Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Atopic Dermatitis
ATOPIC DERMATITIS
Atopic dermatitis is a chronic, intensely pruritic inflammation of the skin. It is characterized by a course marked by exacerbations and remissions. Atopic dermatitis is commonly known as the “itch that rashes” because the rash usually does not develop if the itch is controlled.
I. Etiology
A. Immunologic abnormalities with elevated serum IgE levels
B. Genetic susceptibility
C. Immune dysfunction
D. Epidermal barrier dysfunction
E. Foods, chemicals, and aeroallergens may cause or exacerbate atopic dermatitis.
II. Incidence
A. Most common type of infantile eczema
B. Seen in 10% to 15% of all children
C. Approximately 70% of patients have a family history of atopy.
D. Fifty percent of children with atopic dermatitis develop allergic rhinitis or asthma.
E. Sixty percent to 80% of affected children have onset of disease before 1 year of age; 90% of children manifest disease by age 5.
F. Rare in infants under 2 months because the itch-scratch cycle does not mature until 3 months of age.
III. Subjective findings
A. Marked pruritus; primary symptom
B. Dry skin
1. Scaly
2. Cracked
3. Thickened
C. Skin may be oozing or bleeding
D. May have areas of secondary infection
E. Distribution
1. Infant phase, 2 months to 2 years
a. Scalp
b. Face: Cheeks, chin
c. Neck
d. Chest
e. Extensor surfaces of extremities
2. Childhood phase, 2 years to 10 years: Often localized in flexor folds of
a. Neck
b. Elbows
c. Wrists
d. Knees
3. Adolescent phase: Located primarily in
a. Flexor areas
b. Around eyes
c. Persistent hand dermatitis
F. Pertinent subjective data to obtain
1. Family history of atopy
2. Diagnosis of rhinitis or asthma in child
3. Detailed history of rash
a. Age of onset: Generally develops at an early age.
b. Distribution
c. Episodes exacerbated by foods, emotional stress, physical stress, aeroallergens (pollens, molds, mites, animal dander), thermal changes, types of clothing, powders, soaps, laundry products
d. Heightened response to normal stimuli
e. Treatment used and what was effective
4. History of inflammation of skin accompanied by severe itching: Once itch-scratch cycle is established, skin changes occur and skin becomes dry and scaly with characteristic lesions.
IV. Objective findings
A. Inspect entire body.
1. Skin
a. Xerosis
b. Lichenification
c. Excoriations
d. Cracks and fissures
e. Secondary infection
f. Confluent, erythematous, papular lesions
g. Atypical vascular response, facial pallor, dermatographism, delayed blanch response.
2. Respiratory system
a. Signs of allergic rhinitis
b. Signs of allergic conjunctivitis
c. Signs of asthma
3. Regional lymphadenopathy with secondary infection
B. Laboratory tests: If history is suggestive of food allergies, skin testing and Radioallergosorbent test (RAST) should be ordered.
V. Assessment
A. Diagnosis is clinical: Based on history and clinical findings such as pruritus, typical morphology and distribution of rash, chronic or relapsing, personal or family history of atopy.
B. Differential diagnoses
1. Contact dermatitis: History of exposure, distribution of rash, negative history of atopy
2. Seborrheic dermatitis: Greasy, scaly lesions, negative history of atopy
3. Psoriasis: Distribution of rash (extensor surfaces), lesions with silvery scales, nails may be pitted
4. Scabies: Papules, involvement of interdigital spaces, positive skin scrapings
VI. Plan
The goals of treatment are to control itching, get rash under control, decrease inflammation, repair the skin, prevent flares, moisturize skin, reduce risk of infection, and aggressively treat concurrent infection.
