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Atopic Dermatitis

Epidemiology. The incidence is 7/1,000 but the prevalence in the

I.

Epidemiology and Pathogenesis


A.

Atopic dermatitis has an incidence of 7/1,000 and a prevalence of 3-5% of

pediatric age group approaches 5%, maybe even as high as 10%


in children between the ages of five and 10 years. Ninety five
percent of all patients will have their first outbreak by age five. It

children.

is extremely unusual for patients to have their first manifestation

B.

95% of affected children will have symptoms by age 5.

C.

The inheritance pattern is multifactorial.

number of other dermatitic processes that may present with skin

D.

Pathogenesis is related to immunologic factors, histamine and vasoactive

lesions that look very much like atopic dermatitis. After the age of

mediators.

10, think of other things in your differential diagnosis. And

Triggering factors

although the inheritance isn't clear, it is probably multifactorial,

E.

1. Foods, environmental allergens, and bacteria.

after 10 years of age, which is important when you consider a

with inheritance playing a role. If you look at families with atopic


history, one-third of all the children in these families will develop

2. IgE

atopic dermatitis. About one-third of atopic children will have

3. Individual with genetic predisposition

respiratory symptoms, one-half of these children will continue to

4. Inflammatory mediators: Histamine, prostaglandins, neuropeptides

have respiratory symptoms into adult life. If you have a patient that

5. Inflammation

has both a moderately severe atopic dermatitis as well as asthma,

6. Pruritus

their risk of having atopic dermatitis into adult life is significant.

7. Acute dermatitis
A number of immunologic factors as well as inflammatory

8. Chronic dermatitis
F.

External factors including foods, bacteria, and environmental allergens trigger


the release of cutaneous inflammatory factors, resulting in pruritus and
inflammation of the skin of susceptible individuals. Secondary manipulation

mediators are felt to play a role in the pathogenesis of the


disease. Humoral immunity is felt to play a role based upon some
clinical as well as immunologic findings. There is an increase in
immediate heightened sensitivity to a number of environmental

of the skin [i.e. rubbing and excoriation) produces many of the symptoms of

antigens. There clearly is an increase in serum IgE levels in

acute and chronic dermatitis. Dermatitic changes in the skin result in further

patients with atopic dermatitis. It tends to be relatively moderate

pruritus, thus potentiating an escalating cycle of increasing clinical findings,

and there is clearly an overlap between the normal population and

particularly during flare periods.

those with an atopic diathesis.

There are a number of immunodeficiency syndromes including


Wiskott-Aldrich syndrome, Ataxia-telangiectasia, hyper-IgE, and
hypereosinophilic syndrome in children which have been
associated in some cases with particularly severe presentation of
the atopic diathesis.

Triggering factors may be environmental antigens, such as foods;


a number of allergens; infectious agents, bacteria, fungi, viral
agents.. Inflammatory mediators are released by skin endothelial
cells, and they produce the pruritus. Patients scratch and they
create the itch-scratch cycle. The more they scratch, the more
inflammatory mediators they release. The more they itch, the more
they scratch and if you are going to treat these patients
successfully, you need to interrupt this itch-scratch cycle.

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Clinical presentation.

Diagnostic Criteria for Atopic Dermatitis


Major criteria (all required

Common findings (at

Associated findings (at

In acute dermatitic processes, one sees erythema, vesicles,

for diagnosis)

least two)

least four)

crusting. You may see secondary infection. If the patient has a

Pruritus

Personal or family history

Ichthyosis, xerosis,

Typical morphology and


distribution of rash

of atopy

hyperlinear palms

Immediate skin test


reactivity

Pityriasis alba
Keratosis pilaris

White dermographism
Anterior subcapsular
cataracts

Facial pallor, infraorbital


darkening
Dennie-Morgan folds
Keratoconus

flare of their atopic dermatitis, you will see acute changes in the
skin. Patients with chronic changes will have lichenification or
accentuation of the normal skin margins with thickening of the
epidermis. These patients will have excoriation and pigmentary
change. They will have scale. These changes suggest a process
which has been ongoing for days if not weeks or months. Again,
you can see this in association with the acute changes when the
patient has acute flares of their atopic disease.

