atopic dermatitis Flashcards
the most common chronic
relapsing skin disease seen in infancy and childhood
Atopic dermatitis (AD), or eczema,
It affects ____ of children worldwide and frequently occurs in families with other atopic diseases, such as asthma, allergic rhinitis, and food allergy.
10-30%
Infants with AD are predisposed to development of allergic rhinitis and/or asthma later in childhood, a process called
“the atopic march.”
AD is a complex genetic disorder that results in
a defective skin barrier,
reduced skin innate immune responses
exaggerated T-cell responses to environmental allergens
microbes that lead to chronic skin inflammation
Acute AD skin lesions are characterized by
spongiosis,
spongiosis,
marked intercellular edema, of the epidermis
dendritic antigenpresenting cells in the epidermis, such as Langerhans cells, exhibit surface-bound
immunoglobulin (Ig) E molecules.
These antigenpresenting
cells play an important role in cutaneous allergen presentation to
T-helper type 2 (Th2) cells
There is a marked___ macrophages in
acute AD lesions.
perivenular T-cell infiltrate
are found in normal numbers but in different
stages of degranulation.
Mast cells
chronic, lichenified AD is characterized
by a
hyperplastic epidermis with hyperkeratosis, and minimal spongiosis
There are predominantly IgE-bearing Langerhans cells in the
epidermis
There are predominantly macrophages in the
dermal mononuclear cell infiltrate
____numbers are increased, contributing to skin
inflammation.
Mast cell and eosinophil
Two forms of AD
Atopic eczema, Nonatopic eczema
Two forms of AD
Atopic eczema, Nonatopic eczema
is associated
with IgE-mediated sensitization
atopic eczema
is associated
with IgE-mediated sensitization
atopic eczema
aropic eczema occurs in ___ of px with atopic dermatitis
70-80%
is not associated with IgE-mediated sensitization and is seen in 20-30%
of patients with AD
non atopic eczema
non atopic eczema is not associated with IgE-mediated sensitization and is seen in___
of patients with AD
20-30%
Both forms of AD are associated with
eosinophilia
In atopic eczema, circulating T cells expressing the skin homing receptor _____produce increased
levels of Th2 cytokines, including interleukin (IL)-4 and IL-13, which induce isotype switching to IgE synthesis
cutaneous lymphocyte-associated antigen
In atopic eczema, circulating ____expressing the skin homing receptor cutaneous lymphocyte-associated antigen produce increased levels of Th2 cytokines, including interleukin (IL)-4 and IL-13, which
induce isotype switching to IgE synthesis
t cells
In atopic eczema, circulating T cells expressing the skin homing receptor cutaneous lymphocyte-associated antigen produce increased levels of ____________, which
induce isotype switching to IgE synthesis
Th2 cytokines (interleukin (IL)-4 and IL-13)
In atopic eczema, circulating T cells expressing the skin homing receptor cutaneous lymphocyte-associated antigen produce increased levels of Th2 cytokines, including interleukin (IL)-4 and IL-13, which induce isotype switching to ____
IgE synthesis
plays an important role in eosinophil development and survival.
IL -5
Nonatopic eczema is associated with lower ___production than is atopic eczema.
IL-4 and IL-13
Compared with the skin of healthy subjects, both unaffected skin and acute skin lesions of patients with AD have an decreased number of cells expressing IL-4 and IL-13
increased
___ have significantly fewer cells that express IL-4 and IL-13
Chronic AD skin lesions
increased numbers of cells that express IL-5, granulocyte-macrophage colony-stimulating factor, IL-12, and interferon (IFN)-γ than acute AD lesions
Chronic AD skin lesions
Chronic AD is characterized by a
shift from a Th2-dominant to a Th1-dominant profile
The infiltration of ____ correlates with severity of AD, blocks keratinocyte differentiation, and
induces epidermal hyperplasia.
IL-22–expressing T cells
The infiltration of IL-22–expressing T cells
correlates with severity of AD, blocks keratinocyte differentiation, and induces
epidermal hyperplasia.
The infiltration of IL-22–expressing T cells
correlates with severity of AD, ____________, and
induces epidermal hyperplasia.
blocks keratinocyte differentiation
The development of AD skin lesions is orchestrated by local tissue expression of proinflammatory
cytokines and chemokines
play a central role in defining the nature of the inflammatory infiltrate in AD.
cytokines and chemokines
The chemotactic protein, _____, is highly upregulated in AD and preferentially attracts cutaneous lymphocyte-associated antigen positive T cells to the skin
CCL27
are increased in AD skin lesions, resulting in chemotaxis of eosinophils, macrophages, and Th2 lymphocytes expressing their receptor (CCR3).
