Domino_5-Minute Clinical Consult, 33e

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Dermatitis, Atopic

MEDICATION First Line

ADDITIONAL THERAPIES • Methods to reduce house-mite allergens (micropore filters on heating, ventilation, and air-conditioning systems; impermeable mattress covers) • Behavioral relaxation therapy to reduce scratching • Bleach baths may reduce staph colonization, but the definitive evidence for benefit in the condition is lacking. Recommend 1/2 cup of standard 6% household bleach for a full tub of water and soak for 5 to 10 minutes, blotting the skin dry upon leaving the bath. COMPLEMENTARY & ALTERNATIVE MEDICINE • Evening primrose oil (includes high content of fatty acids) – May decrease prostaglandin synthesis – May promote conversion of linoleic acid to ω -6 fatty acid • Probiotics may reduce the severity of the condition, thus reducing the medication use. ONGOING CARE FOLLOW-UP RECOMMENDATIONS Patient Monitoring Evaluate to ensure that secondary bacterial or fungal infection does not develop as a result of disruption of the skin barrier. Most patients with AD are colonized by S. aureus . There is a little evidence for the routine use of antimicrobial interventions to reduce skin bacteria, but the treatment of clinical infection with coverage for S. aureus is recommended. DIET • Trials of elimination may find certain “triggers” in some patients. • Breastfeeding in conjunction with maternal hypoal lergenic diets may decrease the severity in some • American Academy of Dermatology Association: http://www.aad.org/skin-conditions/dermatology -a-to-z/atopic-dermatitis • National Eczema Association: www.nationaleczema.org PROGNOSIS • Chronic disease • Declines with increasing age • 90% of pediatric patients have spontaneous resolu tion by puberty. • Localized eczema (e.g., chronic hand or foot derma titis, eyelid dermatitis, or lichen simplex chronicus) may continue in some adults. infants (varying opinions). PATIENT EDUCATION

COMPLICATIONS • Cataracts are more common in patients with AD. • Skin infections (usually S. aureus ); sometimes subclinical • Eczema herpeticum – Generalized vesiculopustular eruption caused by infection with herpes simplex or vaccinia virus – Causes acute illness requiring hospitalization • Atrophy and/or striae if fluorinated corticosteroids are used on face or skin folds • Systemic absorption may occur if large areas of skin are treated, particularly if high-potency medications and occlusion are combined. REFERENCES 1. Frazier W, Bhardwaj N. Atopic dermatitis: diagnosis and treatment. Am Fam Physician . 2020;101(10):590–598. 2. Berkey F, Wiedemer J. Atopic dermatitis: more than just a rash. J Fam Pract . 2021;70(1):13–19.

• Frequent systemic lubrication with thick emollient creams (e.g., Eucerin, Vaseline) over moist skin is the mainstay of treatment before any other interven tion is considered. The “soak and seal” method is recommended. • Infants and children: short-course and moderate potency steroids such as hydrocortisone valerate 0.2% for flares followed by 0.5–1% topical hydro cortisone creams or ointments (Use the “fingertip unit [FTU]” dosing.) • Adults: higher potency topical corticosteroids in areas other than face and skin folds • Short-course, higher potency corticosteroids for flares; then, return to the lowest potency that will control dermatitis. • Topical immunomodulators (tacrolimus or pimecro limus) may be considered as first-line therapy for AD in children aged . 2 years. They may be used in combination with topical corticosteroids (2). • Antihistamines for pruritus (e.g., hydroxyzine 10 to 25 mg at bedtime and as needed); limited benefit as sole treatment Second Line • Crisaborole, a PDE-4 inhibitor, decreases itching, inflammation, excoriation, and lichenification. It is FDA-approved for moderate-to-severe AD in patients $ 3 months. It is a 2% topical ointment applied twice daily. It is expensive. • Plastic occlusion in combination with topical medication to promote absorption (not to be used on face) • Topical tricyclic doxepin, as a 5% cream, may decrease pruritus. • Modified Goeckerman regimen (tar and ultraviolet light) • Topical antibiotics promptly at the first sign of secondary skin infection • Dupilumab, a biologic that targets mediators of inflammation (IL-22, IL-17, IFN- γ ), is FDA-approved for moderate-severe AD in patients $ 6 months of age. It is injected weekly and is the only biologic agent approved for the treatment of AD. It is extremely expensive. • American Academy of Dermatology’s “choosing wisely” campaign recommends against routine antibiotic use unless there is clear evidence of secondary bacterial infection; use of oral/injectable corticosteroids; skin prick testing or radioallergosor bent blood testing (1) ISSUES FOR REFERRAL • Ophthalmology evaluation for persistent vernal conjunctivitis • If using topical steroids around the eyes for extended periods, ophthalmology follow-up for cataract evaluation • For consideration of systemic immunotherapy (cyclosporine, azathioprine, methotrexate) in the most severe cases and when associated mental health affects quality of life