**Part 4**

**New Treatments** 

266 Atopic Dermatitis – Disease Etiology and Clinical Management

Nassif A, Chan S, Storrs FJ, et al. Abnormal skin irritancy in atopic dermatitis and in atopy

Niordson A, Stahl D. Treatment of psoriasis with Clinitar cream: a controlled clinical trial. *Br* 

Ong P, Boguniewicz M. Atopic Dermatitis. *Primary Care: Clinics in Office Practice*

Oosting A, de Bruin-Weller M, Terreehorst I, et al. Effect of mattress encasings on atopic

Reitamo S, Van Leent E, Ho V, et al. Efficacy and safety of tacrolimus ointment compared

Ruiz-Maldonado R, Zapata G, Tamayo L, et al. Cushing's syndrome after topical application

Shelley W, Shelley E, Talanin N. Self-potentiating allergic contact dermatitis caused by doxepin hydrochloride cream. *J Am Acad Dermatol.* 1996;34:143–144. Sicherer S, Sampson H. Food hypersensitivity and atopic dermatitis: pathophysiology,

Simon-Nobbe B, Denk U, Poll V, et al. The spectrum of fungal allergy. *Int Arch Allergy* 

Sloper K, Wadsworth J, Brostoff J. Children with atopic eczema. I: Clinical response to food

Schmid-Grendelmeier P, Simon D, Simon H, et al. Epidemiology, clinical features and

Schmitt J, Schäkel K, Schmitt N, Meurer M. Systemic treatment of severe atopic eczema: a

Soter N, Fleischer A Jr, Webster G, et al. Tacrolimus ointment for the treatment of atopic

Sowden J, Berth-Jones J, Ross J, et al. Double-blind, controlled, crossover study of cyclosporin in adults with severe refractory atopic dermatitis. *Lancet* 1991; 338:137. Stoppoloni G, Prisco F, Santinelli R, et al. Potential hazards of topical steroid therapy. *Am J* 

Tan B, Weald D, Strickland I, et al. Double-blind controlled trial of effect of housedust-mite allergen avoidance on atopic dermatitis. *Lancet* 1996;347(8993):15–8. Van Leent F, Gräber M, Thurston M, et al. Effectiveness of the ascomycin macrolactam SDZ

Weatherhead S, Wahie S, Reynolds N, et al. An open-label, dose-ranging study of

immunology of atopic dermatitis. *Allergy* 2005;56:845-851.

systematic review. *Acta Derm Venereol* 2007; 87:100

Dutch mite avoidance study. *J Allergy Clin Immunol* 2002;110(3):500–6. Paller A, Eichenfield L, Leung D, et al. A 12 week study of tacrolimus ointment for the

dermatitis outcome measures in a double-blind, placebo-controlled study: the

treatment of atopic dermatitis in pediatric patients. *J Am Acad Dermatol.* 

with that of hydrocortisone acetate ointment in children with atopic dermatitis. *J* 

epidemiology, diagnosis, and management. *J Allergy Clin Immunol* 1999;104(3 Pt

elimination and subsequent double-blind food challenge. *Q J Med*. 1991;80(292):677-

dermatitism in adult patients, part II: safety. *J Am Acad Dermatol.* 2001;44(suppl):S39-

ASM 981 in the topical treatment of atopic dermatitis. *Arch Dermatol.* 1998;134:805-

methotrexate for moderate-to- severe adult atopic eczema. *Br J Dermatol* 2007;

without dermatitis. *Arch Dermatol.* 1994;130:1402–1407.

Raimer S. Managing pediatric atopic dermatitis. *Clin Pediatr.* 2000;39:1-14.

of corticosteroids. *Am J Dis Child.* 1982;136:274-275.

*Allergy Clin Immunol.* 2002;109:539-546.

*J Clin Pract.* 1985;39: 67–68, 72.

2008;134:1348-1359.

2001;44:S47-S57.

2):S114–22.

693.

S46.

809.

156:346.

*Immunol* 2008;145(1):58–86.

*Dis Child* 1983;137:1130-1131.

**16** 

*USA* 

**Occlusive Therapy in Atopic Dermatitis** 

*1University of Southern California, Keck School of Medicine, Los Angeles, California 2University of Nebraska Medical Center, College of Medicine, Omaha, Nebraska 3University of California Davis, School of Medicine, Sacramento, California 4University of California San Francisco, Department of Dermatology* 

The treatment of atopic dermatitis (AD) can be challenging for dermatologists and other healthcare professionals. Conventional treatments consisting of emollients and topical corticosteroids are often insufficient for severe and/or refractory AD. Other therapies include systemic corticosteroids, photochemotherapy using psoralen and ultraviolet-A light, and cyclosporine. However, all of these approaches have potentially serious side effects and relative contraindications, especially in children. Over the past two decades, occlusive therapy has been advocated as a safe and effective treatment modality for individuals with acute erythrodermic AD and those with severe and/or refractory AD. (Nicol 1987;

Occlusive therapy usually involves the application of emollients, antiseptics, or topical corticosteroids under either wet wrap dressings (WWD) or dry wrap dressings (DWD). This consists of moistened open-weave cotton tubular bandages (eg. Tubifast, Tubigauz) in WWD occlusion, versus dry gauze, plastic wraps, or hydrocolloid dressings (eg.

More recently, however, occlusion alone using a hydrogel patch has been utilized. The theory is that a major component in the pathophysiology of AD is barrier dysfunction. In fact, many current therapies target this barrier defect (i.e., pseudoceramide moisturizers and skin barrier emulsions). As such, an ideal repair mechanism would completely eliminate microbe and allergen penetration and transepidermal water loss in AD, both of which lead to xerosis, hypersensitivity, pruritus, and inflammation. The hydrogel patch, therefore,

Regardless of the treatment approach, occlusive therapy offers many advantageous such as a cooling effect on inflamed skin, increased penetration of topical agents, enhanced skin hydration, and a barrier to external antigens and trauma (i.e. scratching). Reported disadvantages include the cumbersome and time-consuming nature of the application process, risk of allergic reaction to the occlusive material itself, and possible increased risk of infectious complications such as folliculitis, furunculosis, or cellulitis. An additional concern is that occlusion may cause skin maceration if used incorrectly, or can paradoxically

Duoderm) in DWD occlusion. (Nicol 1987; Goodyear et al. 1991; Bridgman 1995)

offers an innovative approach to *complete* barrier repair. (Park et al. 2011)

Goodyear et al. 1991; Bridgman 1995; Devillers and Oranje 2005)

**1. Introduction** 

Misha M. Heller1, Eric S. Lee2, Faranak Kamangar3,

Wilson Liao4 and John Y. M. Koo4

*San Francisco, California* 

Misha M. Heller1, Eric S. Lee2, Faranak Kamangar3,

Wilson Liao4 and John Y. M. Koo4 *1University of Southern California, Keck School of Medicine, Los Angeles, California 2University of Nebraska Medical Center, College of Medicine, Omaha, Nebraska 3University of California Davis, School of Medicine, Sacramento, California 4University of California San Francisco, Department of Dermatology San Francisco, California USA* 
