II. Epidemiology

  1. Inherited sensitive skin (Atopic Patient)
  2. Incidence
    1. Affects 11% of children in U.S
    2. Affects 17.8 Million people in U.S.
    3. Most cases go undiagnosed
  3. Onset
    1. Typically presents with first 2 years of life (most often within first 6 months)
    2. Diagnosed in first 5 years in 90% of patients
    3. Many cases remit by age 3-5 years

III. Pathophysiology

  1. Disrupted Epidermis due to underlying filaggrin protein defect
  2. Allows for Dermis immune cell exposure to environmental antigens
    1. IgE Antibody response
    2. Increased T-helper 2 subtype activity
    3. Antigen-specific T-Cells secrete IgE binding factors
  3. Leads to inflammatory response
    1. Intense itching ensues due to a low itch threshold to provocative factors
    2. Scratching leads to further inflammation, resulting in a spiraling itch-scratch cycle

IV. Types

  1. Acute Atopic Dermatitis
    1. Weeping, crusting lesions with overlying Vesicles
  2. Subacute Atopic Dermatitis
    1. Dry, Scaling, erythematous Papules and Plaques or
    2. Pityriasis alba
  3. Chronic Atopic Dermatitis
    1. Lichenification (e.g. Lichen Simplex Chronicus)

V. Associated Conditions: Atopic Triad (Family History)

  1. Eczematous Dermatitis (Atopic Dermatitis)
  2. Allergic Rhinitis
  3. Asthma
    1. Lifetime asthma Prevalence in patients with Atopic Dermatitis: 30%

VI. Provocative Factors

  1. Sweating
  2. Bacterial colonization
  3. Rough clothing
  4. Chemical irritants
  5. Emotional Stress
  6. Foods
    1. Cow's milk
    2. Wheat
    3. Eggs
    4. Soy
    5. Peanut and tree nuts
    6. Fish
  7. Environment
    1. Dust or mold
    2. Cat dander
    3. Temperature changes
    4. Low humidity

VII. Symptoms: Pruritus

  1. Described as "The itch that rashes" (when scratched)

VIII. Signs: Infants and young children

  1. Dermatitis characteristics
    1. Erythema and Edema
    2. Exudate
    3. Crusting
    4. Scaling
  2. Dermatitis Location
    1. Face (especially cheeks)
    2. Scalp
    3. Trunk
    4. Extensor surface of arms and legs

IX. Signs: Older children and adults

  1. Dermatitis characteristics
    1. Similar Eczematous skin changes as with infants
    2. "Hot and sweaty fossa and folds"
  2. Dermatitis Location
    1. Flexor wrists and ankles
    2. Antecubital fossa
    3. Popliteal fossa
    4. Hands
    5. Upper Eyelid Inflammation (erythema, fine scale and lichenification)
    6. Anogenital area

X. Diagnosis

  1. Pruritus (Required) and
  2. Additional Criteria (3 or more of the following)
    1. Asthma or Allergic Rhinitis history
    2. Flexor fold involvement
    3. Flexor fold dermatitis visible on exam
    4. Generalized Dry Skin
    5. Onset of rash before age 2 years
  3. Efficacy
    1. Test Sensitivity: 95%
    2. Test Specificity: 97%
  4. References
    1. Brenninkmeijer (2008) Br J Dermatol 158(4): 754-65 [PubMed]

XI. Differential Diagnosis: Varied Atopic Dermatitis presentations present a broad differential

XII. Complications (associated with intense scratching)

  1. Secondary infection
    1. Impetigo
    2. Cellulitis
    3. Eczema herpeticum (Kaposi varicelliform eruption)
      1. Painful papulovesicular rash spread over localized skin region
      2. Skin infected by Herpes Simplex Virus infection
  2. Direct scratching complications
    1. Lichen Simplex Chronicus
    2. Prurigo nodularis

XIII. Management: Dermatology referral indications

  1. Diagnosis uncertain
  2. Pruritus and other symptoms refractory to treatment (especially if impacting sleep, school or work attendance)
  3. Facial Eczematous Dermatitis refractory to treatment
  4. Severe Atopic Dermatitis
  5. Frequent exacerbations of Eczematous Dermatitis
  6. Systemic medications required for maintenance or frequent exacerbations
  7. Allergic Contact Dermatitis (consider on face, Eyelids and hands)

