DERM 13: Atopic Dermatitis Flashcards
1
Q
What are the risk factors for atopic dermatitis? (4)
A
- < 5 years old
- family history
- other atopic conditions
- environmental factors – diet, househould and geographic environment
2
Q
What is the pathophysiology of atopic dermatitis?
A
type I IgE-mediated hypersensitivity reaction
3
Q
What is atopic dermatitis?
A
- chronic, pruritic, relapsing, inflammatory
- periods of flares and remission
4
Q
What are the essential features for atopic dermatitis diagnosis?
A
pruritus and eczema (acute, subacute, chronic)
5
Q
What are the additional features for atopic dermatitis diagnosis?
A
- early age onset
- atopy
- xerosis (dry skin)
6
Q
What are the differential diagnoses in adults?
A
- seborrheic
- nummular
- irritant or allergic contact dermatitis
- lichen simplex chronicus
- asteatotic eczema
7
Q
What are the differential diagnoses in children?
A
- seborrheic
- nummular
- irritant or allergic contact dermatitis
- impetigo
- scabies
- dermatophyte infection
8
Q
How does seborrheic dermatitis differ from atopic dermatitis?
A
mainly affects scalp + oil body parts
- red, scaly patches, flakes
9
Q
How does nummular dermatitis differ from atopic dermatitis?
A
round, pruritic, +/- oozing
- resembles ringworm
10
Q
Describe the presentation/symptoms in infants (< 2 years).
A
- starts on face (cheeks, forehead, scalp)
- not on diaper area
- erythematous papules or ill-defined plaques
- edema, weeping, crusting, scale
11
Q
Describe the presentation/symptoms in children (2-12 years).
A
- flexural folds (neck, wrists, ankles, antecubital and popliteal fossa)
- maybe face
- less vesicles than infants
- more erythematous papules and plaques
- scale
- lichenification, excoriation due to scratching
12
Q
Describe the presentation/symptoms in older children (> 12 years) and adults.
A
- flexural skin, wrists, ankles, eyelids
- head and neck type – upper trunk, shoulders, scalp
- lichenified plaques, scale, excoriations
- thickened, dry skin
13
Q
Describe mild disease.
A
- localized patches of dry skin, infrequent itching
- no impact on sleep, daytime activities
14
Q
Describe moderate disease.
A
- localized patches of dry skin, erythematous, pruritic
- some impact on sleep, daytime activities
15
Q
Describe severe disease.
A
- > 30% BSA, persistent pruritis, extensive lichenification, cracking,
- oozing, alter pigmentation
- major impact: sleep, QOL
16
Q
What are the goals of therapy? (5)
A
- remove/modify underlying cause/exacerbants
- achieve/maintain target lab/diagnostic targets
- minimize morbidity – rash symptoms (pruritus, plaque size/number), episodes (frequency, severity), complications (infection), non-rash symptoms (sleep, absenteeism, psychological stress)
- minimize adverse drug reactions
- optimize quality of life (patient-specific)
17
Q
What are some potential triggers? (3)
A
- allergens: exposure to aeroallergens, many develop asthma/allergic rhinitis later in childhood
- irritants: abrasive materials (wool), products promoting dry skin (detergents, soap, astringents, alcohol)
- foods: high correlation, but no established causation
18
Q
What is the basic management for all patients at all times?
A
- skin care: emollients, occlusives, humectants, barriers
- antiseptic measures: no evidence
- trigger avoidance
19
Q
What do emollients do?
A
soften and smooth scales
- Cetaphil
20
Q
What do occlusives do?
A
retard water evaporation
- petrolatum, mineral oil
21
Q
What do humectants do?
A
attract and hold water
- urea, ammonium lactate
22
Q
What do barriers do?
A
repair agents
- CeraVe
23
Q
Mild Disease
What is the acute treatment?
A
low potency topical corticosteroid (OTC) BID for up to 3 days beyond clearance
24
Q
Mild Disease
What are low potency topical corticosteroids useful for?
A
atopic dermatitis marked by hyperproliferation, inflammation, immunologic involvement
25
Mild Disease
What are the monitoring points for effectiveness?
- symptom (pruritis, erthema, plaque size, QOL) improvement within 1 week
- complete resolution in 2 weeks
26
Mild Disease
What are the monitoring points for safety?
- advise how to recognize and address allergic contact dermatitis
- prior negative response to acute treatment
- appropriate taper upon resolution
27
Topical Corticosteroids
What are higher potency corticosteroids used for?
thick skin, more severe
- avoid face, groin, axilla, children < 12
28
Topical Corticosteroids
What are lower potency corticosteroids used for?
ideal for longer use, larger surface area, face and other thin skin, children
29
Topical Corticosteroids
What can help with penetration?
occlusion
- plastic dressings result in 7x increase in penetration (all vehicles)
- avoid face or intertriginous areas – irritation, folliculitis, infection
- for low/medium potency only
30
Topical Corticosteroids
What are the side effects of short-term use?
- low SE, maybe allergic contact dermatitis
- systemic adverse effects low – HPA suppression, cataracts/glaucoma, osteoporosis, hypereglycemia
31
Topical Corticosteroids
What are the side effects of long-term use?
