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Editorial development by MIMS MedComms.
This booklet is not intended as a substitute for professional care.Any liability or obligation for loss or damage howsoever arisingis hereby disclaimed. © 2014 MIMS Pte. Ltd. All rights reserved.No part of this publication may be reproduced by any process
in any language without the written permission of the publisher.MIMS Pte. Ltd., No 6 Shenton Way,OUE Downtown 2, #15-08, Singapore 068809Tel: (65) 6290 7400 Fax: (65) 6290 7401E-mail:[email protected] Website: www.mims.com
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ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS
Understanding theRole of Emollients
in Atopic DermatitisManagement
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IFC
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Adelaide Ann Hebert
David Luk Chi Kang
Hardyanto Soebono
Hugo Van Bever
Inne Arline Diana
Kyu-Han Kim
Maria Victoria Dizon
Marysia Stella Recto
Yoke Chin Giam
Zakiudin Munasir
Understanding theRole of Emollientsin Atopic DermatitisManagement
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CONTENTSForeword 3
Introduction 4
What to consider when selecting moisturizers 7
Classification of moisturizers 9
Anti-inflammatory agents 10
Recommendations on moisturizer use 11
Moisturizer recommendations by specialty groups 12
Other factors to consider when choosing moisturizers 14
The Asian patient experience 17
Therapeutic patient education 18Patient education and counselling 19
SMART goals 20
Conclusions 21
References 23
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FOREWORDEffective treatment of atopic dermatitis (AD) involves treating the skin
barrier defect inherent in these patients. To do this, patients should be
advised to have adequate hydration and to use moisturizers regularly.
There are but a few available moisturizers supported by scientific evidence.
The booklet published by the Pediatric Dermatology Subspecialty Core
Group of the Philippine Dermatological Society entitled “A Guide toUnderstanding Moisturizers in Atopic Dermatitis” summarizes the most
commonly accessible moisturizing products and grades the quality of
evidence supporting the efficacy and safety of their active ingredients.
Among the factors that may be considered in the choice of treatment
options for any case are the overall benefits perceived by the clinician
on these products, and the patient’s profile. Through analysis of these
factors, one may be able to determine the rationale for choosing thebest moisturizer options for the appropriate patient.
Treatment adherence is vital in primary and secondary prevention of
the symptoms of AD. Different strategies may be on hand to help a
clinician in the effort to promote reduction of flares and to improve
overall quality of life.
This booklet gives an overview of the status of moisturizer use in Asians
with AD based on the consensus points discussed during the 2014 AsianAtopic Dermatitis Summit.
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ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS
Atopic dermatitis (AD) is a chronic pruritic inflammatory disorder characterized
as a defect in the skin barrier. This alteration in the barrier leads to increased
penetration by environmental allergens and infective organisms that cause
persistent inflammation in the skin. Although the barrier defect has been considered
in the past as an epiphenomenon, it is now believed to play a major role in the
pathophysiology of the disease.1 (Figure 1)2
FIGURE 1. Effect of barrier dysfunction on Th2 induction. Barrier dysfunction in line with filaggrindeficiency will lead to Th2 skewing conditions, which may play an important role in the developmentof AD
Legend: TSLP, thymic stromal lymphopoietin; Th2, T helper 2 cells; PAR-2, protease activated receptor-2
Reprinted from Journal of Dermatological Science, 70/1, Kabashima K, New concept of the pathogenesis of atopic dermatitis:Interplay among the barrier, allergy, and pruritus as a trinity, Page No. 4, Copyright (2013), with permission from Elsevier.
INTRODUCTION
External stimuli
Barrier disruption
Mechanical injury
TSLP upregulation
PAR-2 activation
Filaggrin mutation
Increased pH
Kallikrein activationProtease containing–
protein antigenexposure
Th2 induction
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ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS
As AD is chronic and relapsing, the most important treatment strategy is to treat
and prevent flares and repair the skin barrier in the long term. (Figure 2)
Among the available treatment modalities, moisturizers are the most fundamental
requirement for optimal treatment of AD regardless of the severity.3 These
moisturizers hydrate the skin and repair skin barrier function.4 Worldwide, in all theguidelines on management, moisturizer use is a key and basic step in the treatment
of AD. 3,5-11 (Figure 3)3
FIGURE 2. AD is described as a chronic and relapsing skin disorder
FIGURE 3. Stepwise management approach to AD
Adapted from Akdis CA, Akdis M, Bieber T, et al. Diagnosis and treatment of atopic dermatitis in children and adults: EuropeanAcademy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL ConsensusReport. J Allergy Clin Immunol 2006;118:152-69.
STEP 1 Basic Treatment: Skin hydration,emollients, avoidance of irritants,identification and addressing ofspecific trigger factors
I N T E
N S I T
Y O F
D I S
E A S ESTEP 2 Low-mid potency TCS and/or TCI*
TCS = Topical corticosteroidsTCI = Topical calcineurin inhibitors
CyA = Cyclosporine A*Over the age of 2 years
STEP 3 Mid-high potency TCS and/or TCI*
STEP 4 Systemic therapy (e.g. CyA) or UV therapy
Time
AD Severity
D r y s k i n
o n l y
M i l d
t o
m o d e r
a t e A D
M o d e r a
t e
t o s e v e r e A
D
R e c a l c i t r a
n t ,
s e v e r e
A D
FLARE FLARE FLARE
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The severity of chronic diseases, especially AD, has a definite impact on the quality
of life (QOL) of both the patient and the family. As a result, certain priority patientgroups with similar disease morphologies have been considered to benefit from
specific moisturizer types. However, there remains to be a clinical classification
system to objectively determine which types of moisturizers are best suited for these
AD phenotypes. Products may be chosen according to whether these contain the
necessary ingredients (i.e. occulsives, humectants, or emollients) to match specific
profiles.
