Atopic Dermatitis (Eczema)

Diagnosis
H&P:
Personal or FHx of atopy (asthma, allergic rhinitis, atopic dermatitis)?
The 3 phases of eczema present differently.
Differential Diagnosis.
Diagnostic criteria.
Is the severity mild, moderate, severe?
Are there secondary infections like impetigo, staph infection,  HSV?
Main features are dry skin, severe pruritus, and hyperreactivity of the skin to various environmental stimuli.
Treatment
1) Emollients (Moisturizers).
–Use moisturizers with high oil content and low water content. E.g. Creams (Cetaphil, Eucerin) and petrolatum-based ointments (hydrolatum/petroleum jelly, Aquaphor). I often Rx ceramide-containing moisturizers like Cerave Cream and Restoraderm b/c they also add ceramide lipids to the skin in addition to hydrating it.
-Moisturize every part of the body liberally, even parts that are asymptomatic.
-Moisturize at least two times per day and immediately after bathing or washing hands.
–Soak & seal.
-Proper hydration is key because 1) It decreases the need for topical steroid by about 50% and 2) Controlling the xerosis controls dermatitis.
Non-pharmacologic treatment of pruritus and dry skin.
2) Topical corticosteroids.
-1st-line for flare-ups. Also, 1st-line for moderate to severe atopic dermatitis. Counsel about effective use and side effects.
-Triamcinolone 0.1% ointment for body. Desonide or hydrocortisone ointment/cream for face and sensitive areas.
3) Treat itching (Antipruritics).
-Tx especially if it’s disrupting sleep or if there is a significant allergy component / allergic rhinitis. Antihistamines (nonsedating during the day).
4) Treat skin infections staph colonization.
-For severe cases, twice weekly dilute bleach baths plus intranasal mupirocin ointment 5 consecutive d/ mo. Avoid routine use of oral antibiotics.
5) Eliminate exacerbating factors to prevent flares.
– Probiotics. They have been shown to prevent eczema.
6) Refer when indicated.

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Key Points & Links

• Ointments are more hydrating.
• Tacrolimus and Pimecrolimus are macrolide immune suppressants whose creams and ointments are used to treat eczema.
• Atopy: 30% of pts w/ atopic dermatitis(AD) also have asthma; 35% of AD patients also have Allergic rhinitis.
• “Atopy refers to the genetic tendency to develop allergic diseases such as allergic rhinitis, asthma and atopic dermatitis (eczema). Atopy is typically associated with heightened immune responses to common allergens, especially inhaled allergens and food allergens” (AAAAI, n.d.).
• “Lotions, which have a high water and low oil content, can worsen xerosis via evaporation and trigger a flare of the disease. In contrast, thick creams, which have a low water content, or ointments (eg, petroleum jelly), which have zero water content, better protect against xerosis, but some patients may complain that they are greasy.” Uptodate.com
• Assessment & Plan.
• Eczema in infants: A case close to home.
• Choosing a topical steroid.
• Soaks / Bath Additives for Children with  Eczema.
• “Secondary impetiginization, with honey-colored crust, is common in infants.”

References / Reading

Am Fam Physician. 2012 Jul 1;86(1):35-42. Atopic Dermatitis: An Overview. http://www.aafp.org/afp/2012/0701/p35.html

https://www.uptodate.com/contents/treatment-of-atopic-dermatitis-eczema

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/dermatology/atopic-dermatitis/

https://www.aaaai.org/conditions-and-treatments/conditions-dictionary/Atopy