C-C chemokines,
RANTES (regulated regulated on activation, normal T-cell expressed and secreted),
monocyte chemotactic protein-4,
eotaxin
Other C-C chemokines, RANTES (regulated regulated
on activation, normal T-cell expressed and secreted), monocyte chemotactic protein-4, and eotaxin are increased in AD skin lesions, resulting in
chemotaxis of eosinophils, macrophages
Th2 lymphocytes expressing their receptor (CCR3).
In healthy people, the___acts as a protective barrier against external irritants, moisture loss, and infection.
skin
Proper function of the skin depends on
adequate moisture
lipid content
functional immune responses
structural integrity.
is a hallmark of AD.
Severely dry skin
Severely dry skin results from compromise of the epidermal barrier, which leads to
excess transepidermal water loss
allergen penetration
microbial colonization
, a structural protein in the epidermis,
and its breakdown products are critical to skin barrier function
Filaggrin
Genetic mutations in the filaggrin gene family have been identified in up to ___ of patients with severe AD.
50%
Cytokines found in allergic inflammation, such as __________can also reduce filaggrin expression
IL-4
IL-13
IL-22
IL-25
tumor necrosis factor (TNF)
AD patients thereby have increased risk of bacterial, viral, and fungal infection related to impairment of adaptive immunity, including a loss of barrier function and impaired generation of antimicrobial peptides
AD patients thereby have increased risk of bacterial, viral, and fungal infection related to impairment of innate immunity, including a loss of barrier function and
impaired generation of antimicrobial peptides
AD patients thereby have increased risk of bacterial, viral, and fungal infection related to impairment of innate immunity, including ______
a loss of barrier function
impaired generation of antimicrobial peptides
AD typically begins in
infancy
Approximately___ of patients experience
symptoms in the 1st yr of life,
50%
Approximately 50% of patients experience
symptoms in the
‘Ist yr of life
additional 30% are diagnosed
between
1 and 5 yr of age
an additional ___ are diagnosed
between 1 and 5 yr of age
30%
are the cardinal features of AD
Intense pruritus, especially at night,
and cutaneous reactivity
cause increased skin inflammation that contributes to
the development of more pronounced eczematous skin lesions.
Scratching and excoriation
Foods , aeroallergen, infection, reduced humidity, excessive
sweating, and irritants can lessen pruritus and scratching
Exacerbate
Foods
(
cow milk, egg, peanut, tree nuts, wheat, fish, shellfish
Aeroallergens
pollen, grass, animal dander, dust mites), infection
Infection (
staphylococcus,
herpes simplex, molluscum
Irritants
wool, acrylic, soaps, toiletries, fragrances,
detergents
Acute AD skin lesions are
intensely pruritic with erythematous
papules (Figs.
manifests as erythematous,
excoriated, scaling papules
Subacute dermatitis
Chronic AD is characterized by
Iichenification, and fibrotic papuleS
Thickening of the skin with
accentuated surface markings,
Lichenification
All 5 types of skin reactions may coexist in the same individual.
3
Most patients with AD have ___ irrespective of their stage of
illness.
dry, lackluster skin
Skin reaction pattern and distribution do not vary with the patient’s age and disease activity
Vary
AD is generally more acute in ____
Infancy
AD is generally more acute in infancy and
involves the
face, scalp, and extensor surfaces of the extremities
The
diaper area is usually affected
Spared
Older children and children with chronic
AD have lichenification and localization of the rash to the
flexural folds
of the extremities
AD often goes into _____as the patient grows
older, leaving an adolescent or adult with skin prone to itching and inflammation when exposed to exogenous irritants
Remission
There are no specific laboratory tests to diagnose AD
True
Many patients
have peripheral blood
eosinophilia and increased serum IgE levels
can identify the allergens
JSerum IgE measurement or prick skin testing
Serum IgE measurement or prick skin testing can identify the allergens -to which patients are desensitized.
true
AD is diagnosed on the basis of 3 major features:
pruritus, an eczematous
dermatitis that fits into a typical presentation, and a chronic or
chronically relapsing course (
Associated features, such as ___
, are variably present
a family history of asthma, hay fever, elevated IgE, and immediate skin
test reactivity
should be considered for
infants presenting in the 1st yr of life with diarrhea, failure to thrive,
generalized scaling rash, and recurrent cutaneous and/or systemic
infection
Severe combined immunodeficiency
Syndrome
) should be excluded in any
infant with AD and failure to thrive
Histiocytosis
X-linked recessive disorder associated with thrombocytopenia,
immune defects, and recurrent severe bacterial infections,
Wiskott-Aldrich syndrom
is characterized by a rash almost indistinguishable from that in
AD.
