Você está na página 1de 38

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 arising
is 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 068809
Tel: (65) 6290 7400 Fax: (65) 6290 7401
E-mail:enquiry.sg@mims.com Website: www.mims.com

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

Understanding the
Role of Emollients
in Atopic Dermatitis
Management

IFC

Understanding the
Role of Emollients
in Atopic Dermatitis
Management
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

CONTENTS
Foreword 3
Introduction 4
What to consider when selecting moisturizers

Classification of moisturizers

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

18

Patient education and counselling

19

SMART goals

20

Conclusions 21
References 23

FOREWORD
Effective 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 to
Understanding 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 patients profile. Through analysis of these
factors, one may be able to determine the rationale for choosing the
best 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 Asian
Atopic Dermatitis Summit.

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

INTRODUCTION
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

External stimuli

Filaggrin mutation
Increased pH

Barrier disruption

Mechanical injury

Protease containing
protein antigen
exposure

Kallikrein activation

PAR-2 activation
TSLP upregulation

Th2 induction

FIGURE 1. Effect of barrier dysfunction on Th2 induction. Barrier dysfunction in line with filaggrin
deficiency will lead to Th2 skewing conditions, which may play an important role in the development
of 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.

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)

FLARE

FLARE

FLARE

AD Severity

Time

FIGURE 2. AD is described as a chronic and relapsing skin disorder

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 the
guidelines on management, moisturizer use is a key and basic step in the treatment
of AD. 3,5-11 (Figure 3)3
STEP 4 Systemic therapy (e.g. CyA) or UV therapy
t,
ran
cit AD
l
a
c
e
Re ever
s

STEP 3 Mid-high potency TCS and/or TCI*

e
rat D
de re A
o
E
M eve
s
AS
E
to
IS

STEP 2 Low-mid potency TCS and/or TCI*

STEP 1 Basic Treatment: Skin hydration,


emollients, avoidance of irritants,
nly
identification and addressing of
no
i
k
s
specific trigger factors
Dry

to
OF
ld AD
Y
Mi rate
T
SI
de
mo
EN

IN

TCS = Topical corticosteroids


TCI = Topical calcineurin inhibitors
CyA = Cyclosporine A
*Over the age of 2 years

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: European
Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus
Report. J Allergy Clin Immunol 2006;118:152-69.

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

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 patient
groups 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.

How dry is your skin?


Grade

Dryness Scale

Healthy Skin

Feeling Dry but Healthy Skin

White Flaking Skin

Slight Scaling

Severe Scaling with Cracks

Severe Cracking

Note: Used for visual representation. Not a validated scale.

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 preventing
the disease.
6

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

WHAT TO CONSIDER WHEN SELECTING


MOISTURIZERS
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.

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 the
skin homing receptor, CLA, and recirculate through unaffected AD skin where they can engage allergen-triggered IgE+ LCs and
mast cells (MCs) that contribute to Th2 cell development. Skin injury by environmental allergens, scratching, or microbial toxins
activates keratinocytes to release proinflammatory cytokines and chemokines that induce the expression of adhesion molecules
on vascular endothelium and facilitate the extravasation of inflammatory cells into the skin. Keratinocyte-derived thymic stromal
lymphopoietin (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 (M ), and eosinophils. IL-12
production 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.

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

Rationale for moisturizer use


Humectants
pass into
corneocytes
with trapped
water

Occlusive
traps
water
H2O

H2O

H2O
H2O

H2O

Emollient
mimics
epidermal
lipids

H2O

H2O
H2O

H2O
H2O

H2O

H2O

H2O
H2O
H2O

H2O
Humectant
Water

FIGURE 5. Reestablishment of the protective skin barrier with moisturizers

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 objective
parameters. 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 absence
of fragrances, additives or other sensitizing agents.20
8

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

CLASSIFICATION OF MOISTURIZERS
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 to
enhance 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

Biological
similarity

Some examples

Humectants

Attract and bind


water
from deeper
epidermis to SC

NMF in corneocytes

Glycerin
Alpha hydroxy acids Hyaluronic acid
Pyrrolidone carboxylic acid
Sodium pyrrolidone
carboxylic acid (Na PCA)
Sodium and ammonium lactate
Sorbitol
Urea

