Sandbox:Shalinder: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
 
(18 intermediate revisions by the same user not shown)
Line 1: Line 1:
__NOTOC__
__NOTOC__
 
{{Xyz}}
{{CMG}}; {{AE}} {{S.S}}
{{CMG}}; {{AE}}


==Overview==
==Overview==
Atopic dermatitis is a chronic or relapsing hypersensitive manifestation of the skin. Common physical examination findings of atopic dermatitis include pruritus, eczematous lesions, xerosis and lichenification. The lesions are usually age specific and can be in various stages of development. The lesions can involve any area of body in severe cases, but usually it is uncommon to find lesions in  the axillary, gluteal, or groin area.
The mainstay of treatment for atopic dermatitis depends upon the severity of the disease and is treated with combination of conservative and medical therapy. The goals of treatment include elimination of aggravating factors, skin barrier function repair, maintaining skin hydration and pharmacologic treatment of skin inflammation.


==Physical Examination==
==Conservative Therapy==
The clinical presentation of atopic dermatitis is highly variable, depending upon the patient's age and disease activity.


===Appearance of the Patient===
*Patients with atopic dermatitis usually appear normal.
===Vital Signs===
*Vitals signs in atopic dermatitis patients are usually within normal limits.
===Skin===
* '''Primary findings''':<ref name="Thestrup-Pedersen2000">{{cite journal|last1=Thestrup-Pedersen|first1=K.|title=Clinical aspects of atopic dermatitis|journal=Clinical and Experimental Dermatology|volume=25|issue=7|year=2000|pages=535–543|issn=0307-6938|doi=10.1046/j.1365-2230.2000.00696.x}}</ref>
** Atopic Itch: Severe pruritus- cardinal feature of atopic dermatitis (must be present)
** Atopic dry skin: xerosis (especially during winters)
** Atopic eczema: location of lesions has age-specific patterns
** Stigmata of AD
* Constant scratching may lead to lichenification.
* An acute eczematoid eruption (with erythematous papules) appears after patients scratch their skin
* Most severe form of atopic dermatitis can include erythroderma
* '''Typical morphology and distribution''':<ref>{{cite journal|title=Japanese Dermatological Association Criteria for the diagnosis of atopic dermatitis|journal=The Journal of Dermatology|volume=29|issue=6|year=2002|pages=398–398|issn=03852407|doi=10.1111/j.1346-8138.2002.tb00292.x}}</ref>
** Eczematous dermatitis: Symmetrical lesions
{| class="wikitable"
{| class="wikitable"
|+
|+
!'''Acute atopic dermatitis'''
!'''Elimination of exacerbating factors'''
!'''Subacute or chronic atopic dermatitis''':
!'''Maintaining skin hydration'''
!'''Controlling pruritus'''
|-
|-
|
|
* Erythema, exudates, papules, vesicles, scales and crusts
* Avoid trigger factors such as low humidity, overheating of skin
* Can usually get  infected with ''Staphylococcus aureus''
* Treating stress and anxiety
* Lesions are intensely pruritic
* Avoid exposure to solvents and detergents
* Treat skin infections such as ''Staphylococcus aureus'' and herpes simplex
|
|
* Infiltrated erythema, prurigo, scales and crusts
* '''Emollients and moisturizers'''
* Lesions are dry or excoriated erythematous papules
** Thick creams, ointments (eg, petroleum jelly) with low/zero water content
* Lichenification (chronic scratching may result in skin thickening) and fissuring may develop over time
** Immediately after 5-minute, lukewarm baths BID
|}
* '''Bathing practices'''
*'''Age-specific patterns''':<ref name="pmid97349034">{{cite journal |vauthors=Rudikoff D, Lebwohl M |title=Atopic dermatitis |journal=Lancet |volume=351 |issue=9117 |pages=1715–21 |date=June 1998 |pmid=9734903 |doi=10.1016/S0140-6736(97)12082-7 |url=}}</ref>
** Warm soaking baths or showers using mild or soap-free cleansers
{| class="wikitable"
|+
!'''Infants and young children(zero to two years)'''
|-
|
|
* Earliest lesions:
* Conservative
** Presents with erythema and exudation of the creases(antecubital and popliteal fossae)
** Tepid baths
** Wet dressings (wet wraps)
** Moisturizers containing anti-pruritic ingredients such as phenol, menthol, and camphor


