Contents

Search

atopic dermatitis (atopic eczema)

Etiology: 1) idiopathic 2) inherited tendency to dry, sensitive, pruritic skin 3) lowered itch threshold with itch-scratch-rash cycle 4) not an allergic condition - food allergy uncommon cause of flares [3] - high sodium intake associated with atopic dermatitis [44] 5) evidence for altered T-cell function Epidemiology: 1) common in patients with other atopic disorders a) allergic rhinitis b) allergic asthma 2) the disorder generally begins in infancy 3) in many children, the disorder resolves by age 3-5 years - persistence of childhood-onset atopic dermatitis is common [45] 4) uncommon as a new disorder in older children & adults - adult onset atopic dermatitis in 25% [45] 5) infants whose parents clean their pacifiers by sucking on them are at lower risk for developing eczema [10] 6) both sexes are affected 33 Pathology: - pathology involves both immune response & skin barrier - skin barrier leakage, with penetration of allergens - dysregulation of CD4+ type 2 helper T (Th2)-cells - large T-cell infiltrates similar to psoriasis [25] - excessive production of IL-4, IL-5, IL-13, IL-22 IL-51, & UBXD8 - excessive production of IgE - CBARA1 binds IgE in patients with severe skin manifestations Genetics: - mutations in the filaggrin gene (FLG) affects 30-50% of white patients [33] - IL31 & IL31RA is up-regulated in lesional keratinocytes of patients with atopic dermatitis - overexpression of cornifelin - autoantigens binding IgE: NACA, KRT6A - genes links to susceptibility: COL29A1, MS4A2, FLG, SOCS3, PHF11 Clinical manifestations: 1) chronic condition with exacerbations & remissions 2) generally presents during childhood [3] 3) family history of atopy (allergic rhinitis, asthma &/or food allergy) 4) pruritus, dry skin (xerosis) 5) distribution a) infants - face, cheeks, trunk, extensor surfaces (generally spares diaper area) b) children (2-12 years of age) - antecubital fossa, popliteal fossa, neck, wrist, ankle c) adults - hands, eyelids, genitalia, neck, flexural areas (antecubital fossa, popliteal fossa) [3] 6) lesion morphology a) infants - erythema, scaling, papules, vesicles, oozing b) children - inflammation, coalesced papules, lichenification c) adults - scaling, erythema, lichenification, hyperkeratosis d) vesicles (acute), lichenification (chronic) 7) associated features a) pigmentary changes including pityriasis alba b) extra infraorbital eyelid fold (Dennie-Morgan line) c) white dermatographism (white blanch after blunt stroke) d) xerosis, keratosis pilaris, ichthyosis vulgaris e) facial erythema or pallor f) conjunctivitis g) cataracts (10%) h) hyperlinear palms, dermatitis of hands 8) primarily a disease of childhood, but may persist into adulthood as eczema, sensitive skin or hand dermatitis [3] 9) triad of allergic rhinitis, asthma, eczema [3] * images [17,21,33] Laboratory: 1) no specific laboratory tests 2) elevated serum IgE (80%) - not helpful for diagnosis [39] 3) eosinophilia (80%) 4) positive skin testing is common 5) gram stain of pustular lesions Special laboratory: - avoid routine testing for food allergies [3] Differential diagnosis: 1) infants a) irritant dermatitis, seborrhea, candidiasis b) Wiskott-Aldrich syndrome, ataxia telangiectasia, phenylketonuria, acrodermatitis enteropathica, Histiocytosis X 2) children a) contact dermatitis, psoriasis, polymorphous light eruption b) scabies, tinea, HIV 3) adults - psoriasis, lichen simplex chronicus, drug eruption, nummular eczema, contact dermatitis Complications: 1) secondary bacterial infection - Staphylococcus aureus (very common, normal skin flora) - formation of pustules is characteristic - impetigo - treatment with topical mupirocin 2) secondary viral infections a) Herpes simplex (eczema herpeticum); can be life-threatening b) Molluscum contagiosum c) papilloma virus 3) secondary fungal infections - Dermatophytosis - Candidiasis 4) exfoliative erythroderma: can be life-threatening (different than eczema herpeticum?) 