Managing Atopic Dermatitis with
Emollient Therapy
Paul S. Horowitz, MD, FAAP
Discovery Pediatrics
Valencia, CA, USA
1
Disclosure
• Paul Horowitz, MD, has acted as a consultant and temporary
advisor to Johnson & Johnson Consumer Inc. and Abbott
Nutrition and is a member of a speakers’ bureau for Abbott
Nutrition.
• He has been an investigator for clinical trials and received grant
funding or honoraria from Johnson & Johnson Consumer Inc.
and was sponsored for this presentation.
• Some of the research presented in this presentation was
sponsored by Johnson & Johnson Consumer Inc.
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Skin Function
• Natural protective barrier from
•
•
•
•
•
physical injury
pathogenic microbes
chemical agents
UV radiation
extreme temperatures
• Helps to restrict fluid and water loss
• Sensory perception: temperature,
pressure, touch and pain
• Temperature regulation of the body
Skin Image - © Anita Potter / Shutterstock®
1. Irving V: Caring for and protecting the skin of pre-term neonates. J Wound Care 2001, 10:253-6.
2. 2. Nikolovski J, Stamatas GN, Kollias N, Wiegand BC: Barrier function and water-holding and transport properties of infant stratum corneum are different from adult and continue to
develop through the first year of life. J Invest Dermatol 2008, 128:1728-36.
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HEALTHY SKIN
SKIN PARAMETER
Surface
STRUCTURE
ADULT
INFANT
Microrelief Lines
Less Dense
Stratum Corneum (SC)
Thicker ~10 µm
Epidermis
Stratum Corneum (SC)
Thicker
Lower
Natural Moisturizing Factor
Concentration
Sebum
Higher
Trans-epidermal water loss
Lower
Surface pH
Lower
More Dense
↑water retention
Thinner ~7 µm
↑permeability
Thinner (~20% vs. Adult)
Higher
(older infants, drier at birth)
↑skin hydration
Lower
↑dryness
Lower (7-10 mo old)
↓hydro-lipid film
Higher
↑water evaporation
More Alkaline (newborn)
↑potential infections
Thickness
Water
Content
COMPOSITION
NMF
Surface
Lipids
TEWL
FUNCTION
pH
Higher
Telofski et al. Dermatology Research and Practice, vol 2012. 2. G.N. Stamatas et al. International Journal of Cosmetic Science, 2011, 33, 17-24
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Skin Lipids Play an Important Role in Maintaining
Skin Barrier Integrity for Healthy Skin
Stratum Corneum Lipid Content by Weight
12%
59%
29%
Free Fatty Acids
Cholesterol
Ceramides
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Defective Skin Barrier in AD
Defective Barrier
Increased levels of
irritants and allergens
Increased TEWL
Cytokine release
Dermal inflammation
Atopic dermatitis
1. Epidermal Barrier Dysfunction in Atopic Dermatitis. Michael J. Cork, et al., Journal of Investigative Dermatology (2009) Vol 129
2. Lebwohl M, et al. Cutis. 2005;76:S7-S12
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Barrier Dysfunction Leads to Symptoms
• Dry Skin (xerosis)
• Itching (pruritis)
• Inflammation and redness (erythema)
• Scaling
• Elevated serum IgE
• With a chronic or chronic relapsing course
• Symptoms come and go with exacerbation (flares)
Bieber N Engl J Med 2008; Williams N Engl J Med. 2005
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Atopic Dermatitis (AD) Epidemiology
• Chronic, immune mediated, relapsing skin condition
• ~6% of the global population is affected
1
• 44.9 million in 2011 (2016 predicted to be 46 million)
2
• Epidemiological studies suggest prevalence increasing
3
• 2005 – 1 in 74 people in England was newly diagnosed
• Atopic Dermatits is one of the most common chronic
4,5
relapsing childhood dermatoses
1.
Datamonitor 03/2007 Atopic Dermatitis Report; 2. Deckers IAG, et al. Plos ONE 2012;7(7):e39803; 3. Simpson CR, et al. J Roy Soc Med. 2009;102:108-117; 4. Lewis-Jones S. Int J Clin Pract. 2006;60(8):984-992; 5. Emerson
RM, et al. Brit J Dermatol. 2008;139(1):73-76.
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Atopic Dermatitis – Challenging to Treat
Treatment Steps Adapted to
Disease Severity in AD
• Short Term Objectives
• Long Term Objectives
• Reduce severity & frequency
of flares
• Systemic medication often
off-label in children
• Rx therapies associated
with AEs and morbidity
Step 4
Recalcitrant,
severe
Moderate-severe
Mild-moderate
Dry skin only
SEVERITY OF AD
• Control of flares, immediate
reduction of itch, heal skin
Step 3
Step 2
Step 1
Systemic therapy
(CyA) or UV
Mid-high potency TCS
and/or TCI
Low-mid potency TCS
and/or TCI
Skin hydration, moisturizer
CyA, Cyclosporin A. TCS, topical corticosteroid. TCI, topical Immunomodulator
Akdis et al. J Allergy Clin Immunol 2006;118:152–69
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Emollient Use May Reduce Risk of AD in Infants
• Daily full-body use of an emollient (oil, cream/gel,
ointment) from birth daily prevented atopic dermatitis
1
in 124 neonates at high risk of AD
• Daily application of an emulsion moisturizer during
first 32 weeks of life reduced risk of AD in 56 patients
2
at high risk
• Regular oil baths in 118 infants reduced xerosis and
3
could possibly reduce AD
1 . Simpson EL, et al. J Allergy Clin Immunol. 2014;134:818-23. 2. Kvenshagen BK, et al. Allergol Immunopathol. (Madr). 2014. 3. Horimukai K, et al. J Allergy Clin Immunol. 2014;134:824-30.
