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Childhood Atopic DermatitisBasic Dermatology CurriculumLast updated October 14, 201311Module InstructionsThe following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology.We encourage the learner to read all the hyperlinked information.

22Goals and ObjectivesThe purpose of this module is to help develop a clinical approach to the evaluation and initial management of patients presenting with atopic dermatitis.After completing this module, the learner will be able to:Identify and describe the morphology of atopic dermatitisRecognize that superficial infections often complicate atopic dermatitis.Recommend an initial treatment plan for a child with atopic dermatitisProvide patient/parent education about daily skin care for a child with atopic dermatitisDetermine when to refer to a patient with atopic dermatitis to a dermatologist

33Case OneCarolyn44Case One: HistoryHPI: Carolyn is a 10 month-old girl who was brought to the pediatric clinic by her mother for an itchy red rash for the last 7 months. The rash waxes and wanes, involving Carolyns face. Her mother reports Carolyn is bathed daily using a normal soap. Sometimes they use moisturizing lotion if her skin appears dry. They recently introduced peas into her diet and wonder whether this may be contributing to the rash.PMH: Normal birth history. She is healthy aside from an episode of wheezing at 5 months of age. No hospitalizations or surgeries. Medications: noneAllergies: noneFamily history: Mother has asthma and allergic rhinitisSocial history: Lives in a house with her parents, no pets or recent travelROS: itches all night

55Case One: Skin Exam

How would you describe her skin exam?66Case One: Skin ExamErythematous ill-defined patches with overlying scale and erosions on her cheeks

77Case One, Question 1What elements in the history are important to ask in this case?Does she scratch or rub her skin?Does the rash keep her awake at night? Which moisturizers are used and where?All of the above

8Case One, Question 1Answer: dWhat elements in the history are important to ask in this case?Does she scratch or rub her skin? (Provides information about associated pruritus, which will impact treatment)Does the rash keep her awake at night? (Provides information about severity, which will impact treatment)Which moisturizers are used and where? (May provide information about the distribution. Also, lack of using a moisturizer may be exacerbating the problem)All of the above

99Case One, Question 2What is the most likely diagnosis given the history and skin exam findings?Atopic dermatitisContact dermatitisPsoriasisScabiesSeborrheic dermatitis1010Case One, Question 2Answer: aWhat is the most likely diagnosis given the history and skin exam findings?Atopic dermatitisContact dermatitis (would expect history of contact with allergen and erythema with superimposed vesicles or bullae)Psoriasis (presents as erythematous plaques with an adherent silvery scale)Scabies (intensely pruritic papules, often with excoriation, burrows may be present)Seborrheic dermatitis (would expect erythematous patches and plaques with greasy, yellowish scale)1111Case One, Question 3Which of the following statements supports the diagnosis of atopic dermatitis:Chronic nature of the rash Distribution of the rash Family history of atopic disease Symptom of pruritus All of the above

1212Case One, Question 3Answer: eWhich of the following statements supports the diagnosis of atopic dermatitis:Chronic nature of the rash (present x 7 months)Distribution of the rash (predominantly on the cheeks)Family history of atopic disease Symptom of pruritus (itching)All of the above

1313Atopic Dermatitis: The BasicsAtopic dermatitis (AD) is a chronic, pruritic, inflammatory skin disease with a wide range of severityAD is one of the most common skin disorders in developed countries, affecting up to 20% of children & 1-3 % of adultsIn most patients, AD develops before the age of 5 and typically clears by adolescencePrimary symptom is pruritus (itch)AD is often called the itch that rashesScratching to relieve AD-associated itch gives rise to the itch-scratch cycle and can exacerbate the diseasePatients experience periods of remission and exacerbation