Hand dermatitis
Repeated cutaneous
infections

Age related patterns will help you make the diagnosis. In infancy,
all areas of the skin fair game for presentation of the skin lesions
with the exception of protected areas. The diaper area is
invariably spared until the patients are toilet-trained. Then you

Relative Greasiness of Common Skin Lubricants


Lubricant

Greasy-ness

Petrolatum

More Greasy

start to see lesions in the diaper area and this is a reliable finding.
Widespread disease affects the head and neck, the extremities.
The trunk may be relatively spared because it is a relatively
protected site. This child has both some acute changes of

Aquaphor ointment base

erythema and scaling and crusting. This child has some chronic

Mineral oil

changes and lichenification. In fact, in this age group, it is probably


more common to see involvement over the extensor surfaces of

Eucerin cream

the arms and legs because the flexural creases are actually

Keri lotion

relatively spared sites. So in this age group, you expect to see

Lubriderm lotion

exactly the opposite of what you see in a slightly older child. The

Cetaphil lotion

scalp is a common area of involvement. Certainly, in younger

LactiCare lotion

infancy, you see seborrhea, but if it is seborrheic dermatitis, it

Moisturel skin lubricant-moisturizer

doesn't itch and if it itches you need to consider the possibility of

Nutraderm lotion
G.

Less greasy

Adolescence and Adulthood. In adults, the lesions are usually restricted to


the flexural creases. However, in some patients, involvement of the palms
and soles may become particularly prominent,

atopic dermatitis.

In a slightly older age group, in the childhood age groups, after


infancy when you get into older toddlers through school age you
tend to see flexural involvement. It doesn't have to be restricted
only to the flexural creases and on occasion it may be widely
disseminated; the diaper area in these children ,who are usually
toilet-trained, can certainly be involved. The dorsal flexural

2. Viral infections (herpes simplex, molluscum)

surfaces can be involved and again you see both complaints of an

3. Chronic fungal infection


I.

Complications of Atopic Dermatitis


1. Secondary bacterial infection

H.

acute and chronic dermatitis here. Lichenification is symmetric

Differential Diagnosis
1. Seborrheic dermatitis

crusting pruritus is commonly involved and this area can be


thought of as being one of the flexural creases that you typically
see in school-aged children.

2. Irritant dermatitis
3. Papular acrodermatitis

In teenagers and adults, flexures tend to be involved

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4. Psoriasis
5. Fungal infection

90%, of children will have their disease go into remission in the

6. Scabies
J.

preferentially. Probably three-quarters, maybe as many as 85-

late school-aged years or adolescent years. But certainly there


are some patients who have persistent disease. There are many

Treatment of Atopic Dermatitis

patients who will go into remission only to have recurrence of their

1. Lubricants

lesions when they get involved in occupations or hobbies that

2. Brief, regular bathing. Use of mild oaps

expose them to irritants.

3. Topical steroid
4. Environmental control measures

Hand dermatitis with chronic dermatitis, thickening of the skin,

5. Antibacterials

lichenification on the extensor surfaces of the fingers, is a typical

6. Foods?

finding in adolescents and adults. Involvement of the sides of the


digits of both the hands and feet, occasionally the palms and the

7. Allergy Rx?

soles with deep-seated vesicles which are incredibly pruritic. They


may rupture at the surface leaving a crust at the surface.
Potency of Topical Steroid Preparations

Prurigo nodularis. There are some patients who rather than

Group

Generic name

Trade name

Potency

Clobetasol propionate

Temovate cream 0.05%

High potency

Betamethasone dipropionate

Diprolene cream 0.05%

Amcinonide

Cyclocort ointment 0.1%

normal thickness. Inflammation is present, suggesting chronic

Diprosone ointment 0,05%

change. Some of those patients create prurigo nodularis. This is

rubbing and scratching, are pickers. And these are picker's

Betamethasone dipropionate

Florone ointment 0.05%

Diflorasone diacetate

Halog cream O. 1%

Halcinonide

Lidex cream 0.05%

Fluocinonide

nodules. These patients develop thickening of the skin. If you


biopsy the skin, you see the epidermis may be 10-15 times its

Lidex ointment 0.05%

certainly an associated finding, and I think, in most children when


you see prurigo nodularis you are dealing with an atopic.

Maxiflor ointment 0.05%

Hyperlineary of the palms and soles is a relatively common finding

Topicort cream 0.25%

Fluocinonide

associated with atopic dermatitis. It may also be seen in

Diflorasone diacetate

association with ichthyosis. Thickening of the skin as well of the

Desoximetasone

palms and soles and ichthyosis vulgarisis common in, patients


Diprosone cream 0.05%

with atopic dermatitis. Discrete papules that often have this

Benisone gel 0.025%

predilection for involvement around hair follicles are common..

Betamethasone valerate

Valisone ointment O.1%

Nummular eczema is characterized by vesiculation, crusting,

Triamcinolone acetonide

Aristocort ointment 0.1%

erythema, intense pruritus, typically in teenage girls, typically on

Flurandrenolide

Cordran ointment 0.05%

the proximal extremities. Not necessarily associated with other

Kenalog ointment 0.1%

Betamethasone dipropionate
Betamethasone benzoate

typical findings of atopic dermatitis.This as a manifestation of

Triamcinolone acetonide

Synalar cream 0.025%

atopic disease.

