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Eczema/Atopic Dermatitis, Emergency Medicine


Basics


Description


  • Atopic dermatitis is the most common cause of eczema and the terms are often used synonymously.
    • Associated with allergic diseases such as asthma and allergic rhinitis
  • Eczema literally means "out boil" and refers to spongiosis, the process where microvesicles form and rupture, leaving erythema, edema, crusting, and oozing
  • Pruritus is highly characteristic
    • Patient rub and scratch skin breakdown with oozing and crusting
    • Chronically this causes epidermal hyperplasia and hyperkeratosis
  • 90% of patients colonize with Staphylococcus aureus, and are prone to episodes of superinfection

Risk Factors


Genetics
  • Family history of atopy (asthma, allergic rhinitis) typical
  • Mutation of the filaggrin protein, part of the epidermal barrier, is strongly associated

Etiology


Atopic dermatitis is caused by a deficit in epidermal integrity that allows foreign substances to enter and trigger immune responses.  

Diagnosis


Signs and Symptoms


History
  • Rash, pruritus, and atopy traditionally prompt the diagnosis
  • UK diagnostic criteria = pruritus and 3 of the following:
    • Flexural distribution
    • Atopic history (asthma or allergic rhinitis)
    • History of dry skin
    • Onset age <2 yr
    • Objective signs of flexural dermatitis
  • Additional findings:
    • Cutaneous infections
    • Itch when sweating
    • Intolerance to wool and lipid solvents
    • Triggered by stress

Physical Exam
Dermatitis, located on areas of trauma or motion such as hands and feet and flexural areas  
  • Epidermal compromise:
    • Dry skin
    • Weeping
    • Oozing
    • Finally crusting
  • Inflammation:
    • Maculopapular erythema
    • Edema
  • Scratching leads to:
    • Excoriation
    • Cracking
    • Lichenification
    • Hyperkeratosis
  • Additional findings:
    • Icthyosis, palmar hyperlinearity, keratosis pilaris
    • Hand or foot dermatitis
    • Nipple eczema
    • Cheilitis
    • Dennie-Morgan infraorbital fold
    • Orbital darkening
    • Facial pallor or facial erythema
    • Pityriasis alba
    • Perifollicular accentuation
    • White dermographism or delayed blanch

  • 70% of all cases begin during the 1st 5 yr of life
  • Only 10% of cases start in adulthood
  • 30% of children with atopic dermatitis develop asthma, 35% develop allergic rhinitis
  • Infant distribution is classically extensor surfaces and head and face

Essential Workup


History and physical exam  

Diagnosis Tests & Interpretation


Lab
  • Clinical diagnosis
  • IgE commonly elevated but does not usually need to be tested

Diagnostic Procedures/Surgery
Generally reserved for settings outside of the ED:  
  • Radioallergosorbent test (RAST) sometimes used to identify allergic triggers
  • Patch testing used if contact dermatitis is suspected

Differential Diagnosis


  • Seborrheic dermatitis
  • Neurodermatitis (lichen simplex chronicus)
  • Allergic contact dermatitis
  • Irritant dermatitis
  • Psoriasis
  • Dyshidrosis
  • Ichthyosis
  • Scabies

Treatment


Ed Treatment/Procedures


  • Mild disease or disease of the head and neck:
    • Low-potency corticosteroids such as hydrocortisone 1-2.5%
    • Eucerin cream: Apply to affected areas BID
  • Moderate or severe disease of the trunk and extremities:
    • Higher-potency corticosteroids such as triamcinolone 0.1% (moderate potency) or fluocinonide 0.05% ointment (high potency)
  • Severe disease of the head and neck:
    • Topical calcineurin inhibitors such as pimecrolimus and tacrolimus
  • 1st-generation antihistamines:
    • Diphenhydramine, hydroxyzine are used for relief of itching but are only weakly effective
  • Behavioral interventions:
    • Avoid excessive bathing
    • Use of tepid water and mild soaps
    • Frequent use of emollients (Eucerin cream, Aquaphor ointment)
  • Bacterial superinfection: Cephalexin, cefazolin:
    • Consider MRSA

