Interventional Procedures, The usefulness of ultraviolet (UV) light plus oral psoralen in the treatment of AD has been used as short-term treatment of AD, including natural sunlight, narrow-band ultraviolet light B (NB-UVB), broad-band ultraviolet light B (BB-UVB), ultraviolet light A (UVA) [86..].
NB-UVB is the most commonly recommended light therapy due to its efficacy, availability, and low risk of side effects. Phototherapy is generally recommended in the treatment of AD refractory to conventional topical medication and can be used as monotherapy or in combination with TCS.
Use with TCIs is not recommended. In children, phototherapy has demonstrate efficacy and safety in multiple studies. Various lasers (e.g., excimer, diode, and pulse dye) and extracorporeal photochemotherapy are additional modes of treatment for AD; the latter is used in generalized and erythrodermic AD patients. There is a theoretical increased risk of skin cancer with long-term phototherapy due to exposure to UV light. Although one large study found no significant association between NB-UVB therapy and skin cancer, treatment with PUVA was found to have a slight increase in children in incidence of basal cell carcinoma.
Several promising agents are currently under investigation in the treatment of AD. These agents, inncluding biologics, are not currently FDA- approved for use in children, though there are ongoing studies examining their use in pediatric populations.
Lipoxins are endogenous anti-inflammatory molecules derived from thee metabolic breakdown of arachidonic acid. These are activated during inflammation and inhibit the production of pro-inflammatory cytokines, such as IL-12, IL-13, lipoxin quality of life. This was a randomized, double-blind, placebo-controlled, parallel-group trial of patients 1-12 months of age with varying disease severity that compared the lipoxin cream with mometasone furoate cream, a mid-potency topical steroid. Extend and rate of recovery were similar to that of patients in the 0.1% mometasone furoate cohort.
Another biologic that has been used off-label in pediatric AD is omalizumab, a humanized monoclonal antibody that binds to free IgE and surface-bound IgE on mast cells and basophils. A case series of seven paients (aged 6-19) years with severe AD demonstrated clinical improvement of symptoms after 3 to 6 months of treatment. A recent systematic review, however, stated no concrete evidence of the effectiveness of omalizumab as a treatment for AD.
Recombinant Interferon Gamma
Several studies have examined the use of subcutaneous recombinant interferon gamma (rIFN-y) in AD. IFN-y is a cytokine that is involved in innate and adaptive immunity. in the first double-blind, placebo-controlled trial of rIFN-y in moderate to severe AD in children and adults, rIFN-y was found to have an age-related, improved clinical response in the pediatric cohort versus adults.
Sixty-seven percent of children ages 3 to 20 reported greater than 50% improvement compared to 56% of adults ages 21-40 and 44% of adults ages 41-65. Side effects included flu-like symptoms, transient transaminase elevation, and granulocyte suppression.
Dupilumab, a fully human monoclonal antibody against interleukin-4 receptor alpha, is a biologic that was recently FDA approved for use in adults with moderate to severe AD. Dupilumb blocks signaling from two key cytokines in the type 2 inflammatory pathway, IL-4 and IL-13. In phase III trials, significantly more patients treated woth 300 mg bi-weekly showed 75% improvement in Eczema Area and Severity Index (EASI) from baseline compared with the placebo group. in additon, treatment resulted in improvement of other endopoints, including pruritus, symptoms of anxiety and depression, and quality of life.
A phase 2a, open label trial of 78 children and adolescents, aged 6-18, with moderate to severe AD (NCT02407756) demonstrated mean improvement of pruritus and EASI scores, especially in the younger cohort, at incresing subcutaneous doses (from 2 to 4 mg/kg). Dupilumab is a promising thrapy in AD and is expected to alter future management of the disease toward a more personalized approach. Though its use is currently only approved in adults, it may benefits the younger pediatric population once studied and found to be safe in children. Interventional Procedures.
Early treatment of AD in children may delay or prevent the atopic march. Although the pathogenesis of AD is multivariate and complex, therapeutic interventions target two major areas of dysfunction: (1) the defective skin barrier leading to early sensitization to allergens and (2) the dysfunction skin immune response to allergens and irritants. Interventional Procedures.
Topical moisturizers and topical anti-inflammatory medications are the cornerstones of AD treatment moisturizers and topical corticosteroid, any combination of both with gentle skin care can effectively control most mild to moderate AD lesions. Moderate to severe and recalcitrant AD, however, may require the addition of phototherapy or systemic medications. Special considerations are made for pediatric patients, as severe adverse effects of systemic medications and high dose topical corticosteroids must be weighed against thee benefits of treatment. Emerging therapies, such as crisaborole and dupilumab, are welcome additons to the current aresenal of treatments for AD. Interventional Procedures.
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