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 Atopic Dermatitis in Emergency Medicine

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PostSubject: Atopic Dermatitis in Emergency Medicine   Mon Mar 28, 2011 9:58 am

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[center]Atopic Dermatitis in Emergency Medicine


Introduction
 Background
Eczema, or atopic dermatitis, is a common inflammatory disease of the skin. The condition often has its start in childhood
 and follows a variable and sometimes unremitting course. Historically,
 this disease has been considered a part of a triad of "atopy" that  included asthma and allergic rhinitis,
 though this association has recently come into question. Although not a cause of significant mortality, the visible and chronic nature of  eczema can be a source of emotional stress.
Pathophysiology

The  precise mechanism for the development of eczema is unknown.
Whether the  clinical manifestations of atopic dermatitis (AD) are the result of  violation of the epidermis and the subsequent contact between environmental irritants and immune cells, or the reverse sequence, is debatable. Nonetheless, the epidermis is the first line of defense  
between the body and the environment and, when intact, shields the body from a variety of irritants, allergens, and microbes. This barrier,  which is maintained by differentiated keratinocytes and structural  
proteins, can be compromised by inheritance, trauma, decreased humidity,change in pH, and infection.
Atopic skin additionally has  diminished ability to maintain water; this dry skin leads to scratching,  which further contributes to the release of proinflammatory mediators.  Eczema is a biphasic T-cell – mediated
disease: TH2 is more prevalent in  the acute phase, and TH1 predominates in the chronically affected skin.1 Patients  with atopic dermatitis have elevated serum IgE levels, peripheral  eosinophilia, and overall
greater numbers of immune mediators and  cytokines.
Frequency
Atopic dermatitis
 is the most common inflammatory skin disease in children, affecting up to 17% of the pediatric population in the United States, with increasing  prevalence over the past several decades.
United States
Prevalence of atopic dermatitis ranges from approximately 7-17% in children.2 A small percentage of affected children will have the disease into adulthood.
International
Studies  in Japan and Northern Europe have found similar prevalence, with  industrialized and westernized nations noting increasing trends of patients with atopic dermatitis.
Mortality/Morbidity
Mortality  is not associated with atopic dermatitis. The impact of eczema is hard  to measure but has real personal, social, and financial
consequences.  The burden includes but is not limited to professional fees,  hospitalization, pain/suffering, social isolation, poor self-esteem,  and work and/or school performance or absence.
Additionally, patients  suffering from atopic dermatitis are prone to
bacterial superinfection.
Sex
Data shows a slightly increased prevalence of atopic dermatitis in female children.

Age
Atopic  dermatitis predominantly affects infants and young children.
Eczema is  apparent in the first year of life in 60% of cases, and its
onset is  before 5 years in 75% of cases.3 Onset of eczematous appearing disease in adulthood should lead the physician to consider another diagnosis.
A  triphasic course of atopic dermatitis across the lifespan has been  proposed. Phase I develops before IgE sensitization has taken place and
occurs mostly in infants who are likely genetically predisposed to the disease. Phase II involves IgE sensitization to food, environmental  
antigens, or both. Phase III is the product of chronic scratching and is characterized by the formation of IgE autoantibodies against proteins of keratinocytes and endothelial cells.

Clinical
 History
The  hallmarks of atopic dermatitis are intense pruritus, chronic eczematous  skin lesions, and epidermal thickening and hypertrophy.

  • The emergency physician often is the first to diagnose atopic dermatitis.
     The most common presentation is that of infants, usually younger than 6 months, brought in by their parents for a persistent rash. Before  
    coming to the ED, the parents may have tried a number of  over-the-counter and home remedies. Parents usually report that the rash
     has waxed and waned for months with a history of dry skin since birth.
  • Clinicians should inquire about a family history of asthma,
     hay fever, allergy, and other atopic diseases. Patients with pertinent medical or family history of such disease tend to have a worse  
    prognosis.
  • Parents may also give a history of poor sleep or  increased irritability in the patients, which is due to the desire to  scratch the skin during sleep. Atopic dermatitis begins with intense  pruritus,
    leading the patient to scratch, which results in the  characteristic rash.
  • Atopic dermatitis typically is not  associated with fever or other constitutional symptoms, and the presence  of these should prompt the
    clinician to look for bacterial  superinfection.