1414AD: Clinical FindingsLesions typically begin as erythematous papules, which then coalesce to form erythematous plaques that may display weeping, crusting, or scaleDistribution of involvement varies by age:Infants and toddlers: eczematous plaques appear on the cheeks forehead, scalp and extensor surfacesOlder children and adolescents: lichenified, eczematous plaques in flexural areas of the neck, elbows, wrists, and anklesAdults: lichenification in flexural regions and involvement of the hands, wrists, ankles, feet, and face (particularly the forehead and around the eyes)Xerosis is a common characteristic of all stages1515Case One, Question 4What percentage of children with atopic dermatitis also have or will develop asthma or allergic rhinitis?0-15%15-30%30-50%50-80%80-100%16Case One, Question 4Answer: dWhat percentage of children with atopic dermatitis also have or will develop asthma or allergic rhinitis? 50-80% of children will have another atopic diseaseAsthmaAtopic dermatitisAllergic rhinitisThe Atopic Triad1717Typical AD for Infants and Toddlers

Affects the cheeks, forehead, scalp, and extensor surfaces

Erythematous, ill-defined plaques on the cheeks with overlying scale and crustingErythematous, ill-defined plaques on the lateral lower leg with overlying scale181819More Examples of Atopic DermatitisNote the distribution of face and extensor surfaces

Typical AD for Older Children

Affects flexural areas of neck, elbows, knees, wrists, and anklesLichenified, erythematous plaques behind the kneesErythematous, excoriated papules with overlying crust in the antecubital fossa

2020Atopic Dermatitis EczemaEczema is a nonspecific term that refers to a group of inflammatory skin conditions characterized by pruritus, erythema, and scale. Atopic dermatitis is a specific type of eczematous dermatitis. 2121Atopic Dermatitis: PathogenesisThe cause of AD is multifactorial and not completely understood The following factors are thought to play varying roles:GeneticsSkin Barrier DysfunctionImpaired Immune ResponseEnvironment

2222Back to Case OneCarolyn23Case One, Question 5Which of the following recommendations would you provide to Carolyns parents?Daily or twice daily application of moisturizing ointment or creamHydrocortisone 2.5% ointment to the face twice daily for up to 2 weeks or until betterHydroxyzine 1 tsp. (1mg/kg) PO at bedtimeMild cleanserAll of the above

2424Case One, Question 5Answer: eWhich of the following recommendations would you provide to Carolyns parents?Daily or twice daily application of moisturizing ointment or creamHydrocortisone 2.5% ointment to the face twice dailyHydroxyzine 1 tsp. (1mg/kg) PO at bedtimeMild cleanser, as little as needed to remove dirtAll of the aboveCarolyn is having an exacerbation of her AD and needs both gentle skin care and treatment of the inflammation in her skin2525Atopic Dermatitis: TreatmentCombination of short-term treatment to manage flares and longer-term strategies to help control symptoms between flaresRecommend gentle skin careTepid baths without washcloths or brushesMild synthetic detergents (cleansers) instead of soapsPat dryEmollients: petrolatum and moisturizers Use ointments or thick creams (no watery lotions)Apply once to twice daily to whole body (and immediately after bathing for optimal hydration, so-called soak and seal) Identification and avoidance of triggers and irritants (such as wool and acrylic fabrics)2626

Atopic Dermatitis: Treatment274 Major ComponentsAnti-inflammatoryAntibacterialAnti-pruriticMoisturizer27AD Treatment: MoisturizersWide range of moisturization options, from cheap to outrageously expensiveGreasier ointments are better in general as they:Tend to have less preservatives than creamsTend to act as occlusive agents supplementing barrier function immediatelyTend not to sting or burn when appliedHowever, greasier preparations can be unpleasant for some patients, and adherence may sufferIn such cases, heavier creams are superior to lotions2828AD Treatment: Anti-inflammatoryTreat acute inflammation with topical corticosteroidsOintments are preferred vehicles over creams (as with moisturizers)Low potency is usually effective for the faceBody and extremities often require medium potencyUsing stronger steroid for short periods and milder steroid for maintenance helps reduce risk of steroid atrophy and other side effectsPotential local side effects associated with topical corticosteroid therapy use include striae, telangiectasias, atrophy, and acne2929AD Treatment: Anti-inflammatoryTopical calcineurin inhibitors: 2nd-line therapy Use when the continued use of topical steroids is ineffective or inadvisableNot great during a severe flare: can sting/burn and are probably comparable to only a mid-potency corticosteroid in terms of clinical effectHave been studied and shown to be effective at preventing flares when used twice weekly to trouble spots once the disease is controlled (proactive treatment)3030AD Treatment: Anti-pruritusLimited options for itchAntihistaminesMay help break the itch/scratch cycle1st generation H1 antihistamines (e.g. hydroxyzine) are helpful probably due to sedation effects as much as itchTopical anti-pruritics (e.g., camphor/menthol or pramoxine)Minimally effective, short-term relief only; can be allergic sensitizers as well

