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Eczema

Eczema is frequently called atopic dermatitis because it was noted to occur in individuals with allergic symptoms, e.g., allergic rhinitis (hay fever) and asthma. The term atopic simply means allergic. Even though eczema was considered to be an allergic problem, allergy seems to be less likely as our understanding of the disease increases. Physicians know that eczema is a very complex disease and contains allergic as well as non-allergic elements in different individuals. As a result, the treatment of every individual may vary.

While the causes of eczema continue to be investigated, certain things are known about the disease. The skin is much more easily irritated than normal skin. Dryness of the skin is a primary component and results in significant itching. Eczema is known as “the itch that rashes”. Itching is made worse by irritants on the skin. Winter months are particularly bothersome because of the dry winter air. Flares in the summer months can occur after exercise because sweat is a significant irritant. Citrus or some vegetables, e.g., tomato, can act as a primary irritant when they touch the skin. Stress in some individuals can affect the skin. While emotional factors may play a role in flaring eczema, they are not considered a primary source of causing the onset of eczema, if it is not already present.

Eczema occurs in about 3% of the population. In about 80% of those individuals, the onset occurs in the first year of life. One-half are free of disease by age 2 years, about one-fourth by the end of adolescence, and the remaining one-fourth will continue to have eczema into adult life. Some individuals do not have the onset of symptoms until adolescence or adulthood.

Treatment is multifaceted and includes lifestyle modification as well as various types of medication. A portion of treatment will be listed in the accompanying tables. Adequate attention to clothing, diet manipulation, and attention to the emotional well-being of the affected patient are very important. It is preferable for a patient with eczema to wear clothing which will not irritate the skin; soft cotton material would be best. The room temperature should be kept moderate with controlled humidity (between 35-50%). Overheating and perspiration should be avoided.

Some investigators believe there is a genetic tendency for eczema with approximately 50% of eczema patients ultimately developing allergic rhinitis and/or asthma. This is compared to about 20% without the presence of eczema. While allergy skin testing and allergy injection treatment are usually helpful in cases of allergic rhinitis and/or asthma, it is generally agreed that this is often not the case with eczema. In some individuals, starting allergy shots for allergic rhinitis and/or asthma may actually result in significant flaring of the eczema.

Prevention

  • Trim fingernails short
  • Cotton gloves at night if needed to decrease scratching
  • Clothing should be double rinsed after washing to remove all residual detergent (irritants)
  • Avoid excessive room temperatures
  • Wear light, non-occlusive clothing (e.g., cotton instead of polyester)
  • Keep the bedroom moderate (cool) and avoid excessive bed clothing
  • Allergen contact or ingestion avoidance (e.g., foods, pets, dust mite) can reduce stimulation of the skin

Treatment

  • Bathing for moisturization, e.g., soaking in tepid water for 30-45 minutes at least once daily and if possible 2-3 times.
  • Within 2 minutes after getting out of the tub, a lubricating cream or ointment should be applied to help hold the moisture in the skin. Examples include Aquaphor, Curel, Moisturel, Eucerin, Keri, Lubriderm, Acid Mantle, Unibase, Vanicream, petrolatum, and chilled Noxzema,etc. Newer medications include Triceram/Certopic, Impruv, Mimyx, Nourica Repair, Cerave, Atopiclair, and Hylira. Some of the newer medications are by prescription only. None of the medications in the above list contain steroids.
  • In general, lotions should be avoided since they contain alcohol which may sting and provide limited moisture.
  • If marked irritation or weeping areas are present, wet wraps with a drying solution (e.g., Burrow’s solution, one tablet mixed in one quart of water is available by prescription) will avoid the stinging or burning sensation that can occur with bathing.
  • Addition of oil or similar substances to the bath water generally has little effect on increasing moisturization.
  • Pat dry with a soft towel; do not “rub” dry since this will remove natural, protective oils from the skin.
  • Showers do not add moisture to the skin and actually remove the protective oils from the skin resulting in increased dryness.
  • Topical steroids are the mainstay of therapy for more severe eczema. Ointments or creams are generally used.
  • Nonsteroidal medications that help the immune system in the skin may be necessary either in addition to or in place of topical steroids if the topical steroids are not adequate for relief. Examples of the nonsteroidal medications are Elidel and Protopic.
  • Antibiotics, topical and/or oral, may be needed if the lesions become infected. An alternative to antibiotics is the use of Clorox baths. One-quarter to one-half cup of Clorox in a full bath provides antibacterial activity that will treat all known bacterial infections. No resistant bacteria to Clorox are known.

Conditions Treated

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The Current State of Oral Immunotherapy

Food Allergies and OIT

From the American Academy of Allergy, Asthma & Immunology
https://www.aaaai.org/

What is oral immunotherapy for food allergy?
Oral immunotherapy (OIT) refers to feeding an allergic individual an increasing amount of an allergen with the goal of increasing the threshold that triggers a reaction. For example, a person allergic to peanuts may be given very small amounts of peanut protein that would not trigger a reaction. This small amount is gradually increased in the allergist’s office or a clinical research setting over a period of months. The goal of therapy is to raise the threshold that may trigger a reaction and provide the allergic individual protection against accidental ingestion of the allergen. OIT is not a curative therapy.  Individuals who receive OIT will continue to carry epinephrine, read labels closely, etc., and it is not expected that OIT will lead to ingestion of the allergen without limitation.