Occlusives

Form a hydrophobic
film to retard TEWL
of SC

Intercellular
lipid bilayers
- Ceramide
- Cholesterol
- Free fatty acids

Carnauba wax
Lanolin
Mineral oils
Olive oil
Petrolatum Silicone
Cetyl/stearyl alcohol Propylene glycol
Squalene
Stearic acid

Emollients

Smoothens skin
by filling the
cracks between
desquamating
corneocytes

Natural lipids found on


skin and sebum

Collagen
Colloidal oatmeal
Elastin
Glyceryl stearate
Isopropyl myristate/isostearate
Isopropyl palmitate
Isostearyl alcohol
Jojoba oil
Keratin
Lauric acid
Linoleic acid
Linolenic acid
Octyl octanoate/stearate
Oleic acid
Propylene glycol
Shea butter
Stearic acid

TABLE 1. Moisturizer classification

Legend: SC, subcutaneous layer; NMF, natural moisturizing factor; TEWL, transepidermal water loss
9

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

ANTI-INFLAMMATORY AGENTS
New anti-inflammatory agents are added into the formulation because of
their steroid-sparing effects.23 These agents include glycyrrhetinic acid, palmitoylethanolamine, 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
OH

O
HO

H3C
CH3

O
CH3

CH3
H

HO

H3C

OH

HO

Glycyrrhetinic
acid

H3C

Vitis vinifera
extract

OH
OH

HO
OH

CH3

H
H3C CH3

OH

HO

Telmesteine

H
N

OH

OH
0

S
HO

HO

OH

Ceramide

NH
O

Palmitoyl-ethanolamine
CH3

FIGURE 6. Two-dimensional molecular representations of commonly used anti-inflammatory agents


for moisturizers

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 and
children to have anti-inflammatory action on top of barrier repair features.25-27
10

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

RECOMMENDATIONS ON MOISTURIZER
USE
Guidelines have general recommendations on moisturizer use.3,13,24,43
These are:
FOR PATIENTS TO:

FOR DOCTORS TO:

Apply the product regularly even


when no actual inflammatory skin
lesions are seen.

Inform patients of the cost of


moisturizers and other treatments.
Prescribe the less expensive creams
if cost is an issue.

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.

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).

11

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

MOISTURIZER RECOMMENDATIONS BY
SPECIALTY 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

Ceramide
Kernel oil

Emollient
Emollient

Shea butter
Filaggrin breakdown
product
PalmitoylEthanolamine
Sunflower oil
Glycyrrhetinic acid
Telmesteine
Vitis vinifera
Hyaluronic acid
Lactic acid
Propylene glycol
Urea
Mineral oil
Olive oil
Petrolatum
Virgin coconut oil

Notes

Repairs stratum corneum integrity & function


Reduces water loss from the skin
Preserves the integrity of the stratum corneum
barrier
Emollient
Provides a stable carrier of antioxidant substances
and supplies lipids to the skin
Emollient and humectant with
Enhances skin barrier integrity
anti-inflammatory properties
Increases skin hydration and helps restore fissured
and dry skin
Emollient and humectant with
Cannabinoid receptor agonist with antianti-inflammatory properties
inflammatory, analgesic and antioxidant effects
Emollient and humectant with
Reduces dryness, flaking, itching and redness
anti-inflammatory properties
Improves lichenification and excoriations
Emollient with anti-inflammatory Potentiates action of steroids on the skin due to its
properties
structural similarity with cortisone
Emollient with anti-inflammatory Scavenging action on free radicals and may offer
properties
protection against oxidizing agents responsible for
epithelial damage
Emollient with anti-inflammatory Reduces pro-inflammatory cytokines and
properties
synergistically augments the inhibition of
membrane peroxidation effects of antioxidants
Humectant
Very hygroscopic
Emollient
Has a major organizational role within the collagen
bundle
Decreases TEWL
Humectant
Emollient
Reduces dryness and scaling
No barrier function disruption
Humectant
Makes skin supple and smooth
Emollient
Absorbs moisture into the skin
Humectant
Moisturizes the skin by decreasing TEWL in adult
AD patients
Occlusive
Semi-occlusive layer that retards water evaporation
Penetrates upper layers of stratum corneum
Occlusive
Semi-occlusive layer that retards water evaporation
Occlusive
Prevents TEWL
Occlusive
Decreases TEWL
Increases fibroblast proliferation and
neovascularisation
Antioxidant, anti-inflammatory

