Ferri – Atopic Dermatitis

Mar 20, 2020 admin DA LIỄU 0

Atopic Dermatitis

  • Fred F. Ferri, M.D.

 Basic Information

Definition

Atopic dermatitis is a genetically determined eczematous eruption that is pruritic, symmetric, and associated with personal family history of allergic manifestations (atopy). Box 1 summarizes criteria for atopic dermatitis. Modified criteria for children with atopic dermatitis are described in Box 2.

BOX 1Criteria for Atopic Dermatitis

Major criteria

Must have three of the following:

  1. •

    Pruritus

  2. •

    Typical morphology and distribution

    1. •

      Flexural lichenification in adults

    2. •

      Facial and extensor involvement in infancy

  3. •

    Chronic or chronically relapsing dermatitis

  4. •

    Personal or family history of atopic disease (e.g., asthma, allergic rhinitis, atopic dermatitis)

Minor criteria

Must also have three of the following:

  1. 1.

    Xerosis

  2. 2.

    Ichthyosis or hyperlinear palms or keratosis pilaris

  3. 3.

    IgE reactivity (immediate skin test reactivity, RAST test positive)

  4. 4.

    Elevated serum IgE

  5. 5.

    Early age of onset

  6. 6.

    Tendency for cutaneous infections (especially Staphylococcus aureus and HSV)

  7. 7.

    Tendency to nonspecific hand/foot dermatitis

  8. 8.

    Nipple eczema

  9. 9.

    Cheilitis

  10. 10.

    Recurrent conjunctivitis

  11. 11.

    Dennie-Morgan infraorbital fold

  12. 12.

    Keratoconus

  13. 13.

    Anterior subcapsular cataracts

  14. 14.

    Orbital darkening

  15. 15.

    Facial pallor or facial erythema

  16. 16.

    Pityriasis alba

  17. 17.

    Itch when sweating

  18. 18.

    Intolerance to wool and lipid solvents

  19. 19.

    Perifollicular accentuation

  20. 20.

    Food hypersensitivity

  21. 21.

    Course influenced by environmental or emotional factors

  22. 22.

    White dermatographism or delayed blanch to cholinergic agents

HSV, Herpes simplex virus; RAST, radioallergosorbent assay.

From James WD, et al.: Andrews’ diseases of the skin, ed 12, Philadelphia, 2016, Saunders.

BOX 2Modified Criteria for Children with Atopic Dermatitis

Essential features
  1. 1.

    Pruritus

  2. 2.

    Eczema

    1. •

      Typical morphology and age-specific pattern

    2. •

      Chronic or relapsing history

Important features
  1. 1.

    Early age at onset

  2. 2.

    Atopy

  3. 3.

    Personal or family history

  4. 4.

    IgE reactivity

  5. 5.

    Xerosis

Associated features
  1. 1.

    Atypical vascular responses (e.g., facial pallor, white dermatographism)

  2. 2.

    Keratosis pilaris, ichthyosis, or hyperlinear palms

  3. 3.

    Orbital or periorbital changes

  4. 4.

    Other regional findings (e.g., perioral changes, periauricular lesions)

  5. 5.

    Perifollicular accentuation, lichenification, or prurigo lesions

From James WD, et al.: Andrews’ diseases of the skin, ed 12, Philadelphia, 2016, Saunders.

Synonyms

  1. Eczema

  2. Atopic neurodermatitis

  3. Atopic eczema

ICD-10CM CODES
L20.9 Atopic dermatitis, unspecified
L20.89 Other atopic dermatitis

Epidemiology & Demographics

  1. •

    Incidence is between 5 and 25 cases/1000 persons.

  2. •

    Highest incidence is among children (10% to 20%). It accounts for 4% of acute care pediatric visits. It affects 1% to 3% of the adult population.

  3. •

    Onset of disease before age 5 yr in 85% of patients.

  4. •

    More than 50% of children with generalized atopic dermatitis develop asthma and allergic rhinitis by age 13 yr.

  5. •

    Concordance in monozygotic twins is 77%.

Physical Findings & Clinical Presentation

  1. •

    Atopic dermatitis presentation can be subdivided into three phases:

    1. 1.

      Acute: vesicular, crusting, weeping eruption

    2. 2.

      Subacute: dry, scaly, erythematous papules and plaques

    3. 3.

      Chronic: lichenification from repeated scratching

  2. •

    The lesions are typically on the neck, face, upper trunk, and bends of elbows and knees (symmetric on flexural surfaces of extremities) (Figs. 1 and E2). Atopic dermatitis lesions are usually discrete but vaguely delineated, scaly, and erythematous.

    FIG.1 

    A, Flexural atopic dermatitis with lichenification. Many of the skin changes are secondary to scratching. Linear lichenification, as shown here, and excoriations are typical. B, Hertoghe sign: loss of the outer eyebrow may occur in the atopic patient as a result of chronic rubbing.
    From White GM, Cox NH, [eds]: Diseases of the skin, a color atlas and text, ed 2, St Louis, 2006, Mosby.
    FIG.E2 

    Flexural involvement in childhood atopic dermatitis.
    From James WD, et al.: Andrews’ diseases of the skin, ed 12, Philadelphia, 2016, Saunders.
  3. •

    There is dryness, thickening of the involved areas, discoloration, blistering, and oozing.

