1. UNC Department of Family Medicine
Atopic Dermatitis
Adam Goldstein, MD
Associate Professor
UNC Department of Family Medicine
Chapel Hill, NC

2. Objectives
Improve ability to accurately diagnose and manage 90% of cases of atopic dermatitis
Recognize differences in infant, childhood and adult presentations of atopic dermatitis
Improve ability to diagnose and manage conditions associated with and sometimes confused with atopic dermatitis

3. Atopic Dermatitis: Definition
Atopic dermatitis = eczema = itchy skin
Greek- meaning
(ec-) over
(-ze) out
(-ma) boiling
Infants & small children (affects 1 in 7)
Atopic dermatitis of childhood may reappear at different site later in life.

4. Atopic Dermatitis: Cause
The exact cause is unknown.

5. Atopic Dermatitis: Cause
(Charlesworth, Am J Med, 2002)

6. Atopic Dermatitis: Cause
? Inborn skin defect that tends to run in families, e.g. asthma or hay fever
85% with high serum IgE and + skin tests food & inhalant
(Jones, Clin Rev Allergy, 1993)

7. Morphology

8. Distribution
In infants, the face is often affected first, then the hands and feet; dry red patches may appear all over the body.
In older children, the skin folds are most often affected, especially the elbow creases and behind the knees.
In adults, the face and hands are more likely to be involved.

9. Distribution

13. Hand Eczema

14. Foot Eczema

15. Atopic Derm Adults

16. Atopic Derm Adults

17. Atopic Dermatitis: Associated features
The skin is usually dry, itchy & easily irritated by:
soap
detergents
wool clothing
May worsen in hot weather & emotional stress.
May worsen with exposure to dust & cats.

18. Associated Findings
Pityriasis alba

19. Associated Findings
Xerosis

20. Associated Findings
Keratosis Pilaris

21. Associated Findings
Ichthyosis

22. Hyperlinear Palmar Creases

23. Diagnosis Major characteristics Pruritus with or without excoriation
Typical morphology and distribution
Chronic relapsing dermatitis
Personal or family history of atopy (asthma, allergy, atopic derm, contact urticaria)
Other characteristics
Xerosis/Ichthyosis/palmar hyper/kerat. pilaris
Early age of onset
Cutaneous colonization and/or overt infections
Hand/foot/nipple/contact dermatitis, cheilitis, conjunctivitis, Erythroderma, subcapsular cataracts
(Drake, JAAD, 1992)

24. Differential Diagnosis
Seborrheic dermatitis

25. Differential Diagnosis
Seborrheic dermatitis
Scabies

26. Differential Diagnosis
Seborrheic dermatitis
Scabies
Drugs

27. Differential Diagnosis
Seborrheic dermatitis
Scabies
Drugs
Psoriasis

28. Differential Diagnosis
Seborrheic dermatitis
Scabies
Drugs
Psoriasis
Allergic contact dermatitis

29. Differential Diagnosis
Seborrheic dermatitis
Scabies
Drugs
Psoriasis
Allergic contact dermatitis
Cutaneous T-cell lymphoma

30. Atopic Dermatitis: Treatment
1. Reduce contact with irritants (soap substitutes)
2. Reduce exposure to allergens
3. Emollients
4. Topical Steroids
5. Antihistamines
6. Antibiotics
7. Steroid sparing
8. Other (herbals, soaps)

31. 1. Reduce contact with irritants
Avoid overheating: lukewarm baths, 100% cotton clothes, & keep bedding to minimum
Avoid direct skin contact with rough fibers, particularly wool, & limit/eliminate detergents
Avoid dusty conditions & low humidity
Avoid cosmetics (make-ups, perfumes) as all can irritate
Avoid soap- use soap substitute
Use gloves to handle chemicals and detergents

32. Soap Substitutes
Cetaphil- soap substitute- far less drying and irritating than soap
Cleansing & moisturizing formulations, all OTC
Lotion, bar, ‘soap’, cream, sunscreen
Costs about $8-9 for 16 oz.

33. 2. Reduce exposure to allergens
Keep home, especially bedroom, free of dust.
Allergic reactions include house dust mite, molds, grass pollens & animal dander.
Special diets will not help most individuals b/c little evidence that food is major culprit.
If food allergies exists, most likely d/t dairy products, eggs, wheat, nuts, shellfish, certain fruits or food additives.

