Sx:

Acute characterized by weeping vesicles, chronic by pruritus and lichenification

Atopic: h/o stress, allergies, asthma

Contact: h/o contact, especially when wet; burning more than itching; appears within 24 h of contact, hyperpigmentation may occur later

Neurodermatitis: h/o stress, dependent personality, self-excoriation

Si:

Atopic: medial, infraorbital skin pleat (Morgan-Dennie fold)

Contact: linear lesions somewhere if caused by Rhus plants, non-anatomic patterns

Neurodermatitis: scratching

No spread

w atopic type, incr (30% prevalence) staph infections due to absence of antimicrobial peptides (Nejm 2002;347:1151)

r/o "ID" REACTION (autosensitization), which may follow any rash, especially chronic ones of lower extremities like stasis dermatitis

Lab:

Serol:in atopics, IgE elevated 95 IU and/or 3 pos RAST tests to common allergens (Nejm 1997;337:17,20) often

Rx:

Preventive

• Avoid vaccinations and herpes infections in atopic dermatitis
• Lactobacillus po qd 1 mo pre- and 6 mos postpartum decr eczema incid in infants by 50% at age 2 yr (Lancet 2001;357:1076)

of disease:

• Wet soaks with Domeboro's soln, etc, 10-20 min qid
• Topical steroids immediately after soaks, then emollients like Eucerin, Lubriderm, petrolatum, Crisco, mineral oil
• Antihistamines po, especially hydroxyzine, which can be taken in high doses but may be sedating; and antipain meds, since itching is a form of pain
• Doxepin (tricyclic antidepressant) 5% topical cream helps though it is absorbed (Med Let 1994;36:99)
• Steroids, topically with occlusion; avoid systemic because of rebound
• Tar preparations occasionally help
• Crushed plantain (Nejm 1980;303:583, Shakespeare's Romeo and Juliet 1.2.52-53) for poison ivy
• Tacrolimus (Protopic) 0.03% or 0.1% ointment bid helps (related to cyclosporine) (Med Let 2001;43:33; Nejm 1997;337:816), no skin atrophy if used on face or neck; cmplc: burning sensation, photosensitivity, possible immunosuppression, skin malignancies and lymphomas (black box warning), eczema herpeticum, acute facial flushing w alcohol use (Nejm 2001;351:2740); 30 gm of 0.1% = $60
• Pimecrolimus (Elidel) (Med Let 2002;44:48) 1% topical crm bid; similar to tacrolimus but less potential immunosuppresion; a macrolide that suppresses T-cell cytokines and may cause skin cancers and lymphomas; $50/30 gm