  4. •

    Papular lesions are frequently found in the antecubital and popliteal fossae.

  5. •

    In children, red scaling plaques are often confined to the cheeks and the perioral and perinasal areas.

  6. •

    Hertoghe sign: loss of the outer eyebrow from chronic rubbing (Fig. 1, B).

  7. •

    Constant scratching may result in areas of hypopigmentation or hyperpigmentation (more common in blacks).

  8. •

    In adults, redness and scaling in the dorsal aspect of the hands or about the fingers are the most common expression of atopic dermatitis; oozing and crusting may be present.

  9. •

    Secondary skin infections may be present (Staphylococcus aureus, dermatophytosis, herpes simplex).

Etiology

Unknown; elevated T-lymphocyte activation, defective cell immunity, and B-cell IgE overproduction may play a significant role.

Diagnosis

Differential Diagnosis

  1. •

    Scabies

  2. •

    Psoriasis

  3. •

    Dermatitis herpetiform

  4. •

    Contact dermatitis

  5. •

    Photosensitivity

  6. •

    Seborrheic dermatitis

  7. •

    Candidiasis, tinea

  8. •

    Lichen simplex chronicus

  9. •

    Other: xerosis, impetigo, Wiskott-Aldrich syndrome, PKU, ichthyosis, HIV dermatitis, nonnummular eczema, histiocytosis X, malignancies (T-cell lymphoma/Mycosis fungoides, Letterer-Siwe disease), graft-versus-host disease, metabolic and nutritional deficiencies (zinc, niacin, pyridoxine deficiencies)

Workup

Diagnosis is based on the presence of three of the following major features and three minor features.

Major Features

  1. •

    Pruritus

  2. •

    Personal or family history of atopy: asthma, allergic rhinitis, atopic dermatitis

  3. •

    Facial and extensor involvement in infants and children

  4. •

    Flexural lichenification in adults

Minor Features

  1. •

    Elevated IgE

  2. •

    Eczema-perifollicular accentuation

  3. •

    Recurrent conjunctivitis

  4. •

    Ichthyosis

  5. •

    Nipple dermatitis

  6. •

    Wool intolerance

  7. •

    Cutaneous S. aureus infections or herpes simplex infections

  8. •

    Food intolerance

  9. •

    Hand dermatitis (nonallergic irritant)

  10. •

    Facial pallor, facial erythema

  11. •

    Cheilitis

  12. •

    White dermographism

  13. •

    Early age of onset (after 2 mo of age)

Laboratory Tests

  1. •

    Lab tests are generally not helpful.

  2. •

    Elevated IgE levels are found in 80% to 90% of atopic dermatitis.

  3. •

    Consider skin biopsy only in cases unresponsive to treatment.

Treatment

Nonpharmacologic Therapy

  1. •

    Clip nails to decrease abrasion of skin

  2. •

    Avoidance of triggering factors:

    1. ○

      Sudden temperature changes, sweating, low humidity in the winter

    2. ○

      Contact with irritating substance (e.g., wool, cosmetics, some soaps and detergents, tobacco)

    3. ○

      Foods that provoke exacerbations (e.g., eggs, peanuts, fish, soy, wheat, milk)

    4. ○

      Stressful situations

    5. ○

      Allergens and dust

    6. ○

      Excessive hand washing

  3. •

    Phototherapy in moderation may be effective in resistant cases.

General Rx

  1. •

    Emollients can be used to prevent dryness. Severely affected skin can be optimally hydrated by occlusion in addition to application of emollients.

  2. •

    Low-potency topical corticosteroids (e.g., 1% to 2.5% hydrocortisone) may be helpful and are generally considered first-line therapy. Use intermediate-potency steroids (e.g., triamcinolone, fluocinolone) for more severe cases and limit potent corticosteroids (e.g., betamethasone, desoximetasone, clobetasol) to severe cases. Table 1 summarizes relative potencies of topical corticosteroids.

