Atopic Dermatitis Overview

Evaluation and Management of Atopic Dermatitis (Eczema)

• Atopic dermatitis is a common skin condition, especially in children.
• It causes inflammation, itching, and rash.
• Various types of eczema exist, including acute, subacute, and chronic.

Outline/Disclosures

• Acute eczematous inflammation is characterized by erythema, edema, vesiculation, and weeping. Itching is common in this type of eczema.
• Subacute eczematous inflammation features erythema, edema, papules and plaques, dry scale, hyperpigmentation, and lichenification. Itching is present.
• Chronic eczematous inflammation includes erythema, edema, papules/plaques, dry scale, hyperpigmentation, lichenification, and itching.
• Atopic dermatitis is a chronic skin condition with a tendency for relapses and remissions which results in eczema.
• Keratosis pilaris is a benign skin condition characterized by rough, slightly scaly skin.
• Pityriasis alba is a common, chronic skin condition that causes white spots on the face.
• Nummular eczema is a type of eczema characterized by coin-shaped lesions.
• Pompholyx (dyshidrotic eczema) is an inflammatory skin condition characterized by small blisters and intense itching on the hands and feet.
• Irritant contact dermatitis arises from contact with an irritant, causing a rash.
• Allergic contact dermatitis is an allergic reaction triggered by contact with an allergen.
• Rhus dermatitis is inflammation from contact with poison ivy, oak, or sumac.
• Lichen simplex chronicus presents as chronic skin thickening (lichenification) due to persistent scratching.

Acute Eczematous Inflammation

• Erythema, edema, vesiculation, erosion, wet/"weeping," and pruritus (itching) are common in this type of eczema.
• A history of trigger or varying etiologies, like atopic flare, allergy/irritant contact, scabies, or fungal infections, may be noted.
• Treatments include avoiding triggers, gentle skin care, topical steroids, antihistamines, and rarely, oral prednisone or cyclosporine.

Subacute and Chronic Eczematous Inflammation

• Erythema, edema, papules/plaques, dry scale, hyperpigmentation, and lichenification are associated symptoms.
• Itching (pruritus) is present.
• Varying etiologies, such as atopic, allergic or irritant contact, and lichen simplex chronicus, can cause exacerbation of the condition.
• Scabies or fungal infections may also lead to inflammation.
• Treatment includes avoiding triggers, gentle skin care, topical steroids, or other anti-inflammatory medications, oral antihistamines, phototherapy (NBUVB), Dupilumab (Dupixent), Methotrexate, cyclosporine, etc, and JAK1 inhibitors.

Atopic Dermatitis Prevalence and Epidemiology

• The prevalence of atopic dermatitis in the US pediatric population ranges from 1-20% with the highest prevalence in industrialized countries.
• The condition has increased more over the last four decades, similar to asthma.
• Onset in babies often happens in the first 6-12 months, and by around 5 years old more than 85% of babies will have been diagnosed.
• If onset is less than 2 years of age, about 20% will have persistent atopic dermatitis and about 50% will develop asthma (often in combination with allergies).
• Severity of atopic dermatitis and food allergies increase the risk of asthma and allergic reactions
• A family history of atopic conditions (atopic march) strongly indicates a future risk of atopic dermatitis.

Differential Diagnosis

• Possible conditions to rule out include psoriasis, contact dermatitis, lichen planus, pityriasis lichenoides, lichen simplex chronicus, seborrheic dermatitis, id reaction, dermatitis herpetiformis, scabies, immunodeficiency, and primary ichthyosis.

AD Associations: Ichthyosis Vulgaris

• Is a genetic skin disorder characterized by a predisposition to dryness, hyperlinearity, and plate-like scaling.
• It is frequently underrecognized in medical practice.

AD Associations: Keratosis Pilaris (KP)

• A benign skin condition associated with atopy.
• Usually associated with dry skin and ichthyosis. Treatments consist of moisturizers, soothing cleansers, and appropriate topical or oral medication that a doctor will prescribe.

AD Associations: Other Conditions

• Atopic dermatitis frequently co-occurs with asthma, allergic rhinitis, dry skin, and ichthyosis, and/or food allergies (an estimated 33% of young children with moderate to severe AD have food allergies).
• These conditions don't necessarily cause one another but often exist together.

AD & Food Allergy

• Food allergies are reported by 12-30% of adults and 6-8% of children under 4.

