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__NOTOC__
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{{Xyz}}
{{CMG}}; {{AE}} {{S.S}}
{{CMG}}; {{AE}}
 
==Overview==
The most common symptoms of atopic dermatitis include pruritus, distribution of rash on age- specific patters and dry skin. Patients often have personal or family history of asthma or allergic rhinitis.
 
==History and Symptoms==
===History===
Patients with atopic dermatitis may have a positive history of:<ref name="pmid23712284">{{cite journal |vauthors=Leung DY |title=New insights into atopic dermatitis: role of skin barrier and immune dysregulation |journal=Allergol Int |volume=62 |issue=2 |pages=151–61 |date=June 2013 |pmid=23712284 |doi=10.2332/allergolint.13-RAI-0564 |url=}}</ref>
*cutaneous hyper-reactivity to diverse environmental stimuli:
**exposure to food and inhalant allergens
**changes in physical environment (including humidity, pollution etc)
**irritants
**microbial infection
**stress
*personal or family history of type I hypersensitivity
*asthma
*allergic rhinitis
 
===Common Symptoms===
Common symptoms of  atopic dermatitis include:<ref name="DeleuranVestergaard2014">{{cite journal|last1=Deleuran|first1=M.|last2=Vestergaard|first2=C.|title=Clinical heterogeneity and differential diagnosis of atopic dermatitis|journal=British Journal of Dermatology|volume=170|year=2014|pages=2–6|issn=00070963|doi=10.1111/bjd.12933}}</ref>
*Severe pruritus - can cause sleep loss
*Chronic or relapsing skin lesions
*Distribution of rash on:
**Facial and extensor surfaces in infants and young children
**Flexural lichenification in older children and adults
 
===Less Common Symptoms===
Less common symptoms of atopic dermatitis include:<ref name="pmid9734903">{{cite journal |vauthors=Rudikoff D, Lebwohl M |title=Atopic dermatitis |journal=Lancet |volume=351 |issue=9117 |pages=1715–21 |date=June 1998 |pmid=9734903 |doi=10.1016/S0140-6736(97)12082-7 |url=}}</ref>
* Facial pallor
* Dry skin especially in winter)
* Nonspecific dermatitis of the hands and feet
* Food intolerance
* Itch when sweating
 
==References==
{{Reflist|2}}
 
{{WH}}
{{WS}}
[[Category: (name of the system)]]


==Overview==
==Overview==
Common physical examination findings of atopic dermatitis include pruritus, eczematous lesions, xerosis and lichenification. The lesions are usually age specific and can be in various stages of development. The lesions can involve any area of body in severe cases, but usually it is uncommon to find lesions in  the axillary, gluteal, or groin area.
The mainstay of treatment for atopic dermatitis depends upon the severity of the disease and is treated with combination of conservative and medical therapy. The goals of treatment include elimination of aggravating factors, skin barrier function repair, maintaining skin hydration and pharmacologic treatment of skin inflammation.
 
==Physical Examination==
The clinical presentation of atopic dermatitis is highly variable, depending upon the patient's age and disease activity.
 
===Appearance of the Patient===
*Patients with atopic dermatitis usually appear normal.  
 
===Vital Signs===


*Vitals signs in atopic dermatitis patients are usually within normal limits.
==Conservative Therapy==


===Skin===
* '''Primary findings''':
** Severe pruritus- cardinal feature of atopic dermatitis
** Eczematous lesions- location of lesions has age-specific patterns
** Xerosis (especially during winters)
** Lichenification
* An acute eczematoid eruption (with erythematous papules) appears after patients scratch their skin
* '''Eczema''':
** '''Acute atopic dermatitis''':
*** The skin is erythematous with papules and vesicles, and can usually get  infected with ''Staphylococcus aureus''
*** Lesions presents as intense pruritic erythematous papules and vesicles with exudation and crusting
** '''Subacute or chronic atopic dermatitis''':
*** The skin is dry, infiltrated and usually lichenified with scales and fissures. In severe cases the disease can lead to erythroderma
*** Lesions are dry, scaly, or excoriated erythematous papules
*** Lichenification (chronic scratching may result in skin thickening) and fissuring may develop over time
***
** '''Age-specific patterns''':
{| class="wikitable"
{| class="wikitable"
|+
|+
!'''Infants and young children(zero to two years)'''
!'''Elimination of exacerbating factors'''
!'''Maintaining skin hydration'''
!'''Controlling pruritus'''
|-
|-
|
|
* Earliest lesions:
* Avoid trigger factors such as low humidity, overheating of skin
** Presents with erythema and exudation of the creases(antecubital and popliteal fossae)
* Treating stress and anxiety
 