A. Maintenance phase: “Soak and seal”
1. Bathe daily for 5 to 10 minutes in warm water with mild soap (Dove, Aquanil, or Cetaphil lotion); pat dry.
2. Moisturize immediately after bathing (within 3 minutes). Use one of the following:
a. Aquaphor lotion
b. Eucerin cream or lotion
c. Nivea cream or lotion
d. Moisturel lotion
e. Petrolatum
f. Note: Ointments penetrate the dermis better and are superior for all but the most acute exudative lesions but are not tolerated as well because they are greasy and messy. Creams are effective and are better tolerated by child and family. Lotions are not as effective but are preferred for scalp applications.
3. Mimyx Cream, tid
a. Available by prescription
b. No age restrictions
c. Steroid-free
d. Restores skin barrier
e. Use as maintenance to extend remission.
f. Avoid sun exposure.
4. Antihistamines to control pruritus
a. Atarax: For children under 6 years of age, 50 mg/d in divided doses; for children over 6 years of age, 50 to 100 mg/d in divided doses
or
b. Benadryl: For 2 to 6 years of age, 6.25 mg every 4 to 6 hours (maximum 37.5 mg/d); for 6 to 12 years of age, 12.5 mg every 4 to 6 hours (maximum 150 mg/d)
c. Atarax and Benadryl are sedating but more effective in controlling pruritus than newer, nonsedating antihistamines.
B. Mild flare or breakthrough symptoms
1. Continue maintenance phase.
2. 1% hydrocortisone cream for face and intertriginous areas.
3. Lowto mid-potency topical corticosteroid (see Appendix I, p. 535)
4. Antihistamines: Adjust the dosage to control pruritis.
C. Moderate to severe flare
1. Continue maintenance phase.
2. 1% hydrocortisone cream for face and intertriginous areas.
3. Increase potency of topical corticosteroid (see Appendix I, p. 535)
4. Antihistamines: Maximize the dosage to control pruritis.
D. Second line of therapy for moderate to severe if symptoms do not resolve with above treatment. Use for short-term or intermittent therapy.
1. Continue maintenance.
2. Topical immunomodulator for children over 2 years of age
a. Tacrolimus (Protopic): 0.03% ointment
(1) For moderate to severe breakthrough
(2) Apply thin layer twice daily to affected areas.
(3) Continue for one week after resolution of flare.
b. Pimecrolimus (Elidel): 1% cream
(1) For mild to moderate breakthrough
(2) Apply thin layer twice daily to affected areas.
(3) Continue use until resolved.
E. Severe, refractory atopic dermatitis
1. Prednisone 2.5 mg/kg/d for 10–14 days.
a. Taper off by day 14.
b. May flare after cessation.
c. Usually clears for months after course of treatment.
F. Secondary infection: Anti-staphylococcal antibiotics
1. Dicloxacillin: Under 40 kg, 12.5 to 25 mg/kg/d in four divided doses for 10 days; over 40 kg, 125 to 250 mg qid
2. Augmentin: Under 40 kg, 45 mg/kg/d every 12 hours (oral suspension or chewables only); over 40 kg, 500 mg every 12 hours (dosed according to adult recommendations)
3. Keflex: 25 to 50 mg/kg/d every 12 hours; over 20 kg, 250 to 500 mg every 12 hours
G. Topical steroid preparations
1. Do not use with occlusive wrapping (i.e., saran wrap); increases systemic absorption.
2. Use does not replace frequent and regular use of moisturizers.
3. Use nonfluorinated products to circumvent adrenal suppression and skin atrophy.
4. Ointments sting less than creams and penetrate dermis better; avoid use of ointment with acute, exudative lesions.
5. Use lowest potency that controls symptoms but an adequate enough potency to treat effectively.
6. Use only 1% hydrocortisone cream on face and intertriginous areas.
7. Continue use until flare is controlled, then continue treatment with maintenance regimen.
H. Topical immunomodulators
1. Indicated for short-term and intermittent therapy for the nonimmunocompromised children who have had inadequate clinical response to topical corticosteroids
2. Use for children over 2 years of age.
3. With tacrolimus, studies show 90% improvement in 12 weeks; with pimecrolimus, studies show 35% of patients were clear or almost clear at 6 weeks.