* Over the following few weeks:
*
** highly pruritic, red, scaly and crusted lesions, usually localized to the cheeks, the forehead and scalp, and the extensors of the lower legs
* Lesions are ill-defined, erythematous, scaly, and crusted (eczematous) patches and plaques.
* The most commonly involved areas:
** Scalp, cheeks and extensor side of the extremities.
** Flexural areas, especially the neck fold, may be involved
* Midline of the face and the tip of the nose is spared (Yamamoto’s sign)
* Diaper area is generally spared
* Lichenification is uncommon in infancy
|-
!'''Older children and adolescents (2 to 16 years)'''
|-
|
* Lichenification is characteristic of childhood atopic dermatitis
 
* Areas involved:
** Flexural areas, particularly the antecubital and popliteal fossae, and buttock-thigh creases
** Volar aspect of the wrists and ankles may be involved
** "Atopic dirty neck" - neck and sides of the neck may show a reticulate pigmentation
* Thickened plaques show lichenification and excoriation
* Xerosis is generalized
* Dennie-Morgan folds (i.e. increased folds below the eye) along with erythema and scaling around the eyes is often seen
* Centrofacial pallor is common
* Dry skin and fissuring behind the ears or on the earlobe (infra-auricular and retroauricular fissuring)
* In African-American children, follicular papular lesions are prominent and striking and hypopigmentation and hyperpigmentation
|-
!'''Adults (from puberty onward)'''<ref name="pmid18402293">{{cite journal |vauthors=Kulthanan K, Samutrapong P, Jiamton S, Tuchinda P |title=Adult-onset atopic dermatitis: a cross-sectional study of natural history and clinical manifestation |journal=Asian Pac. J. Allergy Immunol. |volume=25 |issue=4 |pages=207–14 |date=December 2007 |pmid=18402293 |doi= |url=}}</ref>
|-
|
* Lesions are more localized and lichenified.
* Areas involved:
** Facial involvement is common, especially the forehead and periorbital regions.
** Lichenification occurs in skin flexures such as wrists, hands, ankles, feet, fingers, and toes
 
* A brown macular ring around the neck may be present (localized deposition of amyloid)- "Atopic dirty neck"
* Xerosis is prominent
|}
|}
* '''Associated symptoms with atopic dermatitis''':<ref name="RotheGrant-Kels19963">{{cite journal|last1=Rothe|first1=Marti Jill|last2=Grant-Kels|first2=Jane M|title=Diagnostic criteria for atopic dermatitis|journal=The Lancet|volume=348|issue=9030|year=1996|pages=769–770|issn=01406736|doi=10.1016/S0140-6736(05)65206-3}}</ref>
{| class="wikitable"
|+
!'''Atopic stigmata'''
(associated cutaneous findings seen in atopic dermatitis patients)
|-
|
* Atypical vascular responses
** Centrofacial pallor
** delayed blanch response
* Skin
** Keratosis pilaris
** Palmar hyperlinearity
** Pityriasis alba
** ichthyosis
* Ocular/periorbital
** Periorbital darkening and Dennie-Morgan infraorbital folds
** Hertoghe's sign- thinning or absence of the lateral portion of the eyebrows
* Other
** Infra-auricular and retro-auricular fissuring
** Nipple eczema
** White dermographism
** Perifollicular accentuation
|-
|
|}
* '''Clinical phenotypes of atopic dermatitis:'''
** Localized and morphological variants of atopic dermatitis are present in both children and adults.
** These variants can present as only clinical feature of atopic dermatitis or can present in association with age related manifestations.
{| class="wikitable"
|+
! colspan="2" |Different phenotypes of atopic dermatitis<ref name="pmid21054785">{{cite journal |vauthors=Pugliarello S, Cozzi A, Gisondi P, Girolomoni G |title=Phenotypes of atopic dermatitis |journal=J Dtsch Dermatol Ges |volume=9 |issue=1 |pages=12–20 |date=January 2011 |pmid=21054785 |doi=10.1111/j.1610-0387.2010.07508.x |url=}}</ref>
|-
| colspan="2" |
* Acute vs chronic eczema
* Intrinsic vs extrinsic atopic eczema
* Early onset vs late onset
* Mild vs severe eczema
* Increased IgE vs non-atopic
* S. aureus infection/colonization, disseminated viral or fungal infections e.g. EH, molluscum contagiosum, Malassezia
* Associated with ichthyosis, keratosis pilaris, palmar hyperlinearity, early onset, severe and persistent eczema (FLG null genotype)
|-
!Localized variants
!Morphological variants
|-
|
* Hand eczema
* Juvenile palmar and plantar dermatitis
* Eyelid dermatitis
* Atopic cheilitis
* Periorificial dermatitis
* Nipple dermatitis
|
* Nummular eczema
* Atopic prurigo