* Avoid exposure to solvents and detergents
* Over the following few weeks:
* Treat skin infections such as ''Staphylococcus aureus'' and herpes simplex
** highly pruritic, red, scaly and crusted lesions, usually localized to the cheeks, the forehead and scalp, and the extensors of the lower legs
* Lesions are ill-defined, erythematous, scaly, and crusted (eczematous) patches and plaques.
* The most commonly involved areas:
** Scalp, cheeks and extensor side of the extremities.
** Flexural areas, especially the neck fold, may be involved
* Midline of the face and the tip of the nose is spared (Yamamoto’s sign)
* Diaper area is generally spared
* Lichenification is uncommon in infancy
|-
!'''Older children and adolescents (2 to 16 years)'''
|-
|
|
* Lichenification is characteristic of childhood atopic dermatitis
* '''Emollients and moisturizers'''
 
** Thick creams, ointments (eg, petroleum jelly) with low/zero water content
* Areas involved:
** Immediately after 5-minute, lukewarm baths BID
** Flexural areas, particularly the antecubital and popliteal fossae, and buttock-thigh creases
* '''Bathing practices'''
** Volar aspect of the wrists and ankles may be involved
** Warm soaking baths or showers using mild or soap-free cleansers
** "Atopic dirty neck" - neck and sides of the neck may show a reticulate pigmentation
* Thickened plaques show lichenification and excoriation
* Xerosis is generalized
* Dennie-Morgan folds (i.e. increased folds below the eye) along with erythema and scaling around the eyes is often seen
* Centrofacial pallor is common
* Dry skin and fissuring behind the ears or on the earlobe (infra-auricular and retroauricular fissuring)
* In African-American children, follicular papular lesions are prominent and striking and hypopigmentation and hyperpigmentation
|-
!'''Adults (from puberty onward)'''
|-
|
|
* Lesions are more localized and lichenified.
* Conservative
* Areas involved:
** Tepid baths
** Facial involvement is common, especially the forehead and periorbital regions.
** Wet dressings (wet wraps)
** Lichenification occurs in skin flexures such as wrists, hands, ankles, feet, fingers, and toes
** Moisturizers containing anti-pruritic ingredients such as phenol, menthol, and camphor


* A brown macular ring around the neck may be present (localized deposition of amyloid)- "Atopic dirty neck"
*
* Xerosis is prominent
|}
|}
* '''Associated symptoms with atopic dermatitis''':
{| class="wikitable"
|+
!'''Atopic stigmata'''
(associated cutaneous findings seen in atopic dermatitis patients)
|-
|
* Atypical vascular responses
** Centrofacial pallor
** delayed blanch response
* Skin
** Keratosis pilaris
** Palmar hyperlinearity
** Pityriasis alba
** ichthyosis
* Ocular/periorbital
** Periorbital darkening and Dennie-Morgan infraorbital folds
** Hertoghe's sign- thinning or absence of the lateral portion of the eyebrows
* Other
** Infra-auricular and retro-auricular fissuring
** Nipple eczema
** White dermographism
** Perifollicular accentuation
|-
|
|}
* '''Clinical phenotypes of atopic dermatitis:'''
** Localized and morphological variants of atopic dermatitis are present in both children and adults.
** These variants can present as only clinical feature of atopic dermatitis or can present in association with age related manifestations.


{| class="wikitable"
==Medical Therapy==
|+
*Pharmacologic medical therapies for atopic dermatitis can be classified according to the several severity scales( (i.e SCORAD index, the eczema area and severity index [EASI], and the patient-oriented eczema measure [POEM]) which includes characteristics of the rash, questions about itch, sleep, impact on daily activities, and persistence of disease.
! colspan="2" |Different phenotypes of atopic dermatitis
===Atopic dermatitis===
|-
| colspan="2" |
* Acute vs chronic eczema
* Intrinsic vs extrinsic atopic eczema
* Early onset vs late onset
* Mild vs severe eczema
* Increased IgE vs non-atopic
* S. aureus infection/colonization, disseminated viral or fungal infections e.g. EH, molluscum contagiosum, Malassezia
* Associated with ichthyosis, keratosis pilaris, palmar hyperlinearity, early onset, severe and persistent eczema (FLG null genotype)
|-
!Localized variants
!Morphological variants
|-
|
* Hand eczema
* Juvenile palmar and plantar dermatitis
* Eyelid dermatitis
* Atopic cheilitis
* Periorificial dermatitis
* Nipple dermatitis
|
* Nummular eczema
 
