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Dermatitis, Atopic

- 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

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 synthesisMay 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 herpeticumGeneralized vesiculopustular eruption caused by infection with herpes simplex or vaccinia virusCauses 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.