5) tachyphylaxis 6) early-onset atopic dermatitis associated with higher risk of - food allergy (odds ratio 7) - asthma (odds ratio 2.9) 7) risk allergic rhinitis & rhinoconjunctivitis associated early-onset & late-onset (odds ratio 4.0 & 3.2, respectively) [24,33] 8) increased risk of bone fractures including hip fracture, vertebral fracture & wrist fracture [29] - overall RR=1.07 with more severe disease associated higher risk - 2-fold increased risk of hip fracture with severe disease [29] 9) topical calcineurin inhibitors & crisaborole 2% most likely to cause local application-site reactions - topical glucocorticoids least likely [48] 10) increased skin thinning with longer-term topical glucocorticoids - not so with short-term topical glucocorticoids [48] Management: 1) pharmacologic agents a) topical agents - fragance-free synthetic detergents rather than soap - moisturizers, emollients (1st line) [42] - use frequently & long term - petroleum jelly, Eucerin, Keri, Lubriderm - useful for prevention of atopic dermatitis in neonates [13] - low potency glucocorticoids for face, infants, intertriginous areas - hydrocortisone cream 1% BID - desonide (Tridesilon) cream 0.05% BID - twice weekly medium potency glucocorticoids for lichenified areas - may also need occlusive therapy for 10-14 days - palms, soles of feet, very thick eruptions - triamcinolone 0.1% cream - mometasone furoate (Elocon) 0.1% cream or ointment - tar ointments (Fototar, T-Derm, Estar 5%) - wet dressings for acute, weeping dermatitis - normal saline - Burrow's solution - wet dressing over topical glucocorticoid [9] - occluive wet wrap therapy - potent topical glucocorticoids, JAK inhibitors & tacrolimus 0.1% most effective topical anti-inflammatory treatments for eczema [48] - mild topical glucocorticoids, PDE-4 inhibitors & tapinarof 1% among the least effective treatments [48] - topical calcineurin inhibitor (tacrolimus, pimecrolimus) - recalcitrant eczema - may be useful for face, eyelids & intertriginous areas where steroid atrophy is more likely [14] - can alternate with glucocorticoids [4,5] - replacing high-potency glucocorticoid with calcineurin inhibitor can allow resolution of skin atrophy, telangiectasias, & striae [41] - topical phosphodiesterase 4 (PDE-4) inhibitor - crisaborole (Eucrisa) topical FDA-approved [22,42] - topical roflumilast 0.15% [38] - topical Janus kinase (JAK) inhibitor ruxolitinib [42] - lukewarm baths for children [14] - bleach bath (sodium hypochlorite 0.005%) 5-10 minutes for 5 consecutive days of benefit [7,14] - risks of topical antiseptics may outweigh benefits [42] - topical mupirocin for Staphylococcal infection (see Complications:) - risks of topical antimicrobials may outweigh benefits [42] b) systemic agents - antibiotics for secondary infection - erythromycin 250-500 mg PO QID - dicloxacillin (Dynapen) 250-500 mg PO QID - antihistamines for pruritus [14] - hydroxyzine (Atarax) 10-25 mg PO QHS - diphenhydramine (Benadryl) 25-50 mg PO QHS - prednisone for severe cases - immunosuppressants (cyclosporine, methotrexate, azathioprine, mycophenolate) [46] - biologic agents - dupilumab (Dupixent) safe with intermediate effectiveness [23,25,26,43] - first biologic agent with robust evidence of efficacy [26] - omalizumab [30] - ruxolitinib (Jakafi) 1.5% BID [31] - abrocitinib high dose effective but among the most harmful [34,43] - upadacitinib (Rinvoq) 30 mg POO QD superior to dupilumab (Dupixent) 300 mg SQ every other week in patients with moderate-to-severe a topic dermatitis [36] - more harmful than dupilumab (Dupixent) [43] - lebrikizumab, & tralokinumab are of intermediate effectiveness & have favorable safety profile [43] - nemolizumab + topical glucocorticoid & topical calcineurin inhibitor shows improvement in inflammation & pruritus [47] - interferon-gamma (investigational) - Lactobacillus fermentum may be of benefit [6] c) tachyphylaxis may complicate management 2) phototherapy with narrow-band ultraviolet B radiation [11] 3) patient education a) avoid sweating, temperature extremes, low humidity b) avoid wool clothing c) short, infrequent bathing, tepid water d) cetaphil or mild soaps (Dove, Basis, Tone, Purpose, not Ivory) e) keep skin well hydrated with moisturizers, bathing oils f) control not cure is goal of therapy g) not an emotional disorder, but is exacerbated by stress h) dietary avoidance or elimination [46] - low sodium diet may mitigate symptoms [44] 4) follow-up a) asthma or allergic rhinitis will develop in 50% b) cataracts will develop in 10% (15-25 years of age) c) infantile form: 2/3 resolve by childhood d) childhood form: 2/3 resolve by puberty

