Atopic Dermatitis (Atopic Eczema)

Although most cases of atopic dermatitis (AD) begin in childhood (often in infancy), AD may start at any age. The disease frequently remits spontaneously—reportedly in 40% to 50% of children—but it may persist, or return in adolescence or adulthood and possibly endure for a lifetime. Traditionally, patients and their families were advised that children “will outgrow eczema”; however, this optimistic prognosis is not always realized.
AD is a type of eczema that occurs in association with a personal or family history of atopy (asthma or allergic rhinitis). In adults, AD often displays a variety of clinical manifestations that are often quite different in appearance and location than seen in the pediatric age group.

(Discussed in Chapter 4: Eczema in Infants and Children)

The distribution of lesions may be similar to that seen in early childhood (i.e., in flexural folds); however, adult and adolescent AD tends to also arise on extensor locations: the posterior neck (Fig. 13.19), dorsa of the hands (Fig. 13.20), wrists, shins, ankles, and feet. AD may be limited to the lips (Fig. 13.21), areolae (Fig. 13.22), eyelids, as well as vulvar or scrotal areas (Figs. 13.23 and 13.24).

The diagnosis of atopic dermatitis is generally made clinically, especially in those patients with an atopic history.
A skin biopsy is performed if the diagnosis is in doubt.

Differential Diagnosis

Contact Dermatitis (see above)

Location and shape of lesion(s) may be suggestive and the history may reveal an irritant or allergic contactant.

Scabies (see Chapter 29: Bites, Stings, and Infestations)

History may reveal exposure. Tends to involve wrists and web spaces of fingers and is less likely to occur above the neck in adults.

Psoriasis (see Chapter 14: Psoriasis)

At times, psoriasis can be clinically and histopathologically indistinguishable from eczema. Psoriasis is less likely to itch and tends to occur more often on extensor areas.

Tinea Pedis, Corporis, Manuum, and Capitis (see Chapter 18: Superficial Fungal Infections)

KOH or fungal culture is positive.

Management

Topical Therapy (see Chapter 4: Eczema in Infants and Children, and “Introduction: Topical Therapy”)

General Principles

The application of an appropriately chosen topical steroid—potent or super potent may be necessary for exuberant flares or for chronic lichenified areas—evenly and sparingly one or two times daily to the affected area(s) until the skin is clear of dermatitis.
As the dermatitis improves, the frequency of application may be decreased, or a less potent topical corticosteroid may be prescribed.
“Stronger” is often preferable to “longer.”

Face and Body Folds (Intertriginous Regions)

Use a low-potency corticosteroid cream or ointment or a topical calcineurin inhibitor such as Protopic ointment (tacrolimus) 0.1% or Elidel cream 1% (pimecrolimus).
In more severe cases of atopic dermatitis, initial therapy may be with a higher-potency steroid, followed by a less potent preparation or a topical calcineurin inhibitor for maintenance.

Body (Trunk, Arms, legs, scalp)

Treatment can be initiated with a midstrength (class 4) cream, ointment, foam, or a midstrength (class 3) agent. Even a superpotent (class 1) agent, such as clobetasol 0.05%, may be used for limited periods until control is achieved.
A 1-lb jar of triamcinolone acetonide cream or ointment 0.1% is economical.

Topical Immunomodulators

Protopic ointment (tacrolimus), a nonsteroidal immunomodulator, is as effective as a class 4 or 5 topical steroid in the treatment of atopic dermatitis and is often used as an alternative to topical steroids, particularly for AD on the face or intertriginous areas (axillae and groin), where the long-term use of high-potency steroids is limited.
When applied twice daily, Protopic may cause transient side effects, such as burning and itching.
The 0.1% concentration has been approved for the treatment of atopic dermatitis in those >16 years of age.
Elidel cream (pimecrolimus), a nonsteroidal immunomodulator, is considered equipotent to a class 5 or 6 topical steroid.

Infection

Open, weeping, crusted, impetiginized lesions may be treated with a drying agent, such as Burow solution, before topical steroids are applied.
Clorox bleach—1/2 to 1 cup per tubful of water for 2 to 3 days, then 2 to 3 times per week.
Topical antibiotics—2% mupirocin cream or ointment (Bactroban) and 1% retapamulin ointment (Altabax).
For patients with secondary herpes simplex infection (Kaposi varicelliform eruption), oral antiviral therapy and possibly hospitalization may be required.

Phototherapy

Natural sunlight or phototherapy with ultraviolet B rays is often very effective for widespread skin involvement.

