22: Atopic Dermatitis Flashcards
What are the major features of Atopic Dermatitis (AD)?
The major features of Atopic Dermatitis (AD) include:
- Pruritus
- Eczematous dermatitis (acute, subacute, or chronic) with typical morphology and age-specific patterns
- Facial and extensor involvement in infancy
- Flexural eczema or lichenification in children and adults
- Common associations include personal or family history of atopy, xerosis or skin barrier dysfunction, and immunoglobulin E reactivity.
What is the prevalence of Atopic Dermatitis in children in the US and other industrialized countries?
The prevalence of Atopic Dermatitis (AD) in children is estimated to be between 10% to 20% in the US, Northern and Western Europe, Japan, Australia, and other industrialized countries. There is a noted female preponderance for AD with a female to male ratio of 1.3 to 1.0. Additionally, African Americans have a higher prevalence of the disease in the United States.
What are the cutaneous findings associated with Atopic Dermatitis?
The cutaneous findings associated with Atopic Dermatitis (AD) include:
- Acute eczematous lesions: erythematous papulovesicles, often with pinpoint crusting or frank weeping.
- Subacute to chronic lesions: scale, excoriation, and lichenification.
- Darker skin tones: follicular accentuation, flat-topped papules in lichenified areas, and a tendency toward hyperpigmentation in inflamed areas.
- Patients may present with a mixture of both acute and chronic lesions in multiple areas of the body simultaneously or even in the same lesion.
What psychosocial impacts are associated with Atopic Dermatitis in children and adults?
The psychosocial impacts associated with Atopic Dermatitis (AD) include:
- In children: Higher prevalence of ADHD, anxiety, conduct disorder, and autism, with the risk of ADHD mediated by sleep disturbance due to pruritus.
- In adults: Increased levels of anxiety and depression. Antiinflammatory therapy can help alleviate both anxiety and depression symptoms in adults.
What are some common atopic comorbidities associated with Atopic Dermatitis?
Common atopic comorbidities associated with Atopic Dermatitis (AD) include:
- Allergic rhinitis
- Asthma
- Food allergies
- Eosinophilia
- High levels of total and specific serum IgE
- Predisposition toward allergic comorbidities
AD is often the first atopic disease to develop, but these diseases can occur in any order and in any combination.
What diagnostic criteria should be used to confirm atopic dermatitis?
The Hanifin-Rajka criteria, which include pruritus, eczematous dermatitis with typical morphology and age-specific patterns, and a personal or family history of atopy, should be used to confirm atopic dermatitis.
What are the major clinical features of atopic dermatitis (AD) in children and adults?
The major clinical features of atopic dermatitis (AD) include:
1. Pruritus
2. Eczematous dermatitis (acute, subacute, or chronic) with typical morphology and age-specific patterns
3. Facial and extensor involvement in infancy
4. Flexural eczema or lichenification in children and adults
5. Common associations include personal or family history of atopy, xerosis or skin barrier dysfunction, and immunoglobulin E reactivity.
How does the prevalence of atopic dermatitis (AD) vary by demographic factors such as age, gender, and ethnicity?
The prevalence of atopic dermatitis (AD) varies by several demographic factors:
- Age: Prevalence in children is between 10% to 20%.
- Gender: There is a female preponderance for AD with a ratio of 1.3:1 (F:M).
- Ethnicity: African Americans have a higher prevalence of AD in the United States compared to other ethnic groups.
- Geographic Location: Higher prevalence is noted in rural settings compared to urban centers within the same country.
What are the non-cutaneous findings associated with atopic dermatitis (AD) and their clinical significance?
Non-cutaneous findings associated with atopic dermatitis (AD) include:
1. Atopic Comorbidities: Signs of T helper 2 (Th2) immune activation such as high levels of total and specific serum IgE, eosinophilia, and predisposition toward allergic comorbidities. Higher prevalence of food allergies, asthma, and allergic rhinitis.
2. Psychosocial Impact: Increased risk of mental health issues, including anxiety and depression, particularly in adults.
What is the most common bacterial infection found in atopic dermatitis (AD)?
The most common bacterial infection found in AD is superficial Staphylococcus aureus infections.
What role do type 2 cytokines play in atopic dermatitis regarding Staphylococcus aureus infections?
Type 2 cytokines augment the killing effect of Staphylococcus aureus toxins on keratinocytes and their blockade appears to reduce skin infections in AD.
What is eczema herpeticum and what are its potential complications in atopic dermatitis?
Eczema herpeticum (EH) is a serious viral complication characterized by multiple itchy, vesiculopustular lesions that can become hemorrhagic and crusted. It may lead to large, denuded areas that can be fatal in some cases.
What are the ocular problems commonly associated with atopic dermatitis?
Common ocular problems associated with AD include eyelid dermatitis, chronic blepharitis, atopic keratoconjunctivitis, and vernal conjunctivitis. These can lead to visual impairment and other disabling symptoms.
What is the significance of using dilute sodium hypochlorite baths in the management of atopic dermatitis?
The use of dilute sodium hypochlorite baths (bleach baths) appears to improve the severity of atopic dermatitis by reducing Staphylococcus aureus colonization.
What are the potential consequences of eczema vaccinatum in patients with atopic dermatitis?
Eczema vaccinatum can cause a severe widespread eruption resembling eczema herpeticum in patients with AD, particularly if they are exposed to vaccinated individuals.
What is the relationship between hand dermatitis and atopic dermatitis?
Hand dermatitis is often nonspecific and can be aggravated by repeated wetting and washing with harsh soaps, leading to occupational disability in atopic individuals.
What are the potential triggers for exfoliative dermatitis in patients with atopic dermatitis?
Exfoliative dermatitis can be triggered by superinfection with toxin-producing Staphylococcus aureus, herpes simplex infection, or withdrawal of topical/systemic glucocorticoids used to control severe AD.
What immunological factors contribute to susceptibility to Staphylococcus aureus infections in atopic dermatitis?
Factors include blunted antimicrobial peptide expression, elevated pH, and disrupted skin barrier, which promote Staphylococcus aureus growth.
