questions 5

Atopic Dermatitis (Eczema)

Topic updated on 10/11/17 7:57pm

  • A 25-year-old medical student with a history of severe atopic dermatitis presents to her dermatologist’s office. She recently started clinical rotations in the hospital, which she reports is stressful. She also reports to using hand sanitizer multiple times per day, which has exacerbated the atopic dermatitis on both of her hands, causing them to ooze and sting. She reports feeling so itchy at night that she is unable to sleep. Physical exam reveals large erythematous plaques on her hands and flexural surfaces including neck, antecubital fossa, and behind the knees. She is directed to use topical steroids for the body and topical tacrolimus for the face. Given the severity of her disease, her physician suggests considering a new drug, dupilumab, in the future.
  • Clinical definition
    • a chronic and pruritic inflammatory skin disease also known as eczema
  • Epidemiology
    • prevalence
      • very common
      • 10-20% prevalence
    • demographics
      • primarily affects children but can affect all ages
    • risk factors
      • family history
      • living in urban setting
      • Western diet
  • Etiology
    • combination of genetic, dietary, and environmental causes
  • Pathogenesis
    • filaggrin deficiency or dysfunction may contribute to decreased water retention, impaired tight-junction formation, and reduced ceramide content
    • cutaneous inflammation with infiltrating T-cells can cause epidermal thickening, contributing to functional impairment of epidermal barrier
  • Genetics
    • mutations
      • loss of function mutation in filaggrin (FLG) gene
        • filaggrin is an epidermal structural protein
        • increases risk for developing atopic dermatitis and other allergic disorders
  • Associated conditions
    • atopic triad
      • eczema (atopic dermatitis)
      • asthma
      • allergic rhinitis
    • food allergy
    • Wiskott-Aldrich syndrome
      • suspect when there is eczema along with recurrent infections and thrombocytopenia
    • Hyper-IgE syndrome
      • suspect when there is eczema along with recurrent cold abscesses and high serum IgE
  • Prognosis 
    • recurrent and relapsing disease
    • majority of childhood eczema will improve or resolve as they get older
    • adult eczema often evolve into chronic hand eczema
  • Symptoms
    • pruritus
      • sleep disturbance
    • excoriations from scratching
  • Physical exam
    • dry and rough skin
    • acute flares
      • diffuse erythematous patches and plaques with oozing and crusting papules/vesicles
    • chronic lesions
      • poorly demarcated patches and plaques with scale, excoriation, and lichenification
      • hyperlinearity of palms or soles
    • location
      • commonly on skin flexures in children and adults
      • commonly on the face in infancy
  • Labs
    • may have ↑ serum IgE
  • Biopsy
    • indication
      • to confirm diagnosis
    • findings
      • epidermal intercellular edema (spongiosis)
  • Making the diagnosis
    • most cases are clinically diagnosed
  • Seborrheic dermatitis
  • Contact dermatitis
  • Ichthyosis vulgaris  
  • Nutritional deficiency
  • Conservative
    • emollients and moisturizers
      • indications
        • enhance repair of epidermal barrier
        • apply soon after bathing
  • Medical
    • topical therapy
      • corticosteroids
        • indications
          • first-line treatment for acute flares
        • types
          • low-potency topical steroids
            • can use on face and neck
          • medium or high-potency topical steroids
            • cannot use on face, neck, or anogenital area
          • adverse effects
            • long-term use carries risk of skin atrophy
      • calcineurin inhibitor
        • indications
          • for use on face, anogenital, and neck area
          • for disease recalcitrant to steroids
          • alternative to steroids
        • drugs
          • tacrolimus
    • systemic therapy
      • indications
        • for severe or refractory atopic dermatitis
      • drugs
        • cyclosporine
        • azathioprine
        • dupilumab
  • Procedural
    • phototherapy
      • indications
        • for severe or refractory atopic dermatitis
        • for patients not willing to take systemic therapy for atopic dermatitis
      • modalities
        • ultraviolet light therapy
        • psoralen plus ultraviolet A (PUVA)
  • Secondary bacterial infection
  • Eczema herpeticum


Qbank (2 Questions)

(M2.DM.8) A 20-year-old man presents to his primary care doctor complaining that his skin looks "scaly." He notes that his skin has become progressively dry and itchy over the past several years, and he is embarrassed about its appearance and doesn't want his skin to progress to the "lizard skin" his father had. Past medical history is significant for asthma and keratosis pilaris. On exam, he is well-appearing with normal vital signs His neck and chest appear as seen in Figure A. What is his most likely diagnosis? Topic Review Topic
FIGURES: A          

1. Atopic dermatitis
2. Psoriasis
3. Contact dermatitis
4. Ichthyosis vulgaris
5. Lichen planus

(M2.DM.12) A 5-month-old male infant presents to your office in January. His mother complains that his cheeks are "red and scaly." She's concerned that they are uncomfortable, since she's noticed him scratching them. The rash has worsened since winter started. Otherwise, he has no medical history. Family history is relevant for asthma and some seasonal allergies. On exam, his cheeks bilaterally are erythematous with erosion, scaling and excoriated papules and plaques. Small, similar appearing patches are also present on his chest. What is the most likely outcome for this condition? Topic Review Topic

1. Spontaneous resolution in 1 month
2. Resolution with topical steroids in 1 month
3. Resolution with antibiotics in 1 month
4. Recurrence, regardless of treatment
5. Recurrence, lessened by antibiotics

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