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Conflicts of

 Geoffrey Potts MD, FAAD interest  Assistant Professor of CURRENT INVESTIGATOR FOR PFIZER ATOPIC I WILL DISCUSS OFF LABEL USE OF MEDICATIONS DERMATITIS CLINICAL TRIAL USING PO JAK AND WILL ASSOCIATE GENERIC NAMES WITH Dermatology - WSU INHIBITOR BRAND AS WELL FOR FAMILIARITY  MSMS Annual Meeting 2020  10/21/2020

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Spongiotic Dermatitis

Objectives  Histopathology cannot definitively differentiate between the different clinical forms of eczematous dermatitis  Normal Skin  Acute spongiotic dermatitis  Describe management and pitfalls in dermatitis  Classically for allergic contact  Recognition of types of pruritic dermatitis including  Subacute spongiotic dermatitis atopic, contact, and mimickers to improve patient care and quality of life  Classically for atopic/nummular  Chronic spongiotic dermatitis  Classically for prurigo/LSC

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Eczematous Dermatitis Atopic Dermatitis (AD)

 Atopic Dermatitis  Atopic Dermatitis  Contact dermatitis  Contact dermatitis  Allergic   Irritant Allergic  Irritant  Nummular dermatitis  Nummular dermatitis  Seborrheic dermatitis  Seborrheic dermatitis  Neurodermatitis  Neurodermatitis  Lichen Simplex Chronicus (LSC)  Lichen Simplex Chronicus (LSC)  Prurigo nodularis (PN)  Prurigo nodularis (PN)  Stasis dermatitis  Stasis dermatitis  Asteatotic dermatitis  Asteatotic dermatitis  Dyshidrotic hand dermatitis (pomphylox)  Dyshidrotic hand dermatitis (pomphylox)

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Atopic Dermatitis Atopic Triad

 The itch that rashes defined with the Hanifin Rajka criteria  Part of the atopic triad  Barrier dysfunction and inflammatory disease

Nibbering B, Ubags NDJ. Microbial interactions in the atopic march. Clin Exp Immunol. 2020 Jan;199(1):12-23. doi: 10.1111/cei.13398. Epub 2019 Nov 27. PMID: 31777060; PMCID: PMC6904645. 7 8

Allergic March Age distribution

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Eczema in skin of color Epidemiology

 More commonly papular, follicular accentuation than  10.7% of children and 7.2% of patches alone adults have AD  Lack same filaggrin mutations of other populations  Early childhood onset but its  Pigmentation and itch often the primary complaints effects can cause whole family unit  Many patients prefer oils and ointments over other to suffer and affect entire lifespan formulations  Less commonly adult onset patients have other triggers

Drucker AM, Wang AR, LiWQ, Sevetson E, Block JK, Qureshi AA. The Burden of Atopic Dermatitis: Summary of a Report for the National Eczema Association. J Invest Dermatol. 2017 Jan;137(1):26-30. doi: 10.1016/j.jid.2016.07.012. Epub 2016 Sep 8. PMID: 27616422. 11 12

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Burden of atopic dermatitis Quality of life The costs of AD to USA is $5.3 billion in 2015  Social isolation in children with AD Direct and indirect costs to  Sleep loss for patient and family patients, families,  Depression hospitalizations,  Dietary restrictions medications, work loss  Failure to thrive  Work absenteeism  Inattentiveness at school  Clothing adjustments  Sports restrictions Drucker AM, Wang AR, Li WQ, Sevetson E, Block JK, Qureshi AA. The Burden of Atopic Dermatitis: Summary of a Report for the National Eczema Association. J Invest Dermatol. 2017 Jan;137(1):26-30. doi: 10.1016/j.jid.2016.07.012. Epub 2016 Sep 8. PMID: 27616422.

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Peng W, Novak N. Pathogenesis of atopic dermatitis. Clin Exp Allergy. 2015 Mar;45(3):566-74. doi: Vakharia PP, Silverberg JI. New and emerging therapies for paediatric atopic dermatitis. Lancet Child Adolesc 10.1111/cea.12495. PMID: Health. 2019 May;3(5):343-353. doi: 10.1016/S2352-4642(19)30030-6. Epub 2019 Mar 20. PMID: 30904349. 25610977. 15 16

Skin barrier repair Contact Dermatitis

 Atopic Dermatitis  Contact dermatitis  Allergic  Irritant  Nummular dermatitis  Seborrheic dermatitis  Neurodermatitis  Lichen Simplex Chronicus (LSC)  Prurigo nodularis (PN)  Stasis dermatitis  Asteatotic dermatitis  Dyshidrotic hand dermatitis (pomphylox)