    TABLE1 Relative Potencies of Topical Corticosteroids (From Most Potent to Weakest)From Paller AS, Mancini, AJ: Hurwitz clinical pediatric dermatology, a textbook of skin disorders of childhood and adolescence, ed 5, 2016, Elsevier.
    Class Drug Dosage Form(s) Strength (%)
    I.Very high potency
    Augmented betamethasone dipropionate Ointment 0.05
    Clobetasol propionate Cream, ointment, foam 0.05
    Diflorasone diacetate Ointment 0.05
    Halobetasol propionate Cream, ointment 0.05
    II.High potency
    Amcinonide Cream, lotion, ointment 0.1
    Augmented betamethasone dipropionate Cream 0.05
    Betamethasone dipropionate Cream, ointment, foam, solution 0.05
    Desoximetasone Cream, ointment 0.25
    Desoximetasone Gel 0.05
    Diflorasone diacetate Cream 0.05
    Fluocinonide Cream, ointment, gel, solution 0.05
    Halcinonide Cream, ointment 0.1
    Mometasone furoate Ointment 0.1
    Triamcinolone acetonide Cream, ointment 0.5
    III-IV.Medium potency
    Betamethasone valerate Cream, ointment, lotion, foam 0.1
    Clocortolone pivalate Cream 0.1
    Desoximetasone Cream 0.05
    Fluocinolone acetonide Cream, ointment 0.025
    Flurandrenolide Cream, ointment 0.05
    Fluticasone propionate Cream 0.05
    Fluticasone propionate Ointment 0.005
    Mometasone furoate Cream 0.1
    Triamcinolone acetonide Cream, ointment 0.1
    V.Lower-medium potency
    Hydrocortisone butyrate Cream, ointment, solution 0.1
    Hydrocortisone probutate Cream 0.1
    Hydrocortisone valerate Cream, ointment 0.2
    Prednicarbate Cream 0.1
    VI.Low potency
    Alclometasone dipropionate Cream, ointment 0.05
    Desonide Cream, gel, foam, ointment 0.05
    Fluocinolone acetonide Cream, solution, oil 0.01
    VII.Lowest potency
    Dexamethasone Cream 0.1
    Hydrocortisone Cream, ointment, lotion, solution 0.25, 0.5, 1
    Hydrocortisone acetate Cream, ointment 0.5-1
  3. •

    Crisaborole 2% ointment is a phosphodiesterase type-4 (PDE4) inhibitor modestly effective for short-term treatment of mild to moderate atopic dermatitis.

  4. •

    Oral antihistamines (e.g., hydroxyzine, diphenhydramine) are effective in controlling pruritus and inducing sedation, restful sleep, and prevention of scratching during sleep. Doxepin and other tricyclic antidepressants also have antihistamine effect, induce sleep, and reduce pruritus.

  5. •

    The topical immunomodulators pimecrolimus and tacrolimus are especially useful for treatment of the face and intertriginous sites, where steroid-induced atrophy may occur. However, due to concerns about carcinogenic potential, the FDA recommends limiting their use for short periods in patients who are intolerant or unresponsive to other treatments. Pimecrolimus cream 1% is applied bid and has antiinflammatory effects secondary to blockage of activated T-cell cytokine production. Tacrolimus ointment (0.03% or 0.1%) applied bid is a macrolide that suppresses humoral and cell-mediated immune responses.

  6. •

    Oral prednisone, IM triamcinolone, Goeckerman regimen, PUVA are generally reserved for severe cases.

  7. •

    Cyclosporine, azathioprine, mycophenolate, and interferon gamma are sometimes tried for recalcitrant disease in adults by physicians who specialize in severe inflammatory skin conditions.

  8. •

    The human monoclonal antibody dupilumab is effective in adults with moderate to severe atopic dermatitis that have not responded to topical therapies. It can be used with or without corticosteroids. It is injected subcutaneously. Cost is a limiting factor.

  9. •

    Table 2 summarizes the management of atopic dermatitis.

    TABLE2 Management of Mild, Moderate, and Severe Forms of Atopic DermatitisFrom Paller AS, Mancini, AJ: Hurwitz clinical pediatric dermatology, a textbook of skin disorders of childhood and adolescence, ed 5, 2016, Elsevier.
    Mild Moderate Severe
    Bathing and barrier repair∗
    Avoidance of irritant and allergic triggers
    Intermittent, short-term use of class VI or VII topical steroids ± topical calcineurin inhibitors
    Treatment of superinfection    		 Bathing and barrier repair∗
    Avoidance of irritant and allergic triggers
    Intermittent, short-term use of class III–V topical steroids ± topical calcineurin inhibitors
    Treatment of superinfection
    Oral antihistamines    		 Bathing and barrier repair∗
    Avoidance of irritant and allergic triggers
    Class II topical steroids for flares; class III–V topical steroids ± tacrolimus ointment for maintenance
    Treatment of superinfection
    Oral antihistamines
    Systemic antiinflammatory agents, ultraviolet light therapy

Disposition

  1. •

    Resolution occurs in approximately 70% of patients by adulthood.

  2. •

    Most patients have a course characterized by remissions and intermittent flares.

Suggested Readings

  • L.A. Beck, et al.: Dupilumab treatment in adults with moderate to severe atopic dermatitis. N Engl J Med. 371:130–139 2014 25006719

  • R. Berke, et al.: Atopic dermatitis: an overview. Am Fam Physician. 86:35–42 2012 22962911

  • S.V. Bershad: In the clinic: atopic dermatitis (eczema). Ann Intern Med. 155 2011 ITC 5–1

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Dermatitis (Patient Information)

Eczema (Patient Information)

 

 

 

 

 

 

 

 

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