Wiskott-Aldrich syndrome
characterized by markedly elevated serum IgE values, recurrent deep-seated
bacterial infections, chronic dermatitis, and refractory dermatophytosis.
One of the hyper-IgE syndromes
Many of these patients have disease as a result of
autosomal dominant
STAT3 mutation
All patients with hyper-IgE
syndrome present with increased susceptibility to viral infections and
an autosomal recessive pattern of disease inheritance.
Some
some patients with hyper-IgE
syndrome
may have a –
Dock 8 (Dedicator of cytokinesis 8) mutation.
This diagnosis
should be considered in __ with severe eczema, food
allergy, and disseminated skin viral infections.
young children
Adolescents who present with an eczematous dermatitis but no
history of childhood eczema, respiratory allergy, or atopic family
history may have
allergic contact dermatitis
A____ may be the problem in any patient whose AD does
Not respond to appropriate therapy.
contact allergen
Sensitizing chemicals, such as
____ can be irritants for patients with AD and are
commonly found as vehicles in therapeutic topical agents
parabens and lanolin,
has been reported in patients with chronic
dermatitis on topical corticosteroid therapy
Topical glucocorticoid allergy
Has nalso been reported with HIV infection as well as with a variety of infestations such as scabies.
Eczematous dermatitis
Eczematous dermatitis has
also been reported with HIV infection as well as with a variety of
infestations such as
Scabies
Other conditions that can be confused
with AD include .
psoriasis, ichthyoses, and seborrheic dermatitis
The treatment of AD requires a systematic, multifaceted approach that incorporates
skin hydration,
Topical anti-inflammatory therapy,
Identification and elimination of flare factors
systemic therapy
Cutaneous hydration is done because patients with AD have impaired skin barrier function from
reduced lipid levels, they present with diffuse, abnormally dry skin, or
xerosis
are first-line therapy
Moisturizers
Lukewarm soaking baths for
____ followed by the application of an occlusive emollient to
retain moisture provide symptomatic relief
15-20 min
Lukewarm soaking baths for
15-20 min followed by the ___to
retain moisture provide symptomatic relief
application of an occlusive emollien
___
of varying degrees of viscosity can be used according to the patient’s
preference.
Hydrophilic ointments
are sometimes not well tolerated
because of interference with the function of the eccrine sweat ducts
and may induce the development of folliculitis1
Occlusive ointments
“therapeutic moisturizers/barrier creams” are available,
containing components such as ___ intended to improve skin barrier function.
ceramides and filaggrin acid
metabolites
Hydration by baths or wet dressings promotes ___
of topical glucocorticoids
transepidermal . penetration
may also serve as effective
barriers against persistent scratching, in turn promoting healing of
excoriated lesions.
Dressings
are recommended for use on severely
affected or chronically involved areas of dermatitis refractory to skin
care.
Wet dressings
It is critical that wet dressing therapy be followed by ___
application to avoid potential drying and fissuring from the
therapy
Topicàl emollient
It is critical that wet dressing therapy be followed by topical emollient application to avoid
potential drying and fissuring from the therapy
Wet dressing therapy can be complicated by ___and should be closely monitored by a physician.
Maceration and 2nd infection
are the cornerstone of antiinflammatory treatment
for acute exacerbations of AD.
Topical corticosteroids
Patients should be carefully
instructed on their use of topical glucocorticoids in order to avoid
potential adverse effects.
True
There are 10 classes of topical glucocorticoids,
ranked according to their potency as determined by vasoconstrictor
assays
7
should not be used on the face or
intertriginous areas and should be used only for very short periods on
the trunk and extremities
ultrahigh-potency glucocorticoids
can be used
for longer periods to treat chronic AD involving the trunk and extremities
Mid-potency glucocorticoids
Long-term control can be maintained with ___ to areas that have healed
but are prone to relapse, once control of AD is achieved after a daily
regimen of topical corticosteroids
twice-weekly applications
of topical fluticasone or mometasone
Compared with creams, ___
have a greater potential to occlude the epidermis, resulting in enhanced
systemic absorption
ointments
Systemic Adverse effects of topical glucocorticoids are
suppression of the hypothalamic–pituitary–
adrenal axis.
Local adverse effects include the
development of striae
and skin atrophy.
