Condition: Atopic Dermatitis (Eczema)

Condition / Comments
Patho/Causative Organism / A chronic, relapsing form of pruritic skin inflammation, often associated with other atopic disorders, such as allergic rhinitis and asthma. Develops from a combination of genetic and immunologic mechanisms that drive cutaneous inflammation. (Staphylococcus aureus and its inflammatory products are believed to have a role in bringing about the epidermal-barrier dysfunction characteristic of atopic dermatitis).
Epidemiological Considerations / Frequently affects infants, children and young adults
Associated with personal/family hx of atopy
Risk Factors / Personal/family history of atopy
Clinical Presentation / For diagnosis, where all are present:
Pruritus- evidence of dry skin, or parental report of scratching by the child
Eczematous changes- either acute, subacute or chronic in typical and age-specific patterns
  • Infants- face, neck, and extensor involvement
  • Older children/adolescents/adults- current or prior flexural lesions
  • In all age groups, there is a sparing of groin and axillary areas and the condition has a chronic or relapsing course
Important features: seen in most cases and adding support to the diagnosis:
  • Early age at onset
  • Xerosis (abnormally dry skin)

Hx. & Key Questions / OPQRST
Ask about personal/family history of atopy
Question about itching, appearance and distribution of lesions. (determine if acute, chronic or relapsing)
Ask about routine skin care including bathing habits as well as products used for dry and itchy skin and medications that have been used in the past to control the condition
Ask about occupation environments
Red Flags / Nil
P/E Key Points / Infant phase: erythema and scaling of the cheeks and chin with sparing of perioral and paranasal areas; involvement of the extensor surfaces of the feet and elbows is also common. Exudative lesions (oozing, weeping) common. Diaper area is spared.
Childhood phase: flexural area involvement; erythematous papules coalesce into plaques and over time, scratching produces lichenification; foot dermatitis common. Exudative lesions less common
Adult phase: localized inflammation of flexural areas with lichenifcation is most common; hand dermatitis occurs much more frequently
Differential Diagnoses & R/O Rationale / Scabies, contact dermatitis, seborrheic dermatitis, ichthyoses psoriasis, and cutaneous lymphoma – differentiate based on history and characteristics of the lesion
Diagnostic Tests / Not routinely indicated
Consider: skin biopsy, immunoglobulin serum levels (IgE elevated), patch testing and skin prick tests
Therapeutic Goals / Chronic recurring condition:
-Relieve generalized dry skin and pruritis
-Treat patches to reduce inflammation and reduce risk of secondary skin infection
-Prevent flare ups caused by environmental irritants
Counseling or Education / Reducing environmental irritants – nonirritating soaps, avoiding perfume products, wool, synthetic fibers, dry grass and leaves
Ointments are less irritating and penetrate better than creams or lotions but ointments have lower compliance rates
Sweating, stress and overheating can increase itching
Pruritis in AD is not histamine-medicated so dose not response well to histamine blockade
Conditions Affecting Choice of Therapy / Immunocompromised
Radiation therapy
Compliance
1st Line Drug(s) / Non-pharmacological 1st choice
Frequent use of lubricating skin emollients to seal in moisture and prevent flares
2nd Line Drug(s) / Face/Intertriginous folds – Low potency corticosteroid
Body and scalp – Medium potency corticosteroid
Palms/soles – High potency corticosteroid
Body Area to be Treated / Fingertip Units (FTUs) Required for One Application (by age group)
3–6 Months / 1–2 Years / 3–5 Years / 6–10 Years / Adults
Face and neck / 1 / 1.5 / 1.5 / 2 / 2.5
1 Arm and hand / 1 / 1.5 / 2 / 2.5 / 4
1 Leg and foot / 1.5 / 2 / 3 / 4.5 / 8
Trunk (front) / 1 / 2 / 3 / 3.5 / 7
Trunk (back, including buttocks) / 1.5 / 3 / 3.5 / 5 / 7
Or
Barrier repair products – Ceramides/cholesterol/free fatty acids – BID
Secondarily infected dermatitis: Antibiotic/corticosteroid combos
Calcineurin inhibitors – Mold to moderate AD - Pimecrolimus cream 1% BID (not for use in children <2)
Moderate to severe AD - Tacrolimus ointment 0.03% - 0.1% oint BID
Pediatric – Tacrolimus 0.03% oint BID
Drug side effects / Corticosteroids – striae, telangiectasia, atrophy, purpura, suppression of HPA axis – very rarely clinically relevant
Barrier repair products – mild burning/stinging
Calcineurin inhibitors – transient burning sensation, skin tingling, pruritis at application site
Complementary Therapies / Frequent use of lubricating skin emollients to seal in moisture and prevent flares and during medicated treatments just apply the treatment first
Bathing in warm (not hot) water for 5-10 minutes to hydrate skin and pat dry, not rubbing
Wet wraps are a useful second-line therapy but need to be supervised by a HCP experienced in this technique
Plan/Management, including Monitoring and F/U / Education re chronic inflammatory disorder and occurrence of flares/recurrences
Use the lowest potency corticosteroid possible for the shortest duration to lessen side effects
Monitor for secondary bacterial infections
Need for Consultation & CNO Standards Rationale / Not indicated unless severe/not responding to tx
Primary, Secondary, and Tertiary Prevention / Primary – N/A
Secondary – Regular use of topical emollients BID
Tertiary – Effective tx of flares to prevent secondary bacterial infections
Pregnancy/Breast-feeding Considerations / Corticosteroid use is safe – low and mid potency preferred over potent or very potent
Corticosteroids– okay for use on nipples when breastfeeding just wipe it off before
Calcineurin inhibitors cannot be used on nipples of breastfeeding mothers