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Airborne contact dermatitis Contact Dermatitis  Involves eyelids and caused by aerosolized chemicals  Irritant contact dermatitis (80%)  Fragrances, preservatives, cosmetics all  Acid, alkali, detergent at certain concentrations common causes  Burns more than itches  Fissures and indistinct borders  This patient had airborne exposure to  Although more common in atopics may not require genetic predisposition methyl-isothiazolinone in paint  Allergic Contact dermatitis (20%)  Hapten related delayed type IV hypersensitivity  Itches more than burns  Vesicles and distinct borders

 Requires genetic predisposition Gorris, Amelie & Valencak, Julia & Schremser, Verena & Bangert, Christine & Kinaciyan, Tamar. (2019). Contact allergy Fonacier LS, Dreskin SC, Leung DY. Allergic skin diseases. J Allergy Clin Immunol. 2010 Feb;125(2 to methylisothiazolinone with 3 clinical presentations in one Suppl 2):S138-49. doi: 10.1016/j.jaci.2009.05.039. Epub 2009 Nov 24. PMID: 19932921. patient. Contact Dermatitis. 82. 10.1111/cod.13384. 19 20

Photoallergic contact dermatitis Baboon Syndrome Spares eyelids as requires exposure to light for dermatitis development  Symmetric Drug Related  “Lime/margarita dermatitis” is from Intertriginous and Flexural phytophotodermatitis Exanthema (SDRIFE)  Systemic contact dermatitis  Metals, beta lactam antibiotics, plants such as Compositae or Balsam of Peru  When related to chemotherapy agents considered toxic erythema of chemotherapy and often involves hands/feet Winnicki M, Shear NH. A systematic approach to systemic contact dermatitis and symmetric drug-related intertriginous and flexural exanthema (SDRIFE): a closer look at these conditions and an approach to intertriginous eruptions. Am J Clin Dermatol. 2011 Jun 1;12(3):171-80. doi: 10.2165/11539080-000000000-00000. PMID: 21469762. 21 22

Patch testing

r XS 1 k positive 11 11111 Doabdial  Testing to chemical based allergens 1.I 1i;  Place disks on back, remove after 48 hours, final reading in 4-8 days from application VaLrylLy, fotliruLar.  Antihistamines ok for symptomatic relief PR:ralei• mtilcration. or licuittiikeutm. ;:rolihrszicHL crylbrom. Ala Do 1211E1 but cannot be on PO corticosteroid doses Allergen dibrre:r Lira WWI higher than 20mg or falsely negative Principal Sources of Contact testing may occur Nickel sulfate Metals in clothing, jewelry, catalyzing agents  TRUE test most common panel Neomycin sulfate Usually contained in creams, ointments Balsam of Peru Topical medications  North American Contact Derm Society has Fragrance mix an expanded panel Fragrances, cosmetics Thimerosal Antiseptics  Personal care products can be tested on Sodium gold thiosulfate Medication an uninvolved area of skin with application for 2-3 days followed by observation to Formaldehyde Disinfectant, curing agents, plastics see if dermatitis develops Quaternium-15 Disinfectant Bacitracin Ointments, powder Cobalt chloride Cement, galvanization, industrial oils, cooling agents, eyeshades Methyldibromo glutaronitrile, phenoxyethanol Preservatives, cosmetics 23 24

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Nickel Neomycin sulfate/Bacitracin

 Most common contact allergen worldwide  Common allergen due to widespread use in wound  Costume jewelry, belt buckle, snap dermatitis care higher rate in atopic children as well as those who  Co-reactant with bacitracin though chemical have had ear piercings structure is different often sensitization happens  Europe has introduced regulations to lower the simultaneously amount of nickel in products  Bacitracin when applied to broken skin (stasis  Dimethylglyoxime is the reagent in nickel tests dermatitis) can lead to anaphylaxis

Ahlström MG, Thyssen JP, Wennervaldt M, Menné T, Johansen JD. Nickel allergy and allergic contact dermatitis: A clinical review of immunology, epidemiology, exposure, and treatment. Contact Dermatitis. 2019 Oct;81(4):227-241. doi: 10.1111/cod.13327. Epub 2019 Jul 9. Dyck ED, Vadas P. Anaphylaxis to topical bacitracin. Allergy. 1997 Aug;52(8):870- PMID: 31140194 1. doi: 10.1111/j.1398-9995.1997.tb02160.x. PMID: 9284988. 25 26