3131AD Treatment: AntibacterialTreat co-existing skin infection with systemic antibioticsStaphylococcus is most common infection by far; methicillin resistance is rising and must be considered

Dilute bleach baths (sodium hypochlorite) have been shown to help decrease skin bacteria and AD severity, although the data is still somewhat limitedAnecdotally, this has been a powerful treatment that seems to decrease infection risk as well3232AD Treatment: AntibacterialTopical antibacerial agents such as mupirocin can also be used to treat localized infections such as impetiginized areas3333When to ReferPatients should be referred to a dermatologist when:Patients have recurrent skin infectionsPatients have extensive and/or severe diseaseSymptoms are poorly controlled with topical steroids3434Case One, Question 5What is the most likely corticosteroid you would choose for Carolyns facial lesions?

Clobetasol ointmentFluocinonide ointmentHydrocortisone creamHydrocortisone ointmentTriamcinolone ointment35Case One, Question 5Answer: dWhat is the most likely corticosteroid you would choose for Carolyns facial lesions?

Clobetasol ointmentFluocinonide ointmentHydrocortisone creamHydrocortisone ointmentTriamcinolone ointment36Topical Steroid StrengthPotency ClassExample AgentSuper highIClobetasol propionate 0.05%HighII Fluocinonide 0.05%MediumIII V Triamcinolone acetonide ointment 0.1%Triamcinolone acetonide cream 0.1%Triamcinolone acetonide lotion 0.1%LowVI VIIFluocinolone acetonide 0.01%Desonide 0.05%Hydrocortisone 1%3737Topical Steroid StrengthRemember to look at the class not the percentageNote that clobetasol 0.05% is stronger than hydrocortisone 1% When several are listed, they are listed in order of strengthNote that triamcinolone ointment is stronger than triamcinolone cream or lotion because of the nature of the vehicle

38Potency ClassExample AgentSuper highIClobetasol 0.05%HighII Fluocinonide 0.05%MediumIII V Triamcinolone ointment 0.1%Triamcinolone cream 0.1%Triamcinolone lotion 0.1%LowVI VIIFluocinolone 0.01%Desonide 0.05%Hydrocortisone 1%38Case One, Question 6Carolyn has developed AD on her wrists and ankles and has been using hydrocortisone 2.5% cream twice daily for 2 months with minimal improvement. Whats the next best step?Increase potency to Triamcinolone 0.1% ointment bid for one weekDecrease potency to Hydrocortisone 1% cream bid for 1 monthContinue with the Hydrocortisone 2.5% cream for another few months to see if she will improveDecrease potency to Hydrocortisone 1% ointment qd for 1 month3939Case One, Question 6Answer: aCarolyn has developed AD on her wrists and ankles and has been using hydrocortisone 2.5% cream twice daily for 2 months with minimal improvement. Whats the next best step?Increase potency to Triamcinolone 0.1% ointment bid for one weekDecrease potency to Hydrocortisone 1% cream bid for 1 monthContinue with the Hydrocortisone 2.5% cream for another few months to see if she will improveDecrease potency to Hydrocortisone 1% ointment qd for 1 month4040Topical Steroid Dosing in ChildrenTopical corticosteroids are safe when used for short intervals with intermittent rest periodsCan cause side effects when used for extended durations, even if low potencyIf symptoms not improving despite prolonged use of low potency steroid, it is frequently necessary to increase potency to treat the inflammation, then stop all corticosteroids to give the skin a rest periodHigh potency steroids must be used with caution and vigilant clinical monitoring for side effects in childrenPotent steroids should be avoided in high risk areas such as the face, folds, or occluded areas such as under the diaper

