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Atopic Dermatitis

Updated : January 31, 2024





Background

Atopic dermatitis, also known as eczema, is a chronic skin condition that causes inflammation, redness, and itching. It is a common condition often seen in individuals with a personal or family history of allergies, such as asthma or hay fever. Atopic dermatitis can appear anywhere on the body but is most commonly found on the face, arms, and legs.

People with atopic dermatitis often have a deficiency in the skin’s natural barrier function, making their skin more susceptible to irritation and infection. Symptoms of atopic dermatitis can range from mild to severe and may include dry, itchy skin; red, inflamed patches of skin; and small bumps that may leak fluid and crust over.

Atopic dermatitis tends to appear in early childhood. It is more common in developed countries and is often accompanied by other allergic conditions, such as asthma and hay fever.

Epidemiology

Atopic dermatitis, also known as eczema, is a common condition that affects people of all ages and races. The global prevalence of atopic dermatitis varies by region and age group. According to the World Health Organization (WHO), the prevalence of atopic dermatitis in children is highest in developed countries and has been increasing in many parts of the world.

It is estimated that up to 20% of children in developed countries have atopic dermatitis, while the prevalence in developing countries is generally lower, ranging from 1% to 10%. In adults, the prevalence of atopic dermatitis is lower than in children, but it can still affect a significant portion of the population. The prevalence of atopic dermatitis in adults varies by region, but it is estimated to affect 2-10% of adults globally.

Anatomy

Pathophysiology

In atopic dermatitis, there is a deficiency in the skin’s natural barrier function, which can make the skin more susceptible to irritation and infection. The skin barrier is the outermost layer of the skin, known as the stratum corneum, which protects the body from external substances and environmental factors. The stratum corneum is made up of dead skin cells held together by a protein called keratin.

In individuals with atopic dermatitis, the stratum corneum is often impaired, leading to a deficiency in the skin’s natural barrier function. Various factors, including genetics, environmental triggers, and inflammation, can cause this deficiency. When the skin barrier is impaired, it becomes more permeable, allowing substances and irritants to enter the skin more easily. This can lead to dryness, itching, redness, inflammation, and an increased risk of infection.

Etiology

The exact etiology of AD is still unknown; however, genetic and environmental factors play an essential role. Genetic studies have identified several genes associated with AD, including filaggrin, FLG, ORMDL3, IL4, and CD14. Environmental factors such as allergens, irritants, and pollutants have also been linked to atopic dermatitis development.

Risk factors for AD include a family history of allergic diseases, living in an urban environment, and having a personal history of allergies. Staphylococcus and streptococcus skin infections are another risk factor for atopic dermatitis patients.

Genetics

Prognostic Factors

In general, many patients with atopic dermatitis get better over time. However, individuals may also have allergic rhinitis and asthma, which may worsen. The condition lasts for decades in the majority of instances of AD with childhood onset. Relapses and remissions of the disease are common, and medication is frequently required to prevent relapses.

Individuals exposed to tobacco, smoking, pet dander, pollen fumes, soap, wool, and detergent regularly may experience ongoing symptoms, and their general quality of life will be poor. In addition to having irritating, persistent, and recurrent itching, it is expensive to treat.

Clinical History

Clinical History

The symptoms vary significantly from person to person and may range from mild to severe. Common symptoms include dry, sensitive skin, itching, red, inflamed skin, papules, and plaques. The rash is usually found on the face, neck, and extremities, but it can also affect the trunk and other areas of the body. The severity can vary over time, with flare-ups occurring periodically.

Physical Examination

Physical Examination

The appearance of the skin lesions can vary depending on the age of the person with atopic dermatitis. In infants, the skin lesions may appear as edematous papules and plaques with vesicles or crusts on the scalp, face, and extensor extremities. Children with atopic dermatitis may have less exudative patches and plaques on the antecubital and popliteal fossae on the elbow and the back of the knee, respectively.

Adults with atopic dermatitis may have chronic thickened lesions that tend to affect the hands. Atopic dermatitis lesions may also be classified as acute (swollen, red papules and plaques with vesicles or crusts), subacute (red, scaly skin with variable crusting), or chronic (thick plaques and scaling).