Medication


  • Aquaphor ointment: Apply to affected areas BID
    • Contains lanolin alcohol
  • Cephalexin: 500 mg (peds: 25-100 mg/kg/24h) PO q6h
  • Diphenhydramine: 25-50 mg (peds: 5 mg/kg/24h) PO or IV q6h
  • Eucerin cream: Apply to affected areas BID
    • Contains lanolin alcohol
  • Fluocinonide 0.05% ointment: Apply to affected areas of body BID for the duration of the flare (high potency)
  • Hydrocortisone 2.5% ointment: Apply to affected areas of body/face BID for the duration of the flare (low potency)
  • Hydroxyzine: 25-100 mg (peds: 2 mg/kg/24h) PO q4-6h
  • Pimecrolimus 1% cream: Apply to affected areas BID (peds: >2 yr of age) for the duration of the flare
  • Tacrolimus ointment: 0.1% (peds: >2 yr of age: 0.03%) apply to affected areas BID for the duration of the flare
  • Triamcinolone 0.1% ointment: Apply to affected areas of body BID for the duration of the flare (mid potency)

First Line
  • Hydrocortisone 2.5% ointment: Apply to affected areas of body/face BID for the duration of the flare (low potency)
  • Aquaphor ointment: Apply to affected areas BID

Second Line
  • Triamcinolone 0.1% ointment: Apply to affected areas of body BID for the duration of the flare (mid potency)
    • Avoid the face and eyelids
  • Fluocinonide 0.05% ointment: Apply to affected areas of body BID for the duration of the flare (high potency)
    • Avoid the face and eyelids
  • Tacrolimus ointment: 0.1% (peds: >2 yr of age: 0.03%) apply to affected areas BID for the duration of the flare
    • Can be used on the face
  • Pimecrolimus 1% cream: Apply to affected areas BID (peds: >2 yr of age) for the duration of the flare
    • Can be used on the face

Follow-Up


Disposition


Issues for Referral
Dermatology referral for problematic cases  

Follow-Up Recommendations


  • Patients should be warned of adverse consequences of treatment:
    • High-potency steroids can cause thinning of the skin
    • Tacrolimus and pimecrolimus cause a stinging sensation for the 1st wk of therapy. Long term use can increase risk of cancer

Pearls and Pitfalls


  • Consider secondary cellulitis, as 90% of patients with atopic dermatitis are eventually colonized with S. aureus
  • Use tacrolimus and pimecrolimus for moderate to severe disease of the head and neck
  • Consider in any patient with a severely pruritic rash
  • Lotions have low lipid content and can cause drying
    • Heavy creams are preferred
  • Do not use triamcinolone or fluocinonide on face or eyelids

Additional Reading


  • Beltrani  VS. Suggestions regarding a more appropriate understanding of atopic dermatitis. Curr Opin Allergy Clin Immunol.  2005;5:413-418.
  • Bieber  T. Atopic dermatitis. N Engl J Med.  2008;358:1483-1494.
  • Wasserbauer  N, Ballow  M. Atopic dermatitis. Am J Med.  2009;122:121-125.
  • Williams  HC. Clinical practice: Atopic dermatitis. N Engl J Med.  2005;352:2314-2324.
  • Zheng  T, Yu  J, Oh  MH, et al. The atopic march: Progression from atopic dermatitis to allergic rhinitis and asthma. Allergy Asthma Immunol Res.  2011;3:67-73.

See Also (Topic, Algorithm, Electronic Media Element)


  • Cellulitis
  • CA-MRSA

Codes


ICD9


  • 691.8 Other atopic dermatitis and related conditions
  • 692.9 Contact dermatitis and other eczema, unspecified cause

ICD10


  • L20.9 Atopic dermatitis, unspecified
  • L20.82 Flexural eczema
  • L30.9 Dermatitis, unspecified
  • L20.89 Other atopic dermatitis

SNOMED


  • 43116000 Eczema (disorder)
  • 24079001 Atopic dermatitis (disorder)
  • 57092006 Flexural eczema (disorder)
  • 238541000 Atopic dermatitis of hands (disorder)
  • 200775004 Atopic neurodermatitis (disorder)
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