Transcript Screening and Periodicity Guidelines

Atopic Dermatitis
April 2015
Pediatric Continuity Clinic Curriculum
Created by: Matthew Pertzborn, PGL-2
Objectives
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Describe the common clinical presentation and diagnosis
of atopic dermatitis
Understand the management of atopic dermatitis
Discuss common co-morbidities and complications of
atopic dermatitis
Case #1
A 12 month old female presents with a 6 month history of
intermittent erythema, dryness, and cracking of the skin on
the face and on the extensor surfaces of the arms. She has
been scratching at the affected areas.
 Question 1-1: What is the differential diagnosis of these
symptoms?
 Question 1-2: What is the typical distribution of atopic
dermatitis?
 Question 1-3: What are common triggers of atopic
dermatitis?
Discussion question 1-1?
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Differential includes:
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Contact dermatitis
Psoriasis
Impetigo
Histiocytosis X (particularly if the distribution involves the diaper
area in children wearing diapers)
Wiskott-Aldrich syndrome
Scabies
Seborrheic dermatitis
Drug reaction
Lymphoma with cutaneous involvement
Immune system disorder (e.g. hyper-IgE syndrome)
Zinc deficiency
Discussion question 1-2?
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It is important to be aware of the typical distribution:
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Infants (most common onset is between 3 and 6 months of age)
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Older Children
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Face
Extensor sites
Trunk
Flexor sites
Antecubital fossa
Popliteal fossa
Neck
Trunk
Typically spares the groin and axillary areas
Stuffy-sounding nose is a common observation
Discussion question 1-3?
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Common triggers/exacerbating factors in atopic dermatitis:
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Food/formula
Mechanical
Soaps
Detergents
Wool
Weather (e.g. low levels of humidity)
Diaphoresis
Dust mites (Dermatophagoides pteronyssinus)
Mold
Pollen
Pets
Bacteria
Stress
Additional Information
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Image From: Pediatrics In Review (Reference #1)
Additional Information
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Often follows a relapsing course
The term “atopic dermatitis” and “atopic eczema” (often
simply called “eczema”) are the same
Itching is very characteristic
IgE often elevated
Case #2
A 3 year old male presents with a 2 year history of intermittent
erythema, dryness, and cracking of the skin on the face and on
the extensor surfaces of the arms. The symptoms were
previously controlled adequately with application of Vaseline after
baths. He has been having multiple flares of these symptoms
despite the Vaseline management and the mother is wondering
what else can be done.
 Question 2-1: What is the first-line management for eczema in
general?
 2-2: What is the best next treatment choice for the patient
above?
 2-3: Is there a non-corticosteroid alternative for severe
disease?
Discussion question 2-1?
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Initial Management of Eczema:
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Removal of potential triggers if possible
Use mild, non-scented soap (e.g. Dove soap) only
Minimize non-soap cleaners
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Should be neutral to low pH, fragrance-free, hypoallergenic if used
Removal of certain detergents for washing clothes. Avoid dryer
sheets (e.g. Bounce) and detergents with fragrances.
Topical moisturizers/emollients (e.g. petrolatum jelly, Aquaphor
ointment)
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Ointments more effective than creams
Lotions should be avoided
Application after bath (immediately after drying)
Application throughout the day
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Exact frequency and amount not well delineated in the literature
Discussion question 2-2?
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Management of acute flares if the initial management is not
adequate:
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Some advocate burst of high-dose corticosteroids with tapering in
potency once controlled, others advocate starting with lowestpotency corticosteroids and then titrating upward
Potency ranges from lowest-potency (class VII (e.g. hydrocortisone
0.25-1%)) to high-potency corticosteroids (class I (e.g. diflorasone))
Caution should be used when applying higher-potency
corticosteroids to the face, neck, or skin-folds as risk of significant
systemic absorption is higher in these areas
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Avoid using higher-potency corticosteroids for more than 2 weeks at a
time
Typically dosed 2x per day
Discussion question 2-2?
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Management of acute flares if the initial managements are
not adequate:
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Wet-wrap therapy can be useful as adjunct
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Involves covering the area on which the topical moisturizer or topical
corticosteroid is applied with a wet bandage and then placing a dry
bandage on top of the wet bandage
Wrap may be kept on for up to 24 hours at a time and this adjunct
has been used for as much as 2 weeks in the literature
Use of this adjunct with mid- to high-potency corticosteroids is
controversial
Discussion question 2-3?
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Topical calcineurin inhibitors
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May be used to avoid side/adverse effects of corticosteroids,
particularly if high-potency corticosteroids are required, skin
atrophy secondary to corticosteroid use occurs, or topical
corticosteroids are required long-term
Topical tacrolimus ointment (0.03-0.1%) or pimecrolimus
cream (1%)
Typically dosed 2x per day
Additional Information
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Clinical pearl: Important to apply emollient/ointment after
every bath (pad down with towel, don’t wipe after the
bath prior to application)
Case #3
A 3 year old male presents with a 2 year history of
intermittent erythema, dryness, and cracking of the skin on
the face and on the extensor surfaces of the arms. Starting
5 days ago, there has been some crusting on the face with a
small amount of yellow oozing
 What other medical conditions (non-infectious) are
associated with eczema?
 Are there increased risk of infectious co-morbidities in
eczema?
 Is there anything that can be done to prevent secondary
infection?
Discussion question 3-1?
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Allergic rhinitis, asthma, and food allergies are associated
with eczema.
Extra careful screening for the above conditions should
occur
Discussion question 3-2?