Systemic adverse effects are related to the
potency of the topical corticosteroid, site of application, occlusiveness of the preparation, percentage of the body surface area covered, and length of use
The potential for adrenal suppression from potent topical corticosteroids
is greatest in
infants and young children with severe AD requiring
intensive therapy
The____are effective in reducing
AD skin inflammation
nonsteroidal topical calcineurin inhibitors
is indicated
for mild to moderate AD.
Pimecrolimus cream 1% (Elidel)
is indicated for moderate to severe AD.
Tacrolimus ointment 0.1% and 0.03% (Protopic)
Pimecrolimus and tacrolimus are approved for
short-term or intermittent long-term treatment of AD in patients
≥2 yr whose disease is unresponsive
who are intolerant of other conventional therapies whom these therapies are inadvisable owing
to potential risks.
Topical calcineurin inhibitors may be better than
topical corticosteroids in the treatment of patients whose AD is
poorly responsive to topical steroid
patients with steroid phobia
patients with face and neck dermatitis
ineffective, lowpotency topical corticosteroids are usually used because of fears of steroid-induced skin atrophy.
patients with face and neck dermatitis,
have antipruritic and antiinflammatory effects
on the skin
Coal tar preparations
antiinflammatory effects are usually not as
pronounced as those of topical glucocorticoids or calcineurin inhibitors.
Coal tar preparations
Tar preparations are useful in
reducing the potency of topical glucocorticoids required in long-term maintenance therapy of AD
Tar shampoos can be particularly beneficial for
scalp dermatitis
Adverse effects associated with tar preparations include
skin irritation, folliculitis, and photosensitivity.
act primarily by blocking the histamine H1
receptors in the dermis, thereby reducing histamine-induced pruritus.
Systemic antihistamines
Systemic antihistamines act primarily by ___
receptors in the dermis, thereby reducing histamine-induced pruritus.
blocking the histamine H1
Systemic antihistamines act primarily by blocking the histamine H1
receptors in the dermis, thereby
reducing histamine-induced pruritus.
is only one of many mediators that induce pruritus of the
skin
Histamine
Because pruritus is usually worse at night,____may offer an advantage with
their soporific side effects when used at bedtime
sedating antihistamines
(hydroxyzine, diphenhydramine)
Because pruritus is usually worse at night, sedating antihistamines (hydroxyzine, diphenhydramine) may offer an advantage with their
soporific side effects when used at bedtime
has both tricyclic antidepressant and H1- and H2-receptor blocking
effects.
Doxepin hydrochloride
Doxepin hydrochloride
has both
tricyclic antidepressant and H1- and H2-receptor blocking
effects.
Short-term use of a sedative to allow adequate rest may be
appropriate in cases of
severe nocturnal pruritus.
may be useful in the small subset of patients with AD and concomitant urticaria.
newer nonsedating antihistamine
Systemic corticosteroids are rarely indicated in the treatment of chronic
AD
Systemic corticosteroids
The dramatic clinical improvement that may occur with systemic
corticosteroids is frequently associated with
a severe rebound flare of AD after therapy discontinuation
may be appropriate for an acute exacerbation of AD while other treatment
measures are being instituted in parallel.
Short courses of oral corticosteroids
If a short course of oral corticosteroids is given, it is important to ____ prevent rebound
flaring of AD.
taper the dosage
begin intensified skin care with topical corticosteroids
frequent bathing
application of emollients
is a potent immunosuppressive drug that acts primarily on T cells by suppressing cytokine gene transcription.
Cyclosporine
Cyclosporine forms a complex with an intracellular protein, ____
cyclophilin
cyclophilin inhibits
calcineurin
phosphatase required for activation of NFAT (nuclear factor of activated T cells
calcineurin
a transcription
factor necessary for cytokine gene transcription
NFAT (nuclear factor of activated T cells),
Cyclosporine ___ for short term
(5 mg/ kg/day)
cyclosporin ___ long-term
1 yr
cyclosporin 1 yr long-term use has been beneficial for
children with severe, refractory AD
cyclosporing possible adverse effects include
renal impairment and hypertension.
is a purine biosynthesis inhibitor used as an
immunosuppressant in organ transplantation that has been used for
treatment of refractory AD.
Mycophenolate mofetil
Aside from immunosuppression, _____have been
reported with mycophenolate mofetil use.
herpes simplex retinitis and dose-related bone marrow suppression
Aside from immunosuppression, _____have been
reported with mycophenolate mofetil use.
herpes simplex retinitis and dose-related bone marrow suppression
Mycophenolate mofetil should be discontinued if the disease does not respond within
4-8 wk.
is an antimetabolite with
potent inhibitory effects on inflammatory cytokine synthesis and cell
chemotaxis.