Fluocinolone acetonide
5

Triamcinolone acetonide

Aristocort cream 0.1%

Flurandrenolide

Cordran SP cream 0.05%


Fluonide cream 0.01%

Ichthyosis vulgaris. This can certainly occur again as an


independent entity. It usually does not present until after six
months of age, so it should not be confused with some of the

Fluocinolone acetonide

Kenalog cream O. 1%

Triamcinolone acetonide

Synalar cream D.01%

Fluocinolone acetonide

Valisone cream 0.1%

newborn period. Typically on the distal extremities. The most

Betamethasone valerate

Westcort cream 0.2%

common sites would be just the lower extremities, the shins.

Hydrocortisone valerate

other ichthyoses that can present with devastating effect in the

These patients may have hyperlineary of the palms and soles.


They may have keratosis pilaris. These thorny little sand-paperylike papules in the back of the upper arms, cheeks and thighs

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Hydrocortisone 1%, urea

which again also are associated with atopic dermatitis.. This is

Alphaderm cream 1%

10%

Locorten cream 0.03/o

inherited. It is autosomal dominant. If you have any question

Flumethasone pivalate

Tridesilon cream 0.05%

about, you can ask their parents to roll up their pants and roll up
their sleeves and see the same thing. You have a 50-50 shot of

Desonide

having it with the parent who brings the kid to see you.

Hydrocortisone 1%

Hytone cream 1%

Hydrocortisone 1%

Hytone ointment 1%

Dexamethasone

Hexadrol cream 0.04%

Keratosis pilaris. It is also seen typically in association with

Medrol ointment 0.25%

atopics. You see the sand-papery papules on the arms and legs

Methylprednisolone

Meti-Derm cream 0.5%

and people present with this a couple of ways. You may see it as
a concomitant finding in atopics. You may see it in the summer

Prednisolone
8

Hydrocortisone 0.5%

when these patients present with erythema of the cheeks. You


Cortaid cream

Low potency

may also see it during the winter when their skin tends to be dry,
when their eczema tends to flare up and when the sand-papery

References

papules on the arms and legs become more prominent.

Hanifin JM: Basic and clinical aspects of atopic dermatitis: a review. Ann Allergy
Pityriasis alba. Pityriasis alba, which translates directly into

52:368-375, 1984.
Hanifin JM, Lobitz WC: New concepts of atopic dermatitis. Arch Dermatol, 113:663,

English as "white spot disease", it is a manifestation of atopic


dermatitis. If you look carefully, you'll see that most of them have

1977.

some fine scale. Many of them will have some finer or more subtle

Krafchik B: Eczematous dermatitis, in Schachner LA, Hansen RC:

erythema and they get postinflammatory hyperpigmentation most

Pediatric Dermatology, Churchill-Livingstone, 1988, pp. 695-724.

typically on the extremities. It can involve the face. If you ask

Leung D, Rhodes R, Geha RS: Atopic dermatitis, in Fitzpatrick TB, Eisen ZA, Wolff K,

careful questions, you will often be able to make the diagnosis of

Freedburg IM, Austen KF (eds}: Dermatology in General Medicine, McGraw-Hill, New

atopic dermatitis.

York, 1987, pp. 13851408.


With the intense inflammation, you can see postinflammatory
pigmentary changes in association with atopic dermatitis and the
intense inflammation, hypo- and hyperpigmentation can occur in
the same patient.

In patients who present with a chronic dermatitic process, you


want to moisten the skin. You want to use products which have oil
and petrolatum in them.

If you have a patient with an acute process and you give them a
water-based product, it may sting and burn. So, it is important that
you consider the vehicle. If you have a patient that develops some
sort of an adverse reaction to the topical preparation, in may in
fact not be the medicated product at all. It may be one of the
components of the vehicle. So you need to look carefully at the
"inert" ingredients.

Single versus combination products. Only agents which have a


single medicated product in them should be used.If you want to
use a number of different agents, if you give them separately, as

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a general rule, they are much less expensive. You can also
control the time for which they are applied. If you have a
combination product, you buy into everything being put on at the
same time. If you have a combination product and a patient has
an adverse reaction, develops contact dermatitis, again you don't
know which medicated product is producing the problem and
you're stuck with having to discontinue the product. Cost
considerations. I suggest that you go to your local pharmacy and
see what they have. There may be certain topical corticosteroids
which they have available in a large quantity, which they have
available in an ointment based product, which is what I generally
use in atopic patients. I think it is reasonable to look and see what
is available and pick out an agent or two in the low potency range
and the middle potency range that you become very comfortable
with.