* Atopic prurigo
 
* Lichen planus-like
 
* Pit<span class="_ _1 current-selection"></span>yriasis alba<span class="_ _1 current-selection"></span>
|}
* '''Localized variants''':
** Atopic hand eczema:
*** Atopic hand eczema typically affects volar wrists and dorsum of the hands.
*** one-third of patients with atopic hand eczema, also reports foot eczema.
*** Common in adults with past medical history of history of atopic dermatitis, and currently do not have dermatitis in typical areas (i.e. flexural)
*** Most common in adults exposed to wet environments
** Eyelid eczema :
*** Some patients of atopic dermatitis, may present with eyelid eczema alone
*** associated with lichenification and presence of Dennie-Morgan lines
** Atopic cheilitis:
*** Also known as lip eczema or cheilitis sicca
*** Presents as dryness, peeling, and fissuring of the lips
** Juvenile papular dermatitis:
*** Primarily occurs in the spring and summer - associated with pollinosis 
*** localized mainly to the elbows and knees 
** Juvenile palmar and plantar dermatitis
*** painful variant of atopic dermatitis
*** Localized on the anterior part of the sole
* '''Morphological variants''':
** Nummular (discoid eczema):
*** Sharply demarcated patches and plaques with inflammation of skin
*** Secondarily infection with Staphylococcus aureus common
*** Commonly affected areas- extremities and buttocks
*** Very difficult to treat
 