Key Opinion Leaders (KOLs) composed of specialists and subspecialists from allergy
and immunology, dermatology (paediatric and adult), and paediatrics from the Asia
Pacific region convened to work on a set of recommendations for the selection of
treatment options in AD that may be applicable within the region. More importantly,
the importance of moisturizers in the management strategy was highlighted, both in
the active and proactive treatment to attain the goal of controlling and preventingthe disease.
Grade Dryness Scale
0 Healthy Skin
1 Feeling Dry but Healthy Skin
2 White Flaking Skin
3 Slight Scaling
4 Severe Scaling with Cracks
5 Severe Cracking
How dry is your skin?
Note: Used for visual representation. Not a validated scale.
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ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS
A basic principle of treatment of AD is optimal skin care that adequately addresses
the skin barrier defect. This skin barrier dysfunction manifests as an increase in
transepidermal water loss (TEWL) and increased penetration of allergens and
infectious agents, leading to inflammation and intense pruritus.3 (Figure 4)
Contributing to this abnormality is a disturbed epidermal terminal differentiation
leading to filaggrin deficiency and reduced natural skin lipids.
WHAT TO CONSIDER WHEN SELECTINGMOISTURIZERS
FIGURE 4. Immunologic pathways in AD
Th2 cells circulating in the peripheral blood of AD patients result in elevated serum IgE and eosinophils. These T cells express theskin homing receptor, CLA, and recirculate through unaffected AD skin where they can engage allergen-triggered IgE+ LCs andmast cells (MCs) that contribute to Th2 cell development. Skin injury by environmental allergens, scratching, or microbial toxinsactivates keratinocytes to release proinflammatory cytokines and chemokines that induce the expression of adhesion moleculeson vascular endothelium and facilitate the extravasation of inflammatory cells into the skin. Keratinocyte-derived thymic stromallymphopoietin (TSLP) and DC-derived IL-10 also enhance Th2 cell differentiation. AD inflammation is associated with increased Th2
cells in acute skin lesions, but chronic AD results in the infiltration of inflammatory IDECs, macrophages (Mφ ), and eosinophils. IL-12production by these various cell types results in the switch to a Th1-type cytokine milieu associated with increased IFN- expression.
Republished with permission of The Journal of Clinical Investigation, from New insights into atopic dermatitis, Leung DYM, et al, 113,5 and 2014; permission conveyed through Copyright Clearance Center, Inc.
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Moisturizers restore the intercellular lipid bilayers’ ability to absorb, retain and
redistribute water by maintaining the integrity of the barrier.14,15 These agents may
penetrate and contribute to the reorganization of the structure of the skin layers.16
(Figure 5)
The effects of moisturizers can be measured using subjective and objectiveparameters. However, the few trials that compare moisturizers have shown that it is
difficult to assess efficacy between products.17-19
There are several genes which contribute to skin types and mechanisms of repair
implying the presence of distinct atopic dermatitis phenotypes; however, is is
unknown which substrate (i.e. moisturizer ingredients) is necessary to address
the specific epidermal defect.20 The choice of moisturizers has therefore been
determined in clinical practice by individual preference, safety, efficacy, and absenceof fragrances, additives or other sensitizing agents.20
Rationale for moisturizer use
FIGURE 5. Reestablishment of the protective skin barrier with moisturizers
Humectantspass intocorneocyteswith trappedwater
Emollientmimicsepidermallipids
Occlusivetrapswater
Humectant
Water
H2O H
2O
H2O
H2OH2O
H2O
H2O
H2O
H2O H
2O
H2O
H2O
H2O
H2O
H2O
H2O
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There are several classes of moisturizers grouped according to their similar
characteristics and these are21:
(1) humectants, e.g. glycerine, 5 to 10% urea, lactic acid
(2a) occlusives, e.g. lipids, petrolatum, or liquid paraffin
(2b) emollients, e.g. fatty acids or cholesterol
These products are formulated in a variety of delivery systems including gels, oils,
creams, ointments, or lotions, and have different compositions and properties toenhance efficacy.22 The following table summarizes the modes of action, properties,
and some representative agents from each class. (Table 1)23,24
Class Mode of action Biologicalsimilarity
Some examples
Humectants Attract and bindwaterfrom deeper
epidermis to SC
NMF in corneocytes GlycerinAlpha hydroxy acids Hyaluronic acidPyrrolidone carboxylic acid
Sodium pyrrolidonecarboxylic acid (Na PCA)Sodium and ammonium lactateSorbitolUrea
Occlusives Form a hydrophobicfilm to retard TEWLof SC
Intercellularlipid bilayers
- Ceramide- Cholesterol- Free fatty acids
Carnauba wax LanolinMineral oils Olive oilPetrolatum SiliconeCetyl/stearyl alcohol Propylene glycolSqualene Stearic acid
Emollients Smoothens skin
by filling thecracks betweendesquamatingcorneocytes
Natural lipids found on
skin and sebum
Collagen Colloidal oatmeal
Elastin Glyceryl stearateIsopropyl myristate/isostearateIsopropyl palmitateIsostearyl alcoholJojoba oil KeratinLauric acid Linoleic acidLinolenic acidOctyl octanoate/stearateOleic acid Propylene glycolShea butter Stearic acid
CLASSIFICATION OF MOISTURIZERS
TABLE 1. Moisturizer classification
Legend: SC, subcutaneous layer; NMF, natural moisturizing factor; TEWL, transepidermal water loss
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New anti-inflammatory agents are added into the formulation because of
their steroid-sparing effects.23 These agents include glycyrrhetinic acid, palmitoyl-
ethanolamine, telmesteine, Vitis vinifera , and ceramide-dominant barrier repair
lipids, and filaggrin breakdown products [e.g. ceramide precursor/pseudoceramide,