Level of
evidence
III
IIIb
Ib
IIb
IIb
Ib
Ib
Ib
Ib
Ib
IIIb
IIIb
IIb
No reports
No reports
IIIb
IIIb

TABLE 2. Common moisturizer ingredients with mechanisms and evidence supporting their use24
12

Legend: Ib, Individual randomized controlled trials (RCTs) with narrow confidence interval; IIb, Individual cohort study and low
quality RCT; III/IIIb, Individual case-control study

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

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

Occlusive
ointment, no water

Occlusive
emollient cream
Mild to
moderate AD

Occlusive
emollient ointment
Very severe AD
More severe AD

Antipruritic emollients for pruritus


Humectant containing emollients for special cases

Priority patient
groups

Class

Definition

Usage

Mild to moderate AD

Occlusive emollient
cream

Oil-in-water emulsion to
prevent water evaporation
from the skin by providing a
film of lipid

More severe AD

Occlusive emollient
ointment

Water-in-oil emulsions
intended to provide a thicker
film of lipid on the skin.

Very severe AD

Occlusive ointment,
no water

White soft
Paraffin (WSP), liquid
paraffin (LP), 50:50 ratio of
the WSP/LP

Patient choice be
considered regarding the
thickness of barrier, variable
lipid content, severity of
condition, body site
Drier skin conditions
requiring a thicker lipid film.
Limited in use because of
patient acceptability
Very dry skin

Where simple
emollients are
ineffective or
greasier products are
unacceptable
Pruritic variants

Humectant
containing
emollients

Emollient product
containing humectants, urea
and glycerin, hold water in
the stratum corneum

Dry skin in cases where


other
products are not acceptable
or effective

Antipruritic emollient

Emollient products
containing
antipruritic agents

Pruritus

FIGURE 7. Dry skin groups and the recommended leave-on moisturizer types

13

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

OTHER FACTORS TO CONSIDER WHEN


CHOOSING MOISTURIZERS
Because personal preference plays a significant role
in the choice of moisturizers, it is necessary for
physicians to take the following factors into
flue
consideration when prescribing
s is in nced by
i
h
T
:
these products3,17:

PERSONAL
PREFERENCE

OR
Weather
conditions

Cost of treatment
Time of day that the
patient applies the
moisturizer

Cosmetic
acceptability
14

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

CONVENIENCE
The Panel also discussed
that it is important to consider:

Availability of products
over-the-counter

Convenient packaging to carry


around in adequate quantities

15

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

CLINICAL BASIS
The choice should not be based on
false economy, but on:

PATIENT
VALUES AND
PREFERENCES

CLINICAL
EXPERTISE

Clinical
Best
Practice

BEST
RESEARCH
EVIDENCE

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

16

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

THE ASIAN PATIENT EXPERIENCE


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, nonherbal, white or transparent cream.
In the guidelines created by the AsiaPacific 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 with
creamier 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 microscopic
evaluation, pH, TEWL levels, presence of allergy specific IgE in oriental versus nonoriental skin) can be used to determine these clinical phenotypes in the future.
17

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

THERAPEUTIC PATIENT EDUCATION


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 patients therapeutic adherence, general
health, and QOL. This resource addresses the patients or their caregivers refusal to
listen.
This will usually include information on32:

The cause or
trigger of AD

The clinical
manifestations
and features of AD

The laboratory
examinations necessary
for diagnosis

Treatment options,
skin care, and
environmental
management

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 patients coping behaviour, sleeplessness
symptoms, anxiety about corticosteroid usage, and other psychological variables.
Hence, clinical outcomes may be improved by providing educational initiatives on
top of conventional treatments for AD.34-36
18

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

PATIENT EDUCATION AND COUNSELLING


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:
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 providing


continuity of care
19

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

SMART GOALS
Another strategy to improve patient outcomes is by identifying specific, measurable,
attainable, relevant, and time-based (SMART) goals. Although originally used for
non-medical purposes39, this technique provides a structured guide for patients to
set treatment objectives to help manage chronic conditions.40,41 (Figure 8)

Specific: State exactly what you want to accomplish


(Who, What, Where, Why)

Measurable: How will you demostrate and evaluatethe extent to


which the goal has been met?

