DISCLOSURES 2018 MOAPA Primary Care Update Conference ATOPIC This speaker has no disclosures to Susan T. Voss DNP, DERMATITIS declare FNP-BC, DCNP, FAANP & ITCH Riverside Dermatology OBJECTIVES ATOPIC DERMATITIS Atopic Dermatitis Itch/Pruritus ▪ Atopic dermatitis (AD) is a chronic, pruritic inflammatory skin disease of unknown origin ▪ Describe the pathophysiology of ▪ Define itch/pruritus ▪ Commonly referred to as eczema AD ▪ Describe the pathophysiology of ▪ Usually starts in early infancy. ▪ Discuss the presentation and itch ▪ In US impacts 10-12% of children diagnostic workup ▪ List/Describe the etiological ▪ Present treatment options classifications of chronic pruritus ▪ Affects a substantial number of adults. ▪ In US 0.9% ▪ Present an algorithm for assessment of itch ▪ AD is commonly associated with elevated levels of immunoglobulin ▪ Discuss pharmacologic and E (IgE). nonpharmacologic treatment options ATOPIC DERMATITIS: ATOPIC DERMATITIS: PATHOPHYSIOLOGY PATHOPHYSIOLOGY ▪Atopic dermatitis arises because of a complex Two main hypotheses have been proposed regarding the interaction of genetic and environmental development of inflammation that leads to AD. factors. ▪The first suggests a primary immune dysfunction resulting in IgE sensitization, allergic inflammation, and a secondary ▪These include defects in skin barrier function epithelial barrier disturbance. making the skin more susceptible to irritation ▪The second proposes a primary defect in the epithelial barrier by soap and other contact irritants, the leading to secondary immunologic dysregulation and resulting in inflammation. weather, temperature and non-specific triggers. ATOPIC DERMATITIS: ATOPIC DERMATITIS: PATHOPHYSIOLOGY STAGES ▪The fact that AD is the first disease to present in a ▪ THREE STAGES series of allergic diseases—including food allergy, ▪ Infantile ▪ 2 months to 2 years of age asthma, and allergic rhinitis, in order—has given rise ▪ Childhood to the “atopic march” theory, which suggests that AD ▪ 2 to 10 years is part of a progression that may lead to subsequent ▪ Adolescent/Adult allergic disease at other epithelial barrier surfaces. ▪ >10 years In all stages, pruritus is the hallmark. Itching often precedes the appearance of lesions; hence the concept that AD is “the itch that rashes” ATOPIC DERMATITIS AD DIAGNOSTIC CRITERIA: CLASSES OF LESIONS MAJOR ▪ Acute ▪ Intensely pruritic erythematous papules and vesicles overlying erythematous skin; frequently associated with extensive excoriations and MUST HAVE THREE OF THE FOLLOWING erosions accompanied by serous exudates • Pruritus ▪ Subacute • Typical morphology and distribution ▪ Erythema, excoriation, and scaling • Flexural lichenification in adults ▪ Chronic • Facial and extensor involvement in infancy ▪ Thickened plaques of skin, accentuated skin markings (lichenification), • Chronic or chronically relapsing dermatitis fibrotic papules (prurigo nodularis); possible coexistence of all 3 types of • Personal or family history of atopic disease lesions in chronic atopic dermatitis • Asthma, allergic rhinitis, atopic dermatitis MUST ALSO HAVE AT LEAST THREE: ▪ Xerosis ▪ Nipple eczema ▪ Ichthyosis/hyperlinear palms/keratosis pilaris ▪ Cheilitis ▪ IgE reactivity (immediate skin test reactivity, AD ▪ Recurrent conjunctivitis AD RAST test positive) DIAGNOSTIC ▪ Dennie–Morgan infraorbital fold DIAGNOSTIC ▪ Elevated serum IgE CRITERIA: ▪ Keratoconus CRITERIA: ▪ Early age of onset MINOR ▪ Anterior subcapsular cataracts ▪ Tendency for cutaneous infections MINOR Orbital darkening (especially Staphylococcus aureus and herpes CONTINUED ▪ simplex virus) ▪ Facial pallor/facial erythema ▪ Tendency to nonspecific hand/foot dermatitis ATOPIC DERMATITIS: PRESENTATION/HISTORY ▪ Pityriasis alba ▪ Itch when sweating ▪Essential historical features to diagnose: ▪ Intolerance to wool and lipid solvents AD ▪Pruritus DIAGNOSTIC ▪ Perifollicular accentuation CRITERIA: ▪ Food hypersensitivity ▪ Central and most debilitating symptom of AD, incessant ▪ Course influenced by environmental and/or MINOR emotional factors ▪Chronic or relapsing history of disease CONTINUED ▪ White dermatographism or delayed blanch to cholinergic agents ▪ Intermittent course with flares and remissions, often for unexplained reasons. ATOPIC DERMATITIS: AD PRESENTATION PRESENTATION/HISTORY INFANTILE ▪Important historical features to supports the ▪ Infantile AD usually begins with erythema and scaling of the cheeks diagnosis: ▪Early age of onset ▪Atopy: Personal and/or family history ▪ Atopy refers to the genetic tendency to develop allergic diseases such as allergic rhinitis, asthma, and atopic dermatitis. Atopy is typically associated with heightened immune responses to common allergens, especially inhaled allergens and food allergens.