IgE-Mediated Food Allergy

• Signs and symptoms of IgE-mediated food allergy typically occur immediately (seconds to minutes) after ingestion, although rarely delayed.
• It presents with a variety of symptoms including cutaneous effects (erythema, pruritus, urticaria, morbilliform rash, angioedema), ocular pruritus, tearing, edema, respiratory issues (congestion, cough, dyspnea, wheezing), gastrointestinal symptoms (angioedema, oral pruritus, tongue swelling, nausea, vomiting, diarrhea), and cardiovascular symptoms (tachycardia, hypotension, dizziness, fainting), or potentially more severe reactions like anaphylaxis.

AD Associations: Food Allergy

• Around 30-40% of children with moderate to severe atopic dermatitis (AD) also have food allergies or food sensitivities.
• The increased prevalence in this group is statistically above the general population.
• It is important not to assume that AD causes food allergies but rather co-occurrence and possible associations between the conditions are likely.

AD Pathogenesis

• A complex interaction of genetic predisposition, immune dysregulation, and epidermal barrier dysfunction (environmental factors) commonly causes atopic dermatitis.
• Acute lesions are often associated with a Th2 immune response while lesions from chronic atopic dermatitis result in a Th1 or Th17 immune response.
• Mechanical trauma, like scratching, leads to chronic inflammation.

AD Diagnosis (Hanifin 2001)

• Pruritus (itching), typical and age-specific eruption pattern, chronic relapsing course, early age onset, IgE reactivity (atopy), and xerosis (dryness) are key diagnostic features.
• Associated conditions like keratosis pilaris, ichthyosis, follicular prominence, periorbital/ocular changes, and perioral/periauricular lesions may assist in diagnosis.
• It is important to rule out scabies, allergic contact dermatitis, seborrheic dermatitis, psoriasis, and ichthyosis.

AD in Infancy (0-6 months)

• Intense itching, erythema, papules, vesicles, oozing, crusting (especially on cheeks, forehead, and scalp), and extension to the trunk and extensors are common.
• It often spares the groin and diaper area.

AD in Childhood

• Chronicity/lichenification, dry skin papules and plaques, and involvement of the wrists, ankles, hands, feet, antecubital, and popliteal areas are common in this stage.
• Common facial involvement includes periorbital, perioral areas and intense itching.

AD in Adolescence/Adulthood

• Manifestations include involvement of flexural areas (head, neck, upper arms, back, dorsal hands, and feet), and dry scaling erythematous papules and plaques, and lichenification.

AD: Other Clinical Signs

• Common additional or associated findings include Dennie-Morgan folds, allergic shiners, linear nasal crease, allergic keratoconjunctivitis, posterior subcapsular cataracts (particularly in adults with severe atopic dermatitis), and keratoconus.

AD Variants: Pityriasis Alba

• Low-grade inflammation typically causing white spots on the face, but can extend to other parts of the body like the trunk or extremities.
• This condition is often misdiagnosed as vitiligo or other skin conditions requiring careful examination.
• Treatment most often involves moisture, sunscreen, and low-potency (or non-steroidal) topical steroids.

Recalcitrant AD: Further Evaluation

• Referral to a dermatologist is crucial if a patient's atopic dermatitis does not respond to standard treatments, including non-response to hydrocortisone.
• Investigating other potential underlying causes including infections and various skin conditions should be considered.
• Assessing for allergens, possibly through patch testing, and evaluating other possible etiologies is important.

Recalcitrant AD Treatment

• Systemic steriods are usually prescribed for severe flares, but they can lead to rebound exacerbations if used inappropriately.
• Dupilumab (Dupixent) or cyclosporine can offer an alternative approach.
• Other immunosuppressants like methotrexate (MTX), azathioprine, and mycophenolate mofetil (MMF), as well as phototherapy (NBUVB), and/or JAK1 inhibitors are also considered but are much less common treatments for refractory cases.

Other Types of Eczema/Dermatitis

• This section lists other common types of eczema/dermatitis for further learning. This information is not in-depth.

Atopic Dermatitis (AD) Management

• The overall recommended management approach is proactive and preventative rather than reactive and focused on symptom resolution alone.
• Prevention strategies are important for the maintenance and management of atopic dermatitis. Prevention involves managing dry skin and associated conditions.
• This includes good skin care through proper hygiene, moisture, avoiding allergens, and other preventative measures.
• Medication and treatment of infections or triggers like bacterial or viral infections should also be considered. This is a summary of the main approaches, and extensive information regarding management should be researched further from reputable sources.

