Atopic Dermatitis

Question 1

What is the pathophys?

Answer 1

• Chronic inflammatory skin disease associated with cutaneous and mucous membranes hyper- reactivity toward environmental triggers that are innocuous to normal, non-atopic individuals
• 80 to 85% have high levels of total IgE which leads to a eczema-type reaction
• In infants, may be a prelude to the development of other atopic disorders later in life
• Genetic impairment of epidermal barrier proposed cause of atopic dermatitis

Question 2

What are the signs & sx’s?

Answer 2

▪ Pruritus main symptom
▪ No primary skin lesion
▪ Skin is typically dry and lesions are scaly – though they may be vesicular, weeping and oozing in the acute stage
▪ Pruritus may be focal or generalized. May be more intense in the evening and at night.

Question 3

What is the diagnosis criteria?

Answer 3

Pruritus must be present plus at least three of the
following:
✓Onset before 2 years old
✓History of Skin crease involvement
✓History of generally dry skin
✓Personal history of asthma or allergic rhinitis (or history
of any atopic disease in 1st degree relative in children
<4 years of age)
✓Visible flexural dermatitis ( or dermatitis of
cheeks/forehead and other outer limbs in children <4 years of age)

Question 4

What are the risk factors?

Answer 4

1. Genetics
2. Environmental exposures/allergens
3. Climate
4. Sweating
5. Physiologic and psychosocial stress
6. Dietary influences
7. Unbalanced skin microbiome
8. Irritants
9. Infections
   10.Itch-scratch cycle

Question 5

When to refer?

Answer 5

• If Dermatitis is acute and vesicular
• If moderate to severe defined as:
  – Large area of body (>30% of BSA)
  – Remains unresponsive
  – Skin appears to be infected
  – Interferes with activities of daily life or sleep patterns

Question 6

What are the goals of tx?

Answer 6

• Eradicate factors that trigger a flare or contact exposure to irritants and allergens
• Ensure symptomatic relief while lessening skin lesions
• Restore skin barrier function
• Implement preventive measures focusing on decreasing the number of episodic flares, lengthening symptom-free periods and prevention of excoriations
• Develop coping strategies and expectations for patients/caregivers

Question 7

What are the non-pharm tx’s?

Answer 7

• Try to shower once weekly (if possible). Bathe in warm water to rehydrate skin and use moisturizers/emollients right after
• Use mild soap or mild non-soap cleanser that are hypoallergenic and fragrance-free as soap may be irritating
• Pat skin to dry
• Trim nails short and smooth * keep clean*
• Avoid occlusive, tight clothing. Recommend cotton or cotton blend, corduroy (avoid nylon, wool).Wash new clothing.
• Limit exposure to sudden temperature changes, maintain moderate humidity
• Avoid triggers, allergens, and irritants
• Use wet compresses for acute weeping or
  oozing lesions
• KEEP SKIN HYDRATED

Question 8

What is the tx?

Answer 8

• Long term moisturizer therapy required
  – Demonstrated to decrease signs and symptoms of atopic dermatitis
  – Key role in maintenance, due to proven effects of increasing time to flare and decreasing number of flares
• When skin is dry, mild itch or irritation, with no patches of dermatitis : emollient, humectants or barrier repair treatment recommended twice daily and after bathing
• In an acute flare, topical corticosteroid plus moisturizers therapy applied to the affected area. The skin lesion should resolve within 2 weeks. If effective, reinforce emollient use for prevention. If not effective, refer to physician.
  – Note: Moisturizers plus topical corticosteroids are more effective than only topical corticosteroids

Question 9

What are other Topical Rx products?

Answer 9

Topical calcineurin inhibitors
– Generally second line therapy when topical corticosteroid therapy failed or was not tolerated
– Reduce inflammation, improve dermatitis and pruritus

– Most common adverse effect: burning or stinging
* Risk of infections due to immunosuppression, may suggest to avoid use on actively infected skin
* Insufficient evidence re: link to risk of malignancy

– Currently two options available:
* Tacrolimus (Protopic®)
* Pimecrolimus (Elidel®)

Question 10

What are the 4 R’s of Management of Atopic Dermatitis?

Answer 10

• Recognize
  – Diagnose condition and seek treatment early
• Remove
  – Triggers
• Restore
  – Moisturizers/Ointments
• Regulate
  – Treatment (OTC & RX)
  – Follow-up

Question 11

Non-prescription Treatments:

Answer 11

• Skin protectants
  – Calamine Lotion
  – Zinc oxide
  – Colloidal oatmeal
• Oral Antihistamines
  – Act by blocking H1 receptors therefore decreasing itch caused by histamine
• Moisturizers
  – Emollients with humectants added - most efficacious
  – Examples: Complex 15, Dermal Therapy, Lac-Hydrin
• Skin cleansers
  – Avoid soap in acute atopic or contact dermatitis
  – Cetaphil® cleanser, Spectro-Jel®, generics
• Astringents
  – Aluminum acetate
  – Can be used as a wet dressing, compress or soak
  – Drying, soothing and mildly antiseptic
  – No evidence of superiority. Saline or tap water
  preferred.