Systemic Treatments

Before resorting to systemic treatments, a “soak-and-smear” regimen may be used. (See “Introduction: Topical Therapy.”)
Systemic steroids should be used in only exceptional circumstances as they can lead to severe rebound flares upon discontinuation.
Immunosuppressive therapy with systemic agents such as cyclosporine, or short-term hospitalization is sometimes necessary in patients with severe unresponsive generalized atopic dermatitis.
Mycophenolate mofetil, azathioprine, and methotrexate are sometimes utilized for chronic, severe refractory atopic dermatitis.

General Management (see also Chapter 4: Eczema in Infants and Children)

Bathing

Frequency of bathing in atopic dermatitis has been the subject of controversy and misunderstanding. There are many reasons not to restrict frequent bathing:

Bathing removes crusts, irritants, potential allergens, and infectious agents.
Bathing provides pleasure and reduces stress.
Bathing hydrates the skin and allows better delivery of corticosteroids and moisturizers.
The addition of Clorox bleach to bath water (“bleach baths”) can be effective (see earlier discussion) for oozing or infected atopic dermatitis.

Bathing Tips

Mild, moisturizing soaps such as Dove or nonsoap cleansers such as Cetaphil Gentle Skin Cleanser should be used.
The patient should be cautioned not to scrub or use harsh soaps on lesional skin (many people are erroneously led to believe that scrubbing with “good soaps” may actually help inflamed skin).
Excessive bathing that is not followed immediately by application of a moisturizer tends to dry the skin.
Excessive toweling and scrubbing should be avoided.

Prevention of Atopic Dermatitis

The following measures may help the patient to avoid or reduce exposure to triggers such as dry skin, irritants, overheating and sweating, and allergens.

Moisturize dry skin: A cream or ointment should be applied immediately after bathing to “trap” water in the skin. However, in warm climates or in the summer, moisturizers may actually be irritating or may interfere with healing.
Suggested ointments: Vaseline Petroleum Jelly, Aquaphor
Suggested creams and lotions: Eucerin, Cetaphil, Lubriderm, Curel, Moisturel
Barrier repair: Atopiclair, MimyX, and Epiceram are multiple-ingredient prescription, nonsteroidal barrier creams that are applied two or three times per day. The barrier cream and lotion CeraVe can be purchased OTC.
Avoid irritants: Use nonirritating fabrics, such as cotton. Avoid wool clothing, overheating and sweating, and excess dryness or humidity.
Avoid known contact and airborne allergens: Common allergens include nickel, pollen, and fragrances.

SEE PATIENT HANDOUTS, “Burow Solution” and “Soak and Smear Instruction Sheet” IN THE COMPANION eBOOK EDITION.

Points to Remember

Topical steroids should be applied only to active disease (inflamed skin) and used until the skin is completely smooth.
When topical steroids are applied immediately after bathing, their penetration and potency are increased.
Low-potency topical steroids or topical immunomodulators are recommended for use on the face and in skin folds, such as the perineal area and underarms.
“Soak and smear” therapy can often be substituted for, or limit the use of, systemic steroids.

Helpful Hints

It should be kept in mind that both irritant and allergic contact dermatitis can coexist when atopic dermatitis is present.
Contact dermatitis is eczema that comes from the outside is and eczema that comes from the inside is atopic dermatitis.
The “gooiest” and cheapest moisturizer is petrolatum.
“Bleach showers” for patients who are unable to take baths an empty spray bottle (like one that used to contain “Windex” spray) can be used as follows:
1. Nearly fill the bottle with warm water
2. Add a capful of Clorox bleach
3. Shake well
4. Spray affected, crusted sites during the shower
5. Rinse well

Clinical Sequelae and Possible Complications

Pruritus leading to rubbing and scratching may result in lichenification, oozing, and secondary bacterial infection (impetiginization), typically caused by Staphylococcus aureus. One should suspect staphylococcal infection if honey-colored crusting or weeping from cracked areas of the skin occurs (Fig. 13.25).
Postinflammatory hyperpigmentation and postinflammatory hypopigmentation are frequent sequelae after lesions resolve.
Eczema herpeticum (Kaposi varicelliform eruption) (Fig. 13.26), a secondary infection with herpes simplex virus, is more commonly seen in childhood (See Chapter 4: Eczema in Infants and Children).

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Basics ⬇

Pathogenesis ⬆ ⬇

Clinical Manifestations ⬆ ⬇

Diagnosis ⬆ ⬇

Other Information ⬆