#559 - Treatment of Eczema, Life’s Essential 8 Update, Sowing Kindness
Take 3 – Practical Practice Pointers©
From the American Academy/College of Allergy, Asthma, and Immunology
1) Updated Guidelines on Atopic Dermatitis (Eczema)
Eczema is one of those conditions that can become almost routine in primary care – often a diagnosis of “convenience” if the etiology of a rash is not immediately apparent. The American Academy (and College) of Allergy, Asthma, and Immunology (AAAI&ACAI) have updated their 2012 guidelines on the treatment of eczema with a major focus on creating trustworthy and equitable guidelines. They used an evidence-based practice center to perform network meta-analyses with systematic reviews on their a priori choice of five major topics: topical treatments, elimination diets, dilute bleach baths, allergen immunotherapy and phototherapy. The guideline committee had a broad multidisciplinary membership – including several primary care representatives as well as patient representatives. They used the GRADE guideline development process and had a focus on equity, especially the presentation of eczema across different skin tones and health disparities in treatment.
The recommendations are summarized as follows:
Basics:
- Ensure an accurate diagnosis and identify any complicating diagnoses
- Provide disease education and an action plan
- Advise avoiding triggers
- Ensure proper medication use and adherence
- Ensure “bland” moisturizer use at least once per day
Topical Treatments:
- Avoid prescription moisturizers in favor of bland (unscented), over-the-counter moisturizers
- Topical steroids (TS) are the mainstay of therapy – avoid high-potency (potency class 1 and 2) for longer than 4 weeks or on sensitive areas (face, skin folds, groin). TS are good for gaining initial control of flares, and for intermittent treatment of minor flares.
- Topical calcineurin inhibitors (TCI, pimecrolimus or tacrolimus) are recommended for flares not controlled by moisturizers also and may also be used for intermittent treatment. Used in recommended doses, they confer no increased risk of cancer.
- For both TS and TCIs, once a day dosing is recommended with slight preference over twice a day, though twice a day is acceptable.
Dilute Bleach Baths:
- Handout with instructions from the National Eczema Organization
- 0.005% (sodium hypochlorite) in lukewarm/tepid water for 10 minutes per bath and done twice per week
- Reduced eczema symptoms by 50% with number needed to treat (NNT) of ~10
- Best reserved for moderate or severe eczema resistant to moisturizers – there are many safety concerns.
Elimination Diets:
- Even though many with eczema also have food allergies, a meta-analysis showed minimal to no benefit of elimination diets for eczema control.
Allergen Immunotherapy:
- In addition to treatment with moisturizers and either TS or TCIs, allergen immunotherapy (against house dust mites or specific allergens) reduced the severity of eczema by about 50%. Patients had a 10% risk of serious adverse reaction to injection immunotherapy but <1% reaction to sublingual therapy. Immunotherapy could help those with allergic rhinitis symptoms also, so a risk-benefit discussion is important for this choice.
Systemic Therapy
- Mostly for moderate-severe eczema despite the above therapies.
- Biologics – dupilumab (6 years and older) and trolukinamab (12 years and older0 are recommended with strong evidence.
- “Small molecules”
- - the oral JAK inhibitors – abrocitinib (100-200 mg/day), baricitinib (2-4 mg/day), and upadacitinib (15-30 mg/day) – are conditionally recommended with low certainty evidence
- Cyclosporine is conditionally recommended with low certainty evidence
- UV light therapy – small-band UV-B therapy can help in addition to the topical treatments.
Treatments to avoid:
- Baricitinib, methotrexate, mycophenolate
- Systemic corticosteroids
John’s Comments:
These are well-done guidelines worthy of our attention in primary care. There is a very nice infographic that summarizes the recommendations in the full text of the guideline. The recommendations to stick with generic, “bland” moisturizers and TS as mainstays of therapy was refreshing. The safety data about TCIs was particularly appreciated, and I will feel better about using them for mild eczema. I will reserve bleach baths for carefully selected patients with moderate-severe eczema and will continue to refer patients to allergy/dermatology for treatments who need interventions beyond those.
Reference:
- Chu DK, Schneider L, Asiniwasis RN, et al. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE– and Institute of Medicine–based recommendations. Annals of Allergy, Asthma & Immunology. 2024;132(3):274-312. Link
From the Literature and the American Heart Association (AHA)
2) Life’s Essential 8 (LE8) and Cardiorespiratory Fitness (CVF)
In 2010, the American Heart Association (AHA) published a “Presidential Advisory” on defining optimal cardiovascular health (CVH) in adults called “Life’s Simple 7”. These were seven metrics which had been shown to improve CVH and promote CV disease prevention. Extensive subsequent evidence provided insights into strengths and limitations of the original approach to defining and quantifying CVH. In response, the AHA convened a writing group to recommend enhancements and updates, which it published in 2022 as “Life’s Essential 8.”
The components of Life’s Essential 8 include:
- Diet: Encourages the DASH diet components for population measure and the Mediterranean Eating Pattern for Americans (MEPA) for individuals.
- Physical activity (PA): The optimal level is >150 minutes (2.5 hours) of moderate physical activity or > 75 minutes of vigorous-intensity physical activity per week.
- Nicotine exposure: Includes use of inhaled nicotine-delivery systems, which includes e-cigarettes or vaping devices, and exposure to second-hand smoke.
- Sleep health: Measured by average hours of sleep per night, with the ideal target level of 7-9 hours daily for adults.