5-sphingosine derived sphingolipid, niacinamide, vitamin B3, pyrrolidone carboxylic
acid (PCA) and arginine].24
Of the available moisturizers with the above ingredients, a few have been
shown to provide effective control of xerosis and with rare adverse outcomes.24
MAS063DP (Atopiclair™) cream, a non-steroidal hydrolipidic combination of
glycyrrhetinic acid, telmesteine, Vitis vinifera or grape seed extract, combined
with hyaluronic acid and shea butter, has been documented in adults andchildren to have anti-inflammatory action on top of barrier repair features.25-27
FIGURE 6. Two-dimensional molecular representations of commonly used anti-inflammatory agentsfor moisturizers
ANTI-INFLAMMATORY AGENTS
Palmitoyl-ethanolamine
Ceramide
Telmesteine
Vitis viniferaextractGlycyrrhetinic
acid
HO
O
O
H3C
H3C CH
3
CH3 CH3
CH3
CH3
H
H
H
OH
OH
O
OH3C O
N
S
HO
NH
O
CH3
HO
HO
HO
HO
OH
OH
OH
OH
OH
O
O
H3C
O
HN
OH
OHHO
0
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RECOMMENDATIONS ON MOISTURIZERUSE
Guidelines have general recommendations on moisturizer use.3,13,24,43
These are:
FOR PATIENTS TO:
• Apply the product regularly evenwhen no actual inflammatory skin
lesions are seen.
• Use moisturizers two to three times
daily, or more as needed.
• Immediately use moisturizers after
washing/bathing to trap moisture in
the skin.
• First apply topical flare treatments
(i.e. topical steroids and
immunomodulators), left on for
at least 30 minutes (1 hour for
tacrolimus), and then followed by
the moisturizer.
• Avoid inserting hands or fingers
into the moisturizer canisters or
pots to avoid contamination of the
contents. They can pour out the
moisturizer into a clean container
with a clean spoon.
FOR DOCTORS TO:
• Inform patients of the cost ofmoisturizers and other treatments.
Prescribe the less expensive creams
if cost is an issue.
• Encourage patients to try a range
of appropriate moisturizers to
empower them.
• Advise patients in hot and humid
areas to cool the topical creams as
this may help provide a soothing
sensation when applied.
• Give ceramide dominant creams
or paraffin for xerosis and use
short term occlusion dressings for
extremely crusted lesions.
• Refer patients with recalcitrant and
severe conditions or when there
are co-existing conditions needing
higher level of treatment (e.g. AD,
asthma, allergic rhinitis, allergic
conjunctivitis, and food allergy).
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MOISTURIZER RECOMMENDATIONS BYSPECIALTY GROUPS
The Pediatric Dermatology Subspecialty Core Group of the Philippine Dermatological
Society published a review of the evidence on specific moisturizer ingredients.24
Below is an abridged adaptation of their appraisal:
Active ingredient Major category Notes Level ofevidence
Ceramide Emollient Repairs stratum corneum integrity & function IIIKernel oil Emollient Reduces water loss from the skin
Preserves the integrity of the stratum corneumbarrier
IIIb
Shea butter Emollient Provides a stable carrier of antioxidant substancesand supplies lipids to the skin
Ib
Filaggrin breakdownproduct
Emollient and humectant withanti-inflammatory properties
Enhances skin barrier integrityIncreases skin hydration and helps restore fissuredand dry skin
IIb
Palmitoyl-Ethanolamine
Emollient and humectant withanti-inflammatory properties
Cannabinoid receptor agonist with anti-inflammatory, analgesic and antioxidant effects
IIb
Sunflower oil Emollient and humectant with
anti-inflammatory properties
Reduces dryness, flaking, itching and redness
Improves lichenification and excoriations
Ib
Glycyrrhetinic acid Emollient with anti-inflammatoryproperties
Potentiates action of steroids on the skin due to itsstructural similarity with cortisone
Ib
Telmesteine Emollient with anti-inflammatoryproperties
Scavenging action on free radicals and may offerprotection against oxidizing agents responsible forepithelial damage
Ib
Vitis vinifera Emollient with anti-inflammatoryproperties
Reduces pro-inflammatory cytokines andsynergistically augments the inhibition ofmembrane peroxidation effects of antioxidants
Ib
Hyaluronic acid HumectantEmollient
Very hygroscopicHas a major organizational role within the collagenbundle
Ib
Lactic acid Humectant
Emollient
Decreases TEWL
Reduces dryness and scalingNo barrier function disruption
IIIb
Propylene glycol HumectantEmollient
Makes skin supple and smoothAbsorbs moisture into the skin
IIIb
Urea Humectant Moisturizes the skin by decreasing TEWL in adultAD patients
IIb
Mineral oil Occlusive Semi-occlusive layer that retards water evaporationPenetrates upper layers of stratum corneum
No reports
Olive oil Occlusive Semi-occlusive layer that retards water evaporation No reports
Petrolatum Occlusive Prevents TEWL IIIb
Virgin coconut oil Occlusive Decreases TEWLIncreases fibroblast proliferation and
neovascularisationAntioxidant, anti-inflammatory
IIIb
TABLE 2. Common moisturizer ingredients with mechanisms and evidence supporting their use24
Legend: Ib, Individual randomized controlled trials (RCTs) with narrow confidence interval; IIb, Individual cohort study and lowquality RCT; III/IIIb, Individual case-control study
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Some AD experts have developed consensus recommendations to address the need
for guidance in the decision to choose moisturizers. Moncrieff, Cork, and Lawson(2013) identified dry skin conditions and recommended moisturizers for use by
healthcare practitioners based on best clinical practice. (Figure 7)13
FIGURE 7. Dry skin groups and the recommended leave-on moisturizer types
Priority patientgroups Class Definition Usage
Mild to moderate AD Occlusive emollientcream
Oil-in-water emulsion toprevent water evaporationfrom the skin by providing afilm of lipid
Patient choice beconsidered regarding thethickness of barrier, variablelipid content, severity ofcondition, body site
More severe AD Occlusive emollientointment
Water-in-oil emulsionsintended to provide a thickerfilm of lipid on the skin.