* Lichen planus-like
==Medical Therapy==
*Pharmacologic medical therapies for atopic dermatitis can be classified according to the several severity scales( (i.e SCORAD index, the eczema area and severity index [EASI], and the patient-oriented eczema measure [POEM]) which includes characteristics of the rash, questions about itch, sleep, impact on daily activities, and persistence of disease.
===Atopic dermatitis===


* Pit<span class="_ _1 current-selection"></span>yriasis alba<span class="_ _1 current-selection"></span>
* '''MIld atopic dermatitis''':
|}
** Topical corticosteroids and emollients - mainstay therapy
* '''Localized variants''':<ref name="pmid21054785" />
*** '''Adult'''
** Atopic hand eczema:<ref name="pmid16956463">{{cite journal |vauthors=Simpson EL, Thompson MM, Hanifin JM |title=Prevalence and morphology of hand eczema in patients with atopic dermatitis |journal=Dermatitis |volume=17 |issue=3 |pages=123–7 |date=September 2006 |pmid=16956463 |doi= |url=}}</ref>
**** Preferred regimen (1): [[drug name|desonide 0.05%]] top. q12h-q24h for 14-28 days
*** Atopic hand eczema typically affects volar wrists and dorsum of the hands.
**** Preferred regimen (2): [[drug name|hydrocortisone 2.5% top.]] q12h-q24h for 14-28 days
*** one-third of patients with atopic hand eczema, also reports foot eczema.<ref name="pmid25716740">{{cite journal |vauthors=Brans R, Hübner A, Gediga G, John SM |title=Prevalence of foot eczema and associated occupational and non-occupational factors in patients with hand eczema |journal=Contact Derm. |volume=73 |issue=2 |pages=100–7 |date=August 2015 |pmid=25716740 |doi=10.1111/cod.12370 |url=}}</ref>
**** Preferred regimen (3): fluocinolone acetonide [[drug name|0.01% top.]] q12h-q24h for 14-28 days
*** Common in adults with past medical history of history of atopic dermatitis, and currently do not have dermatitis in typical areas (i.e. flexural)
**** Alternative regimen (1) tacrolimus 0.1% top. q8h ('''0.03% for adults who do not tolerate the higher dose)'''
*** Most common in adults exposed to wet environments
**** Alternative regimen (2): pimecrolimus 1% top. q8h
** Eyelid eczema:<ref name="pmid24314387">{{cite journal |vauthors=Wolf R, Orion E, Tüzün Y |title=Periorbital (eyelid) dermatides |journal=Clin. Dermatol. |volume=32 |issue=1 |pages=131–40 |date=2014 |pmid=24314387 |doi=10.1016/j.clindermatol.2013.05.035 |url=}}</ref>
**** Alternative regimen (3) crisaborole 2% top.
*** Some patients of atopic dermatitis, may present with eyelid eczema alone
*** '''Pediatric'''
*** associated with lichenification and presence of Dennie-Morgan lines
**** Preferred regimen (1): [[drug name|desonide 0.05%]] top. q12h-q24h for 14-28 days
** Atopic cheilitis:
**** Preferred regimen (2): [[drug name|hydrocortisone 2.5% top.]] q12h-q24h for 14-28 days
*** Also known as lip eczema or cheilitis sicca
**** Preferred regimen (3):  fluocinolone acetonide [[drug name|0.01% top.]] q12h-q24h for 14-28 days
*** Presents as dryness, peeling, and fissuring of the lips
**** Alternative regimen (1) tacrolimus 0.03%  top. q8h ('''Children (>2years)'''
** Juvenile papular dermatitis:<ref name="pmid83084">{{cite journal |vauthors=Rasmussen JE |title=Sutton's summer prurigo of the elbows |journal=Acta Derm. Venereol. |volume=58 |issue=6 |pages=547–9 |date=1978 |pmid=83084 |doi= |url=}}</ref>
**** Alternative regimen (2): pimecrolimus 1% top. q8h
*** Primarily occurs in the spring and summer - associated with pollinosis  
**** Alternative regimen (3): crisaborole 2% top.
*** localized mainly to the elbows and knees  
*  '''Moderate atopic dermatitis'''
** Juvenile palmar and plantar dermatitis
** Topical corticosteroids and emollients are the mainstay of therapy
*** painful variant of atopic dermatitis
*** '''Adult'''
*** Localized on the anterior part of the sole
**** Preferred regimen (1): fluocinolone0.025%. q12h-q24h for 14-28 days
* '''Morphological variants''':<ref name="pmid21054785" />
**** Preferred regimen (2): [[drug name|triamcinolone 0.1% top.]] q12h-q24h for 14-28 days
** Nummular (discoid eczema):
**** Preferred regimen (3): fluocinolone acetonide [[drug name|0.025% top.]] q12h-q24h for 14-28 days
*** Sharply demarcated patches and plaques with inflammation of skin  
**** Alternative regimen (1) tacrolimus 0.1% top. q8h ('''0.03% for adults who do not tolerate the higher dose)'''
*** Secondarily infection with Staphylococcus aureus common
**** Alternative regimen (2): pimecrolimus 1% top. q8h
*** Commonly affected areas- extremities and buttocks
**** Alternative regimen (3) crisaborole 2% top.
*** Very difficult to treat
** '''Pediatric'''
*** Preferred regimen (1): fluocinolone0.025%. q12h-q24h for 14 days
*** Preferred regimen (2): [[drug name|triamcinolone 0.1% top.]] q12h-q24h for 14 days
*** Preferred regimen (3): fluocinolone acetonide [[drug name|0.025% top.]] q12h-q24h for 14-28 days
*** Alternative regimen (1) tacrolimus 0.03%  top. q8h ('''Children (>2years)'''
*** Alternative regimen (2): pimecrolimus 1% top. q8h
*** Alternative regimen (3) crisaborole 2% top.
* '''Severe atopic dermatitis'''