XIV. Management: General Measures

  1. Chronic disease management
  2. Key primary measures
    1. See Pruritus Management
    2. See Dry Skin Management
      1. Includes Frequent skin Emollient use is paramount
    3. Allergan avoidance (limit to products free of perfume and clear of dye)
    4. Eliminate Environmental Allergens
  3. Infection Control
    1. Keep Fingernails short and clean
    2. Staphylococcus aureus colonization in 90% of Eczema
    3. Treat superinfection (Impetigo) as needed
    4. Consider intranasal Bactroban to reduce seeding
  4. Feeding Changes (Very controversial)
    1. Common antigens related to Eczema
      1. Milk, Soy, Egg, Peanut, Wheat
    2. Uncertain whether diet changes improve Eczema
    3. Consider eliminating for 1 month above antigens
      1. Consider starting with cow's milk elimination
      2. Consider Soy-based formula if persists
      3. Consider formal Allergy Testing

XV. Management: Topical Steroid for exacerbation

  1. Consider alternative agents (e.g. Tacrolimus Ointment)
  2. General
    1. Limited use only for exacerbations
    2. Avoid Under-treatment
    3. Consider applying only at night
    4. Start early for exacerbations
    5. Treat all palpable areas
    6. Ointments are preferred
      1. Better tolerated (less burning)
      2. Allergic Reaction to ointment base less common
      3. Helps moisten very Dry Skin
  3. Mild exacerbation
    1. Use for 3-4 days only
    2. Low potency Topical Steroid (e.g. Hydrocortisone 1%)
  4. Moderate exacerbation
    1. Taper over 2 weeks
      1. Use twice daily for 7 days, then
      2. Use once daily for 7 days
    2. For Face and Groin
      1. Limit to Level 5 Topical Corticosteroid or less
      2. Hydrocortisone (0.5%, 1%, 2.5%)
    3. For Eyelid
      1. Tridesilon 0.05% or Aclovate 0.05% ointment or cream applied twice daily for 5-10 days
      2. Consider Tacrolimus 0.1% ointment or Pimecrolimus 1% cream for refractory cases
        1. Risk of malignancy with longterm use (see below)
    4. For body
      1. Hydrocortisone valerate 0.2% (Westcort)
      2. Triamcinolone 0.1% (Kenalog)
  5. Severe exacerbation
    1. High Potency Topical Steroids (e.g. Fluticasone)
    2. Try to avoid Systemic Corticosteroids
    3. Consider maintenance Topical Steroid
      1. Low potency Topical Steroid daily or
      2. High potency steroid (eg. Fluticasone) twice weekly
        1. Berth-Jones (2003) BMJ 326:1367-70 [PubMed]
  6. Other Anti-inflammatory agents
    1. Hydroxyquinolone
    2. Tar Preparations

XVI. Management: Refractory to above therapies

  1. Anti-infective agents
    1. Indication: Impetigo type superinfection
    2. Staphylococcus aureus coverage
      1. Augmentin
      2. Cephalexin (Keflex)
      3. Erythromycin
      4. Dicloxacillin
    3. Herpes Simplex Virus (HSV) coverage if suspected (see Eczema herpeticum under complications)
      1. Acyclovir
      2. Famciclovir
      3. Valacyclovir
  2. Systemic Corticosteroids
    1. Indicated
      1. Severe Eczema exacerbations
      2. Refractory to high potency Topical Steroid
    2. Precautions
      1. Limit use to 1-2 weeks
      2. Works too well (Derails Topical Steroid treatment)
  3. Miscellaneous agents
    1. Ultraviolet Phototherapy
      1. Indicated in widespread refractory Atopic Dermatitis
    2. Accolate 20 mg PO bid
  4. Immunosuppressant (Topical and systemic agents)
    1. Calcineurin Inhibitors (topical)
      1. Highly effective agents
      2. Risk of skin malignancy or Lymphoma with prolonged use (FDA black box warning)
      3. Tacrolimus Ointment (Protopic)
        1. Tacrolimus 1% is approved for adults only, and is as effective as potent Topical Corticosteroids
        2. Tacrolimus 0.03% is approved for age 2 years old and older
      4. Pimecrolimus Cream (Elidel)
        1. Weaker, but may be better tolerated than the Tacrolimus Ointment
        2. Pimecrolimus 1% cream is approved for age 2 years and older
    2. Crisaborole Ointment (Eucrisa)
      1. Phosphodiesterase 4 Inhibitor
      2. Adjunct to moderate Eczema refractory to Corticosteroids for age >2 years old
      3. Apply in thin layer twice daily
      4. Paller (2016) J Am Acad Dermatol 75(3):494-503 +PMID: 27417017 [PubMed]
    3. Other agents
      1. Methotrexate
      2. Cyclosporine (Sandimmune)
      3. Azathioprine (Imuran)