Drier skin conditionsrequiring a thicker lipid film.Limited in use because ofpatient acceptability
Very severe AD Occlusive ointment,no water
White softParaffin (WSP), liquidparaffin (LP), 50:50 ratio ofthe WSP/LP
Very dry skin
Where simpleemollients areineffective orgreasier products areunacceptable
Humectantcontainingemollients
Emollient productcontaining humectants, ureaand glycerin, hold water inthe stratum corneum
Dry skin in cases whereotherproducts are not acceptableor effective
Pruritic variants Antipruritic emollient Emollient productscontainingantipruritic agents
Pruritus
Antipruritic emollients for pruritus
Humectant containing emollients for special cases
Mild tomoderate AD
More “severe” AD
Occlusiveemollient ointment
Occlusiveointment, no water
Occlusiveemollient cream “Very severe” AD
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T h i s i
s influe n c e d b y
:
OTHER FACTORS TO CONSIDER WHENCHOOSING MOISTURIZERS
Because personal preference plays a significant role
in the choice of moisturizers, it is necessary for
physicians to take the following factors into
consideration when prescribing
these products3,17:
Time of day that thepatient applies the
moisturizer
Cost of treatment
Cosmeticacceptability
Weather
conditions
PERSONALPREFERENCE
OR
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The Panel also discussed
that it is important to consider:
Availability of products
over-the-counter
Convenient packaging to carry
around in adequate quantities
CONVENIENCE
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The choice should not be based on
false economy, but on:
CLINICAL BASIS
PATIENT VALUES AND
PREFERENCES
CLINICAL
EXPERTISE
BEST
RESEARCH
EVIDENCE
Clinical
Best
Practice
Overall, until objective parameters identifying the best skin type for the choice of
moisturizers are developed, the decision to choose moisturizers will continue to
depend on the properties that physicians and their patients may find most beneficial
based on subjective considerations and outcomes.9,14
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In a two-year survey done in 1989
in Singapore, AD or eczema ranked
top among the most common skin
disorders amongst Chinese, Malay
and Indian patients.28 Despite the
differences in incidence among the
ethnic groups, the management of AD
was similar and standard moisturizer
was used in all patients.29
In a study cohort of childhood-onset
eczema paediatric patients in Hong
Kong, moisturizers were used on a
regular basis, 1.8 times per day in
mild cases as compared to 2.8 times
per day in moderate to severe cases.30 Patients preferred non-fragrant, non-
herbal, white or transparent cream.
In the guidelines created by the Asia-
Pacific group, they recommended
regular use of moisturizers as
maintenance therapy and as an adjunct to other existing therapies such as topical
steroids.31 Greasy moisturizers were considered best for dry skin and those withcreamier textures for red and inflamed eczema.31 Fragrances and preservatives
should be avoided due to their potential irritant properties.31
The Panel recognizes the potential existence of well-defined clinical phenotypes
of AD in Asians that would optimally benefit from specific moisturizer types. The
moisturizers that will correspond to these phenotypes should ideally be able to
treat both lesional or non lesional skin, and both. A categorization system based
on objective measures (e.g. filaggrin mutation subtypes, confocal microscopicevaluation, pH, TEWL levels, presence of allergy specific IgE in oriental versus non-
oriental skin) can be used to determine these clinical phenotypes in the future.
THE ASIAN PATIENT EXPERIENCE
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Educational programs as shown in clinical guidelines are necessary to improve
awareness in AD patients. These are effective tools to improve treatment compliance
as they include psychological support to the patients and their caregivers.32
Therapeutic patient education (TPE) is a comprehensive program that helps patients
with chronic diseases acquire or maintain the skills they need to manage their life in
the best possible way. This has already been in use in the treatment of many chronic
diseases.33
The aim of this program is to improve the patient’s therapeutic adherence, general
health, and QOL. This resource addresses the patient’s or their caregiver’s refusal to
listen.
