AIDAC October 29-30, 2003 292
Epidemiology
10-20% of children in industrialized countries develop atopic dermatitis Rising incidence, commoner in higher socioeconomic groups Overall clearance 50-60%. 80% of children with severe disease continue to have lifelong exacerbations.
Pediatric Subcommittee of the AIDAC October 29-30, 2003 293
Morbidity
Impact on quality of life occurs at all ages. Psychological problems from visible skin lesions due to stigmatization Itch-scratch cycle Sleeplessness, lack of concentration at school or work Repeated treatments, time involved, financial costs
Cost
Drain on financial resources of patients and health services Costs increase with disease severity, highest in first few years While FDA does not consider pharmacoeconomic issues in drug approvals, we recognize that cost is an important factor in drug availability.
Pediatric Subcommittee of the AIDAC October 29-30, 2003 295
Clinical Manifestations
Seen in early infancy, in 50 - 75% of cases, age of onset is 6 months or younger Clearance rate of 60% expected by age 16, relapses occur in adulthood Worse prognosis severe childhood disease, early onset, concomitant or family history of asthma/allergic rhinitis, biparental history of atopy
Pediatric Subcommittee of the AIDAC October 29-30, 2003 296
Clinical Features
Three main age-related stages. Dry skin and pruritus associated with all stages. Skin barrier function decreased, may lead to increased absorption of topically applied treatments. Usually improves with adequate treatment
Clinical Phases
Infantile Phase ( 0-2 years ) Onset around 3 months of age. Under 6 months, the face and scalp commonly involved, at an older age, limb folds and hands involved Red, scaly, crusted weeping patches with excoriations seen on both cheeks and extensor surfaces of extremities Course chronically relapsing and remitting
Pediatric Subcommittee of the AIDAC October 29-30, 2003 298
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Selection of treatment
This depends on Disease severity Age Compliance Efficacy Safety data Treatment costs
Pediatric Subcommittee of the AIDAC October 29-30, 2003 2915
Rx Treatment Options
1. Topical corticosteroids 2. Topical immunosuppressants 3. Systemic corticosteroids Off-Label and other treatment options 1. Photochemotherapy 2. Cyclosporin 3. Azathioprine 4. Thymopentin 5. Interferon- therapy 6. Traditional Chinese medicine 7. -linoleic acid
Pediatric Subcommittee of the AIDAC October 29-30, 2003 2916
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Topical Immunosuppressants
Newest pharmacological class for AD Introduced in this decade Direct immunosuppressive action in diseases with immunologic basis 2 FDA approved products Tacrolimus (FK506) (trade name Protopic) Pimecrolimus (SDZ ASM 981) (trade name Elidel)
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Background
Protopic (tacrolimus) ointment approved on 12/08/2000, 0.03% ointment approved for children 2 to 15 years, 0.1% ointment approved for adults. Indication in both age groups is short and intermittent long term therapy of patients with moderate to severe AD. Systemic tacrolimus (Prograf) first introduced for prevention of allograft rejection, now used in kidney, liver and heart transplantation
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Background (contd)
Elidel (pimecrolimus) cream 1% approved on 12/13/2001 Indicated for patients 2 years of age and older for short and intermittent long term therapy in the treatment of mild to moderate atopic dermatitis Both drugs not approved for use in children less than 2 years of age Systemic absorption can take place in both adult and pediatric age groups from topical application of both drugs
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Background (contd.)
Pediatric patients enrolled in clinical studies of tacrolimus and pimecrolimus had an increased incidence of certain adverse events eg. viral infections compared to vehicle. Currently, the effects of topical immunosuppressants on the developing immune system are unknown
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Indications for use (Second-line) (Second Both Protopic and Elidel are indicated for patients in whom the use of alternative, conventional therapies are deemed inadvisable because of potential risks, or in the treatment of patients who are not adequately responsive to or are intolerant of alternative, conventional therapies
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