para>Chronic potent fluorinated corticosteroid use may cause striae, hypopigmentation, or atrophy, especially in children.
MEDICATION
First Line
- Frequent systemic lubrication with thick emollient creams (e.g., Eucerin, Vaseline) over moist skin is the mainstay of treatment before any other intervention is considered (1)[A].
- Infants and children: 0.5-1% topical hydrocortisone creams or ointments (use the "fingertip unit [FTU]" dosing) (1)[C]
- Adults: higher potency topical corticosteroids in areas other than face and skin folds
- Short-course, higher potency corticosteroids for flares; then return to the lowest potency (creams preferred) that will control dermatitis.
- Antihistamines for pruritus (e.g., hydroxyzine 10 to 25 mg at bedtime and as needed)
Second Line
- Topical immunomodulators (tacrolimus or pimecrolimus) for episodic use for children >2 years. There is a black box warning from the FDA regarding potential cancer risk.
- Plastic occlusion in combination with topical medication to promote absorption
- For severe AD, consider systemic steroids for 1 to 2 weeks (e.g., prednisone 2 mg/kg/day PO [max 80 mg/day] initially, tapered over 7 to 14 days).
- Topical tricyclic doxepin, as a 5% cream, may decrease pruritus.
- Modified Goeckerman regimen (tar and ultraviolet light)
- Low-dose methotrexate was established as effective treatment in adults, and recent review suggests it is safe for children and adolescents (3)[B].
ISSUES FOR REFERRAL
- Ophthalmology evaluation for persistent vernal conjunctivitis
- If using topical steroids around eyes for extended periods, ophthalmology follow-up for cataract evaluation
ADDITIONAL THERAPIES
- Methods to reduce house mite allergens (micropore filters on heating, ventilation, and air-conditioning systems; impermeable mattress covers)
- Behavioral relaxation therapy to reduce scratching
- Bleach baths may reduce staph colonization, but definitive evidence for benefit in the condition is lacking. Recommend 1/2 cup of standard 6% household bleach for a full tub of water and soak for 5 to 10 minutes, blotting skin dry upon leaving the bath.
COMPLEMENTARY & ALTERNATIVE MEDICINE
- Evening primrose oil (includes high content of fatty acids)
- May decrease prostaglandin synthesis
- May promote conversion of linoleic acid to omega-6 fatty acid
- Probiotics may reduce the severity of the condition, thus reducing medication use.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Evaluate to ensure that secondary bacterial or fungal infection does not develop as a result of disruption of the skin barrier. Most patients with AD are colonized by Staphylococcus. There is a little evidence for the routine use of antimicrobial interventions to reduce skin bacteria, but treatment of clinical infection with coverage for Staphylococcus is recommended.
DIET
- Trials of elimination may find certain "triggers" in some patients.
- Breastfeeding in conjunction with maternal hypoallergenic diets may decrease the severity in some infants.
PATIENT EDUCATION
- http://www.aad.org/skin-conditions/dermatology-a-to-z/atopic-dermatitis
- National Eczema Association: www.nationaleczema.org
PROGNOSIS
- Chronic disease
- Declines with increasing age
- 90% of patients have spontaneous resolution by puberty.
- Localized eczema (e.g., chronic hand or foot dermatitis, eyelid dermatitis, or lichen simplex chronicus) may continue in some adults.
COMPLICATIONS
- Cataracts are more common in patients with AD.
- Skin infections (usually Staphylococcus aureus); sometimes subclinical
- Eczema herpeticum
- Generalized vesiculopustular eruption caused by infection with herpes simplex or vaccinia virus
- Causes acute illness requiring hospitalization
- Atrophy and/or striae if fluorinated corticosteroids are used on face or skin folds
- Systemic absorption may occur if large areas of skin are treated, particularly if high-potency medications and occlusion are combined.
REFERENCES
11 Thomsen SF. Atopic dermatitis: natural history, diagnosis, and treatment. ISRN Allergy. 2014;2014:354250.22 Wollenberg A, Seba A, Antal AS. Immunological and molecular targets of atopic dermatitis treatment. Br J Dermatol. 2014;170(Suppl 1):7-11.33 Deo M, Yung A, Hill S, et al. Methotrexate for treatment of atopic dermatitis in children and adolescents. Int J Dermatol. 2014;53(8):1037-1041.
ADDITIONAL READING
- Boguniewicz M, Leung DY. Recent insights into atopic dermatitis and implications for management of infectious complications. J Allergy Clin Immunol. 2010;125(1):4-13.
- Catherine Mack Correa M, Nebus J. Management of patients with atopic dermatitis: the role of emollient therapy. Dermatol Res Pract. 2012;2012:836931.
- Lifschitz C. The impact of atopic dermatitis on quality of life. Ann Nutr Metab. 2015;66(Suppl 1):34-40.
SEE ALSO
Algorithm: Rash, Focal
CODES
ICD10
- L20.9 Atopic dermatitis, unspecified
- L20.89 Other atopic dermatitis
- L20.83 Infantile (acute) (chronic) eczema
- L20.84 Intrinsic (allergic) eczema
- L20.82 Flexural eczema
ICD9
691.8 Other atopic dermatitis and related conditions
SNOMED
- 24079001 Atopic dermatitis (disorder)
- 402196005 Childhood atopic dermatitis
- 402195009 Infantile atopic dermatitis
CLINICAL PEARLS
- Institute early and proactive treatment to reduce inflammation. Use the lowest potency topical steroid that controls symptoms.
- Monitor for secondary bacterial infection.
- Frequent systemic lubrication with thick emollient creams (e.g., Eucerin, Vaseline) over moist skin is the mainstay of treatment before any other intervention is considered.