ATOPIC

DERMATITIS
 Goals and Objectives
▪ The purpose of this module is to help develop a clinical
approach to the evaluation and initial management of patients
with atopic dermatitis.

▪ After completing this module, the learner will be able to:

• Identify and describe the morphology of atopic dermatitis
• Recognize the role of secondary infections in atopic dermatitis
• Recommend an initial treatment plan for a child with atopic dermatitis
• Provide patient/parent education about skin care for a child with atopic dermatitis
• Determine when to refer a patient with atopic dermatitis to dermatologist

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Atopic Dermatitis (AD)
• chronic, highly pruritic (itchy) inflammatory
skin disease.
• one of the most common skin disorders in
children
• The disorder results in significant morbidity
and adversely affects quality of life.
• The intense itching characteristic of the
disease often leads to skin trauma and
significant sleep disturbances
AD is a primary skin barrier defect
that facilitates the development of
other atopic condition

It is often the initial step in the

“atopic march”

may also be a causative factor in the

development of food allergy.
 AD often starts in early infancy;

approximately 45% of all cases begin within the

first 6  months of life
Epidemiology
60% during the first year,

5% before 5  years of age.

up to 70% of children with AD will go into

clinical remission before adolescence.
•children with AD are at high risk of developing food allergies, asthma and
allergic rhinitis.

•Severe AD in infancy is a major risk factor for allergies to egg and peanut.

•AD of increased severity and chronicity is particularly associated with

food allergy, and that it precedes the development of food allergy,
suggesting a causal relationship .
•
When to refer to • Urgent (within 2 weeks) referral for
Dermatologist? specialist dermatological advice is
recommended for children with atopic
dermatitis if:

1. the atopic dermatitis is severe and has not

responded to optimum topical therapy
after 1 week

2. treatment of bacterially infected atopic

dermatitis has failed.
• Referral for specialist dermatological advice is recommended for
children with atopic dermatitis if:

1. the diagnosis is, or has become, uncertain

2. management has not controlled the atopic dermatitis satisfactorily based on
a subjective assessment by the child, parent or carer (for example, the child
is having 1–2 weeks of flares per month or is reacting adversely to many
emollients)
3. atopic dermatitis on the face has not responded to appropriate treatment
4. the child or parent/carer may benefit from specialist advice on treatment
application (for example, bandaging techniques)
5.) contact allergic dermatitis is suspected (for example,
persistent atopic eczema or facial, eyelid or hand atopic
eczema)

6.) the atopic dermatitis is giving rise to significant social or

psychological problems for the child or parent/carer (for
example, sleep disturbance, poor school attendance)

7.) atopic dermatitis is associated with severe and recurrent

infections, especially deep abscesses or pneumonia.
 PATHOGENESIS
• The cause of AD is multifactorial and not
completely understood
• The following factors are thought to play varying roles:
– Genetic predisposition
– Skin barrier dysfunction
– Immune dysregulation
– Environment
 PATHOGENESIS

• Type 1 hypersensitivity (IgE-mediated) reaction as a result of the

release of vasoactive substances from mast cells & basophils that
have been sensitized by the interaction of the antigen with IgE.

• More likely to be a disorder of the immune system – Defective cell-

mediated immunity.
SKIN SYMPTOMS:

• Dry skin

• Pruritus is the Sine Qua Non of Atopic Dermatitis, “Eczema is the

itch that rashes.”

• Constant scratching leads to vicious cycle of itch > Scratch >

Rash > Itch (rash is the lichenification of the skin).
 CLINICAL MANIFESTATION

ACUTE:
poorly defined erythematous patches, papules with or
without scale, skin is “puffy” & edematous, erosions, crusted,
excoriations (from scratching),secondarily infected (S.
aureus), pustules.
 CHRONIC :
•LICHENIFICATION

•FISSURES

•ALOPECIA- lateral 1/3 of eyebrows from rubbing of eyelids

•PERIORBITAL HYPERPIGMENTATION

•DENNIE-MORGAN SIGN – characteristic infraorbital fold

in the eyelids
 INFANTILE
ATOPIC
DERMATITIS
excoriations
SKIN LESIONS :
●ACUTE
➢ERYTHEMA, EDEMA W/ OR W/OUT SCALES
➢PUFFY & EDEMATOUS
ATOPIC DERMATITIS
CLINICAL
MANIFESTATIONS
●ACUTE
➢ EROSIONS
●CHRONIC
➢ LICHENIFICATIONS
CLINICAL MANIFESTATIONS
●CHRONIC
➢INFRAORBITAL FOLD IN THE EYELIDS = DENNIE MORGAN
DISTRIBUTION
➢FLEXURES
• DISTRIBUTION
➢ FRONT & SIDES OF NECK
DISTRIBUTION
➢ EYELIDS = DENNIE MORGAN
• DISTRIBUTION
➢ FACE (FOREHEAD & CHEEKS)
DISTRIBUTION
➢ DORSA OF THE HANDS & FEET
DIAGNOSIS

• History in infancy, clinical findings

• Of the major features: Pruritus, Chronic

or remitting eczematous dermatitis with
typical morphology and distribution are
essential for diagnosis

• Other features:
• Allergy or elevated IgE
• Severe Combined Immunodeficiency Syndrome –
• Infants presenting in the first year of life with failure to thrive,
diarrhea, a generalized scaling erythematous rash, and recurrent
cutaneous and/or systemic infections

• Wiskott–Aldrich syndrome
• Cutaneous findings almost indistinguishable from AD
• thrombocytopenia,
• variable abnormalities in humoral and cellular immunity, and
• recurrent severe bacterial infections
• It is important to recognize that an adult who presents
with an eczematous dermatitis with :
• no history of childhood eczema, respiratory allergy, or
atopic family history may have allergic contact
dermatitis
MANAGEMENT
4 MAJOR
COMPONENTS Anti Inflammatory

