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Key Features

Essentials of Diagnosis

  • Pruritic, exudative, or lichenified eruption on face, neck, upper trunk, wrists, hands, antecubital and popliteal folds

  • Personal or family history of allergies or asthma

  • Tendency to recur

  • Onset in childhood in most patients; onset after age 30 is very uncommon

General Considerations

  • Also known as eczema

  • Looks different at different ages and in people of different races

  • Diagnostic criteria include

    • Pruritus

    • Typical morphology and distribution (flexural lichenification, hand eczema, nipple eczema, and eyelid eczema in adults)

    • Onset in childhood

    • Chronicity

  • Also helpful diagnostically are

    • A personal history of asthma or allergic rhinitis

    • A family history of atopic disease (asthma, allergic rhinitis, atopic dermatitis)

    • Xerosis-ichthyosis

    • Facial pallor with infraorbital darkening

    • Elevated serum IgE

    • Repeated skin infections

Clinical Findings

Symptoms and Signs

  • Itching may be severe and prolonged

  • Ill-defined, scaly, red plaques affect the face, neck, and upper trunk

  • Flexural surfaces of elbows and knees are often involved

  • In chronic cases, the skin is dry, leathery, and lichenified

  • In dark-skinned patients with severe disease, pigmentation may be lost in lichenified areas

  • During acute flares, widespread redness with weeping, either diffusely or in discrete plaques

Differential Diagnosis

  • Seborrheic dermatitis

  • Impetigo

  • Secondary staphylococcal infections

  • Psoriasis

  • Lichen simplex chronicus (circumscribed neurodermatitis)

Diagnosis

Laboratory Tests

  • Eosinophilia and increased serum IgE levels may be present

Treatment

Medications

Local treatments

  • Corticosteroids

    • Apply sparingly once or twice daily

    • Begin with triamcinolone 0.1% ointment or a stronger corticosteroid, then taper to hydrocortisone 1% ointment or another slightly stronger mild corticosteroid (alclometasone 0.05% or desonide 0.05% ointment)

    • Taper as the dermatitis clears to avoid corticosteroid side effects and to prevent rebounds

  • Tacrolimus 0.03% and 0.1% ointment applied twice daily

    • Effective as a first-line steroid-sparing agent

    • Burning on application occurs in about half but may resolve with continued treatment

    • Does not appear to cause corticosteroid side effects

    • Safe on the face and eyelids

  • Pimecrolimus 1% cream is similar but burns less

  • Use tacrolimus and pimecrolimus sparingly and for as brief a time as possible

  • Avoid tacrolimus and pimecrolimus in patients at high risk for lymphoma (ie, those with HIV, iatrogenic immunosuppression, prior lymphoma)

Systemic and adjuvant therapies

  • Prednisone

    • Start at 1 mg/kg orally daily for adults

    • Taper off over 2–4 weeks

    • Use as long-term maintenance therapy is not recommended

  • Bedtime doses of hydroxyzine, diphenhydramine, or doxepin may be helpful via their sedative properties in reducing perceived pruritus

  • Antistaphylococcal antibiotics

    • First-generation cephalosporins may be helpful

    • Doxycycline if methicillin-resistant Staphylococcus aureus is suspected

  • Phototherapy

  • Dupilumab is a targeted immunomodulator with minimal systemic adverse effects and requires minimal laboratory monitoring

  • Oral cyclosporine, mycophenolate mofetil, methotrexate, tofacitinib, or azathioprine may be used ...

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