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Secondary skin infections possible:
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Appropriate systemic antibiotic therapy if secondary infection
occurs (depends on local resistance profiles)
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Staphylococcus aureus most common
Clindamycin
Bactrim
If secondary infections frequent:
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Mupirocin to the nares if Staphylococcus aureus colonization suspected
(BID x10 days)
Bleach baths if signs of secondary infection present (may also do this
prophylactically if eczema is extensive)
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Can reduce colonization dramatically
1/4-1/2 cup household bleach (6% sodium hypochlorite) in half-filled bath
Stay in bath 20 minutes then rinse with fresh water after
Typically weekly
Lukewarm temperature
Additional Information
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Clinical pearl: Remember to ask about family history of
allergic rhinitis (seasonal allergies), hay fever, asthma, and
eczema.
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70% of patients with eczema have atopic disease in other
members of the family
PREP Question
PREP 2014 Item 141:
The mother of a 7-month-old infant is frustrated that the infant’s atopic
dermatitis is not getting better. He is awake “all night” scratching and is
irritable and fussy. She has been giving him diphenhydramine every 8
hours and applying hypoallergenic moisturizer and a topical
corticosteroid cream twice a day. The infant was breastfed until 3
months ago and then switched to a cow milk-based formula. On physical
examination, you notice that he has dry, erythematous papules and
patches, with excoriation marks on his face, neck, antecubital fossae,
popliteal fossae, and back. He has normal growth parameters.
Of the following, the MOST appropriate next step in this infant’s
management is to recommend:
A. discontinuing diphenhydramine and switching him to daily loratadine
B. eliminating cow milk, egg, soy, and wheat from his diet
C. Introducing cow milk on a trial basis to see if the rash worsens
D. switching to hypoallergenic formula and a diet of only rice and chicken
E. testing for pertinent, potential food allergen triggers
PREP Question
PREP 2014 Item 141:
The mother of a 7-month-old infant is frustrated that the infant’s atopic
dermatitis is not getting better. He is awake “all night” scratching and is
irritable and fussy. She has been giving him diphenhydramine every 8
hours and applying hypoallergenic moisturizer and a topical
corticosteroid cream twice a day. The infant was breastfed until 3
months ago and then switched to a cow milk-based formula. On physical
examination, you notice that he has dry, erythematous papules and
patches, with excoriation marks on his face, neck, antecubital fossae,
popliteal fossae, and back. He has normal growth parameters.
Of the following, the MOST appropriate next step in this infant’s
management is to recommend:
A. discontinuing diphenhydramine and switching him to daily loratadine
B. eliminating cow milk, egg, soy, and wheat from his diet
C. Introducing cow milk on a trial basis to see if the rash worsens
D. switching to hypoallergenic formula and a diet of only rice and chicken
E. testing for pertinent, potential food allergen triggers (see PREP
2014 for explanation)
PREP Question
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PREP 2014 Item 106:
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The parents of a 3 year old boy would like him to be tested for allergies.
The parents report that the boy has had worsening symptoms of itchy
eyes, sneezing fits, and nasal congestion since the family got a new dog 1
year ago. The parents would like the boy tested to determine if they
need to give the dog away. They are reluctant to stop the boy’s daily
antihistamine and are disappointed to learn that skin testing cannot be
performed while taking this medication.You decide to obtain bloodspecific IgE testing. However, the parents have read on the internet that
the “scratch test” is a better test. Of the following, you are MOST likely
to advise the parents that in this situation, blood-specific IgE testing is:
A. Comparable to skin testing
B. Less expensive and better tolerated by children than skin testing
C. More accurate than skin testing
D. The only testing that can be done because he is too young for skin
testing
E. A preliminary test and you will obtain skin testing to confirm the
results
PREP Question
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PREP 2014 Item 106:
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The parents of a 3 year old boy would like him to be tested for
allergies. The parents report that the boy has had worsening
symptoms of itchy eyes, sneezing fits, and nasal congestion since the
family got a new dog 1 year ago. The parents would like the boy
tested to determine if they need to give the dog away. They are
reluctant to stop the boy’s daily antihistamine and are disappointed
to learn that skin testing cannot be performed while taking this
medication. You decide to obtain blood-specific IgE testing. However,
the parents have read on the internet that the “scratch test” is a
better test. Of the following, you are MOST likely to advise the
parents that in this situation, blood-specific IgE testing is:
A. Comparable to skin testing (see PREP 2014 for
explanation)
B. Less expensive and better tolerated by children than skin testing
C. More accurate than skin testing
D. The only testing that can be done because he is too young for skin
testing
E. A preliminary test and you will obtain skin testing to confirm the
results
References and Future Reading
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Eichenfield, Lawrence F., Wynnis L. Tom, Sarah L. Chamlin,
Steven R. Feldman, Jon M. Hanifin, Eric L. Simpson, Timothy G.
Berger, James N. Bergman, David E. Cohen, Kevin D. Cooper,
Kelly M. Cordoro, Dawn M. Davis, Alfons Krol, David J. Margolis,
Amy S. Paller, Kathryn Schwarzenberger, Robert A. Silverman,
Hywel C. Williams, Craig A. Elmets, Julie Block, Christopher G.
Harrod, Wendy Smith Begolka, and Robert Sidbury. "Guidelines
of Care for the Management Of atopic dermatitis." Journal of
the American Academy of Dermatology 70.2 (2014): 338-51. Web.
Cipriani, Francesca, Arianna Dondi, and Giampaolo Ricci.
"Recent Advances in Epidemiology and Prevention of Atopic
Eczema." Pediatric Allergy and Immunology. 10 Dec. 2014. Web. 28
Dec. 2014.
References and Future Reading
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Knoell, K. A., and K. E. Greer. "Atopic Dermatitis."
Pediatrics in Review 20.2 (1999): 46-52. Web.
Krakowski, A. C., L. F. Eichenfield, and M. A. Dohil.
"Management of Atopic Dermatitis in the Pediatric
Population." Pediatrics 122.4 (2008): 812-24. Web.