34. 3. Emollients Emollients soften the skin soft and reduce itching.
Moisture Trapping effectiveness
Best: Oils (e.g. Petroleum Jelly)
Moderate: Creams
Least: Lotions
Apply emollients after bathing and times when the skin is unusually dry (e.g. winter months).

35. Emollients (cont’d)
Large variety (e.g. Vanicream, Eucerin, Lubriderm, Moisturel, Curel, Neutrogena)
Inexpensive emollients include vegetable shortening (Snowdrift by Martha White) and petroleum jelly (Vaseline)
Urea creams
Oils

36. Emollients: Alpha-Hydroxy acid
Creams are excellent for relieving dryness, but can sting & sometimes aggravate eczema
Useful for maintenance when no longer inflamed
Forces epidermal cells to produce keratin that is softer, more flexible and less likely to crack
Preparations
Glycolic Acid (8%)
Lactic Acid or Lac-Hydrin (5-12%)
Urea (3-6%)
Use 1X/ day

37. Emollients: Oils
Consider using bath oil or mineral oil-based lotions in lukewarm bath water
Add to tub 15 minutes into bath
Bath oil preparations:
Alpha-Keri
Aveeno bath
Jeri-Bath
Colloidal oatmeal (Aveeno) reduces itching

38. 4. Corticosteroids Topical steroids very effective
Ointments for dry or lichenified skin
Creams for weeping skin or body folds
Lotions or scalp applications for hair-areas.

39. Corticosteroids Hydrocortisone 1-2.5% applied to all skin.
Quite safe used even for months
Use intermittently thin areas- (eg-face & genitals)
Stronger potency topical steroids for nonfacial/genital regions.
Avoid potent/ultrapotent topical steroid preparations on face, armpits, groins & bottom.

40. Corticosteroids
Once under control, intermittent use of topical corticosteroid may prevent relapse
Systemic steroids may bring under rapid control, but may precipitate rebound
Once daily probably most cost effective
(Green, Br J Dermatol, 2005)

41. Steroids and Young Children
Fluticasone proprionate cream 0.05%
Moderate- severe atopic derm > 3 months
Applied bid 3-4 weeks- mean 64% BSA
No HPA suppression
(Friedlander, J Am Acad Dermatol, 2002)

42. Corticosteroids: Pearls
Different preparations prescribed for different parts of body or for different situations
Educate on
potencies & proper usage
write down directions
Bring all topicals each appointment to clarify use

43. 5. Antibiotics
Atopic eczema frequently secondarily colonized with a bacteria (up to 30%).
Use oral antibiotics in recalcitrant or widespread cases.

45. Keep it simple

47. 6. Antihistamines Oral antihistamines can reduce urticaria & itch
Non-sedating antihistamines less side effects but more expensive
Sedative effect of hydroxyzine & diphenhydramine helpful

48. (Jekler, J Am Acad Dermatol, 1990)
7. Steroid Sparing
Topical calcineurin inhibitors
Tacrolimus ointment & pimecrolimus cream
Oral Cyclosporine
Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation) or combinations of UVA & UVB
(Jekler, J Am Acad Dermatol, 1990)

49. Tacrolimus ointment (0.03%, 0.1% [Protopic])
Mild to moderate eczema
Steroid dependent or signs of atrophy
Non-steroid responsive
BID x 2-4 weeks to evaluate response
Transient stinging possible
Longer disease-free intervals
Cost similar to high potency steroids (30gm/$60)
(Ruzicka, N Engl J Med, 1997)

50. Pimecrolimus cream 1% (15, 30, 100 gm [Elidel])
Approved Dec. 2001
Blocks production/release cytokines T-cells
Moderate eczema
Steroid sparing
Transient stinging 8% children, 26% adults
Cost similar to high potency steroids (30gm/$60)
(Ruzicka, N Engl J Med, 1997)
(Eichenfield, J Am Acad Dermatol, 2002)