Balsam of Peru Thimerosal

 Resin of Myroxylon balsamum var. pereirae tree  Common allergen but not usually relevant to  Flavoring, preservative, and fragrance patient’s contact dermatitis  Beer, chocolate, cola, cosmetics, air fresheners,  Was previously a common preservative in vaccines cleaning products, and numerous other products but now all vaccines under age 6 have other  Contains cinnamein, a combination of cinnamic preservatives acid, benzoyl cinnamate, benzoyl benzoate, benzoic  Still in certain antiseptics acid, vanillin and nerodilol  If used in a product as a preservative (benzoic acid and sodium benzoate) can still be labeled as “FRAGRANCE FREE”

https://www.contactdermatitisinstitute.com/balsam-of-peru-myroxylon-pereirae-resin.php https://www.contactdermatitisinstitute.com/pdfs/allergens/Thimerosal.pdf 27 28

Sodium gold thiosulfate Formaldehyde

 Often a delayed patch test reaction  Preservative in polymer manufacturing,  Previous rheumatoid arthritis treatment but textiles, leather, plasticizers, lacquer, and common in jewelry and dental restorations adhesive  Formaldehyde releasers  Formaldehyde, quaternium-15, DMDM hydantoin, imidazolidinyl urea, diazolidinyl urea, polyoxymethylene urea, sodium hydroxymethylglycinate, 2-bromo-2- nitropropane-1,3-diol (bromopol) and glyoxal.

https://www.contactdermatitisinstitute.com/sodium-thiosulfoaurate- https://www.contactdermatitisinstitute.com/pdfs/allergens/Formaldehyde.pdf gold.php#:~:text=Gold%20sodium%20thiosulfate%20is%20a,and%20previous%20rheumatoid% 20arthritis%20treatment.

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Quaternium-15 Cobalt chloride

 Common formaldehyde releasing  Metal alloys, blue paints, stains, preservative and surfactant in many tools, keys, jewelry, eye shadow, personal care products B12 supplements, orthopedic or  Regulations have led to numerous dental implants changes in manufacturing of particular personal care products  Cosensitivity of nickel and cobalt  Since things change often patients due to alloys with nickel plating with allergic contact dermatitis need to keep an updated “SAFE” list of products known to not contain any of their allergens with positive patch testing Xu S, Kwa M, Lohman ME, Evers-Meltzer R, Silverberg JI. Consumer Preferences, Product Characteristics, and Potentially Allergenic Ingredients in Best-selling Moisturizers. JAMA Dermatol. 2017 Nov 1;153(11):1099-1105. doi: 10.1001/jamadermatol.2017.3046. https://www.contactdermatitisinstitute.com/pdfs/allergens/Cobalt%20(II)%20chloride%20hexa PMID: 28877310; PMCID: PMC5710429. hydrate.pdf 31 32

Methyldibromo glutaronitrile, phenoxyethanol Cosmetics, lotions, glues, detergents, metalworking fluid, toilet tissues, paints, shampoo, and sunscreen Topical corticosteroid You may have to ask the patient repeatedly if they allergies are uncommon but are using wet wipes tixocortol (hydrocortisone)  Another preservative in wet wipes is methyl- group A most common isothiazolinone  Class C corticosteroids  Seventh Generation-Free & Clear Baby Wipes are (clocortolone pivalate or free of the chemical desoximetasone) don’t have cross reaction  Class D2 cross reacts with both group A and B https://www.contactdermatitisinstitute.com/methyldibromo-glutaronitrile-phenoxyeth.php Nguyen HL, Yiannias JA. Contact Dermatitis to Medications and Skin Products. Clin Rev Allergy Immunol. 2019 Feb;56(1):41-59. doi: 10.1007/s12016-018-8705-0.PMID: 30145645. 33 34

Treatment Nummular Dermatitis

 Identify and avoid allergen  Atopic Dermatitis  Haptens can cause dermatitis for more  Contact dermatitis  Allergic than three weeks after exposure  Irritant  If mild or localized medium to high potency  Nummular dermatitis topical corticosteroid  Seborrheic dermatitis  Neurodermatitis  If widespread consider taper of  Lichen Simplex Chronicus (LSC) 1mg/kg/day prednisone over 21 days  Prurigo nodularis (PN)  Medrol dose pack isn’t high enough dose  Stasis dermatitis or long enough time  Asteatotic dermatitis  Dyshidrotic hand dermatitis (pomphylox)