Physical
Atopic  dermatitis is a spectrum of disease that varies in
presentation,  severity, and distribution. Eczema defies a simple definition as the  disease has differing characteristics depending on the age of the  patient and the stage of the disease course.

  • Lesions may  be acute, subacute, or chronic, each with a characteristic appearance.  Lesions from one stage can convert into another stage at any time due to  processes such as manipulation,
    irritation, allergy, or infection.

    • Acute lesions are intensely itchy and present as vesicles and blisters with intense redness.
    • Subacute  disease is characterized by slight-to-moderate itching, pain, stinging,  burning and redness, scaling, and fissuring of the skin
      with a parched  and scalded appearance.
    • Chronic eczematous inflammation  demonstrates thickened skin, accentuated skin lines, excoriations, and  fissuring accompanying a
      moderate-to-intense itch.


  • The pattern of skin manifestations also differs across the lifespan.

    • In infantile atopic dermatitis, pruritic, red, scaly, and crusted lesions
       are typically found on the extensor surfaces and cheeks or scalp, with severe cases possibly presenting with vesicles, serous exudates, or  
      crusting. The diaper area is protected and usually spared.
    • </li>

    • Irritation around mouth of an infant with atopic     dermatitis.
    • [/url]Irritation around mouth of an infant with atopic     dermatitis.
    • The lesions in the childhood  stage have less exudation; the skin
      often demonstrates lichenified  plaques in a flexural distribution,
      commonly antecubital and popliteal  fossae, volar aspect of the wrists,
      ankles, and neck.
    • </li>

    • Flexural involvement in childhood atopic     dermatitis.

      Flexural involvement in childhood atopic     dermatitis

    </li>

Product Description
 This newly reorganized and expanded Second Edition of the revolutionary reference guide, Atopic Dermatitis,
is the only available text devoted to discussing all aspects of this common disease. Appealing to dermatologists, allergists, family practitioners, and pediatricians in daily practice, as well as physician scientists, medical students, and experimental investigators, this
stand-alone guide addresses recent breakthrough discoveries in genetics and new milestones in immunological research in dermatology.    New highlights in the
Second Edition:  

  • 12 brand new chapters that encompass the latest research
  • the
    latest advances, including regulatory and Th17 cells in atopic dermatitis, cytokines and chemokines, virus infections, autoantigens,
    specific immunotherapy, the immune system and atopic dermatitis, and
    neuromediators and the pathophysiology of pruritus
  • coverage of
    the most recent areas of advancement: pathophysiology, mechanisms and
    cellular aspects, epidemiologic, genetic, and immunologic aspects of
    atopic dermatitis
  • =======================================

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================================



======================
Related Topics:
A Practical Manual Handbook of Dermatology Free Download
Cosmetic Dermatology: Principles and Practice Free Download
Radiation Therapy for Skin Cancer Free Download
Color Atlas of Chemical Peels Free Download
The Manual of Dermatology Free Download
Dermatology in Clinical Practice Free Download
Hair and Scalp Diseases Free Download

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    • Adult eczema has a  similar distribution to that in  childhood
      atopic dermatitis but is  increasingly localized and  lichenified with
      thickened skin, increased  skin markings, and  excoriated and fibrotic
      papules.


  • Certain characteristic patterns are worth mentioning.

    • Eczema that appears as one or several coin-shaped plaques is called nummular eczema.
    • Plaques with prominent skin lines are referred to as lichen simplex chronicus. These lesions are characterized by intense pruritus that ceases when pain replaces itch.