(AAAAI) AD PRESENTATION AD PRESENTATION INFANTILE INFANTILE ▪ Extend to the scalp, neck, forehead, wrists, and extensor extremities. ▪ Can be more widely distributed in infants less than one year. Exudative AD PRESENTATION AD PRESENTATION CHILDHOOD CHILDHOOD ▪ Classic locations ▪ Antecubital fossae ▪ antecubital and popliteal fossae, flexor wrists, eyelids, face, and around the neck. ▪ Progresses from the extensor surfaces to flexor. ▪ Lesions are ▪ often lichenified, indurated plaques ▪ African-American patients may have a lichenoid appearance and favor the extensor surfaces. ▪ Intermingled with isolated, excoriated 2–4 mm papules that are scattered more widely over the uncovered skin. ▪ Severe AD with large BSA can lead to growth retardation AD PRESENTATION AD PRESENTATION CHILDHOOD CHILDHOOD ▪ Popliteal Fossae ▪Hand AD ADPRESENTATION PRESENTATION CHILDHOOD CHILDHOOD ▪ Eyelid ▪ Hyperlinear palms AD PRESENTATION AD PRESENTATION CHILDHOOD ADOLESCENT/ADULT ADOLESCENTS ▪ Eruption often involves: ▪ classic antecubital and popliteal fossae ▪ front and sides of the neck ▪ forehead, and area around the eyes AD PRESENTATION AD PRESENTATION ADOLESCENT/ADULT ADOLESCENTS/ADULTS ▪ Neck OLDER ADULTS ▪ Distribution is generally less characteristic ▪ Localized dermatitis may be the predominant feature, especially hand, nipple, or eyelid eczema. ▪ The skin, in general, is dry and somewhat erythematous. Lichenification and prurigo-like papules are common ▪ Papular lesions tend to be dry, slightly elevated, and flat-topped. ▪ Excoriated and often coalesce to form plaques. ▪ Staphylococcal colonization is nearly universal. ▪ In darker-skinned patients, the lesions are often dramatically hyperpigmented, frequently with focal hypopigmented areas related to healed excoriations. AD PRESENTATION AD PRESENTATION ADOLESCENTS/ADULTS ADOLESCENTS/ADULTS ▪ Nipple eczema ▪ Eyelid AD PRESENTATION ATOPIC DERMATITIS: ADOLESCENT/ADULT ASSOCIATED FEATURES ▪ Secondary infection ▪ Pityriasis alba ATOPIC ATOPIC DERMATITIS: DERMATITIS: ASSOCIATED ASSOCIATED FEATURES FEATURES ▪ Dennie-Morgan fold ▪ Cheilitis ATOPIC DERMATITIS: ATOPIC DERMATITIS: ASSOCIATED FEATURES DIAGNOSIS ▪ Keratosis pilaris ▪ Diagnosis is often based on presentation and history of the rash ▪ If necessary a skin biopsy can be performed ▪ A punch biopsy for H&E ▪ Findings are often nonspecific with spongiotic dermatitis AD: GENERAL MANAGEMENT AD: GENERAL MANAGEMENT EDUCATION AND SUPPORT ▪ Education and support EDUCATION AND SUPPORT ▪ Barrier repair ▪ Patient and parent education is critical!! ▪ Antimicrobial therapy ▪ Action Plan or Stepwise Approach ▪ Environmental factors ▪ Resources ▪ National Eczema Association: www.nationaleczema.org ▪ Antipruritics ▪ National Eczema Society: www.eczema.org ▪ Emotional Support ▪ AD impacts the whole family ▪ Sleep deprivation ▪ Burnout with treatment which can be time consuming AD: GENERAL MANAGEMENT AD: GENERAL MANAGEMENT BARRIER REPAIR BARRIER REPAIR ▪ TO BATHE OR NOT TO BATHE MOISTURIZE / BARRIER REPAIR ▪ Bathing with proper moisturization is key ▪ At least twice a day, at least once after bath/shower ▪ Lightly towel dry and apply moisturizer within 3-5 minutes ▪ Ointment and creams preferred over lotion Seals in moisture and allow water to be absorbed through the stratum ▪ ▪ More humectants corneum. ▪ ▪ Lukewarm water Petrolatum ▪ Vaseline, Aquaphor ▪ Avoid fragrance and dyes ▪ Moist wraps ▪ If child wants to “play” in the water do that first ▪ Ceramide based ointments ▪ After applying soap rinse and get out as soon as possible. ▪ Cerave, Cetaphil Restoraderm, Hylatopic Plus (Rx), Eucerin ▪ Only apply soap to armpits, genitalia, and bottom of feet. AD: GENERAL MANAGEMENT AD: GENERAL MANAGEMENT ANTIMICROBIAL THERAPY ENVIRONMENTAL FACTORS ▪ Treat infections with appropriate topical or systemic antibiotic ▪ Avoid external irritants Stress ▪ Key is to decrease chance for infection by reducing nasal ▪ staphylococcal carriage pre-emptively and keeping the skin ▪ Heat decolonized from Staphylococcus. ▪ Sweating ▪ Mupirocin ointment three times a day to each nostril one week out of ▪ Wool each month. ▪ Avoid contact allergens ▪ Bleach water tepid baths twice weekly ▪ Products with common allergens ▪ ½ cup standard bleach to regular size tub (40 gallons) ▪ Fragrance and dyes ▪ Swimming in chlorine based pool ▪ Wipes with methylisothiazolinone ▪ Parents may also be colonized (80%) ▪ Test for allergens when appropriate AD: GENERAL MANAGEMENT AD: TREATMENT ANTIPRURITICS TOPICAL CORTICOSTEROIDS ▪ Oral antihistamines ▪ Lowest potency steroid ▪ Discuss more with itch discussion ▪ Fluocinolone acetonide topical oil, 0.01% ▪ Topical ▪ Derma-Smoothe FS Body Oil ▪ Ice or cool compresses ▪ Mineral oil and ultra-refined peanut oil based ▪ Moisturizers containing