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Nummular Dermatitis

 Extremities usually involved (more prone to xerosis)  Scrape to rule out tinea as both can be annular  Bathing practices and emollients are preventive  Biopsy if unresponsive DDx

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Seborrheic Dermatitis Seborrheic Dermatitis

 Oily parts of skin with greasy scale  Atopic Dermatitis  Scalp, mid face, back, chest, groin  Contact dermatitis  Allergic  Cradle cap in infants due to maternal  Irritant hormones  Nummular dermatitis  Starts in adolescence  Seborrheic dermatitis  Malassezia furfur overgrowth and  Neurodermatitis sensitivity triggers eczematous process  Lichen Simplex Chronicus (LSC)  If severe and recalcitrant workup for  Prurigo nodularis (PN) neurologic disease or HIV  Stasis dermatitis  Ketoconazole 2% shampoo, cream,  Asteatotic dermatitis corticosteroid topicals, coal tar, sal acid adjuncts  Dyshidrotic hand dermatitis (pomphylox)

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DDx Neurodermatitis

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Neurodermatitis Neurologic

 Overstimulation of C-fiber nerves leading to burning/pruritis  Notalgia paresthetica  Phenotypes include lichen simplex chronicus  Meralgia paresthetica  accentuation of skin lines  Lat fem. cutaneous nerve  Prurigo nodularis with indurated firm discrete nodules  Brachioradial pruritis  Continued rubbing/scratching  Macular amyloid changes due to frequent rubbing in a particular causes macular amyloid distribution depending on nerve or dermatome involved changes on skin  Anesthetics, emollients, PT, weight loss, capsaicin, sun protection

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Psychiatric DDx

 Mood disorders such as depression, anxiety  Treat underlying disorder, wrap/cover involved skin (Unna boot)  Consider N-Acetylcysteine supplementation  600mg daily up to 3600mg daily  Reduces glutamate levels  GI SE

Grant JE, Chamberlain SR, Redden SA, Leppink EW, Odlaug BL, Kim SW. N-Acetylcysteine in the Treatment of Excoriation Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2016 May 1;73(5):490-6. doi: 10.1001/jamapsychiatry.2016.0060. PMID: 27007062. 45 46

Stasis Dermatitis Statis Dermatitis

 Atopic Dermatitis  Venous insufficiency leading to  Contact dermatitis inflammatory edema and overlying  Allergic dermatitis  Irritant  Nummular dermatitis  Compression therapy is mainstay of  Seborrheic dermatitis treatment to avoid ulcers, infection, and  Neurodermatitis scarring of lymphatics  Lichen Simplex Chronicus (LSC)   Prurigo nodularis (PN) Treat concomitant tinea pedis to avoid  Stasis dermatitis cellulitis  Asteatotic dermatitis  Avoid bacitracin and neomycin  Dyshidrotic hand dermatitis (pomphylox)

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Asteatotic Dermatitis Asteatotic Dermatitis

 Atopic Dermatitis  (Eczema craquelé)  Contact dermatitis  “Dry riverbed” appearance  Allergic  Irritant often seen during isotretinoin  Nummular dermatitis therapy or in elderly patients  Seborrheic dermatitis  Avoid harsh soaps  Neurodermatitis  Lichen Simplex Chronicus (LSC)  Wash intertriginous areas  Prurigo nodularis (PN)  Rule out underlying  Stasis dermatitis medications or thyroid disease  Asteatotic dermatitis  HCTZ, amlodipine  Dyshidrotic hand dermatitis (pomphylox)

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Dyshidrotic Hand Dyshidrotic Eczema Dermatitis (pomphylox) (pomphylox)

 Atopic Dermatitis Pomphylox contains larger  Contact dermatitis vesicles/bulla vs the classical  Allergic “tapioca” type vesicles  Irritant  Nummular dermatitis Exquisitely pruritic on hands  Seborrheic dermatitis and feet often worsened due to  Neurodermatitis stress or hyperhidrosis  Lichen Simplex Chronicus (LSC)  Prurigo nodularis (PN)  Stasis dermatitis  Asteatotic dermatitis  Dyshidrotic hand dermatitis (pomphylox)

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DDx Treatments

 Topical emollients, antimicrobials for impetiginized dermatitis, and irritant/allergen avoidance are paramount  Topical steroids are a mainstay of localized therapy and in combination for more widespread disease  Calcineurin inhibitors, crisaborole, intralesional triamcinolone for localized disease  Phototherapy, systemic agents for more widespread or recalcitrant disease  Systemic agents for recalcitrant atopic dermatitis