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Ontology: Dermatitis, Atopic (C0011615)

Definition (MSH) A chronic inflammatory genetically determined disease of the skin marked by increased ability to form reagin (IgE), with increased susceptibility to allergic rhinitis and asthma, and hereditary disposition to a lowered threshold for pruritus. It is manifested by lichenification, excoriation, and crusting, mainly on the flexural surfaces of the elbow and knee. In infants it is known as infantile eczema.
Definition (CSP) chronic inflammatory skin disorder in individuals with a hereditary predisposition to a lowered threshold to pruritus; characterized by extreme itching, leading to scratching and rubbing that result in typical lesions of eczema.
Concepts Disease or Syndrome (T047)
MSH D003876
ICD10 L20 , L20.9, L20.81
SnomedCT 200772001, 200779005, 156331003, 311411000009101, 24079001, 200775004
English Atopic Dermatitides, Atopic Eczema, Atopic Neurodermatitides, Atopic Neurodermatitis, Dermatitides, Atopic, Disseminated Neurodermatitides, Disseminated Neurodermatitis, Eczema, Atopic, Neurodermatitides, Atopic, Neurodermatitides, Disseminated, Neurodermatitis, Atopic, Neurodermatitis, Disseminated, DERMATITIS ALLERGIC, DERMATITIS ATOPIC, Dermatitis allergic, ECZEMA ALLERGIC, ECZEMA ATOPIC, Eczema allergic, Atopic dermatitis NOS, Atopic dermatitis, unspecified, allergic eczema, ECZEMA, ATOPIC, ATOD, DERMATITIS, ATOPIC, atopic eczematous dermatitis (diagnosis), neurodermatitis atopic, atopic neurodermatitis, atopic eczematous dermatitis, atopic neurodermatitis (diagnosis), Dermatitis atopic, Eczema atopic, Dermatitis, Atopic, Dermatitis, Atopic [Disease/Finding], atopic dermatitis, Dermatitis;allergic, Dermatitis;atopic, Eczema;atopic, besnier's prurigo, Atopic Dermatitis, Allergic (intrinsic) eczema (disorder), Atopic dermatitis NOS (disorder), Allergic dermatitis (disorder), Allergic eczema, Atopic dermatitis, Allergic dermatitis, Atopic eczema, Atopic neurodermatitis, Disseminated neurodermatitis, AD - Atopic dermatitis, Atopic dermatitis (disorder), Atopic neurodermatitis (disorder), atopic; eczema, atopic; neurodermatitis, dermatitis; allergic, dermatitis; allergy, disseminated; neurodermatitis, eczema; allergic, eczema; allergy, eczema; atopic, neurodermatitis; atopic, neurodermatitis; disseminated, allergic; dermatitis, allergic; eczema, allergy; dermatitis, allergy; eczema, Atopic dermatitis, NOS, Canine atopy, Eczema, atopic, Neurodermatitis, atopic, Eczema, allergic, atopic eczema, allergic dermatitis
Portuguese DERMATITE ATOPICA, ECZEMA ATOPICO, Eczema alérgico, Eczema atópico, DERMATITE ALERGICA, ECZEMA ALERGICO, Dermatite alérgica, Dermatite atópica, Dermatite Atópica, Eczema Atópico, Neurodermite Atópica, Neurodermite Disseminada