- Body mass index (BMI): BMI continues as a "reasonable" gauge to assess weight categories that may lead to health problems, though acknowledged as being imperfect. BMI of 18.5–24.9 is associated with the highest levels of CV health.
- Blood lipids: Encourages use of non-HDL cholesterol (Total cholesterol minus HDL cholesterol) as the preferred number to monitor. Target is < 130.
- Blood glucose: Use of fasting blood sugar (FBS) or A1C. Target is < 100 or < 5.7.
- Blood pressure: Target measure is < 120/80.
For overall CVH, the writing group endorsed a composite, aggregate score for measuring, monitoring, and assessing change in CV health. The aggregate score is scaled from 0 to 100 points, calculated as the unweighted average of all 8 component metric scores. The group also recommended categorical assessment of overall CVH, with scores of 80-100 be considered high CVH; 50 to 79 as moderate CVH; and 0 to 49 points, low CVH.
A companion paper in 2022 using utilizing the National Health and Nutrition Examination Surveys (NHANES) data for 2013-2018 assessed CVH scores for US adults and found that the overall mean CVH score was 64.7 with mean scores being lowest for diet, PA, and BMI metrics. Overall, only 0.45% of adults had a perfect score of 100; 20% had high CV health (score of 80+), 63% moderate (score of 50 to 79), and 18% had low CV health (score of less than 50). Since that time other studies of the Life’s Essential 8 metrics have shown a direct correlation to CRP measurements and coronary calcification scores.
A recently published study compared CVH scores with cardiorespiratory fitness (CRF).
Akin to the CVH score, CRF is an integrative measure of CVH status that powerfully predicts CVD outcomes and CV and non-CV death across populations and underlying disease states. CRF can be quantified directly using cardiopulmonary exercise testing (CPET) for assessment of peak oxygen uptake (V̇O2).
Using a cohort of Framingham Heart Study (FHS) participants, the authors related an LE8 CVH score with CRF (peak V̇O2) and complementary exercise response patterns in a large (N=1838) community‐based sample, hypothesizing that a greater LE8 score and improvement in LE8 score over time would be associated with greater CRF across age, sex, and underlying CVD status, thereby providing a potential intermediate biomarker for measuring the effects of interventions to promote CVH.
They related total LE8 score, score components, and change in LE8 score over 8 years with peak V̇O2 (log‐transformed) and complementary CRF measures. With a baseline mean LE8 score of 76±12, they found a higher LE8 score was associated favorably with peak V̇O2, ventilatory efficiency, resting heart rate, and blood pressure response to exercise (all P<0.0001). Also, a clinically meaningful 5‐point higher LE8 score was associated with a 6.0% greater peak V̇O2. Over an ≈8‐year interval, a 5‐unit increase in LE8 score was associated with a 3.7% higher peak V̇O2 (P<0.0001). They concluded that higher LE8 score and improvement in LE8 variables over time was associated with greater CRF, highlighting the importance of the LE8 factors in maintaining CRF.
Mark’s Comments:
It was good to see this LE8 score correlate with V̇O2 peak (max). While V̇O2 max has become a sought-after measurement for fitness, this is a more challenging measurement to obtain in the general population so having possible surrogate measures is desirable. I encourage you to take a few minutes to calculate your personal LE8 score. See the 2nd reference. No perfect sore for me, so I have some opportunities for some focused attention. How about you?
References:
From PeerRxMed ( www.PeerRxMed.org )
3) Sowing Kindness by Showing Kindness
“ … all kindness begins with the sown seed.” Mary Oliver from her poem, “What I Have Learned So Far.”
In last week’s PeerRx blog, I encouraged our community to accept the 21-day “Kindness Challenge” by doing an intentional act of kindness daily for 21 days. My own experience thus far has been quite eye-opening. Though I did some things I may have done anyway, I was much more present and aware than normal, and perhaps because of this, it seemed my kindness showed up differently;
- For the man at the gym who hadn’t been there for a while, so I inquired about his absence and learned he’d had an MI (minimal risk factors) and had been rehabbing. That day was the first back at the gym in 2 months for him.
- For the elder who was having trouble navigating some stairs and for whom I stopped and helped.
- For the woman whose dog had broken from the leash and needed help getting her leashed again.
- For my friend who needed some support and encouragement from me as he prepared for an important meeting that had some “behind the scenes dynamics.”
We all could likely create such lists if we stopped to think about it. What has stood out for me so far is the deeper understanding that ultimately, kindness is an action, not simply an intention. And it is that action that integrates the abstract concept of “being kind” with “doing kindnesses.”
One of my favorite poets, Mary Oliver, appears to have internalized this “lesson” in the poem below. As you continue (or start) your own 21-day “Kindness Challenge,” perhaps her words will provide a different perspective as to how you might approach it. This week, may you too be “ignited” as you spread the light of kindness.
What I Have Learned So Far
Meditation is old and honorable, so why should I
not sit, every morning of my life, on the hillside,
looking into the shining world? Because, properly
attended to, delight, as well as havoc, is suggestion.
Can one be passionate about the just, the
ideal, the sublime, and the holy, and yet commit
to no labor in its cause? I don't think so.
All summations have a beginning, all effect has a
story, all kindness begins with the sown seed.
Thought buds toward radiance. The gospel of
light is the crossroads - of indolence, or action.
Be ignited, or be gone.
Mary Oliver
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Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.
Email: mhgreenawald@carilionclinic.org