** Phototherapy or systemic immunosuppressant treatment is the mainstay of therapy
*** '''Adult'''
**** Preferred regimen (1): Phototherapy Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
**** Preferred regimen (2): [[drug name|cyclosporine]] PO 3-5 mg/kg o.d. for 6 weeks ('''monitor BP and serum creatinine q2 weeks for three months, f/u q month)''' 
**** Alternative regimen (1) methotrexatePO
**** Alternative regimen (2): azathioprine PO
**** Alternative regimen (3) mycophenolate mofetil PO
**** Alternative regimen (3) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
*** '''Pediatric'''
**** Preferred regimen (1):
**** Preferred regimen (2): [[drug name|cyclosporine]] PO 3 to 5 mg/kg per day o.d. for 6 weeks ('''monitor BP and serum creatinine q2 weeks for three months, f/b q month)''' 
**** Alternative regimen (1) Phototherapy Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
**** Alternative regimen (2): azathioprine PO
**** Alternative regimen (3) mycophenolate mofetil PO
**** Alternative regimen (3) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
* '''Severe refractory atopic dermatitis'''
** '''Adult'''
*** Preferred regimen (1): Intensive topical therapy
**** Soak and smear: Soak for 15 minutes in a tub of water. Apply desoximetasone 0.25% top. to the whole body, except the groin, axillae, and face
**** Wet wrap therapy: desoximetasone 0.25% top. then occluded with wet wraps q12h
*** Alternative regimen (1) Phototherapy: narrowband ultraviolet B or psoralen plus ultraviolet A two to three times per week
*** Alternative regimen (2): cyclosporine PO 2.5 to 5 mg/kg o.d. ('''C/I -''' '''abnormal renal function, uncontrolled hypertension or infection, and malignancy''')
*** Alternative regimen (3): prednisone 40 to 60 mg o.d. for one week, then taper the dose over the following two to three week
*** Alternative regimen (4): methotrexate 7.5 to 25 mg single weekly dose with folic acid 1 mg o.d.
*** Alternative regimen (5): azathioprine 2 to 3 mg/kg
*** Alternative regimen (6):  mycophenolate mofetil 1 to 2 g/day
*** Alternative regimen (7): mycophenolic acid 720 to 1440 mg/day
*** Alternative regimen (8)  dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
** '''Pediatric'''
*** Preferred regimen (1): Intensive topical therapy
**** Wet wrap therapy: desoximetasone 0.05% top. then occluded with wet wraps q12h-q24h for 2 to 14 days
*** Alternative regimen (1) Phototherapy: narrowband ultraviolet B (UVB)  3 times per week ('''older children > 6 years''')
*** Alternative regimen (2): cyclosporine PO 2.5 to 5 mg/kg o.d. for 2-4 months ('''monitor renal and hepatic function''')
*** Alternative regimen (3): methotrexate 0.5 mg/kg PO single weekly dose with folic acid 1 mg o.d.('''up to a maximum of 25 mg per week''')
*** Alternative regimen (4): methylprednisolone 0.5 mg/kg o.d. for 1-2 weeks tapered over one month
'''Management of Infection:'''
* '''Bacterial''' '''infections''': (most common bacteria - ''Staphylococcus. aureus'')
** Clinically infected skin:
*** Mupirocin 2% top. BID for one to two weeks
*** More extensive infection: oral antibiotic therapy with cephalosporins or penicillinase-resistant penicillins X two weeks
** Clinically uninfected skin:
*** liquid chlorine bleach-  0.5 cup or 120 ml of 6% bleach in a full bathtub [40 gallons or 150 L] of lukewarm water
* '''Viral infections:'''
** Herpes simplex:
*** Acyclovir 200 or 400 mg PO five times daily
*** Famciclovir 750 mg BID for one day or 1500 mg as a single dose
** molluscum contagiosum :
*** cryotherapy, curettage, cantharidin, and podophyllotoxin as first-line therapeutic options
* '''Fungal infections:'''
** Dermatophyte infections'''-''' topical or oral antifungals
'''Controlling pruritus:'''
* Preferred regimen''':'''
** Sedatives: diphenhydramine, hydroxyzine, and cyproheptadine
** Nonsedatives: fexofenadine, cetirizine or loratadine
* Alternative regimen:
** Topical doxepin
** Topical calcineurin inhibitors
***  Pimecrolimus 1% cream or tacrolimus 0.03% to 0.1%