*
*
*
*


*  
* '''MIld atopic dermatitis''':
*  
** Topical corticosteroids and emollients - mainstay therapy
*  
*** '''Adult'''
*  
**** Preferred regimen (1): [[drug name|desonide 0.05%]] top. q12h-q24h for 14-28 days
**** Preferred regimen (2): [[drug name|hydrocortisone 2.5% top.]] q12h-q24h for 14-28 days
**** Preferred regimen (3): fluocinolone acetonide [[drug name|0.01% top.]] q12h-q24h for 14-28 days
**** Alternative regimen (1) tacrolimus 0.1% top. q8h ('''0.03% for adults who do not tolerate the higher dose)'''
**** Alternative regimen (2): pimecrolimus 1% top. q8h
**** Alternative regimen (3) crisaborole 2% top.
*** '''Pediatric'''
**** Preferred regimen (1): [[drug name|desonide 0.05%]] top. q12h-q24h for 14-28 days
**** Preferred regimen (2): [[drug name|hydrocortisone 2.5% top.]] q12h-q24h for 14-28 days
**** Preferred regimen (3):  fluocinolone acetonide [[drug name|0.01% top.]] q12h-q24h for 14-28 days
**** Alternative regimen (1) tacrolimus 0.03%  top. q8h ('''Children (>2years)'''
**** Alternative regimen (2): pimecrolimus 1% top. q8h
**** Alternative regimen (3): crisaborole 2% top.
*  '''Moderate atopic dermatitis'''
** Topical corticosteroids and emollients are the mainstay of therapy
*** '''Adult'''
**** Preferred regimen (1): fluocinolone0.025%. q12h-q24h for 14-28 days
**** Preferred regimen (2): [[drug name|triamcinolone 0.1% top.]] q12h-q24h for 14-28 days
**** Preferred regimen (3): fluocinolone acetonide [[drug name|0.025% top.]] q12h-q24h for 14-28 days
**** Alternative regimen (1) tacrolimus 0.1% top. q8h ('''0.03% for adults who do not tolerate the higher dose)'''
**** Alternative regimen (2): pimecrolimus 1% top. q8h
**** Alternative regimen (3) crisaborole 2% top.
** '''Pediatric'''
*** Preferred regimen (1): fluocinolone0.025%. q12h-q24h for 14 days
*** Preferred regimen (2): [[drug name|triamcinolone 0.1% top.]] q12h-q24h for 14 days
*** Preferred regimen (3): fluocinolone acetonide [[drug name|0.025% top.]] q12h-q24h for 14-28 days
*** Alternative regimen (1) tacrolimus 0.03%  top. q8h ('''Children (>2years)'''
*** Alternative regimen (2): pimecrolimus 1% top. q8h
*** Alternative regimen (3) crisaborole 2% top.
* '''Severe atopic dermatitis'''
** Phototherapy or systemic immunosuppressant treatment is the mainstay of therapy
*** '''Adult'''
**** Preferred regimen (1): Phototherapy Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
**** Preferred regimen (2): [[drug name|cyclosporine]] PO 3-5 mg/kg o.d. for 6 weeks ('''monitor BP and serum creatinine q2 weeks for three months, f/u q month)''' 
**** Alternative regimen (1) methotrexatePO
**** Alternative regimen (2): azathioprine PO
**** Alternative regimen (3) mycophenolate mofetil PO
**** Alternative regimen (3) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
*** '''Pediatric'''
**** Preferred regimen (1):
**** Preferred regimen (2): [[drug name|cyclosporine]] PO 3 to 5 mg/kg per day o.d. for 6 weeks ('''monitor BP and serum creatinine q2 weeks for three months, f/b q month)''' 
**** Alternative regimen (1) Phototherapy Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
**** Alternative regimen (2): azathioprine PO
**** Alternative regimen (3) mycophenolate mofetil PO
**** Alternative regimen (3) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
* '''Severe refractory atopic dermatitis'''
** '''Adult'''
*** Preferred regimen (1): Intensive topical therapy
**** Soak and smear: Soak for 15 minutes in a tub of water. Apply desoximetasone 0.25% top. to the whole body, except the groin, axillae, and face
**** Wet wrap therapy: desoximetasone 0.25% top. then occluded with wet wraps q12h
*** Alternative regimen (1) Phototherapy: narrowband ultraviolet B or psoralen plus ultraviolet A  two to three times per week
*** Alternative regimen (2): cyclosporine PO 2.5 to 5 mg/kg o.d. ('''C/I -''' '''abnormal renal function, uncontrolled hypertension or infection, and malignancy''')
*** Alternative regimen (3): prednisone 40 to 60 mg o.d. for one week, then taper the dose over the following two to three week
*** Alternative regimen (4): methotrexate 7.5 to 25 mg single weekly dose with folic acid 1 mg o.d.
*** Alternative regimen (5): azathioprine 2 to 3 mg/kg
*** Alternative regimen (6):  mycophenolate mofetil 1 to 2 g/day
*** Alternative regimen (7):  mycophenolic acid 720 to 1440 mg/day
*** Alternative regimen (8)  dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
** '''Pediatric'''
*** Preferred regimen (1): Intensive topical therapy
**** Wet wrap therapy: desoximetasone 0.05% top. then occluded with wet wraps q12h-q24h for 2 to 14 days
*** Alternative regimen (1) Phototherapy: narrowband ultraviolet B (UVB)  3 times per week ('''older children > 6 years''')
*** Alternative regimen (2): cyclosporine PO 2.5 to 5 mg/kg o.d. for 2-4 months ('''monitor renal and hepatic function''')
*** Alternative regimen (3): methotrexate 0.5 mg/kg PO single weekly dose with folic acid 1 mg o.d.('''up to a maximum of 25 mg per week''')
*** Alternative regimen (4): methylprednisolone 0.5 mg/kg o.d. for 1-2 weeks tapered over one month
'''Management of Infection:'''
* '''Bacterial''' '''infections''': (most common bacteria - ''Staphylococcus. aureus'')
** Clinically infected skin:
*** Mupirocin 2% top. BID for one to two weeks
*** More extensive infection: oral antibiotic therapy with cephalosporins or penicillinase-resistant penicillins X two weeks
** Clinically uninfected skin:
*** liquid chlorine bleach-  0.5 cup or 120 ml of 6% bleach in a full bathtub [40 gallons or 150 L] of lukewarm water
* '''Viral infections:'''
** Herpes simplex:
*** Acyclovir 200 or 400 mg PO five times daily
*** Famciclovir 750 mg BID for one day or 1500 mg as a single dose
** molluscum contagiosum :
*** cryotherapy, curettage, cantharidin, and podophyllotoxin as first-line therapeutic options
* '''Fungal infections:'''
** Dermatophyte infections'''-''' topical or oral antifungals
'''Controlling pruritus:'''
* Preferred regimen''':'''
** Sedatives: diphenhydramine, hydroxyzine, and cyproheptadine
** Nonsedatives: fexofenadine, cetirizine or loratadine
* Alternative regimen:
** Topical doxepin
** Topical calcineurin inhibitors
***  Pimecrolimus 1% cream or tacrolimus 0.03% to 0.1%