This will usually include information on32:
THERAPEUTIC PATIENT EDUCATION
The effects of these patient and caregiver education programs have been evaluated
in randomized controlled trials. Intervention groups in these studies were shown
to have positive improvement in the patient’s coping behaviour, sleeplessness
symptoms, anxiety about corticosteroid usage, and other psychological variables.
Hence, clinical outcomes may be improved by providing educational initiatives ontop of conventional treatments for AD.34-36
The cause ortrigger of AD
The laboratoryexaminations necessary
for diagnosis
Treatment options,skin care, andenvironmental
management
The clinicalmanifestations
and features of AD
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Treatment adherence is important in AD management to aid in primary prevention
of relapses. Different non-pharmacological strategies are now available to help the
clinicians reduce AD flares.
In addition to physician-led patient education, intervention by dermatology nurses
has been shown to provide additional benefits to patients in their care and control
of symptoms.37 Nurses may achieve this by38:
PATIENT EDUCATION AND COUNSELLING
Educating patients about their skin
condition and its management
Educating about specific medications,
instructions for use and side effects
Treating with anti-inflammatory agents and
maintaining comfort of the patient by tackling
how to self-manage distressing symptoms
Tailoring all skin care regimens to suit
individual patients and their families
Supporting patients by support groups, coping
strategies, stress management, counselling,
listening and talking
Providing time for the patient and providingcontinuity of care
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Overall management points that were outlined by the Panel include:
• Compliance is of utmost importance and patient factors and
preference should always be taken into consideration when choosing
treatment for AD.
• It is important to avoid cleansers with sodium lauryl sulphate, cetyl
alcohol, or strong sensitizers (e.g. bacitracin, neomycin, and polymyxin
B, lavender, etc).• Therapeutic patient education should be carried out.
• Define goals that are patient-specific, measurable, achievable,
agreeable to patient, relevant, result-oriented, and time-limited
(SMART).
• Promote activities to help build a good patient and doctor relationship,
eliciting concerns, requests, showing empathy and caring (e.g.
workshops).• Education of patients and their caregivers on the patient’s skin
condition and management is a key component of the strategies
(e.g. re-enforced nurse counselling, written action plan, patient
information leaflets, finger unit chart, written care instructions).
• Treatment of AD should entail collaboration among the specialists
(e.g. dermatologists, paediatricians, allergists/immunologists,
pulmonologists, ENT, ophthalmologists) to address all interrelatedconditions of the patient (e.g. AD, asthma, allergic rhinitis, allergic
conjunctivitis, food allergy).
CONCLUSIONS
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REFERENCES
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Dermatol Sci 2013;70:3-11.3. Akdis CA, Akdis M, Bieber T, et al. Diagnosis and treatment of atopic
dermatitis in children and adults: European Academy of Allergologyand Clinical Immunology/American Academy of Allergy, Asthma andImmunology/PRACTALL Consensus Report. J Allergy Clin Immunol 2006;118:152-69.
4. Simpson E, Dutronc Y. A new body moisturizer increases skin hydrationand improves atopic dermatitis symptoms among children and adults.J Drugs Dermatol 2011;10:744-9.
5. NICE Pathways. Treatments for atopic eczema in children. Availableat http://pathways.nice.org.uk/pathways/atopic-eczema-in-children#path=view%3A/pathways/atopic-eczema-in-children/treatments-for-atopic-eczema-in-children.xml&content=close.Accessed 22/06/2014.
6. Ring J, Alomar A, Bieber T, et al. Guidelines for treatment of atopiceczema (atopic dermatitis) part I. J Eur Acad Dermatol Venereol 2012;26:1045-60.
7. Ngan V, et al. Severe Atopic Dermatitis ManagementGuideline. Available at http://www.healthhb.co.nz/wp-content/uploads/2012/03/Severe-Atopic-Dermatitis-Management-Guideline.pdf. Accessed 22/06/2014.
8. Australasian Society of Clinical Immunology and Allergy. AtopicDermatitis (Eczema). Available at http://www.allergy.org.au/health-professionals/hp-information/asthma-and-allergy/atopic-dermatitis.Accessed 22/06/2014.
9. Lynde C, Barber K, Claveau J, et al. Canadian practical guide for thetreatment and management of atopic dermatitis. J Cutan Med Surg 2005;8 Suppl 4:1-9.
10. Sinclair W, et al. Guidelines on the management of atopic dermatitisin South Africa. Available at http://www.derma.co.za/images/Guidelines_on_the_management_of_atopic_dermatitis_in_South_Africa.pdf. Accessed 22/06/2014.
11. Rubel D, Thirumoorthy T, Soebaryo RW, et al. Consensus guidelines forthe management of atopic dermatitis: an Asia-Pacific perspective. JDermatol 2013;40:160-71.
12. Schneider L, Tilles S, Lio P, et al. Atopic dermatitis: a practiceparameter update 2012. J Allergy Clin Immunol 2013;131:295-9.
13. Moncrieff G, Cork M, Lawton S. Use of emollients in dry-skinconditions: consensus statement. Clin Exp Dermatol 2013;38:231-8;quiz 238.
14. Kraft JN, Lynde CW. Moisturizers: what they are and a practicalapproach to product selection. Skin Therapy Lett 2005;10:1-8.