- purpura, telangiectasia, striae, focal hypertrichosis, acneiform or rosacea-like eruptions, hypopigmentation, skin atrophy, delayed wound healing or infection
- systemic adverse effects low – HPA suppression, cataracts/glaucoma, osteoporosis, hypereglycemia
32
Moderate to Severe Disease
What is the acute treatment?
medium potency topical corticosteroids BID for up to 3 days beyond clearance
- consider possible secondary infection that may require oral antibiotic
- if flare not resolved in 7 days, consider non-adherence, infection, misdiagnosis, referral
33
Moderate to Severe Disease
What factors play a role in the duration of continuous TCS use?
- if using very high potency agent for flare: treat for ≤ 3 weeks
- if flare unresolved: taper and resume after 1-week steroid-free period
- treat flares until lesions smooth to touch, erythema and pruritis resolved
34
Moderate to Severe Disease
Describe the topical corticosteroid taper in acute treatment/flare resolution.
- ↓ potency of topical corticosteroid and/or ↓ dosing frequency
- at 2 week intervals
- minimizes risk of rebound exacerbation
35
Moderate to Severe Disease
What should be done if a flare resolves and acute treatment is finished?
- return to moisturizers and other basic management
- if patients experience frequent repeated flares at same site: apply TCS 1-2x weekly at this site (intermittent use) – can ↓ relapse rate and increase time to next flare vs. moisturizers alone
36
Moderate to Severe Disease
What is the maintenance treatment?
- topical corticosteroids (medium potency dosed 1-2x per week) OR topical calcineurin inhibitor (tacrolimus, pimecrolimus dosed by severity)
- topical corticosteroids (medium potency dosed 1-2x per week + low potency dosed 1-2x daily)
- topical corticosteroid AND topical calcineurin inhibitor
37
Topical Calcineurin Inhibitors
Compare TCI to TCS.
- slower time to clinical effect
- tacrolimus: 0.1% as effective as medium TCS, 0.03% more effective than low TCS
- pimecrolimus: less effective than medium/high TCS
- may be preferred over TCS in sensitive skin areas
38
Topical Calcineurin Inhibitors
What is the dose for tacrolimus?
- 2-15 years: 0.03% BID
- ≥ 16 years: 0.03% or 0.1% BID
39
Topical Calcineurin Inhibitors
What is the dose for pimecrolimus?
1% BID
40
Topical Calcineurin Inhibitors
What are the side effects?
- sensation of skin burning (pimecrolimus < tacrolimus)
- erythema, pruritis
- photosensitivity – avoid sun exposure
- possible association with ↑ risk of lymphoma
41
Topical Calcineurin Inhibitors
What are the contraindications? (2)
- children < 2 years old
- immunocompromised
42
Topical PDE4 Inhibitors – Crisaborole
What is the use?
- unknown place in treatment relative to TCI, TCS
- patients > 3 months
- mild to moderate disease
43
Topical PDE4 Inhibitors – Crisaborole
What is the dose?
2% ung BID
44
Topical PDE4 Inhibitors – Crisaborole
What are the side effects?
- avoid eyes, mouth, genitalia
- burning, stinging at application site
- no telangiectasia or skin atrophy
45
Moderate to Severe Disease
What is the treatment for refractory disease?
- increase dosing of topical corticosteroids or topical calcineurin inhibitor
- phototherapy and/or immunomodulatory agents – UVA, UVB, cyclosporine, methotrexate, azathioprine
- investigate non-adherence
46
What are some novel therapeutic agents (human monoclonal antibody)? (3)
- dupilumab
- tralokinumab
- janus kinase inhibitors (JAKi) – ruxolitinib, upadacitinib, abrocitinib
47
Dupilumab
What is it used for?
- moderate to severe disease (when topical Rx ineffective or not advised)
- adults and children ≥ 6 years old
48
Dupilumab
What is the dose?
- initial loading dose 600 mg (two 300 mg SC injections at different sites) then - 300 mg every two weeks
300 mg every week may be as ≥ effective
49
Dupilumab
What are the side effects?
- headaches, cold sores, eye inflammation (especially conjunctivitis)
- very rare: serum sickness-like reactions (fever, rash, joint pain, and/or swelling)
- asthma patient breathing symptoms may worsen when stopped
50
Tralokinumab
What is it used for?
- moderate to severe disease (when topical Rx ineffective or not advised)
- adolescents age 12-17
51
Tralokinumab
What is the dose?
initial loading dose 600 mg (two 300 mg SC injections at different sites) then 300 mg every two weeks
52
Tralokinumab
What are the side effects?
- more instance of upper respiratory illness
- injection-site reactions
- conjunctivitis (but < dupilumab)
53
Janus Kinase Inhibitors (JAKi) – Ruxolitinib, Upadacitinib, Abrocitinib
What is it used for?
- moderate to severe disease
- ≥ 12 years old
54
Janus Kinase Inhibitors (JAKi) – Ruxolitinib, Upadacitinib, Abrocitinib
Describe the safety monitoring required.
- laboratory monitoring: CBC, LFT, lipids, TB
- warnings for serious infections, lymphoma, thrombosis, CV events
55
What are the monitoring points for effectiveness?
- symptoms: controlled pruritis, stable plaques
- flares: absence or ↓ frequency/severity
- complications: no infection
- QOL: sleep, no absences
56
What are the monitoring points for safety for TCS?
- skin: discoloration, hypopigmentation, atrophy, wound healing, infection
- administration: quantity, occlusive use
57
What are the monitoring points for safety for TCI?
- skin: paradoxical erythma, pruritus, burning sensation, photosensitivity
58
When should a patient be referred?
clinical presentation appears infectious – crusting, oozing, pus
- mild/limited disease: topical antibiotics
- severe disease: oral antibiotics