What is the most likely secondary complication for a patient with atopic dermatitis who has honey-colored crusting on their lesions?
The honey-colored crusting suggests a secondary bacterial infection, likely caused by Staphylococcus aureus. Management includes the use of antistaphylococcal antibiotics such as cephalosporins or penicillinase-resistant penicillins.
What occupational factors should be considered for a patient with persistent hand eczema despite treatment?
Occupational factors such as repeated hand wetting, exposure to harsh soaps, detergents, and disinfectants should be considered as they can aggravate hand dermatitis.
What is the likely diagnosis for a patient with atopic dermatitis who develops severe erythroderma and systemic toxicity?
The likely diagnosis is exfoliative dermatitis, which could be triggered by superinfection, inappropriate therapy, or withdrawal of topical/systemic glucocorticoids.
What are the implications of Staphylococcus aureus colonization in patients with atopic dermatitis (AD)?
Staphylococcus aureus colonization in AD can lead to skin inflammation, as its toxins activate antigen presenting cells and increase T-cell cutaneous lymphocyte antigen (CLA) expression. This contributes to the severity of AD flares and is associated with a shift in the microbiome towards higher proportions of S. aureus.
How does eczema herpeticum (EH) present in patients with atopic dermatitis, and what are the potential complications?
Eczema herpeticum presents as multiple itchy, vesiculopustular lesions that can cluster and become hemorrhagic and crusted. Complications include painful erosions that may coalesce into large, denuded areas, potentially leading to severe systemic effects and even fatal outcomes in some cases.
What are the common ocular problems associated with atopic dermatitis, and how can they impact patients?
Common ocular problems in atopic dermatitis include eyelid dermatitis, chronic blepharitis, and atopic keratoconjunctivitis, which can cause symptoms like itching, burning, and tearing. These conditions may lead to visual impairment and require careful management to prevent complications such as corneal scarring.
What role do topical steroids play in managing Staphylococcus aureus infections in atopic dermatitis?
Topical steroids can reduce S. aureus counts on the skin, illustrating their role in managing inflammation and susceptibility to infections in atopic dermatitis. However, they should be used judiciously to avoid potential side effects.
What are the potential risks associated with smallpox vaccination in patients with atopic dermatitis?
In patients with atopic dermatitis, smallpox vaccination is contraindicated unless there is a clear risk of smallpox, as it may lead to severe widespread eruptions resembling eczema vaccinatum, which can be life-threatening.
What are the main factors contributing to decreased skin barrier function in atopic dermatitis?
- Downregulation of corneified envelope genes (e.g., keratin, filaggrin, loricrin)
- Reduced ceramide levels
- Increased endogenous proteolytic enzyme activity
- Enhanced transepidermal water loss
These factors lead to increased allergen absorption and microbial colonization, contributing to allergic responses.
How do genetic mutations in filaggrin affect atopic dermatitis?
- Loss-of-function mutations in filaggrin are a major predisposing factor for atopic dermatitis (AD) in European and Asian populations.
- Filaggrin is crucial for the epidermal barrier, and its mutations lead to increased transepidermal water loss and allergen entry, resulting in skin inflammation.
- Patients with filaggrin null mutations often experience early onset of AD, severe eczema, and high allergen sensitization, potentially leading to asthma later in life (atopic march).
What are the immunopathological characteristics of nonlesional and acute atopic dermatitis skin?
- Nonlesional AD skin:
- Mild epidermal hyperplasia
- Sparse perivascular T-cell infiltrate
- Presence of dendritic antigen-presenting cells with surface-bound IgE
- Acute AD lesions:
- Epidermal spongiosis with increased infiltration of activated memory T cells
- Rare eosinophils, basophils, and neutrophils
- Mast cells in various stages of degranulation.
What role do cytokines play in the inflammation of atopic dermatitis?
- Key cytokines involved in AD include IL-4, IL-5, IL-13, IL-25, IL-31, and IL-33, which are predominantly expressed in nonlesional and acute AD skin lesions.
- These cytokines are secreted by various cell types, including innate lymphoid type 2 cells, mast cells, and basophils, contributing to redundancy in allergic inflammation.
- Targeting cytokines rather than specific cells is considered a more effective treatment approach for AD.
What are the implications of decreased skin barrier function in patients with atopic dermatitis (AD)?
Decreased skin barrier function in AD leads to:
1. Increased allergen absorption into the skin.
2. Higher levels of allergic immune responses.
3. Increased susceptibility to microbial colonization.
4. Potential development of food allergies and respiratory allergies in predisposed individuals.
How do genetic mutations in filaggrin contribute to the pathophysiology of atopic dermatitis?
Genetic mutations in filaggrin contribute to atopic dermatitis by:
1. Impairing the epidermal barrier function, leading to increased transepidermal water loss.
2. Allowing greater entry of allergens and irritants, resulting in skin inflammation.
3. Being associated with early onset of AD, severe eczema, and high allergen sensitization, which can lead to asthma development (atopic march).
What are the clinical features that differentiate nonlesional AD skin from acute and chronic AD lesions?
The clinical features differentiating nonlesional AD skin from acute and chronic AD lesions include:
| Type of Skin | Features |
|————-|———-|
| Nonlesional AD | Mild epidermal hyperplasia, sparse perivascular T-cell infiltrate |
| Acute AD Lesions | Epidermal spongiosis, increased infiltration of activated memory T cells, rare eosinophils and neutrophils |
| Chronic AD Lesions | Hyperplastic epidermis, elongation of rete ridges, increased IgE-bearing LCs, and fully granulated mast cells |
What role do cytokines such as TSLP and IL-33 play in the pathogenesis of atopic dermatitis?
Cytokines like TSLP and IL-33 play a crucial role in atopic dermatitis by:
1. Inducing dendritic cells to drive Th0 cells into the Th2 differentiation pathway.
2. Contributing to the expression of other type 2 cytokines (IL-4, IL-5, IL-13) that are involved in allergic inflammation.
3. Being predominantly expressed in nonlesional and acute AD skin lesions, leading to substantial redundancy in allergic inflammatory responses.
What role do IL-4 and IL-13 play in the pathogenesis of Atopic Dermatitis (AD)?