=== HEENT ===
'''Chronic inflammatory skin diseases'''
* HEENT examination of patients with atopic dermatitis is usually normal.
* Contact (allergic, irritant)
* Seborrhoeic dermatitis
** onset during the 1st days or weeks of life, absence of pruritus, and presence of greasy scaling on a yellow-red base
** Involvement of the top of the scalp (cradle cap), axilla, and diaper area makes it more likely the patient has '''seborrheic dermatitis''', vs excoriated dermatitis involving the extensor surfaces, face, and trunk favour '''AE.'''
* Psoriasis
* Lichen simplex chronicus
'''Infectious agents'''
* Candida
* Dermatophytes
* Herpes simplex
* Staphylococcus aureus
* Sarcoptes scabiei
** highly pruritic, erythematous papular lesions. In most cases, the typical burrows can be found on the flexor wrists, finger webs and genitalia. Similar symptoms in other family members
* HIV-associated dermatitis
'''Immunologic disorders'''
* Dermatitis herpetiformis
* Pemphigus foliaceus
* Graft-versus-host disease
* Dermatomyositis
'''Malignant Diseases'''
* Cutaneous T-cell lymphoma (mycosis fungoides, S´ezary syndrome)
* Histiocytosis X (Letterer-Siwe disease)
'''Congenital disorders'''
* Netherton’s syndrome
* Dubowitz syndrome
* Erythrokeratodermia variabilis
'''Immunodeficiencies'''
* Wiskott-Aldrich syndrome (immunodeficiency with thrombocytopenia and eczema)
* Thymic hypoplasia (DiGeorge syndrome)
* Hyper-IgE syndrome
* Severe combined immunodeficiency (SCID)
* Ataxia teleangiectasia
'''Metabolic Diseases'''
* Phenylketonuria
* Tyrosinemia
* Histidinemia
* Zinc deficiency
* Pyridoxine (vitamin B6) and niacin deficiency
* Multiple carboxylase deficiency