What is the current standard of care for treatment of food allergy?
The current standard of care for treatment of food allergy is avoidance of the allergen and treatment of anaphylaxis with auto-injectable epinephrine. While many food allergy treatments, including OIT and epicutaneous immunotherapy (EPIT, or a skin patch), have been considered investigational by professional allergy societies and other key stakeholders, the Allergenic Products Advisory Committee of the Food and Drug Administration (FDA) voted to support approval of a standardized oral immunotherapy (OIT) product for peanut allergy, called PalforziaTM. The indication is for treatment to reduce the incidence and severity of allergic reactions, including anaphylaxis, after accidental exposure to peanut in patients aged 4 to 17 years with a confirmed diagnosis of peanut allergy.

How effective is OIT?
Efficacy in clinical trials has typically been defined by induction of a desensitized state. “Desensitization” refers to the improvement in food challenge outcomes after therapy and relies on ongoing exposure to the allergen. Peanut, egg and milk OIT have been shown to desensitize approximately 60 to 80% of patients studied. Desensitization rates for other foods have not been as closely studied and some evidence suggests OIT may not be equally efficacious for every food allergy. It is important to note that because efficacy has been measured using oral food challenges in trials, it is not yet definitively known whether desensitization can protect patients from real-world accidental exposures (e.g. prevent hospitalization or death).

Some studies have looked at “sustained unresponsiveness” which refers to retention of the protective benefit achieved through therapy and is not reliant on ongoing exposure. Sustained unresponsiveness has not been adequately studied to provide definitive data. Peanut and milk OIT have been reported to induce sustained unresponsiveness in approximately 30 to 70+% of individuals, though a number of variables make broad interpretation of this data difficult, including age of participants in the studies, length of time on therapy, and length of time off therapy at the time the sustained unresponsiveness was assessed. It is assumed that ongoing exposure will be required for the majority of individuals receiving OIT or EPIT; the therapies in their current form are unlikely to produce a permanent, long-standing immunologic change.

What are the side effects of OIT?
The most common side effects involve the gastrointestinal (GI) tract. Typical symptoms include abdominal pain, vomiting and cramping. Some patients have developed eosinophilic esophagitis (EoE), an allergic disease of the esophagus that causes difficulty swallowing, vomiting and abdominal pain, but it is not always clear that EoE was caused by the therapy. EoE typically resolves when therapy is discontinued. Other commonly reported side effects include oral itching, rash, hives, swelling, wheezing and anaphylaxis.

What are some “real-life” considerations with OIT?
Studies thus far have brought to light several “real-life” considerations that will be important to understand as treatment with OIT becomes available. OIT involves a long-term commitment with daily dosing during the up-dosing and maintenance phases which occur over several months to years and possibly indefinitely. Bi-weekly office visits are required to safely assess the tolerability of each consecutive dose level. When dosing at home, certain precautions increase safety but also place restrictions on daily life, such as a home monitoring period after dosing and avoiding an elevation in body temperature (e.g. with exercise, hot showers, etc.) for 2to 4 hours after dosing. In addition, aversion to the taste and smell of the product can be tough to overcome for those who have practiced lifelong avoidance.

What is unknown about OIT?
There are many important questions about OIT that require ongoing study. The precise degree of protection is a topic of active investigation. Will OIT allow individuals to reliably eat products with precautionary labels? The length of treatment and doses used have varied in published studies. The “best” dose to give for any particular allergen is unknown. How to predict which individuals would respond to treatment and those at highest risk of side effects is also unknown. Do treatments have long-term safety risks different from those observed in clinical trials? Is there a way to measure benefit without performing an oral food challenge? Is long-term treatment sustainable? What are the effects of long-term treatment on quality of life and family dynamics? What are the effects of suboptimal adherence on safety and efficacy? Could OIT be combined with another therapy to improve safety and efficacy?

What OIT has been approved for the treatment of food allergy?
The only FDA approved treatment for food allergy is the aforementioned peanut OIT product, PalforziaTM. Other programs for egg and walnut allergies have been announced. There are also a relatively small number of allergists around the country who use commercial food products to offer OIT as a service in their offices, a clinical practice which is not currently and will not be “approved” by the FDA. Only REMS certified providers will be able to prescribe PalforziaTM.

What else should individuals affected by food allergy and their families be aware of when considering OIT?
OIT is a leading investigational and now, marketed treatment, offering the hope of protection from food allergy reactions. However, like most chronic diseases, food allergy treatment will not be a “one size fits all” approach. Thus far, OIT has primarily targeted allergy to single foods; further study is required to determine if multiallergen OIT will be beneficial. Other investigational therapies may become available and carry different risks and benefits. In addition to the safety profile, important considerations will include likelihood of outgrowing an allergy naturally, prevalence of food in the diet/culture, severity of allergy, and risk of exposure. Ultimately, the choice of treatment, including that of active non-intervention, will be based on individual and family factors after careful discussion with one’s physician.

The post The Current State of Oral Immunotherapy appeared first on Oklahoma Allergy and Asthma Clinic.

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