#35: FlexUre Ointments: Atopic Dermatitis

September 29, 2021 | By Sam Masur

A topic…  you don’t want to miss!

Summary

Itching to learn more about how to diagnose and treat atopic dermatitis? We’ve got the perfect episode for you! Pediatric dermatologist Dr. Craig Rohan joins the Cribsiders for an exciting discussion about all things atopic dermatitis. He teaches us about how to diagnose atopic dermatitis, how to differentiate the rash from other mimics,  and successful management strategies.

Credits

• Producer, Writer, and Infographics: Cleo Rochat MD
• Executive Producer: Nicholas Lee MD
• Cover Art: Chris Chiu MD
• Hosts: Justin Berk and Chris Chiu MD
• Editor:Justin Berk MD; Clair Morgan of nodderly.com
• Guest(s): Craig Rohan MD

Atopic Dermatitis Pearls

1. Become familiar with the major and minor criteria for atopic dermatitis 
2. There are many other rashes that may mimic the appearance of atopic dermatitis, including tinea corporis, seborrheic dermatitis, contact dermatitis, viral exanthems and others 
3. Use the “Soak and Seal” method when counseling parents on applying topical emollients
4. Counsel parents on using topical steroids either two weeks on/one week off or five days on/five days off to limit risk of tachyphylaxis

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Atopic Dermatitis Show Notes 

Age of Presentation

• Uncommon to see a newborn with atopic dermatitis
  • Typically rashes presenting in this age group can also be seborrheic dermatitis or immunodeficiencies 
• It is common to see babies ages 2-6 months and children in their toddler years presenting with atopic dermatitis
• AD may also present in middle school and teen years
• Dr. Rohan notes that when AD presents in the older teenage years, it will often persist into adulthood whereas babies may grow out of it

Diagnostic Criteria for Atopic Dermatitis 

Major diagnostic criteria: 

• Pruritus
• Chronic or relapsing dermatitis
• Family history; the most common mutation is in the profilaggrin gene
• Appearance: Expected, classical, eczematous presentation, symmetric, bilateral

Major diagnostic criteria: Also known as the Hanifin criteria

• Hyperlinear palms (extra creases on hands)
• Ocular findings – cataracts
• Intolerance to wool
• Exuberant responses to bug bites
• Intolerance to having perfume sprayed 
• Pityriasis Alba – light hypopigmented patches on photodistributed areas of face
• Keratosis pilaris
• The complete list of the minor diagnostic criteria 

Atopic Dermatitis Appearance

• Common phenotype: antecubital fossa symmetric eruptions, popliteal fossa, eczematous plaques. Can appear as papules confluent into plaques. 
• Nummular eczema – eczematous lesions that appear as “coin-like” plaques 
• The appearance of atopic dermatitis differs between skin types

Disparities in Atopic Dermatitis

• African American children have greater severity of AD, due to structural racism and social determinants of health (Tackett et al, 2019)
• There are also papers that show differences in AD based on insurance status

What Causes Atopic Dermatitis?

• Changes in underlying genes, including the profilaggrin gene – which encodes a lipid that helps to form barrier in epidermis
• Inherited profilaggrin polymorphisms result in diminished skin barrier function, which causes increased immune surveillance of the outside world and results in downstream immunologic effects 

What is the role of skin testing or allergy testing in AD?

• There can be increased IgE and eosinophilia in atopic dermatitis, however, in most cases IgE is not an effective test 
• Expert opinion: Dr. Rohan teaches us that skin testing is a relatively low yield test of Atopic Dermatitis because only a small subset of infants would have an identifiable skin trigger on intradermal skin testing, though it may be more predictive test ask kids get older 
  • The presence of other atopic march factors, severity, age will dictate need for patch testing

Atopic Dermatitis Mimics

• There are many other rashes that may mimic the appearance of atopic dermatitis, including seborrheic dermatitis, contact dermatitis, viral exanthems and others (Siegfried and Hebert, 2015)
• Expert opinion: Dr. Rohan teaches us about a case of tinea corporis mimicking atopic dermatitis pictured below (Image Courtesy of Dr. Craig Rohan)

Management of Atopic Dermatitis

Barriers

• The principle behind barrier treatment is to try to use an emollient that replaces the skin barrier that is missing due to the effect of the profillagrin mutation 
• Hypoallergenic emollients are favored, which are those without preservatives
• Expert opinion: Dr. Rohan teaches us that vaseline in the jar can be easier to apply than bottled emollients 
• “Soak and seal” method of emollient application in atopic dermatitis

1. 1. 1. Bathe in warm water – avoid too high of a temperature that may strip moisture from the skin 
      2. Pat the skin dry with a towel to achieve damp skin
      3. Apply emollient to skin 
      4. Dress with wet cotton onesie followed by a dry cotton onesie 

• Bleach baths: decreases overgrowth of skin flora in atopic dermatitis
  • Recipe is one full bathtub + one capful of household strength bleach 
  • Salt-water baths are effective alternatives 

Clinical Pearl: Dr. Rohan reminds us to not forget about the fingernails in babies with atopic dermatitis! Make sure that the babies nails are not too sharp that they scratch the skin can cause breakdown of the skin barrier 

Topical Steroids

• General management strategy is to use the lowest potency topical steroids that work
• Counsel parents on using topical steroids either two weeks on/one week off or five days on/five days off to limit risk of tachyphylaxis 
• Babies are more prone to increased systemic absorption of topical steroids because of increased surface area ratios, thus they are more prone to side effects from steroids such as thinning of the skin or dyspigmentation 

Topical Calcineurin Inhibitors 

• Example: tacrolimus and pimecrolimus 
• The mechanism of action of TCIs is an inhibitory effect on the activation of T-cells, which decreases the effect of cytokines such as IL-2 (Nakahara, 2017) 
• Medications in this class are FDA approved for ages 2 and up
• Clinical Pearl: Keep these medications in the refrigerator to avoid a stinging sensation upon application 

Other Treatment Options 

• Topical mupirocin can be used as treatment for superinfections
• For severe eczema, can consider alternative medications for severe pruritus, including phototherapy or steroid-sparing medications including cyclosporine, azathioprine, methotrexate, mycophenolate mofetil or biologics 

Take Home Points:

• Atopic dermatitis is a common disorder that can negatively impact the quality of life for families: recognize it, treat it!
• Consider mimickers of AD with eczematous features (seborrheic dermatitis, contact dermatitis) that may only require removal of a trigger to treat  
• The National Eczema Association has great resources for providers and families
• Atopic dermatitis varies widely from case to case; one treatment that works well on one patient may not work as well on another

Goal

Listeners will gain knowledge of the cause, diagnosis, management strategies and counseling pearls for taking care of patients with atopic dermatitis.

Learning objectives

After listening to this episode listeners will…  

1. Understand the major and minor diagnostic criteria for atopic dermatitis 
2. Be familiar with the range of treatment strategies for atopic dermatitis, from barrier protection, topical steroids, and topical calcineurin inhibitors 
3. Recognize rashes that may mimic atopic dermatitis 
4. Understand the health disparities that exist in atopic dermatitis
5. Feel comfortable counseling families on proper application of emollients in patients with atopic dermatitis 

Disclosures

Dr Guest reports no personal financial conflicts of interest. His Department does receive grant funding from Ralexar, Eli Lily for clinical trials.  The Cribsiders report no relevant financial disclosures. 

Citation

Rochat C, Rohan C, Masur S, Lee N, Chiu C, Berk J. “#35: FlexUre Ointments: Atopic Dermatitis”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ September 29, 2021.