Atopic Dermatitis

Andrea R. Waldman, MD, Jusleen Ahluwalia, MD, Jeremy Udkoff, MA,

Jenna F. Borok, BS, Lawrence F. Eichenfield, MD

Slide set prepared by:

Ayan Kusari, MA, Allison M. Han, AB, David Schairer, MD, Lawrence Eichenfield, MD
Learning Objectives
• Understand disease pathogenesis of atopic dermatitis (AD)
• List the age-specific clinical features of AD
• Understand diagnostic criteria associated with AD
• Recognize comorbidities of AD
• Understand infectious complications of AD
• Understand treatment guidelines including recent recommendations for
“proactive” maintenance therapy for AD
• Know the clinical indications for subspecialty referral in AD
• Understand fundamentals of therapeutic patient education on and its role
in AD care
Epidemiology
• AD comes first in the “atopic march” – food allergies, allergic rhinitis,
asthma follow
• Most common chronic inflammatory skin disease
• Affects 12.5% of children in the United States
• Estimated economic burden: $5 billion per year in the United States
• Prevalence still rising in developed nations
• Presents early in life
• 60% by 1 year of age
• 90% by 5 years of age
Pathogenesis
• Genetics
• 46 genes associated with AD so far
• Filaggrin gene most frequently reported association
• Environment
• AD more common in urban settings than rural settings
• Hygiene hypothesis (decreased exposure leads to decreased tolerance to environmental
pathogens)
• Barrier dysfunction
• Increased transepidermal water loss in AD due to barrier dysfunction
• Filaggrin is both a component and modulator of the skin barrier
• Ceramides and natural moisturizing factors contribute to the skin barrier
• Immune dysfunction
• Innate immunity: increased thymic stromal lipoprotein, IL-25, IL-33
• Th2 response: IL-31 promotes pruritus
• Th22 cytokine IL-22 promotes lichenification
Risk Factors/Protective Factors
Risk Factors Protective Factors
Family history
2-3x increased risk with 1 atopic parent
3-5x increased risk with 2 atopic parents
Filaggrin gene mutations
60% with FLG gene mutation develop disease
Cat ownership at birth Dog ownership at birth
Urban environment Rural environment
Clinical Findings
• Xerosis
• Pruritus
• Eczematous lesions
• Acute: erythema, exudates/oozing, vesiculation
• Sub-acute: erythema, scale-crust, excoriations
• Chronic: erythema, excoriations, lichenification
• Age-specific distribution
• Infantile: scalp, cheeks, forehead (spares diaper area)
• Childhood: flexural
• Adult: face (periorbital, perioral), dorsal hands/feet, upper back
• Skin of color
• Pigmentary changes more common
• African Americans: papular/follicular AD more common
• Associated skin conditions
• Keratosis pilaris
• Ichthyosis vulgaris
• Pityriasis alba
Diagnosis
Essential Features Important Features Associated Features
Both must be present: Add support to the diagnosis, Suggestive of AD, but too nonspecific to be
1. Pruritus observed in most cases of AD: used for defining or detecting AD in
2. Eczema (acute, subacute, chronic) 1. Early age at onset research or epidemiologic studies:
a. Typical morphology and age-specific patterns: 2. Atopy 1. Atypical vascular responses (eg, facial
a. Infants/children: facial, neck, and a. Personal and/or family pallor, white dermographism, delayed
extensor involvement history
b. Any age group: current or previous blanch response)
b. IgE reactivity
flexural lesions 3. Xerosis 2. Keratosis pilaris/pityriasis
c. Sparing of the groin and axillary regions alba/hyperlinear palms/ichthyosis
b. Chronic or relapsing history 3. Ocular/periorbital changes
4. Other regional findings (eg, perioral
changes/periauricular lesions)
5. Perifollicular
accentuation/lichenification/prurigo
lesions

Adapted with permission from Eichenfield LF, Boguniewicz M, Simpson EL, et al. Translating atopic dermatitis management guidelines into practice for primary care providers. Pediatrics. 2015;136(3):554–
565.
Differential Diagnosis
Core Differential
• Seborrheic dermatitis
• Psoriasis
• Contact dermatitis (irritant or allergic)
• Photosensitivity dermatoses
• Ichthyoses
• Cutaneous T-cell lymphoma
• Immunodeficiency diseases
• Erythroderma of other causes
• Scabies
Differential Diagnosis (continued)
Nutritional and Metabolic Disorders
• Acrodermatitis enteropathica
• Biotin deficiency
• Celiac disease
• Essential fatty acid deficiency
• Hartnup disease
• Hurler syndrome
• Phenylketonuria
• Prolidase deficiency
• Zinc deficiency
Primary Immunodeficiency Disorders
• Agammaglobulinemia
• Hyperimmunoglobin E syndrome
• Omenn syndrome
• Severe combined immunodeficiency
disorder
• Wiskott-Aldrich syndrome
Other Disorders
• Ataxia-telangiectasia
• Langerhans cell histiocytosis
• Netherton syndrome
Comorbidities
• Other atopic disease: asthma, rhinitis, food allergy
• Sleep disturbance
• Psychiatric comorbidities
• Attention-deficit/hyperactivity disorder
• Anxiety
• Conduct disorder
• Depression
• Controversial/emerging
• Obesity
• Hypertension
• Cancer
Infectious Complications
• Staphylococcus aureus
• Up to 90% of affected skin is colonized in patients with AD
• Estimates of 76% of non-affected skin colonized in patients with AD
• 2%-25% of skin in non-AD patients is colonized
• Case reports of S aureus bacteremia, sepsis, endocarditis, osteomyelitis in patients
with AD
• Streptococcus pyogenes
• 16% of patients with AD colonized
• Herpes simplex virus – eczema herpeticum
• Coxsackievirus A6 – eczema coxsackium
• Poxvirus – molluscum contagiosum
Management: Overview Reprinted with permission from Eichenfield LF, Boguniewicz M, Simpson EL, et al.
Translating atopic dermatitis management guidelines into practice
for primary care providers. Pediatrics. 2015;136(3):554-565.