* Eczematous lesions can be present depending on the age of the patients.
* '''Nonallergic reaction to medication'''
** Infliximab


===Neck===
* Neck examination of patients with atopic dermatitis is usually normal.
* Eczematous lesions can be present depending on the age of the patients.
===Lungs===
* Pulmonary examination of patients with atopic dermatitis is usually normal.
===Heart===
* Cardiovascular examination of patients with atopic dermatitis is usually normal.
===Abdomen===
* Abdominal examination of patients with atopic dermatitis is usually normal.
===Back===
* Back examination of patients with atopic dermatitis is usually normal.
* Eczematous lesions can be present depending on the age of the patients.
===Genitourinary===
* Genitourinary examination of patients with atopic dermatitis is usually normal.
===Neuromuscular===
* Neuromuscular examination of patients with atopic dermatitis is usually normal.
===Extremities===
* Extremities examination of patients with atopic dermatitis is usually normal.
* Eczematous lesions can be present depending on the age of the patients.
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 16:56, 10 October 2018

Xyz Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Xyz from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Interventions

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Sandbox:Shalinder On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Sandbox:Shalinder

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Sandbox:Shalinder

CDC on Sandbox:Shalinder

Sandbox:Shalinder in the news

Blogs on Sandbox:Shalinder

Directions to Hospitals Treating Psoriasis

Risk calculators and risk factors for Sandbox:Shalinder

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

The mainstay of treatment for atopic dermatitis depends upon the severity of the disease and is treated with combination of conservative and medical therapy. The goals of treatment include elimination of aggravating factors, skin barrier function repair, maintaining skin hydration and pharmacologic treatment of skin inflammation.

Conservative Therapy

Elimination of exacerbating factors Maintaining skin hydration Controlling pruritus
  • Avoid trigger factors such as low humidity, overheating of skin
  • Treating stress and anxiety
  • Avoid exposure to solvents and detergents
  • Treat skin infections such as Staphylococcus aureus and herpes simplex
  • Emollients and moisturizers
    • Thick creams, ointments (eg, petroleum jelly) with low/zero water content
    • Immediately after 5-minute, lukewarm baths BID
  • Bathing practices
    • Warm soaking baths or showers using mild or soap-free cleansers
  • Conservative
    • Tepid baths
    • Wet dressings (wet wraps)
    • Moisturizers containing anti-pruritic ingredients such as phenol, menthol, and camphor

Medical Therapy

  • Pharmacologic medical therapies for atopic dermatitis can be classified according to the several severity scales( (i.e SCORAD index, the eczema area and severity index [EASI], and the patient-oriented eczema measure [POEM]) which includes characteristics of the rash, questions about itch, sleep, impact on daily activities, and persistence of disease.

