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Eczema/Atopic Dermatitis, Emergency Medicine

Basics

Description

- 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

- 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

- Epidermal compromise: - Dry skin - Weeping - Oozing - Finally crusting

- 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

- Behavioral interventions: - Avoid excessive bathing - Use of tepid water and mild soaps - Frequent use of emollients (Eucerin cream, Aquaphor ointment)

- 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

  • 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 characteristicPatient rub and scratch skin breakdown with oozing and crustingChronically 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 distributionAtopic history (asthma or allergic rhinitis)History of dry skinOnset age <2 yrObjective signs of flexural dermatitis
  • Additional findings:Cutaneous infectionsItch when sweatingIntolerance to wool and lipid solventsTriggered by stress

Physical Exam

Dermatitis, located on areas of trauma or motion such as hands and feet and flexural areas

  • Epidermal compromise:Dry skinWeepingOozingFinally crusting
  • Inflammation:Maculopapular erythemaEdema
  • Scratching leads to:ExcoriationCrackingLichenificationHyperkeratosis
  • Additional findings:Icthyosis, palmar hyperlinearity, keratosis pilarisHand or foot dermatitisNipple eczemaCheilitisDennie-Morgan infraorbital foldOrbital darkeningFacial pallor or facial erythemaPityriasis albaPerifollicular accentuationWhite 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 bathingUse of tepid water and mild soapsFrequent use of emollients (Eucerin cream, Aquaphor ointment)
  • Bacterial superinfection: Cephalexin, cefazolin:

Medication

  • Aquaphor ointment: Apply to affected areas BID
  • 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
  • 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
  • Pimecrolimus 1% cream: Apply to affected areas BID (peds: >2 yr of age) for the duration of the flare

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 skinTacrolimus 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 dryingHeavy 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)

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)