Note: Topical crisaborole is now approved for mild to moderate AD for ages 2 years and older
Management: Bleach Bath Instructions
Bleach Bath Instructions for Caregivers
1. Use common 6% household bleach to a bathtub full of water (8.75% bleach is 1/3 more concentrated; use
1/3 more water or 1/3 less bleach).
2. Measure the amount of bleach before adding it to the bathwater.
3. For a full tub of water, use ½ cup of bleach. For a half-full tub of water, add ¼ cup of bleach.
4. While the tub is filling, pour the bleach into the water.
5. Wait until bath is fully drawn before placing the child in the tub.
6. Never apply bleach directly on a child’s skin.
7. Soak for 10 minutes.
8. Pat the child’s skin dry after bath.
9. If the child uses eczema medication, apply it immediately after the bath. Then moisturize the child’s skin.
10. As an alternative to bleach baths, comparable dilute bleach solutions can be made using 1 tsp of bleach per
gallon of water. This may be useful in spray bottles for use in showers (eg, for adolescents), or for smaller
baby bathtubs. Alternatively, commercial sodium hypochlorite products that seem to have similar effects to
bleach baths are available.

Management: Topical Steroid Classes
I Very • Betamethasone dipropionate (Diprolene; ointment; 0.05%)
High • Clobetasol proprionate (Temovate; cream, ointment, lotion;
Potency 0.05%)
• Diflorasone diacetate (Psorcon; ointment; 0.05%)
• Halobetasol propionate (Ultravate; cream, ointment; 0.05%)
II High • Amcinonide (Cyclocort; ointment; 0.1%)
Potency • Betamethasone diproprionate (Diprosone/Maxivate;
ointment; 0.05%)
• Desoximetasone (Topicort; cream, ointment 0.25%; gel 0.5%)
• Fluocinonide (Lidex; cream, ointment, gel, solution; 0.05%)
• Mometasone furoate (Elocon; ointment; 0.1%)
• Triamcinolone (Aristocort; cream; 0.5%)
III High • Amcinonide (Cyclocort; cream, lotion; 0.1%)
Potency • Betamethasone diproprionate (Diprosone; cream; 0.05%)
• Betamethasone valerate (Valisone; ointment; 0.1%)
• Diflorasone diacetate (Psorcon; cream; 0.05%)
• Fluticasone propionate (Cultivate; ointment; 0.005%)
• Triamcinolone acetonide (Aristocort; ointment; 0.1%)
Adapted with permission from Eichenfield LF,
Boguniewicz M, Simpson EL, et al. Translating atopic
dermatitis management guidelines into practice for
primary care providers. Pediatrics. 2015;136(3):554–565.
IV Mid • Flucinolone acetonide (Synalar; ointment; 0.025%)
Potency • Hydrocortisone valerate (Westcort; ointment; 0.2%)
• Mometasone fuorate (Elecon; cream, lotion; 0.1%)
• Triamcinolone acetonide (Kenalog, Aristocort; cream; 0.1%)
V Mid • Betamethasone dipropionate (lotion; 0.05%)
Potency • Betamethasone valerate (Valisone; cream; 0.1%)
• Fluticasone acetonide (Synalar; cream; 0.025%)
• Fluticasone propionate (Cutivate; cream; 0.05%)
• Hydrocortisone butyrate (Locoid; cream, ointment, lotion; 0.2%)
• Hydrocortisone valerate (Westcort; cream; 0.2%)
• Prednicarbate (Dermatop; cream; 0.1%)
VI Low • Alclometasone dipropionate (Aclovate; cream, ointment; 0.05%)
Potency • Betamethasone valerare (lotion; 0.1%)
• Desonide (DesOwen/Tridesilon, cream, ointment; 0.05%)
• Fluocinolone acetonide (Derma-Smoothe FS, oil, 0.01%; Synlar,
solution, 0.01%)
• Triamcinolone acetonide (Aristocort, Kenalog; cream; 0.025%)
VII Low • Hydrocortisone acetate (cream; 1%)
Potency • Methylprednisolone acetate (cream; 0.25%)
• Dexamethasone sodium phosphate (cream; 0.05%)
Therapeutics for Refractory Patients

• Patients with severe disease should be referred to a specialist

• Specialists can offer treatments such as the following:
• Narrow-band UVB phototherapy
• Methotrexate
• Systemic immune modulatory agents: cyclosporine, azathioprine, oral steroids
• Dupilumab (novel therapeutic, IL-4 receptor antibody)
• JAK inhibitors
Therapeutic Patient Education

• Formal education programs – effective, but feasibility may be an issue

• Written action plans
• Improve treatment compliance in diabetes and asthma
• Further research is needed in AD
• PowerPoint instruction modules
• Video instruction modules
• Nurse instructional sessions