Complex care for complex eczema in children

Abstract

Atopic dermatitis (AD) is a chronic inflammatory skin disease affecting up to 30% of children. Children with difficult to treat AD are a heterogeneous group who do not respond as expected to AD treatment. Because of the various skills needed to successfully manage AD, multidisciplinary treatment programs have been developed for children who do not respond sufficiently to regular treatment. In Europe, alpine climate treatment has been used for decades to treat patients with AD and/or asthma. No randomized trials have ever been conducted to provide evidence for its effectiveness. In the DAVOS trial, children with difficult to treat AD were randomized to a six week treatment period either in an alpine clinic in Switzerland or in an outpatient setting in the Netherlands, followed by a six month follow-up period. Immediately after alpine climate treatment and after six weeks follow-up, we found significantly greater improvement in disease activity, health-related quality of life and other clinical secondary outcomes in the alpine climate treatment group. This is in line with the results of previous observational studies. A significant reduction in eosinophils in the intervention group was observed, which is in line with previous studies. Clinically successful AD treatment induced changes in blood B- and T-cell subsets immediately after intervention, reflecting reduced chronic stimulation. At the primary endpoint after six months follow-up, we found no significant differences between the intervention and control group regarding disease activity, health-related quality of life, catastrophizing thoughts and coping with itch. Using a personalized, integrative, multidisciplinary (PIM) treatment approach, children in both study arms improved in terms of AD disease activity, health-related quality of life and catastrophizing thoughts about AD. PIM actively involves both the child and his parents and combines patient designed treatment goals with a systematic multidisciplinary approach by the involved health professionals, including assessment of AD, other atopic, pediatric and mental health comorbidities and general well-being. PIM also addresses other factors that may interfere with AD symptoms, such as inadequate treatment regimens or unaddressed comorbidities or family dysfunction. During PIM, multiple health professionals work simultaneously on the same treatment goals, each using treatment strategies from their own field of expertise. For the majority (77%) of children with difficult to treat AD, participation in the trial using PIM resulted in remarkable improvement in disease activity. Predictors for long term treatment success included maternal disease acceptance. A small group of children, mostly girls with multiple somatic complaints, from families where the mother has anxiety for the use of topical corticosteroids is less likely to obtain long term treatment success. These characteristics resemble children with functional somatic symptoms. In this thesis, we have shown that a personalized integrative multidisciplinary treatment approach (PIM) seems to be effective for the majority of children aged 8 to 18 years with difficult to treat AD. An additional value of alpine climate treatment could not be demonstrated on the long term. Identifying and phenotyping difficult to treat and refractory children with AD as accurately as possible, are essential steps for future successful disease management.