Diagnosis  of atopic dermatitis is made by observing  
representative clinical  features of the disease. The Hanifin and Rajka
diagnostic criteria,  which consist of 4 major and 23 minor criteria
has  traditionally been  used, but it is time consuming and not
manageable.  The UK working group  on atopic dermatitis has the
following criteria  for diagnosis, which has  been most extensively
validated in clinical  trials.4 Evidence of itchy skin with 3 more of
the following:

  • History of skin crease involvement
  • Presence of generally dry skin within in the past year
  • Symptoms in a child beginning before the age of 2 years
  • Visible involvement of dermatitis involving flexural surfaces

The complete Hanifin and Rajka criteria are included below:

  • Major criteria (need 3 or more)

    • Pruritus
    • Typical morphology and distribution
    • Flexural lichenification in adults
    • Facial and extensor involvement in infants and children
    • Dermatitis - Chronically or chronically relapsing
    • Personal or family history of atopy (asthma, allergic rhinitis, atopic dermatitis)


  • Minor criteria (need 3 or more)

    • Cataracts
    • Cheilitis
    • Conjunctivitis - Recurrent
    • Eczema - Perifollicular accentuation
    • Facial pallor or erythema
    • Food intolerance
    • Hand dermatitis - Nonallergic
    • Ichthyosis
    • IgE - Elevated
    • Immediate (type I) skin test reactivity
    • Infections (cutaneous)
    • Dennie-Morgan infraorbital fold
    • Itching when sweating
    • Keratoconus
    • Keratosis pilaris
    • Nipple dermatitis
    • Orbital darkening
    • Palmar hyperlinearity
    • Pityriasis alba
    • White dermographism
    • Wool intolerance
    • Xerosis



Causes

Atopic  dermatitis is a complex genetic disease that results from an  
array of  gene-gene and gene-environment interactions. Most experts  
believe that  atopic dermatitis has a genetic basis. This is supported  
by twin studies  and chromosome studies that suggest the trait might be
inherited via a  maternal gene located on chromosome 11. Clinical  
studies have also shown  a higher risk of atopy in children with  
maternal atopy than in children  with paternal atopy.5

Two  theories have been proposed to explain the manifestations of atopic
  dermatitis. Atopic dermatitis was traditionally thought to be caused
by  an innate immunologic disturbance leading to IgE sensitization,  
which  later results in disruption of the epithelial barrier, though  
this  supposed mechanism is falling out of favor. Alternatively, it is  
thought  that skin breakdown precedes the inflammatory process and an  
intrinsic  epithelial cell defect leads to barrier disruption of the  
skin and that  immunologic imbalance is an "epiphenomenon".1 Genetic  
defects in filaggrin, a group of structural proteins, have been cited as
 a major cause of atopic dermatitis.6,7 The upregulation of a protease
stratum corneum chymotryptic enzyme is also being investigated in the  
cause of atopic dermatitis.

Chronic  eczema is a disease that is somewhat behaviorally mediated.  
Skin  thickening and plaque formation is dependent on habitual  
scratching.
==============================

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======================
Related Topics:
A Practical Manual Handbook of Dermatology Free Download
Cosmetic Dermatology: Principles and Practice Free Download
Radiation Therapy for Skin Cancer Free Download
Color Atlas of Chemical Peels Free Download
The Manual of Dermatology Free Download
Dermatology in Clinical Practice Free Download
Hair and Scalp Diseases Free Download

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Workup

 Laboratory Studies

Laboratory testing, including IgE levels, is not necessary or recommended in the evaluation of suspected atopic dermatitis.
Procedures



  • Pathologic  findings of biopsy samples include spongiosis with a
    severely damaged  stratum corneum, with hyperproliferation in advanced
    cases.
  • Histological  studies show an inflammatory infiltrate consisting of
    memory  predominantly CD4 T lymphocytes. Chronic lesions also display
    increased  mast cells, eosinophils, and IgE-bearing Langerhans cells.

Treatment

 Emergency Department Care

Many  patients with atopic dermatitis (AD) present to the ED during
acute  exacerbation. Therapy is targeted toward alleviation of pruritus
and  prevention of scratching. ED physicians must also look for signs
and  symptoms of bacterial superinfection and treat accordingly.