Related

atopic state hand dermatitis

Specific

eczema herpeticum

General

eczematous dermatitis (eczema)

Database Correlations

OMIM correlations

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 919-20
  2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 165
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 17 18. American College of Physicians, Philadelphia 1998, 2006, 2009, 2015, 2018 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. Journal Watch 22(16):128, 2002 Wahn U et al Efficacy and safety of pimecrolimus cream in the long-term management of atopic dermatitis in children. Pediatrics 110:e2, 2002 PMID: 12093983
  5. Journal Watch 25(9):75, 2005 Ashcroft DM, Dimmock P, Garside R, Stein K, Williams HC. Efficacy and tolerability of topical pimecrolimus and tacrolimus in the treatment of atopic dermatitis: meta-analysis of randomised controlled trials. BMJ. 2005 Mar 5;330(7490):516. Epub 2005 Feb 24. Review. PMID: 15731121 http://bmj.bmjjournals.com/cgi/content/full/330/7490/503
  6. Weston S, Halbert A, Richmond P, Prescott SL. Effects of probiotics on atopic dermatitis: a randomised controlled trial. Arch Dis Child. 2005 Sep;90(9):892-7. Epub 2005 Apr 29. PMID: 15863468 - Murch SH. Probiotics as mainstream allergy therapy? Arch Dis Child. 2005 Sep;90(9):881-2. No abstract available. PMID: 16113122
  7. Huang JT et al Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics 2009 May; 123:e808. PMID: 19403473 http://dx.doi.org/10.1542/peds.2008-2217
  8. Prescriber's Letter 17(5): 2010 CHART: Comparison of Topical Corticosteroids COMMENTARY: Management of Eczema in Children Detail-Document#: 260506 (subscription needed) http://www.prescribersletter.com
  9. Dabade TS et al. Wet dressing therapy in conjunction with topical corticosteroids is effective for rapid control of severe pediatric atopic dermatitis: Experience with 218 patients over 30 years at Mayo Clinic. J Am Acad Dermatol 2012 Jul; 67:100 PMID: 21978575
  10. Physician's First Watch, May 7, 2013 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org - Hesselmar B et al Pacifier cleaning practices and risk of allergy development. Pediatrics May 6, 2013 PMID: 23650304 http://pediatrics.aappublications.org/content/early/2013/04/30/peds.2012-3345.full.pdf+html
  11. Darne S et al. Narrowband ultraviolet B (NBUVB) phototherapy in children with moderate to severe eczema - a comparative cohort study. Br J Dermatol 2013 Aug 12 PMID: 23937117 http://onlinelibrary.wiley.com/doi/10.1111/bjd.12580/abstract?systemMessage=Wiley+Online+Library+will+be+disrupted+on+31+August+from+10%3A00-12%3A00+BST+%2805%3A00-07%3A00+EDT%29+for+essential+maintenance
  12. Buys LM. Treatment options for atopic dermatitis. Am Fam Physician. 2007 Feb 15;75(4):523-8. PMID: 17323714
  13. Simpson EL et al. Emollient enhancement of the skin barrier from birth offers effective atopic dermatitis prevention. J Allergy Clin Immunol 2014 Oct; 134:818. PMID: 25282563 http://www.jacionline.org/article/S0091-6749%2814%2901118-X/abstract - Horimukai K et al. Application of moisturizer to neonates prevents development of atopic dermatitis. J Allergy Clin Immunol 2014 Oct; 134:824 PMID: 25282564 http://www.jacionline.org/article/S0091-6749%2814%2901160-9/abstract
  14. Tollefson MM, Bruckner AL Atopic Dermatitis: Skin-Directed Management. Pediatrics. Nov 24, 2014 PMID: 25422009 http://pediatrics.aappublications.org/content/early/2014/11/18/peds.2014-2812.full.pdf+html
  15. Leung DY et al. New insights into atopic dermatitis. J Clin Invest 2004 Mar 3; 113:651 PMID: 14991059
  16. Sidbury R, Tom WL, Bergman JN et al Guidelines of care for the management of atopic dermatitis: Section 4. Prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol. 2014 Dec;71(6):1218-33 PMID: 25264237