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Attributes of Oat in Skin Care
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Composition of Oat Lipids
• Total lipid content of oats – from 2% - 11.8% (dry
weight)
• Triglycerides
• Phospholipids
• Lecithin
• Glycolipids
• Free fatty acids (oleic, linoleic, palmitic, stearic)
Zhou M, et al. J American Oil Chem Soc. 1999;76(2):159-169.
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Buffering Capacity of Colloidal Oatmeal Restores pH
of Damaged Skin to Normal Range
Skin pH
Before
Treatment
8.0
6.8
5.5
Normal
pH Range
4.2 – 5.5
4.3
3.0
Before
Eczema
Forearm Measurements
0
30
Winter Itch
Skin pH After Treatment
With
Colloidal
Oatmeal
60
90
180
Senile Pruritis
Senile Skin
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UV Induced Redness Reduction
Avenanthramides vs. Other Fractions
Separated Oat Fraction Applied 24 Hours After Irradiation
Avenanthramides
Flavonoids
Clinical Evaluation for Erythema
24 Hours After Application
Saponins
0
63
125
188
250
% of redness attenuation per gram after UV irradiation
Vollhardt J, Fielder DA, Redmont MJ. Identification and cosmetic application of powerful anti-irritant constituents of oat grain. XXI IFSCC International Congress
2000, Berlin. Proceedings; 395-402.
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Avenanthramides Inhibit Topical Irritation
IL-8 Release (pg/mL)
from Keratinocytes
270
240
210
180
150
IL-8, Interleukin-8
Unstimulated Stimulated
1
10
100
Avenanthramide (μg/mL)
Wallo W, et al. Poster presented at: 65th annual meeting of the AAD. February 2-6, 2007; Washington, DC.
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Effectiveness of Colloidal Oat Lotion vs. Vehicle Lotion
for Relief of Dry Itchy Skin
A Randomized, Double-Blind Bilateral Controlled Study to Evaluate the Effectiveness of an Oatmeal Containing Lotion vs Vehicle for the Relief of
Dry, Itchy Skin, Johnson & Johnson Consumer Inc. data on file.
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Colloidal Oatmeal Bath* Treatment of Dry and
Sensitive Skin in Atopic Dermatitis
4-week, investigator-blinded, crossover study (N=25)
1.2
1.0
50%
Grading Score
0.8
Itching
0.6
Burning
0.4
67%
0.2
0
Before
After
• *Colloidal oatmeal with ceramides and dexpanthenol.
• Wallo W, et al. Poster presented at: 65th annual meeting of the AAD; February 2–6, 2007; Washington DC.
Daily Oat-based Skin Care Regimen for Atopic Skin: EASI
Composite Score – Ages 12-60 Years
EASI (Mean)
8
* Significant Improvement
(P<0.001)
6
4
*
*
*
Week 4
Week 8
2
0
Baseline
Week 2
EASI, Eczema Area and Severity Index
Fowler JF, et al. J Drugs Dermatol. 2012;11(7):804-807.
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Overall Improvements in QOL After 4 Weeks
Using Colloidal Oatmeal Regimen
Dermatology Life Quality Index Children 2 Months to 6 Years
N=23
10
9
8
6.79
7
6
4.52*
5
4
3
2
1
BASELINE
AFTER 4 WEEKS
0
0
1
2
Nebus J, Wallo W, Eichenfeld L, MD; Poster presented at the 34th Annual Meeting of the Society of Pediatric Dermatology. July 2008
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4
Data Support Safety of Topical Oat Products
• Post-marketing surveillance – No allergies reported by consumers of
1
455,820 products (N=2291) sold during a 3 year period
• Sensitization to cereals did not increase the risk of allergic reactions to
2
oat-containing cosmetics in cereal sensitized atopic adults (N=12)
• No evidence of sensitization to topical colloidal oat in normal and atopic
3
children (N=65)
• Extremely low incidence of adverse or allergic reactions from the use of
oat-based products either in subjects with healthy skin or in those with an
4
existing atopic dermatitis
• No oat sensitivity reported with topical oat in 173 infants under 12
months old treated for inflammatory lesions by moderate and or high
potency topical corticosteroids randomly assigned to receive emollient or
5
not (control group)
1. Criquet M, et al. Clin Cosmet Invest Dermatol. 2012;5:183-93; 2. Goujon C, et al. Dermatology. 2009;218(4):327-33.; 3. Pigatto P, et al. Am J Contact Dermatol.
1997;8(4):207-09; 4. Hopkins J. 2010;5. Grimalt R, et al. Dermatology. 2007;214(1):61-7.
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Key Messages
• Skin performs critical functions
• Infant skin is still developing (SC thinner, NMF & Lipids lower,
TEWL is higher)
• Maintaining skin barrier integrity essential; skin lipids and pH play
important roles
• Skin barrier is defective in AD patients; barrier dysfunction leads to
symptoms (dryness, itching, inflammation, poor QOL, chronic /
chronic relapsing course
• AD Challenging to Treat
• Emollient use may reduce risk of AD in infants (but not all emollients are the
same)
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Key Messages
• Many eczema flare-ups can be prevented with CONSISTENT
emollient use to maintain skin barrier function
• Oat has attributes in skincare that can benefit AD
• Barrier function (lipids), pH buffering capacity, reduce inflammation
(avenanthramides), ceramide formation (lipids)
• Skincare products containing oats:
• Generally recognized as safe (USFDA), sensitization uncommon
• Powerful, time-tested tools in managing AD and can improve patient
QOL
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