=== HEENT ===
'''Chronic inflammatory skin diseases'''
* HEENT examination of patients with atopic dermatitis is usually normal.
* Contact (allergic, irritant)
* Seborrhoeic dermatitis
** onset during the 1st days or weeks of life, absence of pruritus, and presence of greasy scaling on a yellow-red base
** Involvement of the top of the scalp (cradle cap), axilla, and diaper area makes it more likely the patient has '''seborrheic dermatitis''', vs excoriated dermatitis involving the extensor surfaces, face, and trunk favour '''AE.'''
* Psoriasis
* Lichen simplex chronicus
'''Infectious agents'''
* Candida
* Dermatophytes
* Herpes simplex
* Staphylococcus aureus
* Sarcoptes scabiei
** highly pruritic, erythematous papular lesions. In most cases, the typical burrows can be found on the flexor wrists, finger webs and genitalia. Similar symptoms in other family members
* HIV-associated dermatitis
'''Immunologic disorders'''
* Dermatitis herpetiformis
* Pemphigus foliaceus
* Graft-versus-host disease
* Dermatomyositis
'''Malignant Diseases'''
* Cutaneous T-cell lymphoma (mycosis fungoides, S´ezary syndrome)
* Histiocytosis X (Letterer-Siwe disease)
'''Congenital disorders'''
* Netherton’s syndrome
* Dubowitz syndrome
* Erythrokeratodermia variabilis
'''Immunodeficiencies'''
* Wiskott-Aldrich syndrome (immunodeficiency with thrombocytopenia and eczema)
* Thymic hypoplasia (DiGeorge syndrome)
* Hyper-IgE syndrome
* Severe combined immunodeficiency (SCID)
* Ataxia teleangiectasia
'''Metabolic Diseases'''
* Phenylketonuria
* Tyrosinemia
* Histidinemia
* Zinc deficiency
* Pyridoxine (vitamin B6) and niacin deficiency
* Multiple carboxylase deficiency


* Eczematous lesions can be present depending on the age of the patients.
* '''Nonallergic reaction to medication'''
** Infliximab


===Neck===
* Neck examination of patients with atopic dermatitis is usually normal.
* Eczematous lesions can be present depending on the age of the patients.
===Lungs===
* Pulmonary examination of patients with atopic dermatitis is usually normal.
===Heart===
* Cardiovascular examination of patients with atopic dermatitis is usually normal.
===Abdomen===
* Abdominal examination of patients with atopic dermatitis is usually normal.
===Back===
* Back examination of patients with atopic dermatitis is usually normal.
* Eczematous lesions can be present depending on the age of the patients.
===Genitourinary===
* Genitourinary examination of patients with atopic dermatitis is usually normal.
===Neuromuscular===
* Neuromuscular examination of patients with atopic dermatitis is usually normal.
===Extremities===
* Extremities examination of patients with atopic dermatitis is usually normal.
* Eczematous lesions can be present depending on the age of the patients.
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 16:56, 10 October 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

The mainstay of treatment for atopic dermatitis depends upon the severity of the disease and is treated with combination of conservative and medical therapy. The goals of treatment include elimination of aggravating factors, skin barrier function repair, maintaining skin hydration and pharmacologic treatment of skin inflammation.

Conservative Therapy

Elimination of exacerbating factors Maintaining skin hydration Controlling pruritus
  • Avoid trigger factors such as low humidity, overheating of skin
  • Treating stress and anxiety
  • Avoid exposure to solvents and detergents
  • Treat skin infections such as Staphylococcus aureus and herpes simplex
  • Emollients and moisturizers
    • Thick creams, ointments (eg, petroleum jelly) with low/zero water content
    • Immediately after 5-minute, lukewarm baths BID
  • Bathing practices
    • Warm soaking baths or showers using mild or soap-free cleansers
  • Conservative
    • Tepid baths
    • Wet dressings (wet wraps)
    • Moisturizers containing anti-pruritic ingredients such as phenol, menthol, and camphor

Medical Therapy

  • Pharmacologic medical therapies for atopic dermatitis can be classified according to the several severity scales( (i.e SCORAD index, the eczema area and severity index [EASI], and the patient-oriented eczema measure [POEM]) which includes characteristics of the rash, questions about itch, sleep, impact on daily activities, and persistence of disease.