  17. Atopic dermatitis (image) American Academy of Dermatology https://www.aad.org/public/diseases/eczema/atopic-dermatitis
  18. Chamlin SL, Kao J, Frieden IJ, Sheu MY Ceramide-dominant barrier repair lipids alleviate childhood atopic dermatitis: changes in barrier function provide a sensitive indicator of disease activity. J Am Acad Dermatol. 2002 Aug;47(2):198-208. PMID: 12140465
  19. Wollenberg A, Rawer HC, Schauber J. Innate immunity in atopic dermatitis. Clin Rev Allergy Immunol. 2011 Dec;41(3):272-81 PMID: 21181301
  20. Eichenfield LF, Ellis CN, Mancini AJ, Paller AS, Simpson EL. Atopic dermatitis: epidemiology and pathogenesis update. Semin Cutan Med Surg. 2012 Sep;31(3 Suppl):S3-5 PMID: 23021783
  21. Kim BS, James WD (images) Medscape: Atopic Dermatitis http://emedicine.medscape.com/article/1049085-overview
  22. Brown T FDA Approves Crisaborole (Eucrisa) for Atopic Dermatitis. Medscape. Dec 14, 2016. http://www.medscape.com/viewarticle/873305
  23. Blauvelt A et al. Long-term management of moderate-to-severe atopic dermatitis with dupilumab and concomitant topical corticosteroids (LIBERTY AD CHRONOS): A 1-year, randomised, double-blinded, placebo- controlled, phase 3 trial. Lancet 2017 May 4 PMID: 28478972 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31191-1/fulltext
  24. Roduit C, Frei R, Depner M et al. Phenotypes of atopic dermatitis depending on the timing of onset and progression in childhood. JAMA Pediatr 2017 May 22 PMID: 28531273
  25. Bankhead C Using Biology of Atopic Dermatitis to Improve Therapy Following psoriasis model of molecular targeting. MedPage Today. Feb 18, 2018 https://www.medpagetoday.com/meetingcoverage/aad/71229 - Simpson ET, Eichenfield LF Atopic Dermatitis. American Academy of Dermatology (AAD) 2018; Forum 023.
  26. Snast I, Reiter O, Hodak E et al Are Biologics Efficacious in Atopic Dermatitis? A Systematic Review and Meta-Analysis. Am J Clin Dermatol. 2018 Apr;19(2):145-165. Review. PMID: 29098604
  27. Eichenfield LF, Tom WL, Berger TG et al Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014 Jul;71(1):116-32. PMID: 24813302 Free PMC Article
  28. Kantor R, Thyssen JP, Paller AS, Silverberg JI. Atopic dermatitis, atopic eczema, or eczema? A systematic review, meta-analysis, and recommendation for uniform use of 'atopic dermatitis'. Allergy. 2016 Oct;71(10):1480-5. Review. PMID: 27392131 Free PMC Article
  29. Lowe KE, Mansfield KE, Delmestri A et al Atopic eczema and fracture risk in adults: A population-based cohort study. J Allergy Clin Immunol, Feb 2020 PMID: 31757515 Free Article https://www.jacionline.org/article/S0091-6749(19)31251-5/fulltext
  30. Chan S, Cornelius V, Cro S et al Treatment Effect of Omalizumab on Severe Pediatric Atopic Dermatitis. The ADAPT Randomized Clinical Trial JAMA Pediatr. Published online Nov 25, 2019 PMID: 31764962 https://jamanetwork.com/journals/jamapediatrics/article-abstract/2755655 - Wu AC Omalizumab for Atopic Dermatitis. Overtreatment or Lifesaver? JAMA Pediatr. Published online Nov 25, 2019 PMID: 31764954 https://jamanetwork.com/journals/jamapediatrics/article-abstract/2755651
  31. Kim BS, Howell MD, Sun K et al. Treatment of atopic dermatitis with ruxolitinib cream (JAK1/JAK2 inhibitor) or triamcinolone cream. J Allergy Clin Immunol 2020 Feb; 145:572. PMID: 31629805 Free Article https://www.jacionline.org/article/S0091-6749(19)31326-0/fulltext
  32. Broeders JA, Ahmed Ali U, Fischer G Systematic review and meta-analysis of randomized clinical trials (RCTs) comparing topical calcineurin inhibitors with topical corticosteroids for atopic dermatitis: a 15-year experience. J Am Acad Dermatol 2016 Aug; 75:410. PMID: 27177441