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ok4 Mild • Skin hydration Topical treatment (corticosteroids/ • calcineurin inhibitors) • • • Education/Avoid triggers Proactive •  • Hospitalization/ Control of treatment •  • Infections Phototherapy Moderate Cyclosporine A Methotrexate Dupilumab* Mild Moderate Severe Other systemic therapies Systemic therapy <3 3-10 >10 percent of percent of percent of the body the body the body

* A 1111rnnpri fnr (71-174 1 tg 7n i 87 At) 55 56

C Topical corticosteroids

 Mainstay of management for localized atopic dermatitis  Potency measured by vasoconstrictor assay  Ointments sting less than creams (less alcohol) and are more potent due to occlusion  Cream intermediate alcohol content  Solutions (all alcohol) sting the most  Advise using more potent topical corticosteroids no less than two weeks to any one location  Less important for lichenified dermatitis or on palms/soles

Mechanisms of Action of Topical Corticosteroids in Psoriasis Lu´ıs Uva Mechanisms of Actionof TopicalCorticosteroids in PsoriasisLu´ıs Uva, 57 58

Table 40-3 Considerations for choosing a topical corbcosteroid product

Potency Type of Extent of Duration of Location of Usage in infants State of the (Class) dermatosis dermatoses TCS Usage &mato Se3 and children epidermis Side effects of topical corticosteroid Superpotent Avoid extensive For short term Do not use on the Avoid use in infants Best for thick, 11) application use only, face, axillae. and children under lichenitiedor Dermatoses (>50 g weekly) ideally 2-3 submarnmary area 12 years hypertrophicskin:  resistant to weeks at a time or groin avoid with thin skin Striae, Cushing syndrome are intermediate extremely rare but if used on or high High (ii & Illy Severe Avoid extensive For short term Do not use on the Avoid use in infants Best for thick, infants or in those with potency TCS application use only, face, axillae. and children under lichenified or diminished skin barrier on large (>50 g weekly) ideally 2-3 subrnammary area 12 years hypertrophic skin; weeks at a time or groiri avoid with thin skin surface areas for a long time Intermediate Moderate (1V & Best for short Avoid Best on trunk and Avoid extended use Safer for short medium to high potency V) term treatment extended use extremities (>1-2 weeks) in term use on thin steroids can lead to side effects of extensive (>1-2 weeks) infants and children skin: less effective dermatoses in infants and on thicker skin  Prefer alternating steroids and children steroid sparing agents and use Low (VI & VII) Steroid Preferred for Best if long Best choice for Infants and children Best for thin skin: of more potent agents to sensitive treatment of tem treatment face, axilla. groin, not effective on large areas is required and other moist, thicker skin reduce pruritis then taper occluded areas

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Topical calcineurin Phosphodiesterase Inhibitors inhibitors (TCI)  Tacrolimus ointment (approved 0.03% for age 2-  Crisaborole (Eucrisa) blocks PDE4 12) and 0.1% approved for 12 years and up  Same target as Apremilast (Otezla)  Pimecrolimus cream (1%) approved age 2 and  PDE4 inhibitors may have efficacy in other diseases up off label (SLE, Alopecia areata, vitiligo)  Burning/stinging common  Safe on face as steroid sparing agent often used alternating regimen  Approved age 3 months and up for atopic dermatitis  Black box warning for lymphoma due to class effect and rat studies with high oral doses of calcineurin inhibitor  Large registries show no increased risk of lymphoma with TCIs  Stinging and burning with first days of application  Lessened if kept in refrigerator Siegfried EC, Jaworski JC, Kaiser JD, Hebert AA. Systematic review of published trials: long- term safety of topical corticosteroids and topical calcineurin inhibitors in pediatric patients with atopic dermatitis. BMC Pediatr. 2016 Jun 7;16:75. doi: 10.1186/s12887-016- 0607-9. PMID: 27267134; PMCID: PMC4895880. https://dermnetnz.org/topics/crisaborole/ 61 62

Phototherapy Dupilumab

 Inhibits epidermal Langerhans cell  The first systemic agent approved for function and lessens pruritis atopic dermatitis now down to age 6  Narrow Band UVB is mainstay of years therapy due to safety with very  Also approved for asthma and little risk even long term compared eosinophilic esophagitis to systemic therapy  Pen or syringe for subcutaneous  UVA does have risk of NMSC after 250 treatments especially in injection combination with cyclosporine  IL-4/13 inhibitor preventing Th2  Can utilize methotrexate (and differentiation biologics) have synergistic effect on  Rapid improvement in pruritis light therapy

