“Rash.” Certainly, this is not a favorite chief complaint in the Ped ED, but unquestionably it is a common one. While there may be very few “rash emergencies,” there are several significant conditions to ponder (ex, Kawasaki, ITP, HUS) as well as less concerning ones (ex, Molluscum). Additionally, before you dismiss the condition as being “not an emergency,” consider that there may be some helpful advice that you can provide. Often, a few tactful reminders and tips can lend comfort. Let us consider the most recent update [Eichenfield, 2015] on the seemingly ubiquitous Atopic Dermatitis.

Atopic Dermatitis: Basics

• In the US, estimated to affect ~12.5% of pediatric patients!
• Diagnosis:
  • No lab test to make the diagnosis.
  • Combination of symptoms and findings:
    • Relapsing and/or Chronic Pruritic dermatitis
    • Distributed on face, neck, extensor surfaces as well as flexural folds.
    • Erythematous papules and patches
    • Dry skin (xerosis)
    • Excoriations
  • Generally, spares the groin and axilla
• Consider other conditions that may mimic appearance:
  • Psoriasis
  • Ichthyoses
  • Erythroderma
  • Scabies
  • Seborrheic dermatitis
  • Contact dermatitis
  • Photosensitivity dermatitis
  • Immune deficiency disease
  • Cutaneous T-Cell lymphoma

Atopic Dermatitis: Severity

Generally speaking, these are not very distinct classifications and make intuitive sense, but are most useful in helping to determine appropriate care.

• Mild
  • Involves less body surface area
  • Have less exacerbations
  • Has less itch
• Moderate – Severe
  • Involves greater amount of body surface area
  • More persistent symptoms
  • More severe itch
  • Often require maintenance medications to help manage.
    • Like with persistent asthma, “controller” medications can be helpful to manage mod-severe atopic dermatitis.
    • Ex: Tacrolimus and/or Low-Medium potency topical corticosteroids used twice weekly.

Atopic Dermatitis: Routine Management

• Basic skin care is integral in the management of atopic dermatitis.
• These should be re-emphasized for all patients presenting with complaints consistent with atopic dermatitis. [Eichenfield, 2015]
  • Skin Hydration
    • Skin moisturizers used liberally and frequently even to uninvolved skin.
      • Lotions actually can be drying.
      • Favor ointments over lotions.
    • Using mild soaps and apply skin moisturizers when still damp (after bathing).
  • Antiseptic Measures
    • Dilute bleach baths twice weekly (more frequently for those with recurrent skin infections) can help decrease risk of skin infections and decrease atopic dermatitis severity. [Huang, 2011; Huang, 2009]
    • ~0.5 cup of sodium hypochlorite diluted in 40 gallons of water (1 full bath tub)
  • Trigger Avoidance
    • Trigger identification can be challenging, but is also very helpful (just like for any other atopic condition).
    • Some common triggers: soaps, wool and abrasive clothing, lotions, fragrances, tight fitting clothing, food allergens and extremes in temperatures/humidity.

Atopic Dermatitis: Acute Therapy

• Topical corticosteroids
  • For patient’s with Mild Disease
    • Low potency corticosteroids twice daily for up to 3 days beyond improvement.
    • Apply only to area involved with flare.
    • Ex: Hydrocortisone ointment, dexamethasone cream
  • For patient’s with Mod-Severe Disease
    • Medium potency corticosteroids twice daily for up to 3 days beyond improvement.
      • Apply only to area involved with flare.
      • Ex: Triamcinolone ointment, Fluticasone ointment
    • Consider possible secondary skin infection as well.
• Reinforce the need to continue with the Routine Skin Care above.
• May refer to other educational resources, like nationaleczema.org or policy lab.

References