Atopic dermatitis

  • MIld atopic dermatitis:
    • Topical corticosteroids and emollients - mainstay therapy
      • Adult
        • Preferred regimen (1): desonide 0.05% top. q12h-q24h for 14-28 days
        • Preferred regimen (2): hydrocortisone 2.5% top. q12h-q24h for 14-28 days
        • Preferred regimen (3): fluocinolone acetonide 0.01% top. q12h-q24h for 14-28 days
        • Alternative regimen (1) tacrolimus 0.1% top. q8h (0.03% for adults who do not tolerate the higher dose)
        • Alternative regimen (2): pimecrolimus 1% top. q8h
        • Alternative regimen (3) crisaborole 2% top.
      • Pediatric
        • Preferred regimen (1): desonide 0.05% top. q12h-q24h for 14-28 days
        • Preferred regimen (2): hydrocortisone 2.5% top. q12h-q24h for 14-28 days
        • Preferred regimen (3): fluocinolone acetonide 0.01% top. q12h-q24h for 14-28 days
        • Alternative regimen (1) tacrolimus 0.03% top. q8h (Children (>2years)
        • Alternative regimen (2): pimecrolimus 1% top. q8h
        • Alternative regimen (3): crisaborole 2% top.
  • Moderate atopic dermatitis
    • Topical corticosteroids and emollients are the mainstay of therapy
      • Adult
        • Preferred regimen (1): fluocinolone0.025%. q12h-q24h for 14-28 days
        • Preferred regimen (2): triamcinolone 0.1% top. q12h-q24h for 14-28 days
        • Preferred regimen (3): fluocinolone acetonide 0.025% top. q12h-q24h for 14-28 days
        • Alternative regimen (1) tacrolimus 0.1% top. q8h (0.03% for adults who do not tolerate the higher dose)
        • Alternative regimen (2): pimecrolimus 1% top. q8h
        • Alternative regimen (3) crisaborole 2% top.
    • Pediatric
      • Preferred regimen (1): fluocinolone0.025%. q12h-q24h for 14 days
      • Preferred regimen (2): triamcinolone 0.1% top. q12h-q24h for 14 days
      • Preferred regimen (3): fluocinolone acetonide 0.025% top. q12h-q24h for 14-28 days
      • Alternative regimen (1) tacrolimus 0.03% top. q8h (Children (>2years)
      • Alternative regimen (2): pimecrolimus 1% top. q8h
      • Alternative regimen (3) crisaborole 2% top.
  • Severe atopic dermatitis
    • Phototherapy or systemic immunosuppressant treatment is the mainstay of therapy
      • Adult
        • Preferred regimen (1): Phototherapy Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
        • Preferred regimen (2): cyclosporine PO 3-5 mg/kg o.d. for 6 weeks (monitor BP and serum creatinine q2 weeks for three months, f/u q month)
        • Alternative regimen (1) methotrexatePO
        • Alternative regimen (2): azathioprine PO
        • Alternative regimen (3) mycophenolate mofetil PO
        • Alternative regimen (3) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
      • Pediatric
        • Preferred regimen (1):
        • Preferred regimen (2): cyclosporine PO 3 to 5 mg/kg per day o.d. for 6 weeks (monitor BP and serum creatinine q2 weeks for three months, f/b q month)
        • Alternative regimen (1) Phototherapy Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
        • Alternative regimen (2): azathioprine PO
        • Alternative regimen (3) mycophenolate mofetil PO
        • Alternative regimen (3) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
  • Severe refractory atopic dermatitis
    • Adult
      • Preferred regimen (1): Intensive topical therapy
        • Soak and smear: Soak for 15 minutes in a tub of water. Apply desoximetasone 0.25% top. to the whole body, except the groin, axillae, and face
        • Wet wrap therapy: desoximetasone 0.25% top. then occluded with wet wraps q12h
      • Alternative regimen (1) Phototherapy: narrowband ultraviolet B or psoralen plus ultraviolet A two to three times per week
      • Alternative regimen (2): cyclosporine PO 2.5 to 5 mg/kg o.d. (C/I - abnormal renal function, uncontrolled hypertension or infection, and malignancy)
      • Alternative regimen (3): prednisone 40 to 60 mg o.d. for one week, then taper the dose over the following two to three week
      • Alternative regimen (4): methotrexate 7.5 to 25 mg single weekly dose with folic acid 1 mg o.d.
      • Alternative regimen (5): azathioprine 2 to 3 mg/kg
      • Alternative regimen (6): mycophenolate mofetil 1 to 2 g/day
      • Alternative regimen (7): mycophenolic acid 720 to 1440 mg/day
      • Alternative regimen (8) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
    • Pediatric
      • Preferred regimen (1): Intensive topical therapy
        • Wet wrap therapy: desoximetasone 0.05% top. then occluded with wet wraps q12h-q24h for 2 to 14 days
      • Alternative regimen (1) Phototherapy: narrowband ultraviolet B (UVB) 3 times per week (older children > 6 years)
      • Alternative regimen (2): cyclosporine PO 2.5 to 5 mg/kg o.d. for 2-4 months (monitor renal and hepatic function)
      • Alternative regimen (3): methotrexate 0.5 mg/kg PO single weekly dose with folic acid 1 mg o.d.(up to a maximum of 25 mg per week)
      • Alternative regimen (4): methylprednisolone 0.5 mg/kg o.d. for 1-2 weeks tapered over one month