Achievable: Stretch and challenging goals within ability to achieve


outcome. What is the action-oriented verb?

Relevant: How does the goal tie into your key responsibilities?
How is it aligned to objectives?

Time-bound: Set 1 or more target dates, the By when to guide


your goal to successful and timely completion (include deadlines,
dates and frequency)

FIGURE 8. Using SMART goals to improve management of AD

The objective may be written down in the patients personal journal. An example of
this plan as applied in AD is shown below42:
WHAT: The patient will be able to state the names of at least two of
the topical creams used currently and why he or she is using them.
WHY: To increase his or her knowledge about his or her illness
and assist with regimen adherence so that patient can function
independently.
WHEN: By the end of two weeks, the patient should be able to state
the names of the medications and verbalize the purpose for using
these topical creams.

20

Evidently, the healthcare providers involved in the care of patients can optimize
therapy by explaining the long term treatment plan, by being empathetic and
motivating, by being receptive to all queries from the patient and the caregiver, and
by scheduling follow-up appointments early on in order to discuss whether these
goals have been met or not.43

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

CONCLUSIONS
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 patients 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 interrelated
conditions of the patient (e.g. AD, asthma, allergic rhinitis, allergic
conjunctivitis, food allergy).

21

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

22

REFERENCES
1. Vijayanand P, Seumois G, Simspson LJ et al. Interleukin-4 production
by follicular helper T cells requires the conserved Il4 enhancer
hypersensitivity site V. Immunity 2012;36:175-87.
2. Kabashima K. New concept of the pathogenesis of atopic dermatitis:
Interplay among the barrier, allergy, and pruritus as a trinity. J
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 Allergology
and Clinical Immunology/American Academy of Allergy, Asthma and
Immunology/PRACTALL Consensus Report. J Allergy Clin Immunol
2006;118:152-69.
4. Simpson E, Dutronc Y. A new body moisturizer increases skin hydration
and improves atopic dermatitis symptoms among children and adults.
J Drugs Dermatol 2011;10:744-9.
5. NICE Pathways. Treatments for atopic eczema in children. Available
at
http://pathways.nice.org.uk/pathways/atopic-eczema-inchildren#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 atopic
eczema (atopic dermatitis) part I. J Eur Acad Dermatol Venereol
2012;26:1045-60.
7. Ngan V, et al. Severe Atopic Dermatitis Management
Guideline. 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. Atopic
Dermatitis (Eczema). Available at http://www.allergy.org.au/healthprofessionals/hp-information/asthma-and-allergy/atopic-dermatitis.
Accessed 22/06/2014.
9. Lynde C, Barber K, Claveau J, et al. Canadian practical guide for the
treatment 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 dermatitis
in 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 for
the management of atopic dermatitis: an Asia-Pacific perspective. J
Dermatol 2013;40:160-71.
12. Schneider L, Tilles S, Lio P, et al. Atopic dermatitis: a practice
parameter update 2012. J Allergy Clin Immunol 2013;131:295-9.
13. Moncrieff G, Cork M, Lawton S. Use of emollients in dry-skin
conditions: consensus statement. Clin Exp Dermatol 2013;38:231-8;
quiz 238.
14. Kraft JN, Lynde CW. Moisturizers: what they are and a practical
approach to product selection. Skin Therapy Lett 2005;10:1-8.
15. Lynde CW. Moisturizers: what they are and how they work. Skin
Therapy Lett 2001;6:3-5.
16. Lodn M. Effect of moisturizers on epidermal barrier function. Clin
Dermatol 2012;30:286-96.
17. Rawlings AV, Canestrari DA, Dobkowski B. Moisturizer technology
versus 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-based
emollient on eczematous skin in atopic dermatitis: biophysical and
clinical evaluation. Skin Pharmacol Physiol 2008;21:39-45.
19. Peris K, Valeri P, Altobelli E, et al. Efficacy evaluation of an oil-inwater 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 and
treatment of atopic dermatitis with topical therapies. J Am Acad
Dermatol 2014;71:116-32.
21. Arkwright PD, Motala C, Subramanian H, et al. Management of
difficult-to-treat atopic dermatitis. J Allergy Clin Immunol Pract
2013;1:142-51.