4141Parent education and written instruction are key to successAction Plans provide parents and caregivers with easy to follow treatment recommendations and guidance

4242Case One, Question 7Carolyns parents would also like more information regarding the association between food allergies and atopic dermatitis. What can you tell them?A positive allergen test proves that the allergy is clinically relevantElimination of food allergens in patients with AD and confirmed food allergy will not lead to clinical improvementFood allergy is a more likely trigger if the onset or worsening of the AD correlates with exposure to the foodThere is no correlation between AD and food allergies4343Case One, Question 7Answer: cCarolyns parents would also like more information regarding the association between food allergies and atopic dermatitis. What can you tell them?A positive allergen test proves that the allergy is clinically relevant (not true)Elimination of food allergens in patients with AD and confirmed food allergy will not lead to clinical improvement (not true. If the food allergy is clinically relevant, then the elimination of the food allergen will lead to improvement)Food allergy is a more likely trigger if the onset or worsening of the AD correlates with exposure to the foodThere is no correlation between AD and food allergies (not true)4444Allergens and Atopic DermatitisThe role of allergy in AD remains controversialMany patients with AD have sensitization to food and environmental allergensHowever, evidence of allergen sensitization is not proof of a clinically relevant allergyFood allergy as a cause of, or exacerbating factor for, AD is uncommon Identification of true food allergies should be reserved for refractory AD in children in whom the suspicion for a food allergy is highInfants with AD and food allergy may have additional findings that suggest the presence of food allergy, such as vomiting, diarrhea, and failure to thriveElimination of food allergens in patients with AD and confirmed food allergy can lead to clinical improvement4545Case TwoJoanna46Case Two: HistoryHPI: Joanna is a 10-year-old girl with a history of atopic dermatitis, normally well-controlled with emollients and occasional topical steroids who was brought in by her mother with an itchy red rash on the back of her thighs. PMH: atopic dermatitisMedications: hydrocortisone 2.5% ointmentAllergies: noneFamily history: little sister with atopic dermatitisSocial history: Lives in a house with parents and sister. Attends 4th grade, favorite subject in school is spelling.ROS: no fevers4747Case Two: Skin Exam

Multiple erythematous papules and plaques with erosions4848Case Two, Question 1What is your next step in the evaluation of Joannas skin condition?Apply a potent topical corticosteroidObtain a skin bacterial cultureSkin biopsyStart topical antibioticsNone of the above

49Case Two, Question 1Answer: bWhat is your next step in the evaluation of Joannas skin condition?Apply a potent topical corticosteroid (will not help with evaluation)Obtain a skin bacterial cultureSkin biopsy (not necessary for diagnosis)Start topical antibiotics (a large majority of patients with AD are colonized with S. aureus, treating locally with topical antibiotics may not be effective)None of the above

5050Case Two: EvaluationSkin bacterial culture should be considered during acute, weepy flares of AD and when pustules, erosions, or extensive yellow crust are presentPatients with AD are susceptible to a variety of secondary infections such as Staphylococcus aureus and Group A Streptococcal infectionsThese infections are a common cause of AD exacerbationsSystemic antibiotics should be used to treat these infections5151Another Example of Infected AD52

52SDC: provide explanationCase ThreeMark53Case Three: HistoryHPI: Mark is a 9-year-old boy who was brought in by his father who is concerned about the white spots on Marks facePMH: mild asthma, no history of hospitalizationsMedications: albuterol when neededAllergies: noneFamily history: mother had a history of childhood atopic dermatitisSocial history: lives at home with his mother and fatherROS: negative54Case Three, Question 1How would you describe Marks skin exam?