Management of Infection:

  • Bacterial infections: (most common bacteria - Staphylococcus. aureus)
    • Clinically infected skin:
      • Mupirocin 2% top. BID for one to two weeks
      • More extensive infection: oral antibiotic therapy with cephalosporins or penicillinase-resistant penicillins X two weeks
    • Clinically uninfected skin:
      • liquid chlorine bleach-  0.5 cup or 120 ml of 6% bleach in a full bathtub [40 gallons or 150 L] of lukewarm water
  • Viral infections:
    • Herpes simplex:
      • Acyclovir 200 or 400 mg PO five times daily
      • Famciclovir 750 mg BID for one day or 1500 mg as a single dose
    • molluscum contagiosum :
      • cryotherapy, curettage, cantharidin, and podophyllotoxin as first-line therapeutic options
  • Fungal infections:
    • Dermatophyte infections- topical or oral antifungals

Controlling pruritus:

  • Preferred regimen:
    • Sedatives: diphenhydramine, hydroxyzine, and cyproheptadine
    • Nonsedatives: fexofenadine, cetirizine or loratadine
  • Alternative regimen:
    • Topical doxepin
    • Topical calcineurin inhibitors
      •  Pimecrolimus 1% cream or tacrolimus 0.03% to 0.1%

Chronic inflammatory skin diseases

  • Contact (allergic, irritant)
  • Seborrhoeic dermatitis
    • onset during the 1st days or weeks of life, absence of pruritus, and presence of greasy scaling on a yellow-red base
    • Involvement of the top of the scalp (cradle cap), axilla, and diaper area makes it more likely the patient has seborrheic dermatitis, vs excoriated dermatitis involving the extensor surfaces, face, and trunk favour AE.
  • Psoriasis
  • Lichen simplex chronicus

Infectious agents

  • Candida
  • Dermatophytes
  • Herpes simplex
  • Staphylococcus aureus
  • Sarcoptes scabiei
    • highly pruritic, erythematous papular lesions. In most cases, the typical burrows can be found on the flexor wrists, finger webs and genitalia. Similar symptoms in other family members
  • HIV-associated dermatitis

Immunologic disorders

  • Dermatitis herpetiformis
  • Pemphigus foliaceus
  • Graft-versus-host disease
  • Dermatomyositis

Malignant Diseases

  • Cutaneous T-cell lymphoma (mycosis fungoides, S´ezary syndrome)
  • Histiocytosis X (Letterer-Siwe disease)

Congenital disorders

  • Netherton’s syndrome
  • Dubowitz syndrome
  • Erythrokeratodermia variabilis

Immunodeficiencies

  • Wiskott-Aldrich syndrome (immunodeficiency with thrombocytopenia and eczema)
  • Thymic hypoplasia (DiGeorge syndrome)
  • Hyper-IgE syndrome
  • Severe combined immunodeficiency (SCID)
  • Ataxia teleangiectasia

Metabolic Diseases

  • Phenylketonuria
  • Tyrosinemia
  • Histidinemia
  • Zinc deficiency
  • Pyridoxine (vitamin B6) and niacin deficiency
  • Multiple carboxylase deficiency
  • Nonallergic reaction to medication
    • Infliximab

References

Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Sandbox:Shalinder&oldid=1497154"