IL-4 and IL-13 inhibit terminal keratinocyte differentiation, including filaggrin expression, and enhance IL-23 production by dendritic cells.
What role do IL-4 and IL-13 play in the pathogenesis of Atopic Dermatitis (AD)?
IL-4 and IL-13 inhibit terminal keratinocyte differentiation, including filaggrin expression, and enhance IL-23 production by dendritic cells. Their blockade is associated with reduced IL-23 and IL-17 expression in AD skin, suggesting a significant role in the inflammatory process of AD.
How does the immune response in chronic Atopic Dermatitis differ from acute cases?
In chronic AD, there is an increase in Th1 cytokines such as INF-γ, which potentiates skin inflammation. This contrasts with acute AD, where IL-4 and IL-13 are more prominent, dampening responses to interferons and IL-17.
What is the significance of TSLP in the initiation of Atopic Dermatitis?
TSLP (Thymic Stromal Lymphopoietin) can be detected in at-risk infants before the onset of AD, suggesting that the TSLP-Th2-ILC2 pathway plays a critical role in the initiation of Atopic Dermatitis.
What are the main factors contributing to pruritus in Atopic Dermatitis?
Pruritus in AD is influenced by cutaneous hyperreactivity, scratching after allergen exposure, changes in humidity, excessive sweating, and low concentrations of irritants. It is also linked to the release of proinflammatory cytokines and chemokines due to mechanical injury from scratching.
What diagnostic criteria are used to confirm Atopic Dermatitis?
A diagnosis of Atopic Dermatitis is made based on clinical assessment and ruling out other conditions such as psoriasis, scabies, seborrheic dermatitis, or contact dermatitis.
What laboratory tests are recommended for evaluating Atopic Dermatitis?
Routine potassium hydroxide microscopic evaluation can rule out fungal infections. Mineral oil examination for scabies is warranted if burrows or vesicles are present. Patch testing is recommended if allergic contact dermatitis is suspected.
What is the role of IL-4 and IL-13 in the pathogenesis of Atopic Dermatitis (AD)?
IL-4 and IL-13 inhibit terminal keratinocyte differentiation, including filaggrin expression, and enhance IL-23 production by dendritic cells, which is associated with reduced IL-23 and IL-17 expression in AD skin.
How does the chronicity of Atopic Dermatitis affect cytokine profiles and skin inflammation?
In chronic AD, there is an increase in Th1 cytokines such as INF-γ, which potentiates skin inflammation. The early exposure of AD lesions to IL-4 and IL-13 results in a long-lasting, persistent effect that dampens responses to interferons and IL-17.
What are the implications of TSLP in the initiation of Atopic Dermatitis?
TSLP can be detected in at-risk infants before the onset of AD, indicating that the TSLP-Th2-ILC2 pathway plays a critical role in the initiation of Atopic Dermatitis.
What factors contribute to pruritus in Atopic Dermatitis and how can it be managed?
Pruritus in AD is caused by cutaneous hyperreactivity and scratching, which leads to a vicious scratch-itch cycle. Management includes topical corticosteroids and calcineurin inhibitors.
What diagnostic criteria should be considered when diagnosing Atopic Dermatitis?
Diagnosis of AD should be based on clinical assessment and ruled out other conditions such as psoriasis, scabies, and seborrheic dermatitis.
What laboratory tests are recommended to rule out conditions that mimic Atopic Dermatitis?
Routine potassium hydroxide microscopic evaluation can rule out fungal infections, while mineral oil examination for scabies is warranted if burrows or vesicles are present.
What is the significance of positive allergy test results in patients with Atopic Dermatitis (AD)?
Positive allergy test results in patients with AD poorly predict true type I allergic responses in the absence of controlled food challenges.
What laboratory studies are recommended to rule out immunodeficiency associated with eczema?
Laboratory studies include: Complete blood count with differential for white blood cell count, Lymphocyte phenotyping for T cells, B cells, and natural killer cells, Lymphocyte proliferation assays, Genomic DNA analysis for pathogenic variants in genes associated with severe combined deficiency.
What are the histopathological findings in biopsies of Atopic Dermatitis lesions?
Biopsies of AD lesions typically show spongiotic dermatitis on histopathology, which does not allow differentiation among various eczematous processes.
What imaging studies are recommended in the diagnosis of Atopic Dermatitis?
Imaging studies are not recommended in the diagnosis of AD except when ruling out specific immunodeficiencies.
What are the clinical features of Omenn syndrome in relation to Atopic Dermatitis?
Omenn syndrome presents with an erythrodermic rash, elevated IgE, eosinophilia, diarrhea, lymphadenopathy, hepatosplenomegaly, and susceptibility to infections.
What is the role of STAT3 mutations in Hyper-IgE syndrome?
STAT3 mutations in Hyper-IgE syndrome lead to recurrent deep-seated bacterial infections, including cutaneous cold abscesses and pneumonias.
What laboratory studies should be conducted to rule out immunodeficiency in patients with atopic dermatitis (AD)?
Laboratory studies include: Complete blood count with differential for white blood cell count, Lymphocyte phenotyping for T cells, B cells, and natural killer cells, Lymphocyte proliferation assays, Genomic DNA analysis for pathogenic variants in genes associated with severe combined deficiency.
What are the key histopathological findings in atopic dermatitis (AD) lesions?
Histopathological findings in AD lesions include spongiotic dermatitis on histopathology.
What imaging studies are recommended for patients with atopic dermatitis (AD) and when should they be used?
Imaging studies are not recommended in the diagnosis of AD except when ruling out specific immunodeficiencies.
What are the clinical implications of Omenn syndrome in patients with atopic dermatitis (AD)?
Omenn syndrome presents with an erythrodermic rash, elevated IgE levels, eosinophilia, and susceptibility to infections.
How does Wiskott-Aldrich syndrome present in patients with atopic dermatitis (AD)?
Wiskott-Aldrich syndrome is characterized by an eczematous rash associated with thrombocytopenia.
What are the common features associated with Hyper-IgE syndrome (HIE)?