Atopic dermatitis

  • MIld atopic dermatitis:
    • Topical corticosteroids and emollients - mainstay therapy
      • Adult
        • Preferred regimen (1): desonide 0.05% top. q12h-q24h for 14-28 days
        • Preferred regimen (2): hydrocortisone 2.5% top. q12h-q24h for 14-28 days
        • Preferred regimen (3): fluocinolone acetonide 0.01% top. q12h-q24h for 14-28 days
        • Alternative regimen (1) tacrolimus 0.1% top. q8h (0.03% for adults who do not tolerate the higher dose)
        • Alternative regimen (2): pimecrolimus 1% top. q8h
        • Alternative regimen (3) crisaborole 2% top.
      • Pediatric
        • Preferred regimen (1): desonide 0.05% top. q12h-q24h for 14-28 days
        • Preferred regimen (2): hydrocortisone 2.5% top. q12h-q24h for 14-28 days
        • Preferred regimen (3): fluocinolone acetonide 0.01% top. q12h-q24h for 14-28 days
        • Alternative regimen (1) tacrolimus 0.03% top. q8h (Children (>2years)
        • Alternative regimen (2): pimecrolimus 1% top. q8h
        • Alternative regimen (3): crisaborole 2% top.
  • Moderate atopic dermatitis
    • Topical corticosteroids and emollients are the mainstay of therapy
      • Adult
        • Preferred regimen (1): fluocinolone0.025%. q12h-q24h for 14-28 days
        • Preferred regimen (2): triamcinolone 0.1% top. q12h-q24h for 14-28 days
        • Preferred regimen (3): fluocinolone acetonide 0.025% top. q12h-q24h for 14-28 days
        • Alternative regimen (1) tacrolimus 0.1% top. q8h (0.03% for adults who do not tolerate the higher dose)
        • Alternative regimen (2): pimecrolimus 1% top. q8h
        • Alternative regimen (3) crisaborole 2% top.
    • Pediatric
      • Preferred regimen (1): fluocinolone0.025%. q12h-q24h for 14 days
      • Preferred regimen (2): triamcinolone 0.1% top. q12h-q24h for 14 days
      • Preferred regimen (3): fluocinolone acetonide 0.025% top. q12h-q24h for 14-28 days
      • Alternative regimen (1) tacrolimus 0.03% top. q8h (Children (>2years)
      • Alternative regimen (2): pimecrolimus 1% top. q8h
      • Alternative regimen (3) crisaborole 2% top.
  • Severe atopic dermatitis
    • Phototherapy or systemic immunosuppressant treatment is the mainstay of therapy
      • Adult
        • Preferred regimen (1): Phototherapy Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
        • Preferred regimen (2): cyclosporine PO 3-5 mg/kg o.d. for 6 weeks (monitor BP and serum creatinine q2 weeks for three months, f/u q month)
        • Alternative regimen (1) methotrexatePO
        • Alternative regimen (2): azathioprine PO
        • Alternative regimen (3) mycophenolate mofetil PO
        • Alternative regimen (3) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
      • Pediatric
        • Preferred regimen (1):
        • Preferred regimen (2): cyclosporine PO 3 to 5 mg/kg per day o.d. for 6 weeks (monitor BP and serum creatinine q2 weeks for three months, f/b q month)
        • Alternative regimen (1) Phototherapy Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
        • Alternative regimen (2): azathioprine PO
        • Alternative regimen (3) mycophenolate mofetil PO
        • Alternative regimen (3) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
  • Severe refractory atopic dermatitis
    • Adult
      • Preferred regimen (1): Intensive topical therapy
        • Soak and smear: Soak for 15 minutes in a tub of water. Apply desoximetasone 0.25% top. to the whole body, except the groin, axillae, and face
        • Wet wrap therapy: desoximetasone 0.25% top. then occluded with wet wraps q12h
      • Alternative regimen (1) Phototherapy: narrowband ultraviolet B or psoralen plus ultraviolet A two to three times per week
      • Alternative regimen (2): cyclosporine PO 2.5 to 5 mg/kg o.d. (C/I - abnormal renal function, uncontrolled hypertension or infection, and malignancy)
      • Alternative regimen (3): prednisone 40 to 60 mg o.d. for one week, then taper the dose over the following two to three week
      • Alternative regimen (4): methotrexate 7.5 to 25 mg single weekly dose with folic acid 1 mg o.d.
      • Alternative regimen (5): azathioprine 2 to 3 mg/kg
      • Alternative regimen (6): mycophenolate mofetil 1 to 2 g/day
      • Alternative regimen (7): mycophenolic acid 720 to 1440 mg/day
      • Alternative regimen (8) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
    • Pediatric
      • Preferred regimen (1): Intensive topical therapy
        • Wet wrap therapy: desoximetasone 0.05% top. then occluded with wet wraps q12h-q24h for 2 to 14 days
      • Alternative regimen (1) Phototherapy: narrowband ultraviolet B (UVB) 3 times per week (older children > 6 years)
      • Alternative regimen (2): cyclosporine PO 2.5 to 5 mg/kg o.d. for 2-4 months (monitor renal and hepatic function)
      • Alternative regimen (3): methotrexate 0.5 mg/kg PO single weekly dose with folic acid 1 mg o.d.(up to a maximum of 25 mg per week)
      • Alternative regimen (4): methylprednisolone 0.5 mg/kg o.d. for 1-2 weeks tapered over one month