Practice guidelines on the management of atopic dermatitis are available from the Joint Task Force on Practice Parameters for Allergy and Immunology.8



  • Skin care

    • In  the acute setting patients should be
      instructed to bathe once-to-twice  daily using mild soaps (eg, Dove).
      There is no preference over showers  or baths, whichever makes the
      patient most comfortable.
    • The  patient should dry quickly and immediately (within 3 min)
      lubricate the  skin. Many creams and lotions are available, and the
      optimal one is the  greasiest the patient can tolerate.
    • Creams (eg, Eucerin,  Cetaphil) are preferred over lotions, as they
      have lower or no water  content and will not evaporate off of the skin
      during the day. Parents  may use petroleum jelly on infants, but most
      children and adults will  not tolerate the texture.

    </li>
  • Topical steroids

    • Acute  attacks should be treated by mid-high
      strength topical steroids for up  to 2 weeks. Medium-to-high potency
      topical steroids should not be used  on the face or neck area because of
      the potential adverse effects. These  are preferred over low-mid
      strength medications, as they better control  exacerbations. Patients
      should apply the ointment within 5 minutes of  twice-daily bathing.
    • Inform the patient about adverse effects of  topical steroids (eg,
      atrophy, hypopigmentation, striae,  telangiectasia, thinning of the
      skin).

    </li>
  • Antihistamines:  Physicians have been prescribing antihistamines for
    years to control  the pruritus associated with acute atopic dermatitis.
    Little evidence  exists that antihistamines help with the itching in an
    awake patient;  however, the use of sedating antihistamines is
    supported to control  scratching while the patient is asleep.9
  • Systemic  steroids: The use of systemic steroids in the treatment of
    acute  exacerbation of atopic dermatitis is controversial. Most authors
    reserve  oral prednisone (at least 20 mg/d for 7 d) for the most severe
    cases,  although it seems the disease quickly relapses once the
    medication is  discontinued. Patients also tend to discontinue topical
    steroid creams  and other treatment as they feel better, which
    contributes to the  relapse after oral steroids are done.
  • Topical calcineurin  inhibitors: Topical calcineurin inhibitors
    (pimecrolimus 1% and  tacrolimus 0.03%, 0.1%) are available for patients
    older than 2 years.  These medications may be used all over skin
    surfaces (including face,  neck, and hairline) because they do not have
    the side effects seen with  topical steroids. Evidence supports the
    twice-daily use of these creams  during acute exacerbation of atopic
    dermatitis, and some evidence exists  to support use up to 4 years. The
    long-term side effects (including the  possibility of increased risk for
    malignancy) have not fully been  elucidated. For these reasons, the US
    Food and Drug Administration (FDA)  does not recommend long-term use
    yet. Side effects of tacrolimus  include burning and stinging on broken
    skin.
  • Oral  immunosuppressive agents: Patients with refractory atopic
    dermatitis may  benefit from oral immunosuppressive agents, such as
    cyclosporine A.  This medication is effective in treating severe atopic
    dermatitis in the  acute setting. It is not recommended for long-term
    use.
  • Phototherapy  with PUVA, UVA, or UVB is successful in controlling
    atopic dermatitis  but is expensive and may lead to increased risk of
    melanoma and  nonmelanoma skin cancer. Studies evaluating the role of
    several proposed  disease-modifying agents continue to be conducted.
    Results of studies  on IL-4 neutralizing antibody and mast cell
    depleters are promising,  whereas the evidence for probiotics,10,11
    primrose oil, sodium cromolyn, topical caffeine, and dietary exclusion
    is inconclusive and requires more research.