Common features of HIE syndrome include skeletal abnormalities with coarse facial features and prominent frontal bossing.
What management strategies are recommended for Atopic Dermatitis (AD)?
Management strategies for Atopic Dermatitis include education about the disease state and skin hydration.
What are some specific allergens that can trigger Atopic Dermatitis?
Specific allergens that can trigger Atopic Dermatitis include foods and aeroallergens such as dust mites, animal danders, molds, and pollens.
How does emotional stress impact Atopic Dermatitis?
Emotional stress does not cause Atopic Dermatitis but can exacerbate the illness.
What are the clinical features that differentiate Psoriasis from Atopic Dermatitis?
Psoriasis can typically be distinguished from Atopic Dermatitis based on characteristic clinical features.
A child with atopic dermatitis has a history of recurrent viral infections and food allergies. What genetic mutation might be implicated?
Mutations in the DOCK8 gene might be implicated.
What are the key management strategies for patients with Atopic Dermatitis (AD) to identify and eliminate triggers that exacerbate their condition?
Key management strategies include education about the disease state, skin hydration, pharmacologic therapy, and identification of flare factors.
How do emotional stressors impact patients with Atopic Dermatitis, and what strategies can be employed to manage these effects?
Emotional stress does not cause Atopic Dermatitis but can exacerbate symptoms.
What are the specific allergens that patients with Atopic Dermatitis should be aware of, and what measures can be taken to avoid them?
Specific allergens include foods and aeroallergens such as dust mites, animal danders, molds, and pollens.
What are the recommended oral antibiotics for patients infected with S. aureus who are not colonized with resistant strains?
Recommended oral antibiotics include cephalosporins or penicillinase-resistant penicillins.
What topical antibiotics are effective for impetiginized lesions in atopic dermatitis?
Topical antibiotics effective for impetiginized lesions include mupirocin and fusidic acid.
What is the significance of bleach baths in the management of atopic dermatitis?
Bleach baths with dilute sodium hypochlorite may benefit patients with superinfected eczema.
How should herpes simplex infections be diagnosed in patients with atopic dermatitis?
Herpes simplex infections should be diagnosed by polymerase chain reaction identification of herpes genetic material.
What treatment is recommended for cutaneous herpes simplex infections in patients with widespread atopic dermatitis?
Antiviral treatment is critical, with Acyclovir recommended.
What role do systemic antihistamines play in managing pruritus associated with atopic dermatitis?
Systemic antihistamines primarily block H1 receptors in the dermis.
What should be done if skin lesions do not respond to oral antibiotics in patients with atopic dermatitis?
If skin lesions do not respond to oral antibiotics, it should initiate a search for herpes simplex infection.
A child with atopic dermatitis presents with punched-out erosions and vesicles that do not respond to antibiotics. What is the likely diagnosis and treatment?
The likely diagnosis is eczema herpeticum caused by herpes simplex virus. Treatment involves antiviral therapy.
What should be considered if skin lesions do not respond to oral antibiotics?
A search for herpes simplex infection should be initiated, indicated by punched-out erosions, vesicles, or infected skin lesions.
What is the likely diagnosis for a child with atopic dermatitis presenting with punched-out erosions and vesicles that do not respond to antibiotics?
The likely diagnosis is eczema herpeticum caused by herpes simplex virus. Treatment involves antiviral therapy, such as oral acyclovir, and possibly intravenous treatment for severe cases.
What is the rationale behind prescribing bleach baths for patients with atopic dermatitis?
Bleach baths may benefit patients with superinfected eczema by exerting anti-inflammatory effects and reducing Staphylococcus aureus colonization.
What are the recommended oral antibiotics for patients with atopic dermatitis infected with S. aureus?
Recommended oral antibiotics include cephalosporins and penicillinase-resistant penicillins (such as dicloxacillin, oxacillin, or cloxacillin) for patients not colonized with resistant S. aureus strains. Erythromycin and newer macrolide antibiotics are usually of limited utility due to common resistance.
What topical treatments are effective for impetiginized lesions in patients with atopic dermatitis?
Effective topical treatments include mupirocin and fusidic acid, which are equal to or more effective than oral treatments for limited disease. Precautions include avoiding ‘as-needed’ use of topical antibiotics to prevent resistance.
How do bleach baths benefit patients with atopic dermatitis?
Bleach baths with dilute sodium hypochlorite may benefit patients with superinfected eczema, particularly those with recurrent MRSA, through anti-inflammatory mechanisms rather than purely antimicrobial effects.
What steps should be taken when a patient with atopic dermatitis presents with skin lesions that do not respond to oral antibiotics?
Initiate a search for herpes simplex, especially if there are punched-out erosions, vesicles, or infected skin lesions. Diagnosis can be confirmed through polymerase chain reaction identification or Giemsa-stained Tzanck smear.
What is the role of systemic antihistamines in managing pruritus in atopic dermatitis?
Systemic antihistamines primarily block H1 receptors in the dermis, helping alleviate histamine-induced pruritus. However, they may not significantly improve pruritus in atopic dermatitis.
What role do emollients play in the treatment of atopic dermatitis?
Emollients are the cornerstone of treatment for mild AD and serve as an important flare preventive therapy for all levels of disease severity.
What are the potential benefits of using wet dressings in the management of atopic dermatitis?
Wet dressings can promote transepidermal penetration of topical glucocorticoids and are used for severely affected areas. They should be monitored closely to avoid complications.
What are the recommendations for the use of topical corticosteroids in the treatment of atopic dermatitis?
Topical corticosteroids should be used to control acute exacerbations, with long-term maintenance through scheduled intermittent applications. Patients should be educated on proper use to avoid side effects.
How do antihistamines affect pruritus in patients with atopic dermatitis?
Sedating antihistamines may be more effective at night due to their soporific side effects, while topical antihistamines are generally not recommended due to potential sensitization.
What is the significance of transepidermal water loss in patients with atopic dermatitis?
Increased transepidermal water loss contributes to dry skin and microfissures, which can serve as entry points for pathogens, exacerbating the condition.
What should be done if a patient with atopic dermatitis reports worsening symptoms after using a new moisturizer?