15. Lynde CW. Moisturizers: what they are and how they work. SkinTherapy Lett 2001;6:3-5.
16. Lodén M. Effect of moisturizers on epidermal barrier function. ClinDermatol 2012;30:286-96.
17. Rawlings AV, Canestrari DA, Dobkowski B. Moisturizer technologyversus clinical performance. Dermatol Ther 2004;17 Suppl 1:49-56.
18. Breternitz M, Kowatzki D, Langenauer M, et al. Placebo-controlled,double-blind, randomized, prospective study of a glycerol-basedemollient on eczematous skin in atopic dermatitis: biophysical andclinical evaluation. Skin Pharmacol Physiol 2008;21:39-45.
19. Peris K, Valeri P, Altobelli E, et al. Efficacy evaluation of an oil-in-water emulsion (Dermoflan) in atopic dermatitis. Acta Derm Venereol 2002;82:465-6.
20. Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the
management of atopic dermatitis: section 2. Management andtreatment of atopic dermatitis with topical therapies. J Am AcadDermatol 2014;71:116-32.
21. Arkwright PD, Motala C, Subramanian H, et al. Management ofdifficult-to-treat atopic dermatitis. J Allergy Clin Immunol Pract 2013;1:142-51.
22. Lynde C. Moisturizers for the treatment of inflammatory skinconditions. J Drugs Dermatol 2008;7:1038-43.
23. Varothai S, Nitayavardhana S, Kulthanan K. Moisturizers for patientswith atopic dermatitis. Asian Pac J Allergy Immunol 2013;31:91-8.
24. Paediatric Dermatology Subspecialty Core Group and Philippine
Dermatological Society. A Guide to Understanding Moisturizers inAtopic Dermatitis. 2014.
25. Abramovits W, Perlmutter A. Atopiclair™: its position within a topicalparadigm for the treatment of atopic dermatitis. Expert Rev. Dermatol 2007; 2: 115-9.
26. Abramovitz W, et al. A Multicenter, Randomized Vehicle-ControlledClinical Study to Examine the Efficacy and Safety of MAS063DP(AtopiclairTM) in the Management of Mild to Moderate AtopicDermatitis in Adults. J Drugs Dermatol 2006;5: 236-44.
27. Patrizi A, et al. A double blind, randomized, vehicle-controlled clinicalstudy to evaluate the efficacy and safety of MAS063DP (AtopiclairTM)in the management of atopic dermatitis in paediatric patients.Paediatric Allergy and Immunology 2008;19:619-25.
28. Chua-Ty G, Goh CL, Koh SL. Pattern of skin diseases at the National
Skin Centre (Singapore) from 1989-1990. Int J Dermatol 1992;31:555-9.
29. Ho SGY, Chan HHL. The Asian Dermatologic Patient: Review ofCommon Pigmentary Disorders and Cutaneous Diseases. Am J ClinDermatol 2009;10:153-68.
30. Hon KL, Wang SS, Pong NH, Leung TF. The ideal moisturizer: a surveyof parental expectations and practice in childhood-onset eczema. JDermatolog Treat 2013;24:7-12.
31. Rubel D, Thirumoorthy T, Soebaryo RW, et al. Consensus guidelines forthe management of atopic dermatitis: an Asia-Pacific perspective. JDermatol 2013;40:160-71.
32. Shin JY, Kim do W, Park CW, et al. An educational program thatcontributes to improved patient and parental understanding ofatopic dermatitis. Ann Dermatol 2014;26:66-72.
33. Weingarten SR, Henning JM, Badamgarav E, et al. Interventionsused in disease management programmes for patients with chronicillness-which ones work? Meta-analysis of published reports. BMJ2002;325:925.
34. Staab D, von Rueden U, Kehrt R, et al. Evaluation of a parentaltraining program for the management of childhood atopic dermatitis.Pediatr Allergy Immunol 2002;13:84-90.
35. Futamura M, Masuko I, Hayashi K, et al. Effects of a short-termparental education program on childhood atopic dermatitis: arandomized controlled trial. Pediatr Dermatol 2013;30:438-43.
36. Kupfer J, Gieler U, Diepgen TL, et al. Structured education programimproves the coping with atopic dermatitis in children and theirparents-a multicenter, randomized controlled trial. J Psychosom Res2010;68:353-8.
37. Lawton S. Atopic Eczema and Evidence-Based Care. J Dermatol NursesAssoc 2011;4:131-9.
38. Lawton S. Assessing the patient with a skin condition. J TissueViability 2001;11:113-5.
39. Morrison M. History of SMART Objectives. Available at https://rapidbi.com/history-of-smart-objectives. Accessed 13/10/2014.
40. Oakland Southfield Physicians, PC Administrative Network, Inc.SMART Goals: a patient self-management tool. Available at https://www.bcbsm.com/pdf/OSP-SMART_Goals.pdf. Accessed 13/10/2014.
41. Substance Abuse and Mental Health Services Administration.S.M.A.R.T. Treatment Planning. Available at http://www.samhsa.gov/samhsa_news/volumexiv_5/article2.htm. Accessed 13/10/2014.
42. Saint Vincent Catholic Medical Centers. Treatment Plans Using theS.M.A.R.T. Model. Available at https://www.decisionhealth.com/
content/articles/Facilities/SMART_Train_the_trainer.pdf. Accessed13/10/2014.
43. Holden C, English J, Hoare C, et al. Advised best practice for the useof emollients in eczema and other dry skin conditions. J DermatologTreat 2002;13:103-6.