5555Case Three: Skin ExamPoorly defined hypopigmented, scaly patches on the face

5656Case Three, Question 2What is the most likely diagnosis?Pityriasis albaSeborrheic dermatitisTinea versicolorVitiligo57Case Three, Question 2Answer: aWhat is the most likely diagnosis?Pityriasis albaVitiligo (typical lesion is a sharply demarcated, depigmented, round or oval macule or patch)Tinea versicolor (generally does not affect the face)Seborrheic dermatitis (would expect erythematous patches and plaques with greasy, yellowish scale)

5858Diagnosis: Pityriasis AlbaPityriasis alba is a mild, often asymptomatic, form of AD of the facePresents as poorly marginated, hypopigmented, slightly scaly patches on the cheeksTypically found in young children (with darker skin), often presenting in spring and summer when the normal skin begins to tan

5959Pityriasis Alba: TreatmentReassure patients and parents that it generally fades with timeUse of sunscreens will minimize tanning, thereby limiting the contrast between diseased and normal skinIf moisturization and sunscreen do not improve the skin lesions, consider low strength topical steroids or topical calcineurin inhibitor6060Take Home PointsAD is a chronic, pruritic, inflammatory skin disease with a wide range of severityAD is one of the most common skin disorders in developed countries, affecting ~ 20% of children and 1-3% of adultsDistribution and morphology of skin lesions varies by ageA large percentage of children with AD will develop asthma or allergic rhinitisThe pathogenesis of AD is multifactorial; genetics, skin barrier dysfunction, impaired immune response, and the environment play a roleTreatment for AD includes long-term use of emollients and gentle skin care as well as short-term treatment for acute flares6161Take Home PointsAcute inflammation is treated with topical steroidsAntihistamines may help with pruritus and sleep issuesSecondary skin infections should be treated with systemic antibioticsIdentification of true food allergies should be reserved for refractory AD in children in whom the suspicion for a food allergy is highPityriasis alba is a mild form of AD of the face in childrenSunscreen and emollients are the 1st-line treatments for patients with pityriasis albaReassure patients and parents that pityriasis alba will fade with time6262AcknowledgementsThis module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup from 2008-2012.Primary authors: Sarah D. Cipriano, MD, MPH; Eric Meinhardt, MD; Erin F.D. Mathes, MD, FAAD, FAAP; Timothy G. Berger, MD, FAAD.Peer reviewers: Megha M. Tollefson, MD; Anna L Bruckner, MD, FAAD.Revisions: Sarah D. Cipriano, MD, MPH. Last revised July, 2011.6363End of the ModuleAbramovits W. Atopic dermatitis. Section C: Overview of inflammatory skin diseases the latest findings in cellular biology. J Am Acad Dermatol 2005;53:S86-93.Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; 2007. Available from: www.mededportal.org/publication/462Berger Timothy G, "Chapter 6. Dermatologic Disorders" (Chapter). McPhee SJ, Papadakis MA, Tierney LM, Jr.: CURRENT Medical Diagnosis & Treatment 2010: http://www.accessmedicine.com/content.aspx?aID=747.James WD, Berger TG, Elston DM, Chapter 5. Atopic Dermatitis, Eczema, and Noninfectious Immunodeficiency Disorders (chapter). Andrews Diseases of the Skin Clinical Dermatology. 10th ed. Philadelphia, Pa: Saunders Elsevier; 2006: 69-76.Simpson EL. Atopic dermatitis: a review of topical treatment options. Curr Med Res Opin 2010;26:633-40.Spergel JM. Role of allergy in atopic dermatitis (eczema). Uptodate.com. 5/2010.Suh KY. Food Allergy and Atopic Dermatitis: Separating Fact from Fiction. Semin Cutan Med Surg. 2010;29:72-78.6464