Methotrexate
Methotrexate has been used for patients with
recalcitrant AD.
In AD, dosing is more frequent than the weekly dosing used for psoriasis
Methotrexate
is a purine analog with antiinflammatory and antiproliferative effects that has been used for severe AD
Azathioprine
is a significant adverse effect of methotrexate
Myelosuppression
levels may identify individuals at risk for myelosuppression of methotrexate
thiopurine methyl transferase
is often beneficial to patients with AD as long as
sunburn and excessive sweating are avoided.
Natural sunlight
Many phototherapy modalities are effective for AD, including
ultraviolet A-1
ultraviolet B
narrow-band ultraviolet B
psoralen plus ultraviolet A.
is generally reserved for patients in whom standard treatments fail.
Phototherapy
are usually required for phototherapy to be effective
Maintenance treatments
Short-term adverse effects with phototherapy include
erythema, skin pain, pruritus, and pigmentation
Long-term adverse effects include
predisposition to cutaneous malignancies
Unproven Therapies
ifn -y
omalizumab
allergen immunotherapy
probiotics
chinese herbal medications
vitamin D
is known to suppress Th2-cell function.
IFN-γ
Reduction in clinical severity of AD correlated with the ability of IFN-γ to decrease total circulating
eosinophil counts. .
are commonly observed side effects during the treatment course of ifn -y
Influenza-like symptoms
Treatment of patients who have severe AD and elevated serum IgE values with monoclonal anti-IgE may be considered in those with
allergen-induced flares of AD
used in patients with AD sensitized to dust mite allergen showed improvement in severity of skin disease, as well as reduction in topical steroid use.
specific immunotherapy
of the probiotic Lactobacillus rhamnosus
strain GG has been shown to reduce the incidence of AD in at-risk children during the first 2 yr of life.
Perinatal administration
Perinatal administration of the probiotic ___
strain GG has been shown to reduce the incidence of AD in at-risk children during the first 2 yr of life.
Lactobacillus rhamnosus
Perinatal administration of the probiotic Lactobacillus rhamnosus strain GG has been shown to reduce the incidence of AD in at-risk children during the
first 2 yr of life.
The treatment response has been
found to be more pronounced in patients with
positive skin prick test results and elevated IgE values
The beneficial response of_____ is often temporary, and effectiveness may wear off despite continued
treatment.
Chinese herbal therapy
The possibility of_____ remains a concern of chinese herbal therapy
hepatic toxicity, cardiac side effects, or idiosyncratic reactions
The specific ingredients of the herbs also remain to be elucidated, and some preparations have
been found to be contaminated with
corticosteroids.
The specific ingredients of the herbs also remain to be elucidated, and some preparations have
been found to be contaminated with
corticosteroids.
often accompanies severe AD.
vitamin D
enhances skin barrier function, reduces corticosteroid requirements to control inflammation and augments skin antimicrobial function
Vitamin D
can enhance antimicrobial peptide expression in the skin and reduce severity of skin
disease especially in patients with low baseline vitamin D, for example, during the wintertime when exacerbation of AD often occurs
vitamin D
Patients with AD have a low threshold response to irritants that trigger their
itch-scratch cycle.
Patients with AD have a low threshold response to ___that trigger their itch-scratch cycle.
irritants
common triggers of AD
Soaps or detergents
chemicals
smoke
abrasive clothing
exposure to extremes of temperature
humidity
Patients with AD should use soaps with
minimal defatting properties and a neutral pH.
New clothing should be laundered
before wearing to decrease levels of
formaldehyde and other chemicals
Residual laundry detergent in clothing may trigger the
itchscratch cycle;
facilitates removal of the detergent.
using a liquid rather than powder detergent and adding a second rinse cycle
Every attempt should be made to allow children with AD to be as normally active as possible.
true
A sport such as ____ may be better tolerated than others that involve intense perspiration, physical
contact, or heavy clothing and equipment
swimming
Rinsing off___immediately and lubricating the skin after swimming are important.
chlorine
Although ultraviolet light may be beneficial to some patients with AD, ____ should be used to avoid sunburn.
high sun protection factor sunscreens
is comorbid in approximately 40% of infants and young children with moderate to severe AD
Food allergy
Food allergy is comorbid in approximately___of infants and young children with moderate to severe AD
40%
Undiagnosed food allergies in patients with AD may induce____in some patients and urticarial reactions, wheezing, or nasal congestion in others.
eczematous dermatitis
Undiagnosed food allergies in patients with AD may induce eczematous dermatitis in some patients and ____ in others.
urticarial reactions, wheezing, or nasal congestion
Increased severity of AD symptoms and younger age
correlate directly with the presence of
food allergy
Removal of food allergens from the diet leads to significant clinical improvement but requires a great deal of education, because most common allergens
such as _____ contaminate many foods and are difficult to avoid.