The moisturizer may contain irritating preservatives or fragrances. Switching to a thicker, bland emollient with high lipid content is recommended.
What pharmacological options can help manage severe pruritus at night in patients with atopic dermatitis?
Sedating antihistamines like hydroxyzine or diphenhydramine can help manage nocturnal pruritus.
What are the implications of using sedating antihistamines for managing pruritus in atopic dermatitis?
Sedating antihistamines may be beneficial for managing pruritus at night but should be used cautiously due to potential sedation.
How do emollients contribute to the management of atopic dermatitis?
Emollients restore and preserve the stratum corneum barrier, decrease transepidermal water loss, and improve skin hydration.
What precautions should be taken when using wet dressings in atopic dermatitis treatment?
Wet dressings must be monitored closely to prevent complications such as maceration and secondary infections.
What are the recommended practices for using topical corticosteroids in atopic dermatitis management?
Patients should apply topical corticosteroids to affected areas and use emollients on uninvolved skin, with intermittent use of low-potency TCs for sensitive areas.
What factors should be considered when selecting emollients for patients with atopic dermatitis?
Consider lipid content, potential irritants, and patient tolerance. Thicker, bland emollients with high lipid content are preferred.
What is the recommended duration and amount of topical glucocorticoids needed to treat the entire body for atopic dermatitis?
Approximately 840 g (2 lb) of topical glucocorticoids is required to treat the entire body twice daily for two weeks.
What are the seven classes of topical glucocorticoids based on?
The seven classes of topical glucocorticoids are ranked according to their potency based on vasoconstrictor assays.
What are the potential side effects of ultrahigh-potency glucocorticoids?
Ultrahigh-potency glucocorticoids should be used for short periods (usually 2 weeks) and in areas that are lichenified, avoiding the face and intertriginous areas.
What is the significance of using midpotency glucocorticoids in atopic dermatitis treatment?
Midpotency glucocorticoids can be used for longer periods to treat chronic atopic dermatitis involving the trunk and extremities.
What are the side effects associated with topical glucocorticoids?
Side effects include local effects like striae and skin atrophy, and systemic effects such as adrenal suppression.
What is the role of topical calcineurin inhibitors in atopic dermatitis treatment?
Topical calcineurin inhibitors like tacrolimus and pimecrolimus are nonsteroidal immunomodulators for moderate to severe atopic dermatitis.
What is a frequently observed side effect of topical calcineurin inhibitors?
A frequently observed side effect is a transient burning sensation of the skin.
What is the FDA warning associated with topical calcineurin inhibitors?
Topical calcineurin inhibitors carry an FDA black box warning for rare cases of skin malignancy and lymphoma.
What is Crisaborole and its mechanism of action in treating atopic dermatitis?
Crisaborole is a boron-based topical phosphodiesterase 4 (PDE4) inhibitor that decreases proinflammatory cytokine production.
What is the likely condition for a patient with atopic dermatitis who develops severe erythema and burning after discontinuing topical corticosteroids?
The likely condition is steroid withdrawal syndrome.
What are the advantages of topical tacrolimus over topical corticosteroids?
Topical tacrolimus does not cause skin atrophy and is useful for areas like the face and intertriginous regions.
What factors influence the potency and risk of side effects of topical glucocorticoids?
Factors include molecular structure, vehicle, amount and duration of application, occlusion, and host factors like age and skin inflammation.
What is the recommended amount of topical glucocorticoids to treat the entire body twice daily for two weeks?
Approximately 840 g (2 lb) of topical glucocorticoids is required.
What can be considered if a patient with atopic dermatitis is not responding to topical corticosteroids?
Failure to respond may be due to inadequate application. Alternatives include topical calcineurin inhibitors or systemic therapies like dupilumab.
What alternative treatment can be considered for a patient with atopic dermatitis who develops skin atrophy from long-term topical corticosteroid use?
Topical calcineurin inhibitors like tacrolimus or pimecrolimus can be considered.
What are the recommended usage guidelines for ultrahigh-potency glucocorticoids in atopic dermatitis treatment?
They should be used daily or twice daily for very short periods (usually 2 weeks) and in areas that are lichenified.
What factors influence the potency of topical glucocorticoids and the risk of side effects?
Factors include molecular structure, vehicle, amount applied, duration, occlusion, and host factors.
What are the common local and systemic side effects associated with topical glucocorticoids?
Local side effects include striae and skin atrophy; systemic effects include adrenal suppression.
What is the significance of ‘proactive therapy’ in atopic dermatitis management?
Proactive therapy aims to control residual disease by applying active drugs to previously affected areas.
What are the approved uses and safety profiles of topical calcineurin inhibitors in treating atopic dermatitis?
Tacrolimus and pimecrolimus are approved for various age groups with a good safety profile for treatment up to 4 years.
What are the potential risks associated with topical calcineurin inhibitors in atopic dermatitis?
They carry an FDA black box warning for rare cases of skin malignancy and lymphoma, though studies suggest no significant increased risk.
What is the mechanism of action of crisaborole in treating atopic dermatitis?
Crisaborole is a PDE4 inhibitor that decreases proinflammatory cytokine production.
What were the results of the pivotal phase 3 trials for crisaborole 2% ointment in treating mild to moderate atopic dermatitis?
Crisaborole 2% ointment resulted in clear or almost clear disease in 31.4% to 32.8% of the active group compared to 18.0% to 25.4% in controls.
What are the benefits and risks associated with coal tar preparations for atopic dermatitis?
Coal tar may have antipruritic and antiinflammatory effects, but should not be used on acutely inflamed skin due to irritation risks.
What types of phototherapy are beneficial for patients with atopic dermatitis?
Broadband UVB, UVA, narrowband UVB, and UVA-1 phototherapy can be useful adjuncts in treatment.
What are the risks of using coal tar preparations on acutely inflamed skin?
Coal tar preparations should not be used on acutely inflamed skin due to the risk of irritation.
What types of phototherapy are beneficial for atopic dermatitis?
