Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at NSU
An 18-month old Caucasian boy is seen for a follow-up of atopic dermatitis and allergic rhinitis. He was last seen at the clinic 3 months ago and at that time his mother described his symptoms as "8" - the lesions were affecting his face, elbows, the areas behind the ears and knees, and the pubis. He was prescribed Elidel (pimecrolimus) and hydrocortisone 1% for the face BID, and Elidel and triamcinolone 0.1% (Kenalog) for the body BID. The symptoms improved significantly and the mother downshifted local therapy to triamcinolone 0.1% daily a month ago. She also stopped Singulair. Two weeks ago, the skin lesions re-occurred, including new ones on the face and back.
Past medical history (PMH)
Atopic dermatitis, allergic rhinitis.
Medications
Triamcinolone 0.1% for face and body daily, Zyrtec PRN.
Family medical history (FMH)
Mother and sister with allergic rhinitis and atopic dermatitis.
Physical examination
Vital signs: stable (VSS).
Skin: erythematous scaly rash with scratch marks around mouth, behind ears, back of the neck, abdomen, elbows, behind knees, buttocks and penile area.
The rest of the examination is normal.
What is the most likely diagnosis?
An exacerbation of atopic dermatitis ("an itch that rashes"). The physical examination and history was not suggestive of scabies. Some limited skin areas looked suspicious of early superimposed bacterial infection.
What would you do?
The mother was advised to accelerate topic therapy to:
1. Elidel (pimecrolimus) and hydrocortisone 1% for the face BID for 2 weeks. If better, then Elidel (pimecrolimus) and hydrocortisone 1% daily for 1-2 months. If better, then hydrocortisone 1% daily for maintenance until next visit.
2. Elidel and triamcinolone 0.1% for the body BID. for the face BID for 2 weeks. If better, then Elidel (pimecrolimus) and triamcinolone 0.1% daily for 1-2 months. If better, then triamcinolone 0.1% daily for maintenance until next visit.
Keflex was prescribed for 7 days.
The mother was advised on use of skin moisturizers (Eucerin, Aquaphor) on the skin and in the bathtub.
Final diagnosis
Exacerbation of atopic dermatitis.
What did we learn from this case?
One approach to topical treatment of atopic dermatitis exacerbation is:
1. Elidel (pimecrolimus) and hydrocortisone 1% for the face BID for 2 weeks. If better, then Elidel (pimecrolimus) and hydrocortisone 1% daily for 1-2 months. If better, then hydrocortisone 1% daily for maintenance until next visit.
2. Elidel and triamcinolone 0.1% for the body BID. for the face BID for 2 weeks. If better, then Elidel (pimecrolimus) and triamcinolone 0.1% daily for 1-2 months. If better, then triamcinolone 0.1% daily for maintenance until next visit.
The lowest maintenance dose in this regimen is a daily steroid cream.
Topical Treatment of Atopic Dermatitis.
Diagram:
Face
1% HC + E 2/day for 2 weeks
then
1% HC 2/day for 1-2 months
then
1% HC daily for 2 months
Body
0.1% TAC + E 2/day for 2 weeks
then
0.1% TAC 2/day for 1-2 months
then
0.1% TAC daily for 2 months
HC = hydrocortisone; TAC = triamcinolone; E = Eladil. In the diagram above, Eladil is the "rescue" medication and HC/TAC are the maintenance therapy.
Atopic Dermatitis Treatment - Illustrated (click here for full size image).
Barrier creams and emollients for AD include CeraVe (http://cerave.com), Mimyx, EpiCeram (http://epiceram-us.com), Eletone, Theraplex (http:/theraplex.com), Eucerin and Aquaphor.
What is the risk of developing asthma after atopic dermatitis?
Thirty percent.
What antigens should be included in skin prick testing in atopic dermatitis?
Most children developed atopic dermatitis by the age of 2. They have had enough time to develop pollen-related allergies by that time since they have been exposed to pollen only for 1-2 seasons. A "simplified" version of skin prick testing can be done with:
- Negative and positive control (1, 2)
- Indoor allergens (17-20): mites, dog, cat, cockroach
- Foods (21-25): cow milk, soy, eggs, wheat, peanut
Skin prick testing is done on the back which is usually spared from scratching in patients with atopic dermatitis. Those patients may have an exaggerated dermatographic response which should be tested by scratching the letter "A" with a spatula.
If the patient is allergic to any foods, a partial elimination diet can be beneficial.
The atopic dermatitis skin test panel includes indoor allergens and food allergens; no grass, tree or molds.
What treatment is used for scalp lesions in atopic dermatitis?
Capex® Shampoo (0.01% fluocinolone) every other day (QOD) for 2 weeks, then weekly until resolution of lesions.
References
Atopic Dermatitis: A Short Review. Allergy Cases.
What is the risk of developing asthma after atopic dermatitis? Allergy Notes, 2007.
Related articles
Sublingual Immunotherapy (SLIT) in Atopic Dermatitis
Rituximab improves atopic eczema in a small study
Treatment of Staphylococcus aureus Colonization in Atopic Dermatitis Decreases Disease Severity. Jennifer T. Huang et al. Pediatrics, Vol. 123 No. 5 May 2009, pp. e808-e814.
Atopic dermatitis (eczema) skin care: When should I use Aquaphor instead of Eucerin?
Figures:
Published: 07/12/2008
Updated: 05/16/2013
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