Atopic Dermatitis

Dermatitis Pattern of cutaneous inflammation – Acute: erythema, vesicles, pruritis – Chronic: dryness, scaling, lichenification, fissuring, pruritus E.g. seborrheic, atopic, contact

Basics Chronic, pruritic, inflammatory skin disease with a wide range of severity Affects up to 20% of children and 1-3% of adults Atopic triad Primary symptom: pruritus (itch) – Hence, AD is often called “the itch that rashes” – Periods of remission & exacerbation

Note Eczema=/= Atopic dermatitis Atopic dermatitis is a specific type of eczematous dermatitis

Clinical Findings Erythematous papules, which coalesce to form erythematous plaques that may display weeping, crusting, or scale Distribution by age: – Infants: cheeks, forehead, scalp, extensors – Older children: flexors of the neck, elbows, wrist, and ankles – Adults: flexors of the hands, wrists, ankles, feet, and face (forehead, around the eyes)

Infants & toddlers

More examples

Older children & adolescents

Pathogenesis Not clearly understood Probably multifactorial Factors thought to play a role: – Genetics – Skin barrier dysfunction – Impaired immune response – Environment

Treatment Avoidance of triggers and irritants Gentle skin care Combination of short term treatment for flares + longer-term treatment for symptoms between flares

4-pronged approach -Moisturizer -Anti-inflammatory -Topical steroids -Topical calcineurin inhibitors -Anti-pruritus -antihistamines -Antibacterial

Notes Safe for short intervals with intermittent breaks Increase potency to control inflammation, then stop for break Avoid potent steroids in areas of the face, folds, or occluded areas (under diaper)

Take Home Points AD is a chronic, pruritic, inflammatory skin disease Distribution varies by age Pathogenesis is multifactorial Treatment: moisturizer, anti-inflammatory, antipruritic, antibacterial

Contact Dermatitis

Basics Skin condition created by a reaction to an externally applied substance Two types of CD: – Allergic CD – Irritant CD

ACD Occurs when contact with a particular substance-> delayed hypersensitivity reaction Which type? Sensitization process: days Common causes: – Poison ivy, fragrances, formaldehyde, preservatives, nickel, rubber, topical antibx

ACD: Clinical Findings Pruritus (itching) Eczematous, scaly edematous plaques with vesicles in areas of exposure

Rhus Dermatitis

Medication allergy

Nickel Dermatitis

Latex allergy

History Important to take comprehensive hx Onset Location Temporal associations Daily skin care routine, topical products, occupation/hobbies, regular and occasional exposures (lawn care products, animal shampoos)

Treatment Avoidance of allergens – Patch testing Acute – Mild to moderate: topical steroids of medium to strong potenncy – Short course of systemic steroids for acute flares – Wet dressings for extensive oozing/crusting Chronic or > 10% BSA – Refer to dermatology

Patch testing

ICD Inflammatory reaction from exposure to substance that can cause an eruption in most people who come in contact with it No previous exposure necessary May occur from single application, but most commonly from repeated application

ICD: basics Accounts for 80% of all contact dermatitis Often occupation-related Remains at site of contact and resolves in a few days after exposure (ACD: 1-3 wks)

Factors at play Multifactorial – Exogenous (irritant, environmental) – Endogenous (host)

ICD: Clinical Findings Erythema, chapped skin, dryness and fissuring Pruritus Pain when erosions and fissures are present Severe cases: edema, exudate, tenderness

Examples

Treatment Avoidance of irritant – Patient education – Personal protective equipment – Less irritating hygiene products Topical steroid-> reduce inflammation Emollients-> improve barrier repair Patch testing to r/o ACD

Take Home Points Contact dermatitis: ACD and ICD ACD= when contact elicits delayed hypersensitivity reaction ICD= exposure to substance that can cause an eruption in most people Identification and avoidance