Antibacterial

Antipruritic

Moisturizer
Topical Steroids
-are the first-line pharmacologic treatments for AD.
-used to treat acute inflammation.
-effectively control atopic flares through their anti-inflammatory, antiproliferative, and
immunosuppressive actions.
-applied to the red, itchy or inflamed areas on the skin.
-Ointments are preferred vehicles over creams.
-least potent preparation required to control AD (particularly in sensitive areas such as the face, neck,
groin and underarms) should be utilized.
-local side effects of long-term topical corticosteroid use : striae (stretch marks), petechiae (small
red/purple spots), telangiectasia (small, dilated blood vessels on the surface of the skin), skin thinning,
atrophy and acne.
 Topical Steroid Strength
Potency Class Example Agent
• Remember to look at the class not the Super I Clobetasol 0.05%
high
percentage
High II Fluocinonide 0.05%
• Clobetasol 0.05% is stronger than Medium III – V Triamcinolone ointment 0.1%
hydrocortisone 1% Triamcinolone cream 0.1%
Triamcinolone lotion 0.1%
• When several are listed, they are listed in
Low VI – Fluocinolone 0.01%
order of strength VII Desonide 0.05%
Hydrocortisone 1%
• Triamcinolone ointment is stronger Hydrocortisone 2.5%
than triamcinolone cream or lotion
because of the nature of the vehicle
Topical Calcineurin Inhibitors
-TCIs are immunosuppressant agents that have also been shown
to be safe and effective for the treatment of AD, as well as the
prophylaxis of AD flares.
-second line agents
-TCIs—pimecrolimus and tacrolimus
-reserved for patients with persistent disease and/or frequent fares
that would require continuous topical corticosteroid treatment, or in
patients severely affected in sensitive skin areas.
-local adverse effects of TCIs: skin burning and irritation
Moisturizer
• May be the primary treatment for mild disease and must be part of the
regimen for moderate and severe disease.

• Reduces frequency and severity of flares.

• Greasier ointments are better in general.

• However, greasier preparations can be unpleasant for some patients, and

adherence may suffer
Antihistamines
-sedative effects of these agents found to help improve sleep
in patients with AD.
Antibacterial therapy
-secondary infection is present (S. aureus)
-unresponsive to the 1st line topical treatments.
-systemic antibiotics are indicated for widespread secondary
infection.
-first or second generation cephalosporins or anti-
staphylococcal penicillins for 7–10 days are usually effective
in managing the infection.
Phototherapy
-Ultraviolet (UV) phototherapy may be beneficial for the
treatment of AD in adults.
-has a potential for chronic AD and maintenance treatment.
-caution in fair skin and prior history of skin malignancy.
-only for adults and >12 years of age with recalcitrant AD.
 Bathing
• Bathing once or twice daily in warm water for 10–15  min.
• Application of moisturizers soon after bathing is
necessary to maintain good hydration.
• Limited use of soap and cleansers
• Dilute bleach baths (sodium hypochlorite) have been
shown to help reduce AD severity
– 6% household bleach, twice weekly for 10 min, ½ cup to full
bath, ¼ cup to half bath or 1-2 capfuls to baby bath
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 5 Pillars of
Management of AD
• Education and empowerment of patient and caregivers.
• Avoidance and modification of environmental trigger
factors.
• Rebuilding and maintenance of optimal barrier function.
• Clearance of inflammatory skin disorders.
• Control and elimination of the itch-scratch cycle.
 PREVENTION AND PROGNOSIS
• Although there are currently no established primary
prevention strategies for AD, recent trials have
demonstrated the effectiveness of early, consistent
application of emollients for infants at increased risk.
• This simple and cost-effective approach has resulted in a
30–50% reduction in the diagnosis of AD at 6 months.
• Other trials to prevent AD have included usage of dust
avoidance and dust covers for mattresses.
• Prenatal and postnatal (maternal and child)
supplementation of Lactobacillus rhamnosus has shown
promise in prevention.
• Avoidance of known triggers can prevent flare ups.
Avoidance of foods that trigger allergies also help keep flare
ups at bay.
Avoiding secondary infections:
• To avoid secondary infections due to itching and resultant
scratching of the areas, some measures may be taken. With
scratching over time the skin becomes rough and thickened as
well.

• The measures include keeping fingernails very short, smooth and

clean, applying moisturizer when feeling itchy and keeping hands
elsewhere when feeling itchy. There are medications that can
reduce the itchiness.
Provide patient/parent education about skin care for
a child with atopic dermatitis.
Help prevent or treat eczema by keeping your child's skin from
getting dry or itchy and avoiding triggers that cause flare-ups.
Some suggestions as follows:
• Kids should take short baths or showers in warm (not hot)
water. Use mild unscented soaps or non-soap cleansers and
pat the skin dry before putting on cream or ointment. Teens
should use unscented makeup and oil-free facial moisturizers.
• Ask your doctor if it's OK to use oatmeal soaking products in the bath to
help control itching.
• Kids should wear soft clothes that "breathe," such as those made from
cotton. Wool or polyester may be too harsh or irritating.
• Keep your child's fingernails short to prevent skin damage from
scratching. Try having your child wear comfortable, light gloves to bed if
scratching at night is a problem.
• Kids should avoid becoming overheated, which can lead to flare-ups.
• Kids should drink plenty of water, which adds moisture to the
skin.
• Get rid of known allergens in your household and help your
child avoid others, like pollen, mold, and tobacco smoke.
• Stress can make eczema worse. Help your child find ways to
deal with stress (like exercise, deep breathing, or talking to a
counselor).