  33. Rothaus C Atopic Dermatitis. NEJM Resident 360. March 24, 2021 https://resident360.nejm.org/clinical-pearls/atopic-dermatitis-7 - Stander S Atopic Dermatitis. N Engl J Med 2021; 384:1136-1143. March 25 (Review article) PMID: 33761208 https://www.nejm.org/doi/full/10.1056/NEJMra2023911
  34. Bieber T, Simpson EL, Silverberg JT et al Abrocitinib versus Placebo or Dupilumab for Atopic Dermatitis. N Engl J Med 2021; 384:1101-1112. March 25 PMID: 33761207 https://www.nejm.org/doi/full/10.1056/NEJMoa2019380
  35. Gever J JAK Inhibitor Tops Mab for Eczema. New disease-modifying treatment option on the horizon. MedPage Today August 4, 2021 https://www.medpagetoday.com/dermatology/atopy/93891 - Blauvelt A, Teixeira HD, Simpson EL et al Efficacy and Safety of Upadacitinib vs Dupilumab in Adults With Moderate-to-Severe Atopic DermatitisA Randomized Clinical Trial. JAMA Dermatol. 2021 Aug 4 PMID: 34347860 https://jamanetwork.com/journals/jamadermatology/fullarticle/2782803
  36. Slomski A Oral Upadacitinib Beats Subcutaneous Dupilumab for Atopic Dermatitis. JAMA. 2021;326(13):1246 PMID: 34609462 https://jamanetwork.com/journals/jama/fullarticle/2784674
  37. Adults With and Without Atopic Dermatitis Choose Moisturizers for Personal Satisfaction. Dermatologist. 2022. June 14.
  38. Bankhead C Rapid Improvement in Atopic Dermatitis With Topical PDE4 Inhibitor. Disease status, itch improved significantly within 1 to 2 weeks with roflumilast cream. MedPage Today March 20, 2023 https://www.medpagetoday.com/meetingcoverage/aad/103615 - Bunk D Roflumilast Cream 0.15% Approved for Eczema in Patients Aged 6 or Older. Medscape. July 10, 2024 https://www.medscape.com/viewarticle/roflumilast-cream-approved-eczema-patients-2024a1000cpx
  39. NEJM Knowledge+ Dermatology
  40. NEJM Knowledge+ Allergy/Immunology
  41. Drugs for atopic dermatitis. Med Lett Drugs Ther. 2020;62:89-96. PMID: 32555122
  42. Xu AZ, Alexander JT. JAMA Clinical Guidelines Synopsis Topical Therapies for Atopic Dermatitis JAMA. Published online October 27, 2023. PMID: 37889498 https://jamanetwork.com/journals/jama/fullarticle/2811421
  43. Chu AWL, Wong MM, Rayner DG et al. Systemic treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials. J Allergy Clin Immunol. 2023 Dec;152(6):1470-1492 PMID: 37678577 Free article https://www.jacionline.org/article/S0091-6749(23)01112-0/fulltext
  44. Chiang BM, Ye M, Chattopadhyay A et al Sodium Intake and Atopic Dermatitis. JAMA Dermatol. 2024 Jul 1;160(7):725-731. PMID: 38837130 https://jamanetwork.com/journals/jamadermatology/fullarticle/2819233
  45. Kilgore C et al Atopic Dermatitis in Older Adults: Common, Unique, and Challenging to Manage. Medscape. July 11, 2024 https://www.medscape.com/viewarticle/atopic-dermatitis-older-adults-common-unique-and-challenging-2024a1000cqt - Lee HH, Patel KR, Singam V et al A systematic review and meta-analysis of the prevalence and phenotype of adult-onset atopic dermatitis. J Am Acad Dermatol. 2019 Jun;80(6):1526-1532.e7. PMID: 29864464
  46. Chu DK, Schneider L, Asiniwasis RN, et al. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations. Ann Allergy Asthma Immunol. 2024 Mar;132(3):274-312. PMID: 38108679 https://www.annallergy.org/article/S1081-1206(23)01455-2/fulltext
  47. Silverberg JI, Wollenberg A, Reich A, et al. Nemolizumab with concomitant topical therapy in adolescents and adults with moderate-to-severe atopic dermatitis (ARCADIA 1 and ARCADIA 2): results from two replicate, double-blind, randomised controlled phase 3 trials. Lancet. 2024 Jul 24:S0140-6736(24)01203-0 PMID: 39067461
  48. Lax SJ, Van Vogt E, Candy B, et al. Topical anti-inflammatory treatments for eczema: network meta-analysis. Cochrane Database Syst Rev. 2024 Aug 6;8(8):CD015064. PMID: 39105474 PMCID: PMC11301992 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11301992/
  49. NIAMS: Atopic Dermatitis https://www.niams.nih.gov/health-topics/atopic-dermatitis