22. Lynde C. Moisturizers for the treatment of inflammatory skin


conditions. J Drugs Dermatol 2008;7:1038-43.
23. Varothai S, Nitayavardhana S, Kulthanan K. Moisturizers for patients
with 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 in
Atopic Dermatitis. 2014.
25. Abramovits W, Perlmutter A. Atopiclair: its position within a topical
paradigm for the treatment of atopic dermatitis. Expert Rev. Dermatol
2007; 2: 115-9.
26. Abramovitz W, et al. A Multicenter, Randomized Vehicle-Controlled
Clinical Study to Examine the Efficacy and Safety of MAS063DP
(AtopiclairTM) in the Management of Mild to Moderate Atopic
Dermatitis in Adults. J Drugs Dermatol 2006;5: 236-44.
27. Patrizi A, et al. A double blind, randomized, vehicle-controlled clinical
study 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;31:5559.
29. Ho SGY, Chan HHL. The Asian Dermatologic Patient: Review of
Common Pigmentary Disorders and Cutaneous Diseases. Am J Clin
Dermatol 2009;10:153-68.
30. Hon KL, Wang SS, Pong NH, Leung TF. The ideal moisturizer: a survey
of parental expectations and practice in childhood-onset eczema. J
Dermatolog Treat 2013;24:7-12.
31. Rubel D, Thirumoorthy T, Soebaryo RW, et al. Consensus guidelines for
the management of atopic dermatitis: an Asia-Pacific perspective. J
Dermatol 2013;40:160-71.
32. Shin JY, Kim do W, Park CW, et al. An educational program that
contributes to improved patient and parental understanding of
atopic dermatitis. Ann Dermatol 2014;26:66-72.
33. Weingarten SR, Henning JM, Badamgarav E, et al. Interventions
used in disease management programmes for patients with chronic
illness-which ones work? Meta-analysis of published reports. BMJ
2002;325:925.
34. Staab D, von Rueden U, Kehrt R, et al. Evaluation of a parental
training 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-term
parental education program on childhood atopic dermatitis: a
randomized controlled trial. Pediatr Dermatol 2013;30:438-43.
36. Kupfer J, Gieler U, Diepgen TL, et al. Structured education program
improves the coping with atopic dermatitis in children and their
parents-a multicenter, randomized controlled trial. J Psychosom Res
2010;68:353-8.
37. Lawton S. Atopic Eczema and Evidence-Based Care. J Dermatol Nurses
Assoc 2011;4:131-9.
38. Lawton S. Assessing the patient with a skin condition. J Tissue
Viability 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 the
S.M.A.R.T. Model. Available at https://www.decisionhealth.com/
content/articles/Facilities/SMART_Train_the_trainer.pdf.
Accessed
13/10/2014.
43. Holden C, English J, Hoare C, et al. Advised best practice for the use
of emollients in eczema and other dry skin conditions. J Dermatolog
Treat 2002;13:103-6.

Faculty
Profiles

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

FACULTY PROFILES
A/Professor Maria Victoria Dizon
Department of Dermatology
College of Medicine & Surgery
University of Santo Tomas
Manila, Philippines

Associate Professor Maria Victoria Dizon is a Consultant Paediatric Dermatologist


at Makati Medical Center in Manila, Philippines. In addition, she is a Consultant and
Head of Paediatric Dermatology at the University of Santo Tomas, and a Consultant
at Cardinal Santos Medical Center in Manila. A/Prof. Dizon also serves as Associate
Professor at the Department of Dermatology, College of Medicine and Surgery,
University of Santo Tomas, Manila.
She received her medical degree from the College of Medicine and Surgery at the
University of Santo Tomas and continued to pursue her Residency training at the
same institution. A/Prof. Dizon completed her Fellowship training in Paediatric
Dermatology at the Childrens Memorial Hospital of Northwestern University
Feinberg School of Medicine in Chicago.
A/Prof. Dizon is a Diplomate and Fellow of the Philippine Dermatological Society
(PDS). She has been Head of the Subspecialty Group of Paediatric Dermatology of
the PDS since 2009.
A/Prof. Dizon served on the Board of Directors of the PDS and the Board of Examiners
of the Philippine Board of Dermatology from 2007 to 2008. She is currently serving
actively as a member of several advisory boards and head of an international
steering committee. She is a member of various scientific committees and medical
associations in the Philippines.