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Faculty
Profiles
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ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS
Professor Adelaide Ann HebertDepartments of Dermatology and Paediatrics University of Texas-Houston Medical School Texas, Unites States of America
Professor Adelaide Ann Hebert is a Professor of Dermatology and Paediatrics atthe University of Texas-Houston Medical School. She is also Chief of Paediatric
Dermatology at the Memorial Hermann Children’s Hospital. Prof. Hebert earned her
medical degree from Tulane University School of Medicine in New Orleans, Louisiana,
and went on to complete an internship in internal medicine at the University of Texas
Medical Branch, Galveston, Texas, where she subsequently completed her residency
in Dermatology. Prof. Hebert was the only paediatric dermatology Fellow in the
United States when she completed her advanced training at Children’s Memorial
Hospital of Northwestern University in Chicago, Illinois.
Her areas of clinical interest and research include atopic dermatitis, psoriasis,
hyperhidrosis, skin and soft tissue infections, tinea capitis, and disorders of the
mucous membranes.
Prof. Hebert is on the Board of Directors of the Society for Paediatric Dermatology
and the Women’s Dermatological Society and is Chair of the Society for Paediatric
Dermatology Foundation.
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ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS
A/Professor Giam Yoke ChinNational Skin Centre Singapore
Associate Professor Giam Yoke Chin is a Senior Consultant at the National SkinCentre (NSC), Singapore and is the Advisor to the Paediatric Dermatology Division
at the NSC. A/Prof. Giam is also a clinical teacher at the National University of
Singapore and is a visiting consultant to the Paediatric Dermatology clinic at the
National University Hospital. Singapore. A/Prof. Giam received her medical and
doctoral degrees from the National University of Singapore. She underwent training
in various subspecialties of Dermatology and Paediatric Dermatology in the United
Kingdom at the University of Edinburgh (Royal Infirmary Edinburgh) and at St
John’s Institute of Dermatology. In the United States, she trained at the University
of Chicago (Illinois), Children’s Memorial Hospital (New York) and the University of
California, San Francisco (UCSF).
Her clinical and research interests include paediatric dermatology and skin health.
She is an Advisor to the Paediatric Dermatology Division, Education Committee at the
National Skin Centre in Singapore and sits on the Review Committee of Journal of
Philippines Dermatological Society . She is a reviewer for Annals Academy of Medicine
Singapore (AMS) , the Singapore Medical Journal and Paediatric Dermatology (US) .
FACULTY PROFILES
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ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS
Professor Hardyanto SoebonoFaculty of Medicine Gadjah Mada University Yogyakarta, Indonesia
Professor Hardyanto Soebono was Dean of the Faculty of Medicine at GadjahMada University, Yogyakarta, Indonesia from 2000 - 2008. He earned his medical
degree and completed his training in dermatology and venereology at the Faculty
of Medicine, Gadjah Mada University. Thereafter, he conducted further training in
immunodermatopathology, photobiology, immunogenetics and the serology of
leprosy. His doctoral degree focused on the immunoepidemiology of leprosy.
Prof. Soebono is currently the Chairman of the Indonesian Medical Council, a
Fellow of the Asian Academy of Dermatology and Venereology, a member of theInternational Society of Dermatology and International Leprosy Association and
also an honorary member of the Dutch Society of Dermatology and Venereology.
FACULTY PROFILES
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ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS
Dr Inne Arline DianaDivision of Paediatric Dermatology Hospital Dr Hasan SadikinBandung, Indonesia
Dr Inne Arline Diana is Head of the Division of Paediatric Dermatology at the Dr HasanSadikin Hospital, Bandung, Indonesia. She earned her medical degree and trained
as a dermato-venereologist at the Faculty of Medicine, University of Padjadjaran,
Bandung, Indonesia. Dr Diana underwent further training in paediatric dermatology
at the Academic Medical Center, University of Amsterdam, the Netherlands and in
pigmentary disorders at the Netherlands Institute for Pigmentary Disorders. She
also underwent training in phototherapy at the National Skin Centre, Singapore.
Dr Diana is a member of the Indonesian Medical Association, Indonesian Societyof Dermatology and Venereology, International Society of Dermatologic Surgery,
American Society of Dermatologic Surgery, Dermatology and Aesthetic Surgery
International League and is the Chairman of Indonesian Paediatric Dermatology
Study Group.
FACULTY PROFILES
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ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS
Professor Kyu-Han KimDepartment of Dermatology,Seoul National University Hospital,Seoul, Korea
Professor Kyu-Han Kim is Chairman of the Department of Dermatology at SeoulNational University Hospital, Seoul, Korea. He graduated from Seoul National
University College of Medicine and completed his residency in dermatology at Seoul
National University Hospital. He furthered his training and research by completing
his doctoral degree in Dermatology at his alma mater. He subsequently undertook a
research fellowship at the Department of Dermatology, Emory University School of
Medicine, Atlanta, Georgia, USA.
Prof. Kim is former President of Korean Atopic Dermatitis Association and a Boardmember in charge of scientific affairs at both the Korean Society of Investigative
Dermatology and the Korean Society of Atopic Dermatitis. Prof. Kim is on the
editorial board of the Korean Journal of Dermatology and the Korean Journal of
Medical Science , and also on the Advisory Board of Acta Dermato-Venereologica .
