Atopic dermatitis Flashcards
Define atopic dermatitis
Inflammatory skin condition characterised by dry, pruritic skin with a chronic relapsing course
Typically an episodic disease with flares that may occur up to 2-3x a month
What are the types of dermatitis
Atopic: type I/IV IgE-mediated hypersensitivity
Contact: type IV delayed HS reaction after allergen/irritant exposure
Discoid: coin-shaped plaques in middle aged/elderly pts
Dishydrotic (pompholyx), itchy/painful blisters on palms/plantars
Herpeticum: HSV-1 infection (medical emergency)
Seborrhoeic (Cradle cap): yellow/greasy scaly rash of the scalp, paranasal areas, eyebrows
What is the aetiology of atopic dermatitis
Combination of genetic susceptibility and environmental factors
Defect in skin’s barrier function
Filaggrin mutation (stratum corneum has lower levels of natural moisturising factor)
Type I hypersensitivity: Impaired epidermal barrier function due to intrinsic structural and functional skin abnormalities e.g. filaggrin mutation
Type IV hypersensitivity: Immune function disorder in which Langerhans cells, T cells and immune effector cells modulate an inflammatory response to environmental factors
What are the risk factors for atopic dermatitis
Age <5 years
Family history
Allergic rhinitis, hay fever
Asthma
Food allergies
Active and passive exposure to smoke
Urban areas
Smaller families
High socio-economic classes
What are the symptoms of atopic dermatitis
Pruritus (may be seasonal, better in the summer)
Xerosis (dry skin)
Erythema
Scaling
Involving:
Infants: cheeks, forehead, scalp, extensor surfaces
Older children: Extensors of limbs
Children: flexures, particularly the wrists, ankles, antecubital and popliteal fossa
Chronic: neck, upper back, arms, hands and feet
What are the differentials for atopic dermatitis
Psoriasis
Allergic contact dermatitis
Seborrheic dermatitis
Fungal infection
Scabies/other infestation
Food allergy
lWhat are the signs of eczema on examination
Papules and vesicles (weepy/exudative)
- Extensors (infants) or flexors (children/adults)
Pigmented skin: brown, grey, purple bumps
Xerosis
Erythema
Keratosis pilaris (follicular hyperkeratotic papules on the extensor surfaces)
Excoriations
Lichenification (thickening of skin due to repeated scratching)
Hypopigmentation or hyperppigemntation
Nails: pitting and ridging
What investigations should be done for atopic dermatitis
Clinical diagnosis
Assess severity:
± Patient-Oriented Eczema Measure (POEM)
± Infants’ dermatitis quality of life index (IDQoL)
± Children’s dermatology Life Quality Index (CDLQI)
Bloods: IgE raised
Other: skin biopsy (eczema from contact dermatitis and psoriasis), skin prick testing (food allergies), patch testing (contact dermatitis)
What classifies mild eczema
Areas of dry skin with infrequent itching + small areas of redness
Little impact on everyday activities, sleep and psychosocial wellbeing
What classifies moderate eczema
Areas of dry skin
Frequent itching
Areas of redness ± excoriation and localised skin thickening
Moderate impact on everyday activities and psychosocial wellbeing
Frequently disturbed sleep
What classifies severe eczema
Widespread areas of dry skin
Incessant itching
Redness ± excoriation, extensive skin thickening, bleeding, oozing, cracking, alteration of pigmentation
Severe limitation of everyday activities and psychosocial functioning
Nightly loss of sleep
What is the management for mild eczema
Emollients
Mild potency topical corticosteroids
Consider referral to clinical psychologist
What is the management for moderate eczema
Emollients
Moderate potency topical corticosteroids (Step-down approach)
Topical calcineurin inhibitors
Bandages
Consider referral to clinical psychologist
What is the management for severe eczema
Emollients
Potent topical corticosteroids
Phototherapy
Topical calcineurin inhibitors
Bandages
Consider referral to clinical psychologist
What is the management for infected eczema
Skin and swab culture
- Oral flucloxacillin
- Erythromycinc/clarithromycin alternative
What emollients are used for atopic dermatitis and how should they be used
50/50 (greasy), dermol (contains chlorhexidine), e45
Apply to whole body and wait 30 minutes before applying steroid creams
Used for moisturising, washing and bathing
Pump products = reduced infection risk
Apply with the finger tips (FTUs) / 500mg
- 1 FTU = palm of hand, elbows, or knees
Can be used with bandages for chronic lichenified skin
What is the difference between a cream and ointment
Cream = some water (thin, contains preservatives)
Ointment = no water (thick, no preservative)
What is the steroid ladder for atopic dermatitis treatment
From least to most potent
Hydrocortisone
Eumovate/clobetasone
Betnovate/betamethasone
Elocon/mometasone
Dermovate/clobetasol
Note: Apply sparingly to affected areas only
Give examples of topical calcineurin inhibitors and how should they be used
Tacrolimus, pimecrolimus
Topical to active eczema areas
Apply as a thin layer to affected areas, including broken skin, up to twice daily
Do not use on infected skin
Do NOT use under occlusive bandages
Give examples of antihistamines that can be used for atopic dermatitis
Severe itching/urticaria → 1 month trial of non-sedating antihistamine e.g. fexofenadine, cetirizine
Acute flare-up with sleep disturbance → 7-14 days trial of sedating antihistamine e.g. promethazine
When should you refer for atopic dermatitis
⚑ Eczema herpeticum → immediate + empirical treatment with oral/IV Abx and oral/IV acyclovir (due to similar presentation to impetigo)
Severe atopic eczema not responding to optimum therapy within 1 week → Urgent (<2 weeks)
Treatment to bacterially infected eczema has failed → Urgent (<2 weeks)
Non-urgent (>2 weeks)
- Diagnosis uncertain
- Atopic eczema on face not responding
- Contact allergic dermatitis suspected
- Causing significant social and psychological problems
- Severe recurrent infections
What are the complications of atopic dermatitis
Secondary bacterial infection
Impetigo
Secondary viral infection e.g. molluscum contagiosum
Eczema herpeticum
Psychosocial problems: distress, depression, behavioural problems, poor sleep-esteem and confidence, sleep disturbance
Describe eczema herpeticum
Widespread lesions that may coalesce into large, denuded, bleeding areas that can extend over the entire body
Punched out lesions (circular, depressed, ulcerated)
rapidly progressing painful rash, fever, lymphadenopathy and malaise
What is the management for eczema herpeticum
- Admit - medical emergency
- Oral aciclovir (if unwell → IV aciclovir)
- Around the eyes → same day referral to ophthalmologist - Safety net:
- Rapidly worsening eczema
- Clustered blisters
- Punched-out erosions
What is the prognosis for atopic dermatitis
Typically an episodic disease of flares and remissions
May gradually improve as they grow older:
- 65% clearance by the age of 7
- 74% clearance by the age of 16