Consultations

In  cases of uncertain diagnosis or severe atopic dermatitis that is  
resistant to conventional therapy, patients may be referred to a  
specialist such as a dermatologist or an allergist


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Follow-up

Further Inpatient Care

  • Few patients with atopic dermatitis will require hospitalization. Patients with cellulitis or severe secondary infection may require intravenous antibiotics and sedation.
Further Outpatient Care



  • Atopic dermatitis is chronic and relapsing. The main goal of
    treatment is control of the disease, not a cure. Patient education
    about management of flare and recognition of superinfection is
    paramount.
Inpatient & Outpatient Medications

  • Few patients with atopic dermatitis will require
    hospitalization. Patients with cellulitis or severe secondary infection
    may require intravenous antibiotics and sedation.
Deterrence/Prevention

  • Breastfeeding has indisputable benefits in infant nutrition,
    but no strong evidence suggests a protective effect against the
    development of atopic dermatitis, even in children with a family
    positive history.12
  • The mainstay of treatment of atopic dermatitis is prevention of
    outbreaks. Patients should continue to take short showers/baths
    followed by immediate hydration of skin with emollients even during
    rash-free times. They should also continue to avoid any triggers that
    may exacerbate atopic dermatitis.
Complications

  • Excoriations secondary to itch predispose to infection and can
    be recognized by the accumulation of serum, crust, and purulent
    material. Development of vesicle and/or pustules in patients with known
    atopic dermatitis should initiate a search for bacterial or viral
    superinfection; appropriate antibiotics or antivirals should be started
    immediately. Patients with atopic dermatitis are uniquely susceptible
    to herpes simplex, which may occasionally progress to a Kaposi’s varicelliform eruption;
    physicians and patients should be particularly vigilant for this
    condition. This rare complication is characterized by generalized
    involvement, systemic toxicity, and even death. In these cases, the
    patient should be treated with oral acyclovir and monitored closely.
    Topical corticosteroids and/or occlusive dressings are best, at least
    temporarily, discontinued.
  • Exfoliative erythroderma
    is another rare complication, occurring in less than 1% of patients
    with atopic dermatitis. Exfoliative erythroderma demonstrates a marked
    progression caused by widespread Staphylococcus aureus or herpes simplex superinfection and can be life threatening if it is complicated by high-output cardiac failure and heat loss.
  • Atrophy or striae occur if fluorinated corticosteroids are used on the face or in skin folds.
  • Systemic absorption of steroids may occur if large areas of skin
    are treated, particularly if high-potency medications and occlusion are
    combined.
Prognosis

  • About 90% of patients with atopic dermatitis have spontaneous resolution by puberty.
  • Adults who continue to have atopic dermatitis usually have localized dermatitis (eg, chronic hand or foot dermatitis, eyelid dermatitis, lichen simplex chronicus).
  • Unfavorable prognostic factors for atopic dermatitis (in order of relative importance) include the following:

    • Persistent dry or itchy skin in adult life
    • Widespread dermatitis in childhood
    • Family history of atopic dermatitis
    • Associated bronchial asthma
    • Early age at onset
    • Female gender
    </li>
  • The objective when treating a patient for atopic dermatitis is
    control of exacerbations, not elimination of the disease. Using the
    above treatment modalities, patients and their families can hope to
    minimize the frequency and severity of outbreaks.
Patient Education

Given the chronic nature of atopic dermatitis and patients'
concerns about appearance, emotional support and psychological
counseling may be helpful. Physicians need to be sensitive to the needs
of patients and their families

Related Subject
Rook's Textbook of Dermatology - 2010 Edition
MCQ Dermatology
Genital Dermatology Atlas 2010
Atopic Dermatitis in Emergency Medicine

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Multimedia

(Enlarge Image)
Media file 1: Typical atopic dermatitis on the face of an     infant.[ CLOSE WINDOW ]<blockquote></blockquote>Typical atopic dermatitis on the face of an     infant.



(Enlarge Image)
Media file 2: Flexural involvement in childhood atopic     dermatitis.[ CLOSE WINDOW ]<blockquote></blockquote>Flexural involvement in childhood atopic     dermatitis.



(Enlarge Image)
Media file 3: Ir



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