FACULTY PROFILES
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ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS
Dr David Luk Chi KangDepartment of Paediatrics and Adolescent Medicine United Christian Hospital Hong Kong
Dr David Luk is an Associate Consultant in the Department of Paediatrics andAdolescent Medicine at United Christian Hospital, Hong Kong. He is also an Honorary
Clinical Assistant Professor at The University of Hong Kong and The Chinese University
of Hong Kong. Dr Luk earned his medical degree from The Chinese University of
Hong Kong and subsequently obtained his Membership of the Royal Colleges of
Physicians (UK) and Membership of the Royal College of Paediatric and Child Health
(UK). Dr Luk completed his postgraduate diploma in Dermatological Sciences at
University of Wales, UK and a Master of Science in dermatology at Cardiff University,
UK. He undertook further training in dermatology at the Birmingham Skin Centre,
United Kingdom.
Dr Luk is President of the Hong Kong Paediatric and Adolescent Dermatology Society.
He is a Fellow of the Hong Kong Academy of Medicine and the Hong Kong College
of Paediatricians. Dr Luk has published in areas of dermatology and paediatrics with
a particular interest in paediatric dermatology.
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ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS
Dr Zakiudin MunasirDepartment of Allergy and Clinical Immunology University of Indonesia Jakarta, Indonesia
Dr Zakiudin Munasir is Head of the Division of Allergy and Immunology, Departmentof Child Health in the Faculty of Medicine, University of Indonesia - Cipto
Mangunkusumo Hospital. He completed his medical degree at the University of
Indonesia, Jakarta, Indonesia and residency in paediatrics. Dr Munasir subsequently
became a paediatric consultant in allergy and immunology for the Indonesian
Paediatric Society.
Dr Munasir is a member of the working group on allergy and immunology for
the Indonesian Paediatric Society and also a member of the Indonesian Allergyand Immunology Association. He is a member of the European Paediatric Allergy
Rheumatology, World Allergy Organization, European Academy of Allergy and
Clinical Immunology and board member of Asia Pacific Association of Paediatric
Allergy, Respirology and Immunology (APAPARI). He is also an editor for the Asia
Pacific Allergy Journal .
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ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS
A/Professor Marysia Tiongco-RectoSection of Allergy and Immunology Department of Paediatrics University of the Philippines Manila, Philippines
Associate Professor Marysia Tiongco-Recto is Head of the Section of Allergyand Immunology, Department of Paediatrics, Asian Hospital and Medical Centre,
Associate Professor at the Section of Allergy and Immunology in the Department
of Paediatrics, University of the Philippines, Manila, Philippines and associate active
staff at the Department of Paediatrics, Makati Medical Centre.
She earned her medical degree from the University of the Philippines, College of
Medicine. She subsequently completed her residency training in paediatrics and a
post-residency fellowship at the Section of Allergology and Clinical Immunologyat University of the Philippines, Philippine General Hospital Medical Centre.
A/Prof. Tiongco-Recto furthered her training in paediatric allergy and immunology
at the University of Padova, Italy.
A/Prof. Tiongco-Recto is a member of the Philippine Paediatric Society. She is a
Fellow and Advisory Board member of the Philippine Society of Allergy, Asthma and
Immunology and has published widely in the fields of paediatric allergology and
clinical immunology.
FACULTY PROFILES
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Professor Hugo Van BeverDivision of Paediatric Allergy, Immunology and Rheumatology Khoo Teck Puat-National University Children’s Medical Institute Singapore
Professor Hugo van Bever is Professor and Senior Consultant at the Division ofPaediatric Allergy, Immunology and Rheumatology, Khoo Teck Puat-NationalUniversity Children’s Medical Institute, Singapore. He obtained his medical degreeat the State University of Ghent, Belgium where he also completed his paediatricstraining at the Children’s Hospital. He continued his training in paediatric allergy andpulmonology at the University of Antwerp, Belgium, where he eventually becameProfessor in Paediatric Allergy and Pulmonology and Head of the Department ofPaediatrics before moving to Singapore.
His areas of clinical research and interest include paediatric allergy, asthma andrespiratory infections. His current research is focused on eczema, allergic rhinitis,sublingual immunotherapy, primary prevention of allergy and food allergy.
Prof. van Bever is a member of various national and international societies, includingthe European Academy of Allergy and Clinical Immunology (EAACI), the AmericanAcademy of Allergy, Asthma and Immunology (AAAAI), the European Society ofPaediatric Allergy and Clinical Immunology (ESPACI), and the European RespiratorySociety (ERS). He is Past Secretary of the Group Paediatric Asthma and Allergy of
the ERS, Past Secretary of The Belgian Society of Allergy and Clinical Immunology(BELSACI) and Board Member of The Flemish Group of Allergologists. He is a long-standing member of the Asian Pacific Association of Paediatric Allergy, Respirologyand Immunology (APAPARI).
Prof. van Bever has published more than 300 papers in national and international journals. He is a member of the Editorial Board of Paediatric Allergy , Asian PacificJournal of Allergy and Immunology and is Editor in Chief of the Journal of Allergy .Prof. van Bever is a reviewer for the European Journal of Paediatrics, Paediatrics,
Paediatric Allergy and Immunology , Allergy , Paediatric Pulmonology , the EuropeanRespiratory Journal , Paediatric Research, British Medical Journal , the AmericanJournal of Respiratory and Critical Care Medicine and Archives of Diseases inChildhood .
FACULTY PROFILES
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IBC