Definition
A.Dermatitis means inflammation of the skin. It is a broad description describing an abnormal finding of the skin. Causes may be mechanical, environmental, allergic, viral, bacterial, fungal, parasitic, inflammatory, autoimmune (drug, lupus, psoriasis), neoplastic, and occasionally a combination. Treatment requires removing the offending agent and decreasing the inflammation to allow the skin to repair.
B.The most important thing for the new acute care advanced practice provider (APP) is to differentiate and determine whether a skin finding is acute, chronic, and/or emergent. If it is emergent, decide whether it is a condition you can treat yourself or if it requires a consult for dermatology, or if other hospital team specialists are needed.
C.Chronic pruritic inflammatory skin disease is common on flexural areas; this is associated with allergic rhinoconjunctivitis, asthma, and food allergies.
D.Most develop rash after scratching.
Incidence
A.May occur at any age.
1.Typically starts in childhood and may continue through adulthood.
2.About 1% to 3% of adults.
B.In past few decades, it has increased to around 30% for most industrialized countries versus around 10% in other countries.
C.High latitude.
D.Peaks during cold dry weather.
Pathogenesis
A.Thought to be caused by defective skin barrier for healing and maintaining skin integrity, but true cause remains unknown.
Predisposing Factors
A.Family history of atopic dermatitis (AD).
B.Breakdown of skin.
1.Dry skin.
2.Abrasion or injury.
3.Contact dermatitis (allergies, irritants).
C.Seasonal, environmental, or food allergies.
D.Dry weather.
E.Heat.
F.Stress.
Subjective Data
A.Common complaints/symptoms.
1.Itch.
2.Dry skin patches.
3.Burning.
B.Common/typical scenario.
1.Chronic rash that comes and goes.
a.Worse in cooler months; better in summer.
b.Flares with different exposures and seasons.
C.Family and social history.
1.Family history of AD.
2.Frequent hand washer or bather.
D.Review of systems.
1.Usually negative except for cold hands/feet.
2.Seasonal allergies.
Physical Examination
A.Dry erythematous patches.
B.Lichenification of older lesions.
C.Crusting and oozing may happen with and without infection (may be impetiginized).
D.Excoriations (scratched areas).
E.Locations tend to be on face and flexural folds of neck, arms, trunk, legs, wrists, and ankles (see Figure 15.1A and 15.1B).
Diagnostic Tests
A.Potassium hydroxide (KOH) preparation should be negative.
B.Skin biopsy: New lesions are preferred over older lesions that have either been lichenified or burnt out
; hyperpigmented macules and patches may represent postinflammatory hyperpigmentation and not active rash.
Differential Diagnosis
A.Tinea (corporis, gruris, versicolor, manis, pedis).
B.Seborrheic dermatitis.
C.Stasis dermatitis.
D.Scabies.
E.Psoriasis.
F.Contact dermatitis.
G.Molluscum contagiosum.
H.Mycosis fungoides/cutaneous T cell lymphoma.
Evaluation and Management Plan
A.General plan.
1.Avoid triggers.
2.Avoid exacerbations (dry heat, excessive washing/bathing, contact with irritants, or use of irritants).
3.Maintain skin integrity through moisturization and decreasing inflammation.
B.Patient/family teaching points.
1.Practice gentle skin care.
a.Limit bathing to 5 minutes once daily at the most.
b.Limit soap use.
c.Use gentle nonsoap cleansers only.
d.Do not use loofah or washcloth, only use hands to wash body.
e.Only wash dirty
areas: Face, axilla, genitalia, groin, hands, and feet.
f.When drying after bathing pat skin dry gently; do not rub.
g.For flares, apply topical medications within 5 minutes of leaving shower/bath.
h.For nonflared areas and daily maintenance, apply moisturizer within 5 minutes of leaving shower/bath.
i.Avoid wool clothing.
j.Use hypoallergenic laundry detergents, hand soaps, body soaps, facial cleansers, and moisturizers.
k.Use humidifier.
2.Decrease stress.
3.Avoid scratching.
4.Treat early to help limit amount of topical/oral steroids needed.
C.Pharmacotherapy.
1.Topical cream.
a.Moisturizers.
i.Lotions: Tend to not hold moisture in skin despite containing more water than creams and ointments.
ii.Creams: Help lock in moisture better than lotions. Examples: Aveeno cream, Cetaphil cream, CeraVe cream, Eucerin cream, Lubriderm cream, Vanicream.
iii.Ointments: Help lock in moisture better than creams. Examples: Vaseline, petroleum jelly.
iv.Barrier creams: Zinc oxide.
2.Topical steroid, typically twice daily for two consecutive weeks.
a.Low potency for face, neck, groin, inner thighs, and buttocks.
b.Medium potency for other areas.
c.High potency for hands and feet.
3.Oral steroid: Prednisone.
4.Antihistamines.
a.Low to medium strength: Claritin, Zyrtec, Benadryl.
b.Medium to high strength: Hydroxyzine.
5.Phototherapy: Refer to dermatology.
6.Treat any secondary infections with oral therapy (viral, bacterial).
D.Discharge instructions (if standard accepted guidelines exist please use discharge template): If develops systemic signs of toxicity return to emergency department (ED).
Follow-Up
A.Primary care provider in 1 week.
B.Dermatology in 1 to 3 months depending on severity.
Consultation/Referral