Broadband UVB, broadband UVA, narrowband UVB (311 nm), and UVA-1 (340 to 400 nm) phototherapy can be useful adjuncts in treating atopic dermatitis. They exert immunosuppressive effects by blocking the function of antigen-presenting Langerhans cells and altering keratinocyte cytokine production.
What is dupilumab and its significance in atopic dermatitis treatment?
Dupilumab is a fully human monoclonal antibody targeting the IL-4 receptor alpha subunit, blocking cytokine signaling through IL-4 and IL-13 receptors. It is the only FDA-approved systemic agent for the treatment of atopic dermatitis, indicated for adults with moderate to severe disease not adequately controlled by topical therapies.
What factors should be considered before initiating systemic therapies for atopic dermatitis?
The decision to initiate systemic therapies should be based on overall disease severity, response to topical therapy, adherence to previous regimens, the impact of the disease on the patient’s quality of life, and understanding the patient’s comorbidities and preferences.
What are the short-term and long-term adverse effects of photochemotherapy with psoralen and UVA light?
Short-term adverse effects include erythema, skin pain, pruritus, and pigmentation. Long-term adverse effects may include premature skin aging and cutaneous malignancies.
What are the benefits and risks of coal tar preparations for atopic dermatitis?
Coal tar preparations have antipruritic and anti-inflammatory effects but may cause folliculitis, photosensitivity, and have a theoretical risk of being carcinogenic.
What is the mechanism of action of crisaborole and its common side effects?
Crisaborole is a topical phosphodiesterase 4 (PDE4) inhibitor that decreases proinflammatory cytokine production. Common side effects include burning sensations.
What are the potential long-term risks of photochemotherapy with psoralen and UVA light?
Long-term risks include premature skin aging and cutaneous malignancies.
What is the evidence for the efficacy of topical crisaborole?
Phase 3 trials showed that crisaborole resulted in clear or almost clear disease in 31.4% to 32.8% of patients, compared to 18.0% to 25.4% in the control group.
What types of phototherapy are effective for atopic dermatitis and what are the potential risks?
Effective phototherapy options include broadband UVB, narrowband UVB, and UVA-1. Risks include erythema, skin pain, pruritus, and long-term risks like premature skin aging and cutaneous malignancies.
What factors should be considered when deciding to initiate systemic therapies for atopic dermatitis?
The decision to initiate systemic therapies should be based on overall disease severity, response to topical therapy, adherence to previous regimens, impact on quality of life, and understanding of comorbidities and preferences.
What are the potential adverse effects of photochemotherapy with psoralen and UVA light?
Short-term adverse effects include erythema, skin pain, pruritus, and pigmentation. Long-term adverse effects may include premature skin aging and cutaneous malignancies.
What is dupilumab and what role does it play in atopic dermatitis treatment?
Dupilumab is a fully human monoclonal antibody targeting the IL-4 receptor alpha subunit, blocking cytokine signaling through IL-4 and IL-13 receptors. It is the only FDA-approved systemic agent for moderate to severe atopic dermatitis not adequately controlled with topical therapies.
What are the considerations for hospitalization in patients with atopic dermatitis?
Patients with erythrodermic or widespread severe skin disease resistant to outpatient therapy should be considered for hospitalization. Key considerations include removing the patient from allergens or emotional stresses, intense patient education, assurance of compliance with therapy, and clearing the skin for testing.
What are the benefits and risks of natural sunlight for atopic dermatitis?
Natural sunlight can be beneficial; however, it may exacerbate symptoms in high heat or humidity. Benefits include potential therapeutic effects from UV phototherapy, while risks include symptom exacerbation.
What are the potential benefits of combining dupilumab with topical corticosteroids?
The combination has been found to be safe and provides modest increased benefit over monotherapy, with maintenance of benefit over long-term use.
What are the common adverse effects associated with dupilumab treatment?
Common drug-related adverse effects include injection site reactions and conjunctivitis, which is usually mild to moderate and can improve with topical lubricants or anti-inflammatory therapy.
What is the role of systemic glucocorticoids in chronic atopic dermatitis treatment?
Systemic glucocorticoids are rarely indicated but can lead to dramatic improvement, frequently associated with a severe rebound flare after discontinuation.
What are the considerations when using short courses of oral glucocorticoids for atopic dermatitis?
Short courses may be appropriate for acute exacerbations, but it is important to taper the dosage and begin intensified skin care to prevent rebound flaring.
How does cyclosporine function in severe atopic dermatitis treatment?
Cyclosporine is a potent immunosuppressive drug that acts primarily on T cells by suppressing cytokine transcription.
What are the side effects associated with cyclosporine treatment for atopic dermatitis?
Side effects include elevated serum creatinine, renal impairment, hypertension, and drug-drug interactions. Discontinuation may result in rapid relapse.
What is the role of methotrexate in atopic dermatitis treatment?
Methotrexate inhibits inflammatory cytokine synthesis and cell chemotaxis, showing a reduction in disease severity scores in both pediatric and adult patients.
What are the potential risks of long-term methotrexate use in atopic dermatitis patients?
The long-term risk of occult hepatic toxicity is not known, and there are no established guidelines for liver biopsy or imaging.
What is mycophenolate mofetil and its role in treating atopic dermatitis?
Mycophenolate mofetil is a purine biosynthesis inhibitor used as an immunosuppressant for refractory inflammatory skin disorders, showing effectiveness in clearing skin lesions.
What are the potential side effects of mycophenolate mofetil?
Side effects include hematologic toxicity, progressive multifocal encephalopathy, and risks during pregnancy.
What is azathioprine and its effects in atopic dermatitis treatment?
Azathioprine is a purine analog with anti-inflammatory and antiproliferative effects, used in the treatment of atopic dermatitis.
What systemic therapy could be considered for a patient with atopic dermatitis and elevated serum IgE levels?
Systemic therapies like cyclosporine, methotrexate, or dupilumab could be considered for refractory cases.
What are the potential side effects of methotrexate in atopic dermatitis treatment?
Potential side effects include hematologic abnormalities and hepatic toxicity.
What precautions should be taken to prevent rebound flaring when using systemic glucocorticoids?
Precautions include tapering the dosage and intensifying skin care with topical glucocorticoids and emollients.