Spanish DERMATITIS ATOPICA, ECCEMA ATOPICO, Eczema alérgico, Eczema atópico, DERMATITIS ALERGICA, ECCEMA ALERGICO, dermatitis atópica, SAI (trastorno), dermatitis atópica, SAI, dermatitis alérgica, dermatitis atópica (trastorno), dermatitis atópica, eccema alérgico, eccema atópico, eczema alérgico, eczema atópico, neurodermatitis atópica (trastorno), neurodermatitis atópica, neurodermatitis diseminada, Dermatitis alérgica, Dermatitis atópica, Dermatitis Atópica, Eccema Atópico, Neurodermatitis Atópica, Neurodermatitis Diseminada
Italian Dermatite allergica, Eczema allergico, Neurodermatite atopica, Eczema atopico, Neurodermatite diffusa, Dermatite atopica
Dutch eczeem allergisch, allergische dermatitis, eczeem atopisch, allergisch eczeem, atopisch eczeem, allergie; dermatitis, allergie; eczeem, allergisch; dermatitis, allergisch; eczeem, atopisch; eczeem, atopisch; neurodermatitis, dermatitis; allergie, dermatitis; allergisch, eczeem; allergie, eczeem; allergisch, eczeem; atopisch, gedissemineerd; neurodermatitis, neurodermatitis; atopisch, neurodermatitis; gedissemineerd, Atopisch eczeem, niet gespecificeerd, atopische dermatitis, dermatitis allergisch, Atopisch eczeem, Constitutioneel eczeem, Atopische dermatitis, Dermatitis, atopische, Eczeem, atopisch, Eczeem, constitutioneel, Neurodermatitis, atopische, Neurodermatitis, gedissemineerde
French Eczéma allergique, Dermite allergique, Dermite atopique, DERMITE ALLERGIQUE, DERMITE ATOPIQUE, ECZEMA ALLERGIQUE, ECZEMA ATOPIQUE, Eczéma atopique, Eczéma constitutionnel, Dermatite allergique, Dermatite atopique
German Ekzem atopisch, atopisches Ekzem, Ekzem allergisch, atopische Dermatitis, allergisches Ekzem, allergische Dermatitis, Atopisches [endogenes] Ekzem, nicht naeher bezeichnet, Atopisches [endogenes] Ekzem, DERMATITIS ALLERGISCH, DERMATITIS ATOPISCH, EKZEM ALLERGISCH, EKZEM ATOPISCH, Dermatitis allergisch, Dermetitis atopisch, Dermatitis, atopische, Ekzem, atopisches, Neurodermatitis, atopische, Neurodermatitis, disseminierte
Japanese アレルギー性皮膚炎, アレルギー性湿疹, アレルギーセイシッシン, アトピーセイヒフエン, アレルギーセイヒフエン, アトピーセイシッシン, アトピー性湿疹, アトピー性神経皮膚炎, 神経皮膚炎-アトピー性, 神経皮膚炎-汎発性, 内因性湿疹, 痒疹-Besnier, 痒疹-ベニエー, アトピー性皮膚炎, ベニエー痒疹, 播種性神経皮膚炎, 汎発性神経皮膚炎, 湿疹-アトピー性, アトピー皮膚炎, 小児湿疹, 皮膚炎-汎発性神経, 湿疹-小児, Besnier痒疹, 皮膚炎-アトピー性
Swedish Hudinflammation, atopisk
Czech ekzém atopický, Alergický ekzém, Atopická dermatitida, Alergická dermatitida, Atopický ekzém, atopický ekzém, atopická dermatitida, atopická neurodermatitida, dermatitida atopická
Finnish Atooppinen ihottuma
Russian DERMATIT ATOPICHESKII, EKZEMA DETSKAIA, NEIRODERMIT ATOPICHESKII, NEIRODERMIT DIFFUZNYI, EKZEMA ATOPICHESKAIA, NEIRODERMIT KONSTITUTSIONAL'NYI, BENVE-BROKA SINDROM, БЕНВЕ-БРОКА СИНДРОМ, ДЕРМАТИТ АТОПИЧЕСКИЙ, НЕЙРОДЕРМИТ АТОПИЧЕСКИЙ, НЕЙРОДЕРМИТ ДИФФУЗНЫЙ, НЕЙРОДЕРМИТ КОНСТИТУЦИОНАЛЬНЫЙ, ЭКЗЕМА АТОПИЧЕСКАЯ, ЭКЗЕМА ДЕТСКАЯ
Korean 아토피 피부염, 상세불명의 아토피 피부염
Polish Zapalenie skóry atopowe, Atopowe zapalenie skóry, AZS
Hungarian Allergiás dermatitis, Eczema allergiás, Allergiás bőrgyulladás, Atopiás dermatitis, Allergiás ekzema, Atópiás dermatitisz, Atopiás ekcéma, Eczema atopiás
Croatian DERMATITIS, ATOPIČNI, DERMATITIS, ATOPIJSKI, ATOPIJSKI DERMATITIS, NEURODERMITIS
Norwegian Atopisk eksem, Atopisk nevrodermatitt, Disseminert nevrodermatitt, Atopisk dermatitt