Many physicians don't realize how much of a topical agent it takes


to cover the skin surface, hands, face, anal-genital area. One
application requires 2 gm. To cover the entire skin surface once,
takes about 30 gm of the product. So give the patient the amount
of product that you really think they need.

Lubricants. As a general rule, I like safe, simple, inexpensive


bland lubricants. In young children, this means that you can send
them home with a pound jar of Vaseline. You can use those safe
products like Vaseline. You can send them to the store and they
can buy mineral oil inexpensively. By in large, ointment-based
products have few preservatives. They require few stabilizers.
When you get into the cream-based products, they tend to be
more irritating. They tend to be less occlusive and they tend to
have more stabilizers, preservatives and other products in the
vehicle which can get you into trouble. Same thing is true for all
these lubricants.

This is just an abbreviated list of the topical steroids which are


available. Because of the large number of products that are out
there, again, I suggest that you go to your local pharmacy and see
what your pharmacist gets. They may get a number of products.
Pick a couple of the products and a couple of potency ratings in
an ointment-based preparation.

The diaper area stays clear in infants and toddlers because it is


wet all the time and it is protected. It is protected from outside
irritants. It is protected from hands which scratch and excoriate the
skin. Clothes should be kept on. They should not be allowed to

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just run around in their diapers. Protective clothing. Long


underwear at night after they apply the lubricants. It tends to keep
their skin, at least the areas that are covered, under relatively
good control. The older the child, the more likely they are to have
the capability of removing their clothes and doing a lot of damage.
Emollients will get you 50% of the way there. Simple, plain
emollients and low to medium potency topical steroids with an
ointment-based vehicle.

Keeping your clothes on protects you from upholstery. Protects


you from carpeting. Protects you from nummular irritants. Using
common sense when it comes to using cotton or cotton blends.
Anything that makes you itch. Anything that makes the doctor itch
is going to make the patient itch. My recommendation in terms of
water exposure is for bathing to be done regularly. Once a day
would be reasonable in the summer, maybe every other day in the
winter. Swimming. There are some kids who do much better when
they are in the pool. They do much better when they are at the
beach and I encourage these kids to get in as long as they take
the lubricant to the pool side. Antihistamines. There is no
appropriate use of topical antihistamines. When you use it on
inflamed skin, topical antihistamines tend to be potent sensitizers.
In those children who develop urticaria in association perhaps with
food or other antigens, there may be a more systemic role as well
for antihistamines.

Complications of atopic disease. Secondary bacterial infection,


viral infections, a number of chronic infections can be an issue in
atopics. Impetiginitis atopic disease can develop dissemination
and disseminated disease. When you see a child who presents
with an acute flare, a fever, and extremely discrete monotonous
vesicular crusted lesions, you need to consider the possibility of
a primary herpes simplex infection. Probably after impetiginization
of the atopic, disseminated primary herpes simplex should be your
next consideration in a child who presents with an acute flare of
disease and a fever. These lesions can become widespread, they
can occasionally disseminate viscerally. Molluscum.. Atopics tend
to have difficulty managing this and they have chronic and
persistent disease, much longer than you are used to seeing in
the normal non-atopic host. Chronic fungal infections also can be
an issue. Many of these infections can present on a superimposed
severe flare of the atopic disease which can also make it difficult
to recognize them.

Melanoma is a disease of young adults; it is a disease of people

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in their prime, you need to get kids to protect themselves from


sun. There is a good deal of mounting evidence to suggest that
sun plays a major role.

Two percent of all cancer deaths are caused by melanoma. Three


percent of teens by neoplasms. It is key that we recognize that we
need to protect these kids from sun and it is key that we look for
these lesions and identify them when they are thin. A thin
melanoma is under 1 mm. An intermediate melanoma is 1 to 3
mm; over 3 mm we are talking about major morbidity and
significant mortality. Look for changes in color especially if these
changes occur in an irregular asymmetric way. Look for changes
in size. Sudden growth of a mole can certainly be, in most cases,
benign, but it may be the first marker of something going in the
wrong direction. Lesions which rise in height. Certainly if it occurs
again in an asymmetric way, a portion of the mole is becoming
elevated when the rest of it is remaining uniformly level with the
skin surface. Changes in shape. Changes in texture, again
especially if they occur in a non-uniform way. Changes in
sensation. Moles can become irritated and develop inflammation,
but melanomas typically develop an inflammatory infiltrate, and
the patient may complain of itching and burning. New moles,
especially if the new moles don't look like the old moles are a
concern..

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