Atopic Dermatitis April 2015 Pediatric Continuity Clinic Curriculum Created by: Matthew Pertzborn, PGL-2.

Atopic DermatitisApril 2015

Pediatric Continuity Clinic Curriculum

Created by: Matthew Pertzborn, PGL-2

Objectives Describe the common clinical presentation

and diagnosis of atopic dermatitis Understand the management of atopic

dermatitis Discuss common co-morbidities and

complications of atopic dermatitis

Case #1A 12 month old female presents with a 6 month history of intermittent erythema, dryness, and cracking of the skin on the face and on the extensor surfaces of the arms. She has been scratching at the affected areas. Question 1-1: What is the differential

diagnosis of these symptoms? Question 1-2: What is the typical distribution

of atopic dermatitis? Question 1-3: What are common triggers of

atopic dermatitis?

Discussion question 1-1?

Differential includes: Contact dermatitis Psoriasis Impetigo Histiocytosis X (particularly if the distribution involves the

diaper area in children wearing diapers) Wiskott-Aldrich syndrome Scabies Seborrheic dermatitis Drug reaction Lymphoma with cutaneous involvement Immune system disorder (e.g. hyper-IgE syndrome) Zinc deficiency

Discussion question 1-2?

It is important to be aware of the typical distribution: Infants (most common onset is between 3 and 6 months of

age) Face Extensor sites Trunk

Older Children Flexor sites Antecubital fossa Popliteal fossa Neck Trunk

Typically spares the groin and axillary areas Stuffy-sounding nose is a common observation

Discussion question 1-3?

Common triggers/exacerbating factors in atopic dermatitis: Food/formula Mechanical Soaps Detergents Wool Weather (e.g. low levels of humidity) Diaphoresis Dust mites (Dermatophagoides pteronyssinus) Mold Pollen Pets Bacteria Stress

Additional Information

Image From: Pediatrics In Review (Reference #1)

Additional Information Often follows a relapsing course The term “atopic dermatitis” and “atopic

eczema” (often simply called “eczema”) are the same

Itching is very characteristic IgE often elevated

Case #2A 3 year old male presents with a 2 year history of intermittent erythema, dryness, and cracking of the skin on the face and on the extensor surfaces of the arms. The symptoms were previously controlled adequately with application of Vaseline after baths. He has been having multiple flares of these symptoms despite the Vaseline management and the mother is wondering what else can be done. Question 2-1: What is the first-line management

for eczema in general? 2-2: What is the best next treatment choice for the

patient above? 2-3: Is there a non-corticosteroid alternative for

severe disease?

Discussion question 2-1?

Initial Management of Eczema: Removal of potential triggers if possible Use mild, non-scented soap (e.g. Dove soap) only Minimize non-soap cleaners

Should be neutral to low pH, fragrance-free, hypoallergenic if used Removal of certain detergents for washing clothes. Avoid

dryer sheets (e.g. Bounce) and detergents with fragrances. Topical moisturizers/emollients (e.g. petrolatum jelly,

Aquaphor ointment) Ointments more effective than creams Lotions should be avoided Application after bath (immediately after drying) Application throughout the day

Exact frequency and amount not well delineated in the literature

Discussion question 2-2?

Management of acute flares if the initial management is not adequate: Some advocate burst of high-dose corticosteroids with

tapering in potency once controlled, others advocate starting with lowest-potency corticosteroids and then titrating upward

Potency ranges from lowest-potency (class VII (e.g. hydrocortisone 0.25-1%)) to high-potency corticosteroids (class I (e.g. diflorasone))

Caution should be used when applying higher-potency corticosteroids to the face, neck, or skin-folds as risk of significant systemic absorption is higher in these areas Avoid using higher-potency corticosteroids for more than 2 weeks

at a time Typically dosed 2x per day

Discussion question 2-2?

Management of acute flares if the initial managements are not adequate: Wet-wrap therapy can be useful as adjunct

Involves covering the area on which the topical moisturizer or topical corticosteroid is applied with a wet bandage and then placing a dry bandage on top of the wet bandage

Wrap may be kept on for up to 24 hours at a time and this adjunct has been used for as much as 2 weeks in the literature

Use of this adjunct with mid- to high-potency corticosteroids is controversial

Discussion question 2-3?

Topical calcineurin inhibitors May be used to avoid side/adverse effects of

corticosteroids, particularly if high-potency corticosteroids are required, skin atrophy secondary to corticosteroid use occurs, or topical corticosteroids are required long-term

Topical tacrolimus ointment (0.03-0.1%) or pimecrolimus cream (1%)

Typically dosed 2x per day

Additional Information Clinical pearl: Important to apply

emollient/ointment after every bath (pad down with towel, don’t wipe after the bath prior to application)

Case #3A 3 year old male presents with a 2 year history of intermittent erythema, dryness, and cracking of the skin on the face and on the extensor surfaces of the arms. Starting 5 days ago, there has been some crusting on the face with a small amount of yellow oozing What other medical conditions (non-

infectious) are associated with eczema? Are there increased risk of infectious co-

morbidities in eczema? Is there anything that can be done to prevent

secondary infection?

Discussion question 3-1?

Allergic rhinitis, asthma, and food allergies are associated with eczema.

Extra careful screening for the above conditions should occur

Discussion question 3-2?