Ontology: Eczema (C0013595)

Definition (CHV) a type of skin inflammation
Definition (CHV) a type of skin inflammation
Definition (CHV) a type of skin inflammation
Definition (CHV) a type of skin inflammation
Definition (CHV) a type of skin inflammation
Definition (CHV) a type of skin inflammation
Definition (MEDLINEPLUS)

Eczema is a term for several different types of skin swelling. Eczema is also called dermatitis. It is not dangerous, but most types cause red, swollen and itchy skin. Factors that can cause eczema include other diseases, irritating substances, allergies and your genetic makeup. Eczema is not contagious.

The most common type of eczema is atopic dermatitis. It is an allergic condition that makes your skin dry and itchy. It is most common in babies and children.

Eczema is a chronic disease. You can prevent some types of eczema by avoiding irritants, stress, and the things you are allergic to.

Definition (NCI) A form of dermatitis characterized by red, itchy, scaly, or crusty patches that can be chronic or intermittent.(NICHD)
Definition (NCI_NCI-GLOSS) A group of conditions in which the skin becomes inflamed, forms blisters, and becomes crusty, thick, and scaly. Eczema causes burning and itching, and may occur over a long period of time. Atopic dermatitis is the most common type of eczema.
Definition (CSP) pruritic papulovesicular dermatitis occurring as a reaction to many endogenous and exogenous agents.
Definition (MSH) A pruritic papulovesicular dermatitis occurring as a reaction to many endogenous and exogenous agents (Dorland, 27th ed).
Concepts Disease or Syndrome (T047)
MSH D004485
ICD10 L30.9
SnomedCT 156358005, 200885007, 267797006, 156326000, 238538009, 267847004, 43116000, 281104002
English Dermatitis, Eczematous, Eczematous Dermatitides, Eczema, Eczemas, Dermatitides, Eczematous, DERMATITIS ECZEMATOID, ECZEMA, Eczema NOS, Eczematoid dermatitis, eczematous dermatitis, eczema, eczema (diagnosis), eczematoid dermatitis (diagnosis), eczematoid dermatitis, Dermatitis eczematoid, Eczematous dermatitis, Eczematous rash, Eczema [Disease/Finding], eczema nos, eczemas, eczematous rash, Eczema: [discoid] or [NOS], Eczema: [discoid] or [NOS] (disorder), Eczema NOS (disorder), Eczematous Dermatitis, Atopic Dermatitis, Unclassifiable eczema, Eczema (disorder), Unclassifiable eczema (disorder), dermatitis; eczematous, eczematous; dermatitis, Eczema, NOS, Eczematous dermatitis, NOS, Eczema [Ambiguous] (disorder)
French ECZEMA, Dermite eczémateuse, Rash eczémateux, Dermatite eczématoïde, Eczéma SAI, DERMITE ECZEMATIFORME, Eczéma, Dermatite eczémateuse
Portuguese ECZEMA, DERMATITE ECZEMATOSA, Erupção eczematosa, Eczema NE, Dermatite eczematosa, Dermatite eczematóide, Eczema, Dermatite Eczematosa
German EKZEM, Ekzem NNB, Dermatitis, ekzematoid, ekzematoese Dermatitis, ekzematoeseer Ausschlag, DERMATITIS EKZEMATOID, Dermatitis eczematosa, Ekzem
Spanish ECCEMA, Dermatitis eczematosa, Eczema NEOM, Erupción eczematosa, DERMATITIS ECCEMATOIDE, eccema, SAI, eccema, SAI (trastorno), Dermatitis Eczematosa, Eczema, dermatitis eccematosa, dermatitis eczematosa, eccema (trastorno), eccema no clasificable (trastorno), eccema no clasificable, eccema, eczema, Dermatitis Eccematosa, Eccema
Dutch eczemateuze rash, eczematoïde dermatitis, eczeem NAO, eczemateuze dermatitis, dermatitis; eczemateus, eczemateus; dermatitis, eczeem, Dermatitis eczematosa, Eczeem
Italian Dermatite eczematoide, Eczema NAS, Eruzione eczematosa, Dermatite eczematosa, Eczema
Japanese 湿疹性皮疹, 湿疹NOS, シッシン, シッシンNOS, シッシンヨウヒフエン, シッシンセイヒフエン, シッシンセイヒシン, 湿疹, しっしん, 湿疹性皮膚炎, 湿疹様皮膚炎, 皮膚炎-湿疹性
Swedish Eksem
Czech ekzém, Ekzém NOS, Ekzémová dermatitida, Ekzematoidní dermatitida, Výsev ekzému, Ekzém, lišej
Finnish Ekseema
Russian EKZEMA, DERMATIT EKZEMATOZNYI, ДЕРМАТИТ ЭКЗЕМАТОЗНЫЙ, ЭКЗЕМА
Croatian EGZEM
Polish Wyprysk, Egzema
Hungarian Ekzemás kiütés, Eczema k.m.n., Dermatitis eczematoid, Ekcéma, Ekzemás dermatitis
Norwegian Eksem