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For further information, see CMDT Part 6-36: Atopic Dermatitis
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Essentials of Diagnosis
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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
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General Considerations
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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
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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 patients with darker skin with severe disease, pigmentation may be lost in lichenified areas
During acute flares, widespread redness with weeping, either diffusely or in discrete plaques
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Differential Diagnosis
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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)
Vital to 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 (Elidel 1%) cream is similar but burns less than tacrolimus
Crisaborole (Eucrisa 2%) can be effective when applied twice daily
Ruxolitnib (Opzelura 1.5%)
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
Food and Drug Administration black box warning for tacrolimus and pimecrolimus (topical calcineurin inhibitors)
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Systemic and adjuvant therapies
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