PRURITUL : SEMNIFICATIE DIAGNOSTICA SI TRATAMENT

Managementul eficient al pruritului

Pruritul este o problem minor?!

Pruritul cronic impactul afectiuniiDalgard et al., Br J Dermatol 2004Wolkenstein et al., Arch Derm 2003Stnder et al., Dermatology 2010> 40% dintre pacientii adulti cu proleme de piele sufera de prurit cronic

> 8% din populatia generala a Norvegiei sufera de prurit moderat/sever

Prevalenta pruritului cronic in randul populatiei de origine germana este de peste 15% (conform unui studiu pe 11.730 angajati)3Lewis and Finlay, J Invest Dermatol Proc 2004; 9: 169-18002468101214Atopic dermatitisPruritusChronic urticariaAcne inversaPsoriasisUlcus crurisRosaceaAloepcia areataBullous pemph.Dysceratosis foll.Lichen planusVitiligoDiskoid LEBCCDLQI scoreImpact mare n afectarea calitii vieii pacientului!Dermatology life quality index (DLQI) 44pruritul este un factor perturbator al calitatii vietiipruritul cronic poate interfera cu somnul,conducind la epuizare fizica si emotionala,iar la copii poate intrerupe crestereaunele leziuni de grataj pot camufla o dermatoza : exemplu:scabiapruritus sine material termen ambigu,ce indica originea necunoscuta, sistemica ,sau psihogena.

Source:D. Leung, 2000Dermatita atopica Fiziopatologie complexa

Poate s apar la orice vrst!Foto: Google images

Dermatita atopicDermatita de contactPruritul poate avea o multitudine de cauze!

UrticarieIntepaturi de insecte7> 55 %> 65%> 75%123% de parinti care raporteaza ca bebelusii/copiii lor au dificultati de somn in timpul acutizarii dermatitei atopice:Reid et al 94> 75%38MicMareNu are impact123Impactul asupra calitatii vietii pacientilor cu dermatita atopica este?Metz et al 10Mare29Leziunile exsudativeDescuamarea pieliiPruritul123Cel mai relevant simptom pe care pacientii cu dermatita atopica doresc sa-l trateze este:Schmitt et al 07Pruritul310Cum abordam pruritul?Dermatita atopicaDermatita de contact Urticarie / intepaturi de insectePruritus sine materia

Corticoid topicEmolientAntihistaminice

Terapia cauzei este cel mai important pas-se face tratamentul simptomatic in timp ce se cauta posibila cauza a boliila pacientii in virsta cu xeroza cutanata,primul pas este hidratarea acesteia,mai ales iarnaPruritul cu origine nedeterminata nu trebuie sa fie niciodata un diagnostic final.El trebuie reevaluat periodic pentru a determina daca cauza profunda a iesit la lumina.

11PruritTratametul topicAlegerea tratamentului

Dermatocorticoizii Foto: Google images13ADVANTANeste dermatocorticoidul neflorurat cu mecanism de bioactivareInainte de aplicarea pe piele, Advantan este un corticoid similar hidrocortizonului;Dupa aplicare, MPA(metilprednisolon aceponat) se hidrolizeaza in prezenta eczemei in MPP (metilprednisolon propionat) urcand in clasa 3 de potenta si avand un efect antinflamator puternic!Cel mult 3% poate trece in piele si se inactiveaza rapid in sange deci nu influenteaza cortizolul plasmatic;Advantan se absoarbe in principal in zonele afectate si nu induce efecte sistemice 14

DermatocorticoidpotentProfil de sigurantaBIOACTIVAREAdvantanFoto: Google imagesSIGURANTA

FORMULA FARMACEUTIC

ACTIUNE RAPIDAUmed pe umed

i

Gras pe uscat

Advantan MilkAdvantan CremaAdvantan Unguent

Nou!50 gNou!30 gNou!30 g18 Forme Advantan Milk pentru tratarea eczemei acute i supurate uoare pn la moderate, ex: Dermatita Atopica, Dermatita de Contact.Pentru piele umeda sau cu continut normal de apa.

Advantan Crem pentru fazele subacute i supurate ale eczemei.Pentru piele cu scuame, uscata.

Advantan Unguent pentru afeciunile cutanate nesupurate.Pentru piele foarte uscata.