(egg, milk, peanut, wheat, soy)
Removal of food allergens from the diet leads to significant clinical improvement but requires a great deal of education, because most common allergens
such as _____ contaminate many foods and are difficult to avoid.
(egg, milk, peanut, wheat, soy)
Potential allergens can be identified by a
careful history
performing selective skin prick tests
in vitro blood testing for allergen specific IgE.
have a high predictive value for excluding suspected allergens
Negative skin and blood test results for allergen-specific IgE
Positive results of skin or blood tests using foods often do not correlate with clinical symptoms and should be confirmed with
controlled food challenges and elimination diets.
Extensive elimination diets, which can be nutritionally deficient, are often required
rarely
Even with multiple positive skin test results, the majority of patients react to fewer than ___ foods under controlled challenge conditions.
3 foods
In older children, AD flares can occur after intranasal or epicutaneous exposure to aeroallergens such as
fungi, animal dander, grass, and ragweed pollen.
Avoiding aeroallergens, particularly___, can
result in clinical improvement of AD
dust mites
Avoidance measures for dust mite–allergic patients include
using dust mite–proof encasings on pillows, mattresses, and box springs
washing bedding in hot water weekly
removing bedroom carpeting; and decreasing indoor humidity levels with air conditioning.
are usually beneficialfor patients who are not colonized with a resistant S. aureus strain;
Erythromycin and azithromycin
a is recommended for macrolide-resistant S. aureus
first-generation cephalosporin (cephalexin)
is useful in the treatment of localized impetiginous lesions, with systemic antibiotics for widespread infections.
Topical mupirocin
___ contributes to skin colonization with S. aureus; this fact indicates the importance of combining effective anti-inflammatory therapy with antibiotics for treating moderate to severe AD to avoid the need for repeated
courses of antibiotics, which can lead to the emergence of antibioticresistant strains of S. aureus.
Cytokine-mediated skin inflammation
Dilute bleach baths twice weekly may be also considered to reduce S. aureus colonization.
(1 2 cup of bleach in 40 gallons of water)
In one randomized trial the group who received
the bleach baths plus _____had significantly
decreased severity of AD at 1 and 3 mo compared with placebo.
intranasal mupirocin (5 days/mo)
can provoke recurrent dermatitis and
may be misdiagnosed as S. aureus infection.
Herpes simplex virus (HSV)
The presence of____, and infected skin lesions that fail to respond to oral antibiotics suggests HSV infection,
punched out erosions, vesicle
HSV infection can be diagnosed by a
Giemsa-stained Tzanck smear of cells scraped from the vesicle base
viral polymerase chain reaction or culture
should be temporarily discontinued if HSV infection is suspected
Topical corticosteroids
Persons with AD are also susceptible to _____ which is
similar in appearance to eczema herpeticum and historically follows smallpox (vaccinia virus) vaccination
eczema vaccinatum,
are additional viral infections affecting children with AD.
Cutaneous warts and molluscum
contagiosum
infections also can contribute to exacerbation of AD.
Dermatophyte
Patients with AD have been found to have a greater susceptibility to_____fungal infections than nonatopic control subjects.
Trichophyton rubrum
There has been particular interest in the role of ____
(formerly known as Pityrosporum ovale) in AD because it is a lipophilic yeast commonly present in the seborrheic areas of the skin
Malassezia furfur
____ against M. furfur have been found in patients with head and neck dermatitis.
IgE antibodies
may develop in patients with extensive skin involvement.
Exfoliative dermatitis
exfoliative dermatitis is associated with generalized
redness, scaling, weeping, crusting, systemic toxicity, lymphadenopathy, and fever,
exfoliative dermatitis is usually caused by
superinfection (e.g., with toxin-producing S. aureus or HSV infection) or inappropriate therapy.
In some cases, the withdrawal of systemic glucocorticoids used to control severe AD precipitates
exfoliative
erythroderma.
may result in visual impairment from corneal scarring
Eyelid dermatitis and chronic blepharitis
is usually bilateral and can have disabling symptoms that include itching, burning, tearing, and copious mucoid discharge.