24

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

FACULTY PROFILES
Professor Adelaide Ann Hebert

Departments 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 at


the University of Texas-Houston Medical School. She is also Chief of Paediatric
Dermatology at the Memorial Hermann Childrens 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 Childrens 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 Womens Dermatological Society and is Chair of the Society for Paediatric
Dermatology Foundation.

25

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

FACULTY PROFILES
A/Professor Giam Yoke Chin
National Skin Centre
Singapore

Associate Professor Giam Yoke Chin is a Senior Consultant at the National Skin
Centre (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
Johns Institute of Dermatology. In the United States, she trained at the University
of Chicago (Illinois), Childrens 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).

26

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

FACULTY PROFILES
Professor Hardyanto Soebono
Faculty of Medicine
Gadjah Mada University
Yogyakarta, Indonesia

Professor Hardyanto Soebono was Dean of the Faculty of Medicine at Gadjah


Mada 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 the
International Society of Dermatology and International Leprosy Association and
also an honorary member of the Dutch Society of Dermatology and Venereology.

27

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

FACULTY PROFILES
Dr Inne Arline Diana

Division of Paediatric Dermatology


Hospital Dr Hasan Sadikin
Bandung, Indonesia

Dr Inne Arline Diana is Head of the Division of Paediatric Dermatology at the Dr Hasan
Sadikin 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 Society
of 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.

28

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

FACULTY PROFILES
Professor Kyu-Han Kim

Department of Dermatology,
Seoul National University Hospital,
Seoul, Korea

Professor Kyu-Han Kim is Chairman of the Department of Dermatology at Seoul


National 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 Board
member 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.

29

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

FACULTY PROFILES
Dr David Luk Chi Kang

Department of Paediatrics and Adolescent Medicine


United Christian Hospital
Hong Kong

Dr David Luk is an Associate Consultant in the Department of Paediatrics and


Adolescent 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.

30

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

FACULTY PROFILES
Dr Zakiudin Munasir

Department of Allergy and Clinical Immunology


University of Indonesia
Jakarta, Indonesia

Dr Zakiudin Munasir is Head of the Division of Allergy and Immunology, Department


of 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 Allergy
and 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.

31

ASIAN ATOPIC DERMATITIS SUMMIT 2014 CONSENSUS

FACULTY PROFILES
A/Professor Marysia Tiongco-Recto
Section of Allergy and Immunology
Department of Paediatrics
University of the Philippines
Manila, Philippines

Associate Professor Marysia Tiongco-Recto is Head of the Section of Allergy


and 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 Immunology
at 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.

32

FACULTY PROFILES
Professor Hugo Van Bever

Division of Paediatric Allergy, Immunology and Rheumatology


Khoo Teck Puat-National University Childrens Medical Institute
Singapore

Professor Hugo van Bever is Professor and Senior Consultant at the Division of
Paediatric Allergy, Immunology and Rheumatology, Khoo Teck Puat-National
University Childrens Medical Institute, Singapore. He obtained his medical degree
at the State University of Ghent, Belgium where he also completed his paediatrics
training at the Childrens Hospital. He continued his training in paediatric allergy and
pulmonology at the University of Antwerp, Belgium, where he eventually became
Professor in Paediatric Allergy and Pulmonology and Head of the Department of
Paediatrics before moving to Singapore.
His areas of clinical research and interest include paediatric allergy, asthma and
respiratory 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, including
the European Academy of Allergy and Clinical Immunology (EAACI), the American
Academy of Allergy, Asthma and Immunology (AAAAI), the European Society of
Paediatric Allergy and Clinical Immunology (ESPACI), and the European Respiratory
Society (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 longstanding member of the Asian Pacific Association of Paediatric Allergy, Respirology
and 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 Pacific
Journal 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 European
Respiratory Journal, Paediatric Research, British Medical Journal, the American
Journal of Respiratory and Critical Care Medicine and Archives of Diseases in
Childhood.

IBC