Allergic Contact Dermatitis (ACD)

• Characteristic eczema-like reactions due to contact with specific allergens.
• Common triggers include nickel, fragrance, or neomycin/polymyxin B.
• Treatment largely involves avoidance of known triggers, patch testing to identify specific allergens, and topical steroids for managing the dermatitis.

"Rhus Dermatitis" and Phytophotodermatitis

• Reaction to poison oak, sumac, and ivy is a specific type of inflammatory contact dermatitis.
• It features distinctive patterns, often progressing to severe symptoms.
• Prevention and treatment involve washing affected areas, using high-potency topical steroids, antihistamines, and occasionally, oral steroids.

Irritant Contact Dermatitis

• Reactions to irritants, such as harsh chemicals, cleaning agents, or hand sanitizers, may trigger this type of eczema.
• Management typically involves avoiding the irritant, handwashing only as needed, and applying thick moisturizers after cleansing/handwashing.
• Use of hand creams or emollients mixed into creams/ointments may also be helpful.

Pompholyx (Dyshidrotic Eczema)

• This is a type of eczema presenting as skin-based papules and small vesicles primarily occurring on hands and feet.
• Pruritus is commonly observed.
• Treatment involves identifying and removing known triggers, ruling-out other similar conditions, and applying high-potency topical steroids.

Lichen Simplex Chronicus

• Chronic rubbing or scratching can lead to this condition with notable lichenification, hyperpigmentation, and significant pruritus (itching).
• Effective management includes proper skin care, addressing underlying causes (like scabies or fungal infections), using emollients, applying topical steroids, and often addressing associated behavioral factors related to the condition.

AD Treatment: Topical Medications

• Topical medications are generally well-tolerated and easily applied by patients with atopic dermatitis. Oral steroids should generally be reserved as adjuncts to the management of atopic dermatitis and not prescribed for long-term use.
• Use of ointments or creams in conjunction with emollients/moisturisers provides a good strategy for long-term efficacy.

AD Treatment: Controlling Itch

• Oral sedating antihistamines (such as hydroxyzine) are effective for controlling itching in many cases.
• 1-mg/kg of hydroxyzine dose nightly or 0.5 mg/kg given twice per day may be necessary.
• Non-sedating antihistamines however are not generally helpful.

AD Treatment: Bacterial Infections

• Bacterial infections are a common cause of exacerbations of eczema.
• MSSA is a common infection associated with atopic dermatitis.
• Treatment may involve antibiotics like cephalexin at 25-45 mg/kg per day, in divided dosages, and usually given two or three times per day.
• Treatment may be adjusted based on culture results.
• Antibiotic use may need to be adjusted based on the results of a culture.

AD Treatment: Viral Infections

• Common viral infections, such as the flu, cold, and molluscum contagiosum can cause exacerbations of eczema.
• It is important to monitor for, assess, and address these, along with bacterial infections related to atopic dermatitis at a primary level as this often warrants prescription if present.

AD Treatment: Staph Prevention

• Diluted bleach baths, up to ½ cup of bleach per full bath, applied a couple of times per week, is often suggested as a treatment method.
• Topical mupirocin may also be applied twice a day as adjunctive therapy.
• These are primarily preventative treatments if infections associated with bacterial or viral exposures are suspected or identified.

AD: Postinflammatory Changes

• These are common post-inflammatory changes after prolonged inflammation.
• These changes vary and may include darkening or lightening of the skin.
• They are typically transient and reversible but may last for several months or even longer.

Atopic Dermatitis in Various Populations/Stages

• Atopic dermatitis presents differently throughout various stages of life. A common presentation is that children tend to experience the condition differently, in terms of where it appears on their skin. This section outlines the differences in presentation during infancy, childhood, adolescence, and adulthood.
• Atopic Dermatitis can affect all populations and stages of life. The presentation, as well as severity and/or presentation locations of the eczema, may differ. Further research is recommended.

This quiz covers the evaluation and management of atopic dermatitis, commonly known as eczema. You'll learn about its types including acute, subacute, and chronic eczema, along with their characteristics and symptoms. Understanding the chronic nature and various conditions related to eczema is crucial for effective management.