Advantan - succes terapeutic pn la 94% n cazurile de dermatit atopic sever Korotky NG, Taganov AV. The use of steroid advantan (methylprednisolone aceponate) for management of allergodermatoses in children. Vestnik Dermatologii i Venerologii 2000; 3: 61-63Eficacitate

48,5Siguran - Advantan este studiat pentru utilizare de la vrsta de 2 luni _ inregistrarea in Romania este de la 4 luniCasao AV, Cavalle JR. The milk formulation in topical corticotherapy: Outcomes in children with atopic dermatitis. Monografia de Dermatologia 2002; XV,6:399-40 77,7% vindecare n prima sptmn

81,5% vindecare+ 11% ameliorare dup 2 sptmni

21pacieni vindecai6pacieni au avut nevoie de mai mult tratament1pacient vindecat3pacieni ameliorai1pacient fr ameliorareSptmna 1Sptmna 227 pacieni (2 - 48 luni)Rezultate finale:21Siguran pe zone considerate cu risc pentru ali corticoizi

Studiu observaional multicentric, 575 pac. tratai cu Advantan pe fa i perioral, cu vrste ntre 3 luni i 87 ani.Durata maxim de tratament 4 sptmni.Tolerabilitate foarte bun pe fa i perioral.Ruzicka T, Zaumseil RP. Effectiveness and tolerability of methlyprednisolone aceponate (Advantan) in the treatment of eczematous disorders of the face. Z Hautkrankh 2002; 77: 185-189Pe fa - fr semne de atrofie sau dermatit perioral, pn la 4 sptmni!Indici Terapeutici

Luger T, Loske KD, Elsner P et al. Topische Dermatotherapie mit Glukokortikoiden - Therapeutischer Index, Journal der Deutschen Dermatologischen Gesellschaft 2004;7:629-634Advantan are o poziie de lider n clasamentul indicilor terapeutici.Indicele Terapeutic =Beneficii RiscuriSIGURANTA

FORMULA FARMACEUTICA

ACIUNE RAPIDCe tim deja despre eficiena Advantan asupra pruritului?1998 Mensing H, Lorenz BEvaluarea pruritului din perspectiva medicului si a pacientului; evaluarea facandu-se la 2 zile dupa inceperea terapieipeste 80% dintre pacieni i medici:EFECT RAPID i FOARTE RAPID dupa utilizarea ADVANTANMensing H, Lorenz B. Zeitschr Hautkrankh H+G.1998; 73(5): 281501st follow-up : la 2 zileReducerea pruritului!75% dintre pacieni au prezentat o ameliorare distinct dup 5,5 zile de tratament MPA 0,1%.

Dupa 12.5 zile de tratament 0,1%, 43% i 36% dintre pacieni nu au mai prezentat simptome (conform evalurii pacientului i, respectiv, conform evalurii medicului).

Efectul rapid sau foarte rapid cu a fost perceput de peste 80% dintre medici i pacieni.27Ce tim deja despre efectul metilprednisolon aceponat (MPA) asupra pruritului?Experience with methylprednisolone aceponate (MPA) in patients suff eringfrom acute and chronic eczema: Results of a large observational study.Mensing H, Lorenz B. Zeitschr Hautkrankh H+G. 1998; 73(5): 2815

Toate cele 3 forme farmaceutice au fost bine tolerate!75% dintre pacieni au prezentat o ameliorare distinct dup 5,5 zile de tratament MPA 0,1%.28Experience with methylprednisolone aceponate (MPA) in patients suffering from acute and chronic eczema: Results of a large observational study.Mensing H, Lorenz B. Zeitschr Hautkrankh H+G. 1998; 73(5): 2815

MulticenterOpenNon-comparativeObservational

Duration: up to 6 weeks for adults and 3 weeks for children

Patients age: between 2 months and 87 years, with chronic and acute eczema

Treatment: MPA 0.1% once daily as cream, ointment and fatty ointment, as deemed appropriate by clinician.

First follow-up examination: after 25 days. Second follow-up examination: after 710 days.

N = 2,059

75% of patients showed distinct improvement after 5.5 days of MPA 0.1% treatment.

After 12.5 days of 0.1% treatment, 43% and 36% of patients were symptom-free (patient-assessed and physician-assessed, respectively).

Onset of effect was perceived as rapid or very rapid by 80% of physicians and patients.2004 Niedner R, Zaumseil RP Evaluarea pruritului din perspectiva mediculuiCe tim deja despre efectul metilprednisolon aceponat asupra pruritului?Niedner R, Zaumseil RP. Advantan milk/cream/ointment in children with atopic dermatitis and other inflammatory or eczematous dermatoses an observational study in 558 children. Akt Dermatol. 2004; 30: 2003

96.7% dintre pacienti (evaluai de ctre medic) au prezentat mbuntire semnificativ a simptomelor pn la sfritul tratamentului.

n particular, forma moderat spre sever (eritem + prurit) a fost semnificativ redus ca urmare a tratamentului.

Toate cele 3 forme farmaceutice au fost bine tolerate!30Niedner R, Zaumseil RP. Akt Dermatol. 2004; 30: 2003 Advantan milk/cream/ointment in children with atopic dermatitis and other inflammatory or eczematous dermatoses an observational study in 558 children

Abstract:558 children of 128 dermatologic and paediatric offices, suffering from atopic dermatitis (AD) or other inflammatory dermatoses, were treated with Advantan Milk, cream or ointment between July 2001 and March 2002. In most of them (almost 80%) an atopic dermatitis was diagnosed. The mean age was 5.8 year. All 3 formulation of Advantan showed a very fast onset of effect 9after 1-3 days) and a convincing global efficacy: after an average of 16.7 days in 955 of the patients the disease had cleared or at least did improved significantly. At the start of the study the symptoms erythema and pruritus were strongly present in nearly all patients; they completely disappeared during treatment in almost patients. For all formulations, the tolerance of Advantan was excellent (good or very good assessments in 98% of the children).Only one single patient suffered from an spontaneously cleared adverse event.The rapid onset of action, the short treatment duration, the excellent therapy results and tolerability, confirm the best suitability of Advantan in the treatment of children with AD or other inflammatory or eczematous dermatoses.