Ultraviolet B Phototherapy for Psoriasis: Review of Practical Guidelines Dhwani Mehta, Henry W. Lim Am J Clin Dermatol (2016) 17:125–133 63 64

Methotrexate Cyclosporine

 Off label  Off label  Inexpensive agent for monotherapy or combination therapy  Modified (Neoral or Gengraf) NOT Sandimmune  Dosed weekly up to 25mg and must use with folic acid to  Highly effective for erythroderma or for rapid clearance prevent hematologic toxicity with bridge to other therapy  Reversal of overdose with folinic acid (leucovorin)  Main concern is immunosuppression, renal toxicity  Liver toxicity, hepatitis, hematologic toxicity requiring  Malignancy typically a concern in high doses monitoring, TB testing at baseline (transplant use), long term, or in combination with UVA  Less immunosuppression compared to other agents  Short term use safe with close monitoring for blood  Trimethoprim-Sulfamethoxazole can cause life threatening pressure, renal function, infection hematologic toxicity in combination with methotrexate  Long term use associated with hypertrichosis, acne, gingival hyperplasia

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Mycophenolate mofetil JAK/STAT Inhibitors

 Off label  Tofacitinib/Xeljanz (Pfizer) is a JAK 1/3  Before advent of dupilumab was a well inhibitor approved for RA/PsoA tolerated and more widely used systemic  Trials with abrocitinib, baricitinib and many 1 oral agent for severe atopic dermatitis other JAK /2 inhibitors for atopic dermatitis unresponsive to other agents ongoing  Concern regarding hematologic toxicity or  Immunosuppressing GI SE  Elevates CK, lipids, risk of infection (URI, zoster), leukopenia, potentially malignancy  Ruxolitinib is a JAK 1/2 inhibitor studied topically not yet approved

Psoriasis: A STAT3-Centric View Enzo Calautti Int. J. Mol. Sci. 2018, 19, 17 67 68

Other investigational Combination Therapy therapies  MTX or mycophenolate mofetil and NBUVB  IL-31 Nemolizumab  Increased risk of NMSC with cyclosporine and NBUVB  IL-13 Tralokinumab,  Emollients needed no matter the stage Lebrikizumab  Alternating of emollients, topical corticosteroids, and steroid sparing  IL-22 Fezakinumab agents  IL-17 Secukinumab?

Renert-Yuval Y, Guttman-Yassky E. New treatments for atopic dermatitis targeting beyond IL-4/IL-13 cytokines. Ann Allergy Asthma Immunol. 2020 Jan;124(1):28-35. doi: 10.1016/j.anai.2019.10.005. Epub 2019 Oct 14. PMID: 31622669. 69 70

Erythrodermic Atopic Atopic eruption in pregnancy Dermatitis  Not harmful to fetus  DDx?  ID SCALP (Idiopathic, Drug, Leukemia,  History before pregnancy helpful Atopic, Psoriasis/Pityriasis Rubra Pilaris,  Rule out more dangerous dermatoses Contact, Seb derm) (cholestasis of pregnancy or pemphigoid  Systemic illness with wide differential 90% BSA gestationis)  Inpatient management recommended for electrolyte monitoring and supportive care with nutrition, temperature, barrier restoration  Cyclosporine, wet wraps with triamcinolone ointment, occasionally systemic corticosteroids, dupilumab

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Secondary Syphilis

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Palmoplantar pustulosis

Pityriasis Rubra Pilaris

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Mycosis Fungoides (Cutaneous T Cell Lymphoma)

Guttate Psoriasis

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Discoid Lupus Erythematosus

Tinea capitis

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Tinea pedis

Sarcoidosis Ute Nowack, BMC Dermatology20022:15 81 82

Hypertrophic lichen planus

Crusted scabies

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Comorbidities Conclusions

 Eczematous dermatoses are common with a high cost to quality of life and financial burden from infancy all the way to elderly populations  Atopic dermatitis is the next hot subject for clinical research to find therapies that are safe and efficacious  Differential diagnosis is important for proper management

JAAD International Volume 1, Issue 1, July 2020, Pages 50-58 JAAD International Original article Prevalence of baseline comorbidities in patients with atopic dermatitis: A population- based cohort study in Taiwan 85 86

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