51. Tacrolimus ointment & pimecrolimus cream
Licensed for patients > 2 years old mild-moderate eczema\
Safety?
In controlled trials appear safe in adults and children
In 2005, FDA issued warnings about a possible link between the topical calcineurin inhibitors and cancer (? increased risk of lymphoma and skin cancers with topical exposure)
However, no definite causal relationship established     
FDA recommends that these agents are used only as second-line therapy in patients unresponsive to or intolerant of other treatments
Avoid in children younger than two years of age
Use for short periods of time and minimum amount necessary
Avoid continuous use
Avoid in patients with compromised immune systems

52. Ointments (Tacrolimus) better than cream (Pimecrolimus)

53. Oral Cyclosporine and PUVA

54. The patient-oriented eczema measure
Self Monitoring
The patient-oriented eczema measure
(Charman, Arch Dermatol, 2004)

55. Other Psychological support Alternative treatments Chinese herbal tea
Variably effective-not very palatable
Liver toxicity possible

57. Other Evening Primrose Oil / Star Flower Oil
Contains gamma linolenic acid, fatty acid (deficient some atopic subjects)

58. Alternative medications some patients may use for eczema
Licorice
Calendula
Echinacea
Golden Seal
Nettle
Oats

59. Probiotics in primary prevention of atopic disease: a randomized placebo-controlled trial.
Lactobacillus
prenatally to mothers – (FH eczema, AR, asthma)
postnatally for 6 months to infants
Endpoint: Chronic recurring eczema
Eczema in probiotic 50% < than placebo (23% vs 46%)
Number needed to treat = 4.5 (95% CI ).
(Kalliomaki, Lancet 2001)

60. Laughter May Be Best Medicine...For Allergies
Other
Laughter May Be Best Medicine...For Allergies
NEW YORK, NY - Although few would consider allergies to be funny, results of a new study suggest that laughing them off might actually work. Dr. Hajime Kimata, of Unitika Central Hospital in Japan, induced allergic responses on the skin of 26 people with allergic dermatitis by exposing them to house dust mites, cedar pollen and cat hair, and then had them watch ``Modern Times'', featuring Charlie Chaplin. The participants exhibited a significant reduction in their allergic responses after watching the classic comedy, according to the report in the February 14th issue of The Journal of the American Medical Association. The effect lasted for 4 hours after the viewing

61. Other
Coal tar or less messy preps (liquid carbonis detergent 5-10%) in Eucerin or Aquaphor
Chronic lichenified eczema patches
Coal tar smells & stains clothes so apply qhs using old clothes and old linens
Coal tar can provoke a folliculitis.

62. Soaps Mild or Hypoallergenic Dove (unscented): Contains lotion Keri
Oil of Olay
Basis
Purpose
Cetaphil Skin Cleanser (non-soap)
Neutrogena bar
Pure Ivory soap is very drying/irritating

63. Antibacterial Soaps Dial and Lever 2000
Cetaphil antibacterial cleansing bar

64. Evidenced-based review 2002 (BMJ Clinical Evidence)
Positive evidence that:
topical corticosteroids relieve symptoms and are safe
emollients & steroids better than steroids alone
excellent control of house dust mite reduces symptoms if positive mite RAST scores & children
bedding covers most effective
Little to no evidence that:
dietary change reduces symptoms
breast feeding or mother's diet prevents infant eczema

65. Systematic review 2000 Positive evidence: Topical steroids
Insufficient evidence
Ag avoidance pregnancy
Antihistamines
Dietary restriction
Dust mite avoidance
Hypnotherapy
Emollients
Massage
Evening primrose oil
Topical coal tar
Topical doxepin
Chinese herbs
Positive evidence:
Topical steroids
Oral cyclosporine
UV light
Psychological approaches
(Hoare, Health Technol Assess, 2000)

66. Bid vs qd topical steroids Bath additives
Systematic review
Not beneficial:
Cotton clothing
Biofeedback
Bid vs qd topical steroids
Bath additives
Topical antibiotic/steroids vs steroids alone
(Hoare, Health Technol Assess, 2000)

67. Final Pearls Educate parents that the goal is CONTROL not CURE
Atopics exposed to herpes virus or smallpox vaccination may get severe infection with widespread involvement d/t altered skin barrier.