Secondary skin infections possible: Staphylococcus aureus most common

Appropriate systemic antibiotic therapy if secondary infection occurs (depends on local resistance profiles) Clindamycin Bactrim

If secondary infections frequent: Mupirocin to the nares if Staphylococcus aureus colonization

suspected (BID x10 days) Bleach baths if signs of secondary infection present (may also do

this prophylactically if eczema is extensive) Can reduce colonization dramatically 1/4-1/2 cup household bleach (6% sodium hypochlorite) in half-filled bath Stay in bath 20 minutes then rinse with fresh water after Typically weekly Lukewarm temperature

Additional Information Clinical pearl: Remember to ask about family

history of allergic rhinitis (seasonal allergies), hay fever, asthma, and eczema. 70% of patients with eczema have atopic disease

in other members of the family

PREP QuestionPREP 2014 Item 141:

The mother of a 7-month-old infant is frustrated that the infant’s atopic dermatitis is not getting better. He is awake “all night” scratching and is irritable and fussy. She has been giving him diphenhydramine every 8 hours and applying hypoallergenic moisturizer and a topical corticosteroid cream twice a day. The infant was breastfed until 3 months ago and then switched to a cow milk-based formula. On physical examination, you notice that he has dry, erythematous papules and patches, with excoriation marks on his face, neck, antecubital fossae, popliteal fossae, and back. He has normal growth parameters.

Of the following, the MOST appropriate next step in this infant’s management is to recommend:

A. discontinuing diphenhydramine and switching him to daily loratadineB. eliminating cow milk, egg, soy, and wheat from his dietC. Introducing cow milk on a trial basis to see if the rash worsensD. switching to hypoallergenic formula and a diet of only rice and chickenE. testing for pertinent, potential food allergen triggers

PREP QuestionPREP 2014 Item 141:

The mother of a 7-month-old infant is frustrated that the infant’s atopic dermatitis is not getting better. He is awake “all night” scratching and is irritable and fussy. She has been giving him diphenhydramine every 8 hours and applying hypoallergenic moisturizer and a topical corticosteroid cream twice a day. The infant was breastfed until 3 months ago and then switched to a cow milk-based formula. On physical examination, you notice that he has dry, erythematous papules and patches, with excoriation marks on his face, neck, antecubital fossae, popliteal fossae, and back. He has normal growth parameters.

Of the following, the MOST appropriate next step in this infant’s management is to recommend:

A. discontinuing diphenhydramine and switching him to daily loratadineB. eliminating cow milk, egg, soy, and wheat from his dietC. Introducing cow milk on a trial basis to see if the rash worsensD. switching to hypoallergenic formula and a diet of only rice and

chickenE. testing for pertinent, potential food allergen triggers (see

PREP 2014 for explanation)

PREP Question PREP 2014 Item 106:

The parents of a 3 year old boy would like him to be tested for allergies. The parents report that the boy has had worsening symptoms of itchy eyes, sneezing fits, and nasal congestion since the family got a new dog 1 year ago. The parents would like the boy tested to determine if they need to give the dog away. They are reluctant to stop the boy’s daily antihistamine and are disappointed to learn that skin testing cannot be performed while taking this medication. You decide to obtain blood-specific IgE testing. However, the parents have read on the internet that the “scratch test” is a better test. Of the following, you are MOST likely to advise the parents that in this situation, blood-specific IgE testing is:

A. Comparable to skin testing B. Less expensive and better tolerated by children than skin testing C. More accurate than skin testing D. The only testing that can be done because he is too young for skin

testing E. A preliminary test and you will obtain skin testing to confirm the

results

PREP Question PREP 2014 Item 106:

The parents of a 3 year old boy would like him to be tested for allergies. The parents report that the boy has had worsening symptoms of itchy eyes, sneezing fits, and nasal congestion since the family got a new dog 1 year ago. The parents would like the boy tested to determine if they need to give the dog away. They are reluctant to stop the boy’s daily antihistamine and are disappointed to learn that skin testing cannot be performed while taking this medication. You decide to obtain blood-specific IgE testing. However, the parents have read on the internet that the “scratch test” is a better test. Of the following, you are MOST likely to advise the parents that in this situation, blood-specific IgE testing is:

A. Comparable to skin testing (see PREP 2014 for explanation)

B. Less expensive and better tolerated by children than skin testing C. More accurate than skin testing D. The only testing that can be done because he is too young for

skin testing E. A preliminary test and you will obtain skin testing to confirm the

results

References and Future Reading Eichenfield, Lawrence F., Wynnis L. Tom, Sarah L.

Chamlin, Steven R. Feldman, Jon M. Hanifin, Eric L. Simpson, Timothy G. Berger, James N. Bergman, David E. Cohen, Kevin D. Cooper, Kelly M. Cordoro, Dawn M. Davis, Alfons Krol, David J. Margolis, Amy S. Paller, Kathryn Schwarzenberger, Robert A. Silverman, Hywel C. Williams, Craig A. Elmets, Julie Block, Christopher G. Harrod, Wendy Smith Begolka, and Robert Sidbury. "Guidelines of Care for the Management Of atopic dermatitis." Journal of the American Academy of Dermatology 70.2 (2014): 338-51. Web.

Cipriani, Francesca, Arianna Dondi, and Giampaolo Ricci. "Recent Advances in Epidemiology and Prevention of Atopic Eczema." Pediatric Allergy and Immunology. 10 Dec. 2014. Web. 28 Dec. 2014.

References and Future Reading Knoell, K. A., and K. E. Greer. "Atopic

Dermatitis." Pediatrics in Review 20.2 (1999): 46-52. Web.

Krakowski, A. C., L. F. Eichenfield, and M. A. Dohil. "Management of Atopic Dermatitis in the Pediatric Population." Pediatrics 122.4 (2008): 812-24. Web.