4. Do not use with occlusive dressings.
5. May cause local irritation, including vesiculobullous rash
6. May be used on face, hands, neck, and other sensitive areas
7. Have minimal systemic absorption
8. Have no significant adverse effects
9. Do not cause skin atrophy
10. Do not use with active cutaneous infection.
I. Step down treatment once control is achieved.
VII. Education
A. Control of itching is crucial to treatment. Itching and resultant scratching causes skin changes, such as thickening, excoriations, and secondary infections, and sleep disruption.
1. Moisturize frequently.
2. Keep nails short and clean.
3. Use cotton gloves at night.
B. Explain to child and parent that atopic dermatitis is the “itch that rashes” and the importance of aborting the itch-scratch cycle.
C. Atopic dermatitis may wane in time; however, 30% to 80% of children will have exacerbations throughout life, particularly when under physical or emotional stress. Child and parent should understand that this is a chronic, recurrent problem.
D. Do not expose to individuals with varicella, herpes simplex, herpes zoster. If exposed, call for VZIG administration after exposure.
E. If symptoms are exacerbated by exposure to aeroallergens (pollens, molds, animal dander, mites), use environmental control (see protocol for Environmental Control, p. 291).
F. Avoid temperature extremes, excessive humidity, or extreme dryness.
G. Use absorbent, nonocclusive, nonirritating clothing. Cotton clothing is preferable.
H. Launder clothing and linens with mild soap, thoroughly rinse, and avoid fabric softener.
I. Bathing: Use mild soap (Dove), Cetaphil, or baby bath.
J. Apply moisturizer within 3 minutes after bathing to trap moisture in skin.
K. Use frequent applications of bland lubricants or creams. Ointments are most effective but are greasy. Creams are more effective than lotions and better tolerated by child and family.
L. Avoid foods that trigger inflammation.
M. Skin testing and RAST have frequent false-positive results, but if negative, can free child from restrictive diet.
N. Address psychosocial issues for child and family. Incessant scratching and continual use of messy creams and emollients can cause stress within family.
O. Follow treatment plan carefully. Do not overuse medications.
P. Avoid sun exposure; use sunscreen. Studies indicate children with atopic dermatitis have a shorter time to squamous cell carcinoma development.
Q. Child is more prone to fungal infections; Molluscum contagiosum and Verruca vulgaris spread more intensely.
VIII. Follow-up
A. Follow-up must be individualized for each patient according to the severity and extent of atopic dermatitis.
B. Acute exacerbation
1. Return in 1 to 2 weeks to evaluate effectiveness of treatment and compliance with treatment.
2. Potency of topical corticosteroid may need to be adjusted.
C. Secondary infection: Return prn if not improved, or if improvement noted initially and then infection worsens.
D. Routine follow-up
1. Return in 3 to 4 weeks to assess results of maintenance treatment.
2. Return visits as indicated by response to and compliance with treatment
IX. Complications
A. Secondary bacterial infection
B. Psychosocial issues
C. Secondary cutaneous viral infections (vaccinia)
D. Eczema Herpeticum: Widespread lesions in child with herpes simplex
X. Referral
A. Recalcitrant atopic dermatitis for consideration of treatment with phototherapy
B. To allergist for identification of potential allergen triggers
C. Immunocompromised children
D. Children exposed to varicella, herpes simplex, herpes zoster
American Academy of Allergy, Asthma, and Immunology. Address: 611 East Wells Street, Milwaukee, WI, 53202. Telephone: 414-272-6071. Website: http://www.aaaai.org
American Academy of Dermatology. Address: 930 N. Meacham Road, Schaumburg, IL, 60173. Telephone: 888-462-DERM. Website: http://www.aad.org
American College of Allergy, Asthma and Immunology. Address: 85 West Algonquin Road, Suite 550, Arlington Heights, IL, 60005. Website: acaai.org
American Academy of Pediatrics. Address: 141 Northwest Point Boulevard, Elk Grove Village, IL, 60007-1098. Telephone: 847-228-5005. Website: http://www.aap.org