68. Severe herpes infections in children with eczema

69. Atopic Derm and Smallpox Vaccine
(Ann Intern Med 2003;139)

70. Costs H/C 1% Bid-tid 30 gm $3.00 TAC 0.1% Bid $8.00
Fluticasone propionate 0.05%
Qd-bid
$42.00
Mometasone furoate 0.1% Qd
$45.00
Betamethasone dipropionate 0.05%
$20.00
Clobetasol propionate 0.05%
$15.00
Halobetasol propionate 0.05%
$72.00
Pimecrolimus 1%
$56.00
Tacrolimus 0.1%
$60.00
Drugstore.com 2004

71. CASE 1
3 year old female with h/o eczema since 4 months old. Had done well on hydrocortisone 2.5% ointment when flared last winter. Parents ran out of the ointment and have been using vaseline and OTC hydrocortisone 0.5% without improvement. Child is now waking at night and constantly scratching.
What do you want to do?

72. Case Treatment strategy:
Review mild skin care regimen
Confirm use of
mild cleanser
daily moisturizers &
mild laundry detergent
Prescribe sufficient potency & quantity of topical corticosteroids
Which steroid class(es) would you px?

73. Case- topical steroid choices
TAC 0.1% oint. bid worse areas x 7-14 days
Switch to H/C 2.5% ointment BID
Taper over 4 weeks to emollients if possible
Confirm parents understand dangers of prolonged steroid use and not to use potent steroids on face

74. F/U 2 weeks later:
Only slightly improved- now what?

75. Now... Add oral antistaphylococcal agent for 7-14 days.
REVIEW mild skin care regimen
Follow-up in 2 weeks and SUCCESS!

76. CASE 2
34 yo female with h/o hand eczema diagnosed by former MD for 6 years. Seems to get worse in winter, but never goes away entirely. A friend told her it could be a fungus. She was given fluocinonide (lidex) 0.05% cream and it helps some. She wants a refill.

77. CASE 2 Not likely fungus given chronicity
May have secondary staph infection
May need more potent Class I steroid initially, e.g. clobetasol propionate (temovate) ointment
Class II Fluocinonide (lidex) 0.05% cream ok less severe

78. Case 3 75 YO male with chronic itchy spots-
Using hydrocortisone cream 2.5% bid to ankle- minimal improvement
Using Class II Fluocinonide (lidex) 0.05% ointment under occlusion to hip area- “only thing that works”

79. Case 3
2.5% H/C too weak
Fluocinonide (lidex) 0.05% ointment under occlusion causing atrophy
Good case for topical tacrolimus

80. Patient Education
National Eczema Association

81. Thank you.

82. References
Drake LA, et al. Guidelines of Care For Atopic Dermatitis. J Am Acad Dermatol 1992;26:485-8.
Atopic eczema. In Clinical Evidence British Medical Journal Available online at
Correale CE, Walker C, Murphy L, Craig TJ. Atopic Dermatitis: A Review of Diagnosis and Treatment. J Fam Pract 1999; available at
Ruzicka T, Bieber T, Schopf E, et al. A short-term trial of tacrolimus ointment for atopic dermatitis. European Tacrolimus Multicenter Atopic Dermatitis Study Group. N Engl J Med 1997; 337(12):
Eichenfield LF, LuckyAW, Boguniewicz M, et al. Safety and efficacy of pimecrolimus cream 1% in the treatment of mild and moderate atopic dermatitis in children and adolescents. J A Acad Dermatol 2002; 46;

83. References
Charlesworth EN . Pruritic dermatoses: overview of etiology and therapy. Am J Med 2002; 113S, 9A: 25S-33S.
Wahn U, et al. Efficacy and safety of pimecrolimus cream in the long-term management of atopic dermatitis in children. Pediatrics 2002; 110 (1 Pt 1): e2.
Friedlander SF, et al. Safety of fluticasone proprionate cream 0.05% for the treatment of severe and extensive atopic dermatitis in children as young as 3 months. J Am Acad Dermatol 2002; 46:
Hoare C, et al. Systematic review of treatments for atopic eczema. Health Technol Assess 2000; 2:
Green C, Colquitt JL, Kirby J, Davidson P. Topical corticosteroids for atopic eczema: clinical and cost effectiveness of once-daily vs. more frequent use. Br J Dermatol 2005; 152:
Charman CR, Venn AJ, Williams HC. The patient-oriented eczema measure: development and initial validation of a new tool for measuring atopic eczema severity from the patients' perspective. Arch Dermatol 2004; 140: