In children with atopic dermatitis, and after obtaining the control of an outbreak, do you stop the use of TCS and switch to moisturizers alone? or maintain a once to twice application of TCS to prolong the period until the next flare?
It does help to give weekly topical steroid treatment while maintaining the patient on calcineurin inhibitors and moisturizers. Avoidance of commercial soaps is another important advice that can reduce the severity and frequency of exacerbation. Syndet soaps can be also be prescribed.
I would like to ask the fellow clinicans the utility of these new emollients with ceramides and ideal lipid ratio similar to that of skin???
Obviously yes. this is called proactive approach. twice weekly TCS will definitely prolong remission, reduce frequency of outbreaks and obviously limit adverse effect. we can use tacrolimus also for the same purpose but child should be above 2 years of age. Previous approach of continuation with emollient only is not preferred approach now for obvious reasons. Only emollient also help in staph colonization. I have personally used this proactive apporoach in a number of children and result is really outstanding. Smiling parents along with playful child probably say all about it.
Utility of these ceramide containing moisturizers is proven. they are effective no doubt. but the million dollar question is whether they are superior to plain emollients or not. Most of the studies which show they are effective lack a moisturizer comparative.In our country where cost of therapy really matters we can confidently continue with simple emollient rather jumping straight into these novel agent unless they prove themselves superior
The choice of maintanance dermato corticosteroids though highly recommended still remain from my experience based on individuals response, frequency of relapse and severity of eczema. A few cases after remission can do well on moisturizers, emolients and avoidance of trigger factors.
I completely agree with Olayinka , and in my opinion is not necessary to keep dermato corticosterois once or twice per week too long period, and I recommend to switch with inhibitor calcineurine for a while; after remission is better to apply only emolients. In this way avoiding tachiphylaxy ,contact dermatitis to TDC or even skin atrophy. We have to keep in our mind the systemic side effect of TDC in children.
See; in any sense corticosteroid should be reserved for acute and moderate to severe cases, there is no point in long term therapy to continue with TCS. Severe HP axis suppratiion has been noted, specially children's are vulnerable for local as well as systemic side effect due to absorption and can cause abnormal epiphysial closure but one thing is most important ....parent or patient education about the course of disease as much of the outbreaks cud be halted with some suggestion.
1) out approach should be use steroid sparing agents as calcinuerin inhibitor
2) keep steroid for recalcitrant or remission of moderate to severe cases
3) judicial use of emollient for skin barrier repair
AD is a chronic disease, although spontaneous remissions are common in the infancy. Thus, the proactive approach may be useful to prevent the frequent flares.
However, according to Olayinka, the choice of maintanance TCS has to be taken based on individuals response and frequency of relapse. For example, if skin lesions of AD are no longer visible after 3 or 4 weeks of proactive treatment, where the patient should apply corticosteroids? In these cases emollients can be useful. Calcineurine inhibitors should be preferred in thin skin areas.
After clinical improvement i suspend corticosteroids and do the maintenance with emollients and avoid triggers.
I use corticosteroids only in acute phases. In my opinion, it doesn't justify a long therapy with TCS after clinical improvement and should be reserved for more severe cases. An option is to use calcineurin inhibitors.