Atopic keratoconjunctivitis
is associated with papillary hypertrophy or cobblestoning of the upper
eyelid conjunctiva.
Vernal conjunctivitis
Vernal conjunctivitis typically occurs in younger patients and has a marked seasonal incidence with
spring exacerbations
is a conical deformity of the cornea believed to result from chronic rubbing of the eyes in patients with AD
Keratoconus
may be a primary manifestation of AD or from extensive use of systemic and topical
glucocorticoids, particularly around the eyes.
Cataracts
AD generally tends to be mild and persistent in young children, particularly if they have null mutations in their filaggrin genes
more severe
Periods of remission occur more frequently when patients are young
grow older
Spontaneous resolution of AD has been reported to occur after____
age 5 yr
Spontaneous resolution of AD has been reported to occur after age 5 yr in ___of patients affected during infancy, particularly for mild
disease
40-60%
Earlier studies suggested that approximately ___ of children outgrow their AD by adolescence
84%
later studies reported that AD resolves in approximately 20% of children monitored from infancy
until adolescence and becomes less severe in
65%.
Of those adolescents treated for mild dermatitis, ___may experience a relapse of disease as adults,
> 50%
relapse of disease as adults frequently manifests as
hand dermatitis, especially if
daily activities require repeated hand wetting
Predictive factors of a poor prognosis for AD include
widespread AD in childhood
filaggrin gene null mutations
concomitant allergic rhinitis and asthma
family history of AD in parents or siblings
early age at onset of AD
being an only child, and very high serum IgE levels
Breastfeeding or a feeding with a hypoallergenic hydrolyzed formula is not beneficial.
beneficial
Breastfeeding or a feeding with a hypoallergenic hydrolyzed formula is not beneficial.
beneficial
may also reduce the incidence or severity of AD, but this approach is unproven
Probiotics and prebiotics
If an infant with AD is diagnosed with food allergy, the breast feeding mother may not need to eliminate the implicated food allergen from her diet.
need to eliminate
is the mainstay for prevention
of flares as well as for the long-term treatment of AD.
Identification and elimination of triggering factors
applied to the whole body for the first few months
of life may enhance the cutaneous barrier and reduce the risk of eczema.
Emollient therapy
MAJOR FEATURES of AD
Pruritus
Facial and extensor eczema in infants and children
Flexural eczema in adolescents
Chronic or relapsing dermatitis
Personal or family history of atopic disease
ASSOCIATED FEATURES of AD
Xerosis
Cutaneous infections (Staphylococcus aureus, group A
streptococcus, herpes simplex, coxsackievirus, vaccinia,
molluscum, warts)
Nonspecific dermatitis of the hands or feet
Ichthyosis, palmar hyperlinearity, keratosis pilaris
Nipple eczema
White dermatographism and delayed blanch response
Anterior subcapsular cataracts, keratoconus
Elevated serum immunoglobulin E levels
Positive results of immediate-type allergy skin tests
Early age at onset
Dennie lines (Dennie-Morgan infraorbital folds)
Facial erythema or pallor
Course influenced by environmental and/or emotional factors
Cutaneous infections
Staphylococcus aureus,
group A streptococcus
herpes simplex
coxsackievirus
vaccinia
molluscum
warts
Dennie lines
Dennie-Morgan infraorbital folds
CONGENITAL DISORDERS
Netherton syndrome
Familial keratosis pilaris
CHRONIC DERMATOSES
Seborrheic dermatitis
Contact dermatitis (allergic or irritant)
Nummular eczema
Psoriasis
Ichthyoses
INFECTIONS AND INFESTATIONS
Scabies
HIV-associated dermatitis
Dermatophytosis
Insect bites
Onchocerciasis
MALIGNANCIES
Cutaneous T-cell lymphoma (mycosis fungoides/Sézary syndrome)
Letterer-Siwe disease (Langerhans cell histiocytosis)
Letterer-Siwe disease
(Langerhans cell histiocytosis)
AUTOIMMUNE DISORDERS
Dermatitis herpetiformis
Pemphigus foliaceus
Graft-versus-host disease
Dermatomyositis
IMMUNODEFICIENCIES
Wiskott-Aldrich syndrome
Severe combined immunodeficiency syndrome
Hyperimmunoglobulin E syndromes (autosomal dominant and
recessive types)
Immunodysregulation polyendocrinopathy enteropathy X-linked
(IPEX) syndrome
METABOLIC DISORDERS
Zinc deficiency
Pyridoxine (vitamin B6) and niacin
