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Updated: Dec 16 2021

Atopic Dermatitis (Eczema)

Images dermatitis.jpg
  • Snapshot
    • A 25-year-old medical student with a history of severe atopic dermatitis presents to her dermatologist’s office. She recently started clinical rotations in the hospital, which she reports is stressful. She also reports to using hand sanitizer multiple times per day, which has exacerbated the atopic dermatitis on both of her hands, causing them to ooze and sting. She reports feeling so itchy at night that she is unable to sleep. Physical exam reveals large erythematous plaques on her hands and flexural surfaces including neck, antecubital fossa, and behind the knees. She is directed to use topical steroids for the body and topical tacrolimus for the face. Given the severity of her disease, her physician suggests considering a new drug, dupilumab, in the future.
  • Introduction
    • Clinical definition
      • a chronic and pruritic inflammatory skin disease also known as eczema
    • Genetics
      • mutations
        • loss of function mutation in filaggrin (FLG) gene
          • filaggrin is an epidermal structural protein
          • increases risk for developing atopic dermatitis and other allergic disorders
    • Associated conditions
      • atopic triad
        • eczema (atopic dermatitis)
        • asthma
        • allergic rhinitis
      • food allergy
      • Wiskott-Aldrich syndrome
        • suspect when there is eczema along with recurrent infections and thrombocytopenia
      • Hyper-IgE syndrome
        • suspect when there is eczema along with recurrent cold abscesses and high serum IgE
  • Epidemiology
    • Prevalence
      • very common
      • 10-20% prevalence
    • Demographics
      • primarily affects children but can affect all ages
    • Risk factors
      • family history
      • living in urban setting
      • Western diet
  • Etiology
    • Pathogenesis
      • filaggrin deficiency or dysfunction may contribute to decreased water retention, impaired tight-junction formation, and reduced ceramide content
      • cutaneous inflammation with infiltrating T-cells can cause epidermal thickening, contributing to functional impairment of epidermal barrier
    • Combination of genetic, dietary, and environmental causes
  • Presentation
    • Symptoms
      • pruritus
        • sleep disturbance
      • excoriations from scratching
    • Physical exam
      • dry and rough skin
      • acute flares
        • diffuse erythematous patches and plaques with oozing and crusting papules/vesicles
      • chronic lesions
        • poorly demarcated patches and plaques with scale, excoriation, and lichenification
        • hyperlinearity of palms or soles
      • location
        • commonly on skin flexures in children and adults
        • commonly on the face in infancy
  • Studies
    • Labs
      • may have ↑ serum IgE
    • Biopsy
      • indication
        • to confirm diagnosis
      • findings
        • epidermal intercellular edema (spongiosis)
    • Making the diagnosis
      • most cases are clinically diagnosed
  • Differential
    • Seborrheic dermatitis
    • Contact dermatitis
    • Ichthyosis vulgaris
      • presents with dry/rough skin with horny plates
    • Nutritional deficiency
  • Treatment
    • Conservative
      • emollients and moisturizers
        • indications
          • enhance repair of epidermal barrier
          • apply soon after bathing
    • Medical
      • topical therapy
        • corticosteroids
          • indications
            • first-line treatment for acute flares
          • types
            • low-potency topical steroids
              • can use on face and neck
            • medium or high-potency topical steroids
              • cannot use on face, neck, or anogenital area
            • adverse effects
              • long-term use carries risk of skin atrophy
        • calcineurin inhibitor
          • indications
            • for use on face, anogenital, and neck area
            • for disease recalcitrant to steroids
            • alternative to steroids
          • drugs
            • tacrolimus
      • systemic therapy
        • indications
          • for severe or refractory atopic dermatitis
        • drugs
          • cyclosporine
          • azathioprine
          • dupilumab
    • Procedural
      • phototherapy
        • indications
          • for severe or refractory atopic dermatitis
          • for patients not willing to take systemic therapy for atopic dermatitis
        • modalities
          • ultraviolet light therapy
          • psoralen plus ultraviolet A (PUVA)
  • Complications
    • Secondary bacterial infection
    • Eczema herpeticum
  • Prognosis
    • recurrent and relapsing disease
    • majority of childhood eczema will improve or resolve as they get older
    • adult eczema often evolve into chronic hand eczema
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