What are the potential side effects of mycophenolate mofetil?
Potential side effects include hematologic toxicity, herpes retinitis, progressive multifocal encephalopathy, and risks during pregnancy.
What are the benefits of dupilumab treatment for atopic dermatitis?
Benefits include significant improvement in pruritus, quality of life, and reductions in anxiety and depressive symptoms.
What are the specific side effects of concern with systemic cyclosporine?
Specific side effects include elevated serum creatinine, renal impairment, hypertension, and drug-drug interactions.
What is a common complication of using systemic glucocorticoids?
A common complication is a severe rebound flare of atopic dermatitis after discontinuation.
What is the effect of dupilumab on skin infections?
Dupilumab treatment has been associated with a reduction in skin infections.
What is the mechanism of action of dupilumab and its common side effects?
Dupilumab is a monoclonal antibody targeting the IL-4 receptor alpha subunit, blocking IL-4 and IL-13 signaling. Common side effects include injection site reactions and conjunctivitis.
What are the potential risks of discontinuing systemic glucocorticoids in chronic atopic dermatitis?
Discontinuation can lead to a severe rebound flare of atopic dermatitis.
How does cyclosporine impact patients with severe atopic dermatitis?
Cyclosporine can lead to reduced skin disease and improved quality of life, but discontinuation may result in rapid relapse.
What are the long-term risks of methotrexate in atopic dermatitis patients?
The long-term risk of occult hepatic toxicity is not well understood, with no established guidelines for liver biopsy or imaging.
What are the common adverse effects of dupilumab treatment?
Common adverse effects include injection site reactions and conjunctivitis, which may improve with topical lubricants.
What is the role of mycophenolate mofetil in atopic dermatitis treatment?
Mycophenolate mofetil is used as an immunosuppressant for refractory inflammatory skin disorders, effective in clearing skin lesions.
What are the potential side effects of mycophenolate mofetil?
Potential side effects include hematologic toxicity and progressive multifocal encephalopathy, with risks during pregnancy.
What is the role of interferon-gamma in atopic dermatitis treatment?
Interferon-gamma suppresses IgE responses and downregulates Th2 cell proliferation, resulting in clinical improvement.
What is the significance of omalizumab in atopic dermatitis?
Omalizumab targets IgE and has shown conflicting results in atopic dermatitis treatment, suggesting IgE may not play a direct role in its pathogenesis.
What are the findings regarding probiotics in atopic dermatitis treatment?
Perinatal administration of probiotics may help prevent atopic dermatitis in at-risk children, but their efficacy in treatment is less clear.
What are the potential benefits and concerns of Chinese herbal medications for atopic dermatitis?
Chinese herbal medications may benefit severe atopic dermatitis but have concerns regarding hepatic toxicity, cardiac side effects, and contamination.
How does vitamin D supplementation affect children with atopic dermatitis?
Vitamin D may normalize immune responses and increase antimicrobial peptide expression, showing improvement in skin condition.
What is the proposed mechanism of action for probiotics in atopic dermatitis?
Probiotics are thought to establish a gut bacterial milieu that reduces systemic inflammatory responses.
What are the concerns associated with Chinese herbal medications in atopic dermatitis treatment?
Concerns include hepatic toxicity, cardiac side effects, idiosyncratic reactions, and contamination with corticosteroids.
What is the proposed mechanism of action for probiotics in atopic dermatitis (AD)?
Probiotics are thought to establish a bacterial milieu in the gut that reduces systemic inflammatory responses.
What are the concerns associated with Chinese herbal medications for atopic dermatitis?
Concerns include the possibility of hepatic toxicity, cardiac side effects, idiosyncratic reactions, and contamination with corticosteroids.
What is the role of Interferon-gamma in the treatment of atopic dermatitis (AD)?
Interferon-gamma (IFN-γ) is known to suppress IgE responses and downregulate Th2 cell proliferation and function. Studies have shown that treatment with recombinant human IFN-γ results in clinical improvement, correlating with a reduction in clinical severity of AD and decreased total circulating eosinophil counts. Common side effects include influenzalike symptoms early in treatment.
What are the findings regarding the use of Omalizumab in patients with atopic dermatitis?
Omalizumab, a monoclonal antibody targeting IgE, has shown conflicting effects in patients with atopic dermatitis (AD). Although elevated IgE is present in most AD patients, a randomized controlled trial found no clinical effects of omalizumab on AD, suggesting that IgE may not play a direct role in AD pathogenesis.
What does the evidence suggest about the efficacy of probiotics in the treatment of atopic dermatitis?
The efficacy of probiotics in treating atopic dermatitis (AD) is unclear. While some studies suggest that perinatal administration of probiotics may prevent AD in at-risk children, a systematic review of 12 trials found little beneficial effect. A meta-analysis indicated no significant difference in eczema severity between probiotic and placebo groups, highlighting the need for further research into specific subgroups and treatment parameters.
What are the potential benefits and concerns associated with Chinese herbal medications for atopic dermatitis?
Chinese herbal medications may provide temporary benefits for patients with severe atopic dermatitis (AD), but the effectiveness may diminish over time. Concerns include the possibility of hepatic toxicity, cardiac side effects, and idiosyncratic reactions. Additionally, some herbal preparations have been found to be contaminated with corticosteroids, making their use investigational at present.
How does vitamin D supplementation affect children with atopic dermatitis based on recent studies?
Vitamin D supplementation is thought to normalize immune responses and increase antimicrobial peptide expression in atopic dermatitis (AD). A pilot study showed improvement in the Investigator Global Assessment (IGA) score in 80% of children receiving vitamin D compared to 20% in the placebo group. However, the reduction in EASI score was not statistically significant, indicating the need for further research.
What role does oral vitamin D play in patients with atopic dermatitis (AD)?
Oral vitamin D may improve innate immune responses in patients with AD, as suggested by observations comparing lesions in healthy skin and uninvolved AD skin.
What does the Learning Early About Peanut Allergy study suggest about peanut exposure in infants?
The study suggests that early exposure to peanut, rather than delayed exposure, dramatically reduces the risk of developing peanut allergy by age 5 years.