Multiple carboxylase deficiency
Phenylketonuria
List of Aggravating Factors and Counselling for AD Patients
Clothing:
avoid skin contact with irritating fibers (wool, large-fiber textiles)
do not use tight and too warm clothing to avoid excessive sweating
New nonirritating clothing designed for AD children is being evaluated
List of Aggravating Factors and Counselling for AD Patients
Tobacco:
avoid exposure
List of Aggravating Factors and Counselling for AD Patients
temperature:
Cool temperature in bedroom and avoid too many bed covers
Increase emollient use with cold weather
List of Aggravating Factors and Counselling for AD Patients
Infections
Avoid exposure to herpes sores
urgent visit if flare of unusual aspect
List of Aggravating Factors and Counselling for AD Patients
vaccines
normal schedule in noninvolved skin, including egg-allergic patients (
List of Aggravating Factors and Counselling for AD Patients
Sun exposure:
no specific restriction. Usually helpful because of improvement of epidermal barrier. Encourage summer holidays in altitude or
at beach resorts
List of Aggravating Factors and Counselling for AD Patients
Physical exercise, sports:
no restriction. If sweating induces flares of AD, progressive adaptation to exercise. Shower and emollients after
swimming pool
List of Aggravating Factors and Counselling for AD Patients
Food allergens
Maintain breast feeding until 4 mo if possible
Otherwise normal diet, unless an allergy work-up has proven the need to exclude a specific food
List of Aggravating Factors and Counselling for AD Patients
Indoor aeroallergens
House dust mites
Use adequate ventilation of housing; keep the rooms well aerated even in winter
Avoid wall-to-wall carpeting
Remove dust with a wet sponge
Vacuum floors and upholstery with an adequately filtered cleaner once a week
Avoid soft toys in bed (cradle), except washable ones
Wash bed sheets at a temperature higher than 55° every 10 days
Use bed and pillow encasings made of Gore-Tex or similar material
List of Aggravating Factors and Counselling for AD Patients
Furred pets:
advise to avoid. If allergy is demonstrated, be firm on avoidance measures, such as pet removal
List of Aggravating Factors and Counselling for AD Patients
Pollen:
close windows during peak pollen season on warm and dry weather and restrict, if possible, stays outdoors. Windows may be open at
night and early in the morning or during rainy weather. Avoid exposure to risk situations (lawn mowing). Use pollen filters in car. Clothes and
pets can vectorize aeroallergens, including pollen
Categorization of Physical Severity of Atopic Eczema
Normal skin, with no evidence of atopic eczema
clear
Categorization of Physical Severity of Atopic Eczema
Widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing,
cracking, and alteration of pigmentation)
severe
Categorization of Physical Severity of Atopic Eczema
Areas of dry skin, infrequent itching (with or without small areas of redness)
mild
Categorization of Physical Severity of Atopic Eczema
Areas of dry skin, frequent itching, redness (with or without excoriation and localized skin thickening)
moderate
Selected Topical Corticosteroid
Preparations
group 2
Mometasone furoate (Elocon) 0.1% ointment
Halcinonide (Halog) 0.1% cream
Fluocinonide (Lidex) 0.05% ointment/cream
Desoximetasone (Topicort) 0.25% ointment/cream
Betamethasone dipropionate (Diprolene) 0.05% cream
Selected Topical Corticosteroid
Preparations
group 1
Clobetasol propionate (Temovate) 0.05% ointment/cream
Betamethasone dipropionate (Diprolene) 0.05% ointment/lotion/gel
Fluocinonide (Vanos) 0.1% cream
Selected Topical Corticosteroid
Preparations
group 3
Fluticasone propionate (Cutivate) 0.005% ointment
Halcinonide (Halog) 0.1% ointment
Betamethasone valerate (Valisone) 0.1% ointment
Selected Topical Corticosteroid
Preparations
group 4
Mometasone furoate (Elocon) 0.1% cream
Triamcinolone acetonide (Kenalog) 0.1% ointment/cream
Fluocinolone acetonide (Synalar) 0.025% ointment
Selected Topical Corticosteroid
Preparations
group 5
Fluocinolone acetonide (Synalar) 0.025% cream
Hydrocortisone valerate (Westcort) 0.2% ointment
Selected Topical Corticosteroid
Preparations
group 6
Desonide (DesOwen) 05% ointment/cream/lotion
Alclometasone dipropionate (Aclovate) 0.05% ointment/cream
Selected Topical Corticosteroid
Preparations
