Atopic Dermatitis April 2015 - PowerPoint Presentation

Slide1

Atopic DermatitisApril 2015

Pediatric Continuity Clinic Curriculum

Created by: Matthew Pertzborn, PGL-2Slide2

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 dermatitisSlide3

Case #1

A 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?Slide4

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 deficiencySlide5

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 observationSlide6

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

StressSlide7

Additional Information

Image From: Pediatrics In Review (Reference #1)Slide8

Additional InformationOften follows a relapsing course

The term “atopic dermatitis” and “atopic eczema” (often simply called “eczema”) are the same

Itching is very characteristic

IgE

often elevatedSlide9

Case #2

A 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?Slide10

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 literatureSlide11

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 daySlide12

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 controversialSlide13

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 daySlide14

Additional InformationClinical pearl:

Important to apply emollient/ointment after every bath (pad down with towel, don’t wipe after the bath prior to application)Slide15

Case #3

A 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?Slide16

Discussion question 3-1?

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

Extra careful screening for the above conditions should occurSlide17

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 temperatureSlide18

Additional InformationClinical 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 familySlide19

PREP Question

PREP 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

loratadine

B. eliminating cow milk, egg, soy, and wheat from his diet

C. Introducing cow milk on a trial basis to see if the rash worsens

D. switching to hypoallergenic formula and a diet of only rice and chicken

E. testing for pertinent, potential food allergen triggersSlide20

PREP Question

PREP 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

loratadine

B. eliminating cow milk, egg, soy, and wheat from his diet

C. Introducing cow milk on a trial basis to see if the rash worsens

D. switching to hypoallergenic formula and a diet of only rice and chicken

E. testing for pertinent, potential food allergen triggers (see PREP 2014 for explanation)Slide21

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 resultsSlide22

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 resultsSlide23

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.Slide24

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.