Study Design:Multicenter (Germany), Open-label, UncontrolledDuration: 2 weeks for the milk formulation, 3 weeks for the cream and ointment formulationsPatients age: children aged 15 years with AD and other inflammatory dermatosesTreatment: MPA 0.1% milk, cream or ointment once dailyN = 558

Key points:

65% of caregivers reported a 2-3-day onset of clinical effect with MPA 0.1% treatment. 96.7% of patients treated with MPA 0.1% experienced cleared or significant improvement of symptoms (physician-assessed) by treatment end. In particular, moderate to severe redness and itching was markedly reduced over the course of MPA 0.1% treatment. The 3 formulations of MPA 0.1% were well tolerated

In a paediatric population, the successful management of childhood atopic dermatitis (AD) should include the careful evaluation and selection of available therapies, based not only on demonstrated safety and tolerability in small children and infants, but also on their evidence-based, anti-pruritic benefits. Moreover, the speed of anti-pruritic effect should be considered a significant parameter in treatment selection. The fourth-generation topical corticosteroid (TC) methylprednisolone aceponate (MPA) is a potent anti-inflammatory agent with a demonstrated fast and effective itch relief profile in children and infants (as young as 2 months) with AD.

Compared with traditional TCs, MPA has a significantly improved therapeutic index; that is, increased potency without a proportionate increase in side effects. In addition to its established efficacy, the once-daily application and broad range of available formulations make MPA an optimal choice for acute and maintenance therapy in pediatric patients with AD-related pruritus.

The optimization of short-term pruritus relief assessment is an area of active clinical investigation, which utilizes models of inducible itch and currently available topical anti-inflammatory agents. Although preliminary results with MPA 0.1% (Advantan) are encouraging, more research is necessary to characterize the rapid-onset effects of these agents in various chronic skin conditions 16 Indeed, there is a need for clinical trials that examine the potential of topical agents to provide pruritus relief in children in the hours immediately following treatment.

The use of topical treatments that effectively manage AD symptoms and facilitate rapid relief of itch is a necessary part of an integrated treatment approach for AD-associated pruritus. The selection of anti-pruritic agents should be driven by evidence of demonstrated rapid onset of effect, a proven safety profile in children and infants, and the availability of galenic formulations that enable physicians to meet the unique needs of paediatric patients.AVEM DATE RECENTE??31

ISS 1: PRURITUS NiMPA Study 1st resultsFast relief of pruritus using methylprednisolone aceponate to treat nickel sulfate induced eczemaCurto L1, Carnero Ll1, Traveria G2, Roura G2, Gimnez-Arnau A11Department of Dermatology, Hospital del Mar. Universitat Autnoma de Barcelona. 2Adknoma Health Research. Spain

Resultate:

O reducere cu 30% a pruritului conform VAS a fost obtinuta la 75% dintre voluntari la doar 5 ore dupa prima aplicare de Advantan unguent!

VAS = Visual Analogue ScaleConclusion: Methylprednisolone aceponate 0, 1% ointment shows an effective and fast relief of pruritus when ACE is induced in nickel sulphate sensitized patients. Further randomized comparative studies controlled by placebo are required. The effect against pruritus supports the appropriateness of topical corticosteroids to treat ACE symptoms.33Control of inflammation and infectionsAvoidance of triggers (eg, irritants and proved allergens)Barrier repair and maintenanceBoguniewicz M et al., J Allergy Clin Immunol. 2013 Aug;132(2):511-2.e5

Atopic Dermatitis/EczemaTreatment recommendationOcclusivesprevent water evaporationfrom the skin by providinga film of lipidHumectantsHumectants attractand hold water in the stratum corneumEmollientsImprove lipid barrierTopical CorticoidsAntipruritic Emollientscontainingantipruritic agentsWashing productsEmollient washing, Antiseptic waschingBath emollient Protect skin barrierePrevention of infection34Wichtigste Manahme ist die Unterbrechung des Teufelskreises durch Sttzung der Barrierefunktion sowie die Juckreiz- und Entzndungsbekmpfung.

The ABCs of Eczema ManagementABC

Acute Therapy10 14 DaysFor symptom relief during flare-ups:Advantan (night): Fast itch-relief to go from scratching to sleeping

Bepanthen Sensiderm (day): itch-relief during the day

Bepanthen Sensiderm as flare-ups diminish for barrier restorationBarrier restoration 10 14 DaysCare(Basic)Dardia for active hydration