Management of Infection:

  • Bacterial infections: (most common bacteria - Staphylococcus. aureus)
    • Clinically infected skin:
      • Mupirocin 2% top. BID for one to two weeks
      • More extensive infection: oral antibiotic therapy with cephalosporins or penicillinase-resistant penicillins X two weeks
    • Clinically uninfected skin:
      • liquid chlorine bleach-  0.5 cup or 120 ml of 6% bleach in a full bathtub [40 gallons or 150 L] of lukewarm water
  • Viral infections:
    • Herpes simplex:
      • Acyclovir 200 or 400 mg PO five times daily
      • Famciclovir 750 mg BID for one day or 1500 mg as a single dose
    • molluscum contagiosum :
      • cryotherapy, curettage, cantharidin, and podophyllotoxin as first-line therapeutic options
  • Fungal infections:
    • Dermatophyte infections- topical or oral antifungals

Controlling pruritus:

  • Preferred regimen:
    • Sedatives: diphenhydramine, hydroxyzine, and cyproheptadine
    • Nonsedatives: fexofenadine, cetirizine or loratadine
  • Alternative regimen:
    • Topical doxepin
    • Topical calcineurin inhibitors
      •  Pimecrolimus 1% cream or tacrolimus 0.03% to 0.1%

Chronic inflammatory skin diseases

  • Contact (allergic, irritant)
  • Seborrhoeic dermatitis
    • onset during the 1st days or weeks of life, absence of pruritus, and presence of greasy scaling on a yellow-red base
    • Involvement of the top of the scalp (cradle cap), axilla, and diaper area makes it more likely the patient has seborrheic dermatitis, vs excoriated dermatitis involving the extensor surfaces, face, and trunk favour AE.
  • Psoriasis
  • Lichen simplex chronicus

Infectious agents

  • Candida
  • Dermatophytes
  • Herpes simplex
  • Staphylococcus aureus
  • Sarcoptes scabiei
    • highly pruritic, erythematous papular lesions. In most cases, the typical burrows can be found on the flexor wrists, finger webs and genitalia. Similar symptoms in other family members
  • HIV-associated dermatitis

Immunologic disorders

  • Dermatitis herpetiformis
  • Pemphigus foliaceus
  • Graft-versus-host disease
  • Dermatomyositis

Malignant Diseases

  • Cutaneous T-cell lymphoma (mycosis fungoides, S´ezary syndrome)
  • Histiocytosis X (Letterer-Siwe disease)

Congenital disorders

  • Netherton’s syndrome
  • Dubowitz syndrome
  • Erythrokeratodermia variabilis

Immunodeficiencies

  • Wiskott-Aldrich syndrome (immunodeficiency with thrombocytopenia and eczema)
  • Thymic hypoplasia (DiGeorge syndrome)
  • Hyper-IgE syndrome
  • Severe combined immunodeficiency (SCID)
  • Ataxia teleangiectasia

Metabolic Diseases

  • Phenylketonuria
  • Tyrosinemia
  • Histidinemia
  • Zinc deficiency
  • Pyridoxine (vitamin B6) and niacin deficiency
  • Multiple carboxylase deficiency
  • Nonallergic reaction to medication
    • Infliximab

References

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