Dermatitis, Atopic

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 atopy (eg, asthma, allergic rhinitis, atopic dermatitis)

• Tendency to recur

• Onset in childhood most common; after age 30 is 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

• Contact dermatitis

• 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 than tacrolimus

• Crisaborole (Eucrisa 2%) can be effective when applied twice daily

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

• Tacrolimus and pimecrolimus prevent complications of long-term corticosteroid use, including atrophy or striae

• 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 ...