What are the recommendations for introducing solid foods to children with severe eczema or egg allergy?
The 2017 NIAID Expert Panel Addendum Guidelines recommend introducing solid foods at 4 to 6 months of age, starting with solid foods other than peanuts, to help the child demonstrate the ability to consume solid food without nonspecific signs of food allergy.
What is the conclusion of the recent Cochrane review regarding hydrolyzed formula for AD prevention?
The Cochrane review concluded that there was no convincing evidence supporting the use of hydrolyzed formula for the prevention of atopic dermatitis in high-risk infants.
How does protecting the skin barrier with emollients affect the incidence of atopic dermatitis in high-risk infants?
Protecting the skin barrier with emollients early in life in high-risk infants appears promising and has been shown to reduce the incidence of atopic dermatitis by up to 50% in two small studies.
What protective effect do probiotics have on atopic dermatitis development?
Probiotics supplements appear to have a protective effect on the development of atopic dermatitis when delivered both pre- and postnatally.
What is the rationale behind vitamin D supplementation for patients with atopic dermatitis?
Vitamin D is thought to normalize immune responses and increase antimicrobial peptide expression, potentially improving innate immune responses in AD.
What preventive measures could have been taken during infancy for a child with atopic dermatitis and a history of peanut allergy?
Early introduction of peanut-containing foods at 4 to 6 months of age, as recommended by the NIAID guidelines, could have reduced the risk of peanut allergy.
What is the significance of early exposure to peanut in preventing peanut allergy in children with severe eczema?
Early exposure to peanut, rather than delayed exposure, dramatically reduced peanut allergy at age 5 years, as demonstrated by the Learning Early About Peanut Allergy study.
What are the recommendations for introducing solid foods to infants at risk for food allergies?
For children with severe eczema or egg allergy, solid foods should be introduced at 4 to 6 months of age, starting with solid food other than peanuts, to ensure the child can consume solid food without nonspecific signs that could be confused with IgE-mediated food allergy.
What role do probiotics play in the prevention of atopic dermatitis (AD)?
Probiotics supplements appear to have a protective effect on AD development when delivered both pre- and postnatally, although the exact strains, dosing, and timing of the intervention are not standardized.
How does protecting the skin barrier with emollients impact the incidence of atopic dermatitis in high-risk infants?
Protecting the skin barrier with emollients early in life in high-risk infants has been shown to reduce the incidence of AD by up to 50% in two small studies, indicating a promising approach to prevention.
What is the current understanding of the use of hydrolyzed formula for the prevention of atopic dermatitis in high-risk infants?
While some studies have shown a positive effect of hydrolyzed formula for AD prevention, a recent Cochrane review concluded that there is no convincing evidence supporting its effectiveness in high-risk infants.
Atopic dermatitis (AD) has a prevalence peak of 15% to 20% in _____ in industrialized countries.
early childhood
AD is a chronic or chronically relapsing disorder with major features of?
■ Pruritus
■ Eczematous dermatitis (acute, subacute, or chronic) with typical morphology and age-specific patterns (facial and extensor involvement in infancy, flexural eczema or lichenification in children and adults)
■ Family/personal history of atopy
■ Chronic relapsing dermatitis
AD is commonly associated with what 3 features?
■ Personal or family history of atopy (allergic rhinitis, asthma, atopic dermatitis)
■ Xerosis or skin barrier dysfunction
■ Immunoglobulin E reactivity
Enumerate the major and minor features of the Hanifin-Rajka criteria.
Demographic characteristics associated with AD?
Female
Airborne pollution
Hard water
Decreased humidity
Higher income/education
Obesity
Less UV exposure
Psychiatric conditions associated with AD?
ADHD (related to sleep disturbance)
Anxiety
Conduct disorder
Autism
Depression
Most common infection in AD?
Staphylococcus aureus infections.
Increased fibronectin and fibrinogen brought about by inflamed skin act as their binding sites. Increase in type 2 cytokines blunts antimicrobial peptide expression and augments killing effect of S. aureus toxins.
Increased skin pH leads to _____ protease activity.
Increased.
SPINK 5 produces _____ which inhibits 2 serine proteases involved in desquamation and inflammation.
LEKT1
Patients with AD often show signs of _____ immune activation, including high levels of total and specific
serum Ig_, _____philia, and a predisposition toward _____ comorbidities.
T helper 2 (Th2)
E
eosino-
allergic
Patients with AD display an increased susceptibility to what viral infections?
- common warts
- molluscum contagiosum
- eczema herpeticum (IP: 5-12 days, due to defects in interferon pathways)
- eczema vaccinatum (smallpox vaccination)
- eczema coxsackium (HFMD)
It is the most serious virally mediated complication in AD.
Eczema herpeticum
IgE antibodies against _____ are commonly found in AD patients, most frequently in those with head and neck dermatitis.
Malassezia furfur
Atopic keratoconjunctivitis is usually _____ and can have disabling symptoms that include itching, burn-
ing, tearing, and copious mucoid discharge.
bilateral
_____ is a severe bilateral recurrent chronic inflammatory process associated with papillary hypertrophy or cobblestoning of the upper eyelid conjunctiva. It usually occurs in _____ patients and has a marked seasonal incidence, often in the _____. The
associated intense pruritus is exacerbated by exposure
to irritants, light, or sweating.
Vernal conjunctivitis
younger
spring
_____ is a conical deformity of the cornea believed to result from chronic
rubbing of the eyes in patients with AD and allergic rhinoconjunctivitis.
Keratoconus
Exfoliative dermatitis is usually caused by superinfection, for example, with _____ or _____, continued irritation of the skin, or inappropriate therapy. In some cases, the withdrawal of topical or systemic glucocorticoids used to control severe AD may be a precipitating factor.
toxin-producing S. aureus
herpes simplex infection
Atopic dermatitis is associated with decrease in skin barrier function caused by the downregulation of cornified envelope genes (eg, _____, _____, and _____),
reduced ceramide levels, increased endogenous
proteolytic enzyme activity, and enhanced transepi-
dermal water loss.
keratin
filaggrin
loricrin