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Differential Diagnoses

Allergic contact dermatitis

Dermatophytosis

Lichen planus

Lichen simplex

Psoriasis

Scabies

Seborrheic dermatitis

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Oral corticosteroids such as prednisone, methylprednisolone, and dexamethasone are effective in reducing inflammation and controlling other symptoms.

Topical corticosteroids are applied directly to the skin and can help to reduce inflammation. Hydrocortisone is a mild corticosteroid often used as a first-line treatment for mild atopic dermatitis. fluticasone is a medium-strength corticosteroid often used to treat moderate to severe atopic dermatitis. betamethasone, clobetasol, and triamcinolone are potent corticosteroids used to treat severe atopic dermatitis or when other treatments are ineffective.

Topical calcineurin inhibitors (TCIs) are medications used for mild to moderate cases of atopic dermatitis. They may be used as an alternative to corticosteroids. They work by inhibiting calcineurin, an enzyme that plays a role in the activation of immune cells, which can contribute to inflammation. There are two TCIs that are commonly used to treat atopic dermatitis. Tacrolimus and Pimecrolimus are often used to treat moderate to severe atopic dermatitis that does not respond to other treatments or in areas of the body where topical corticosteroids cannot be used.

Antihistamines used in treatment of atopic dermatitis are diphenyhydramine, cetirizine, hydroxyzine, loratadine.

Antibiotics are not typically used as a primary treatment for atopic dermatitis. However, they may be used in some instances to treat or prevent infections that can occur as a result of atopic dermatitis. Atopic dermatitis can cause the skin to become dry, cracked, and inflamed, making it more susceptible to infection. Bacteria, such as Staphylococcus aureus, and fungi, such as Candida, can sometimes infect the skin in people with atopic dermatitis. Antibiotics include penicillin, amoxicillin, cephalexin, cefadroxil, azithromycin, doxycycline, and minocycline.

Biologic agents

Monoclonal antibodies are proteins produced in a laboratory and designed to bind to specific targets on cells. Examples of monoclonal antibodies used in the treatment of atopic dermatitis include dupilumab and tralokinumab. Interleukin inhibitors help regulate the immune system.

Interleukin inhibitors, such as crisaborole, block the action of specific interleukins, which may help reduce inflammation and improve symptoms of atopic dermatitis. Janus kinase (JAK) inhibitors block the activity of specific enzymes involved in the inflammation process. Examples of JAK inhibitors used in the treatment of atopic dermatitis include tofacitinib and baricitinib.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Medication

 

abrocitinib 

100

mg

Tablet

Orally 

every day initially


can increase up to 200mg



diphenhydramine 

Off-label:

25 - 50

mg

Orally 

3-4 times a day


Do not exceed 300 mg per day



ruxolitnib topical 

Apply a thin coating of cream to affected regions of up to 20% body surface area twice a day; do not exceed >60 g/week or one 100-gram tube/2 weeks
After the signs and symptoms of atopic dermatitis (such as itching, rash, and redness) have subsided, discontinue the use



pimecrolimus topical 

Apply a tiny coating to the affected region every 12 hours, limiting the application to that area and continuing as long as the symptoms remain



tacrolimus topical 

Apply a slight coating to the affected region every 12 hours; stop therapy after the symptoms have subsided
If there is no improvement after six weeks, the diagnosis should be reconsidered



fluocinonide 

Apply a small layer topically to the afflicted regions each day



tacrolimus ointment 

0.1% or 0.03% ointment- apply every 12 hours
Cease therapy once indications have resolved
If no progress within a span of 6 weeks, reevaluate the diagnosis



rocatinlimab 

Pending for FDA approval for moderate-to-severe atopic dermatitis rocatinlimab has shown promising results in a Phase 2b clinical trial in terms of efficacy and safety for this specific indication.



 

diphenhydramine 

Age >12 years:

25 - 50

mg

Orally 

every 4-6 hours as required



ruxolitnib topical 

<12 years: Safety and efficacy not established
≥12 years: Apply a thin coating of cream to affected regions of up to 20% of body surface area twice a day; do not exceed >60 g/week or one 100-gram tube/2 weeks
After the signs and symptoms of atopic dermatitis (such as itching, rash, and redness) have subsided, discontinue use
Re-examine the patient if signs and symptoms do not improve after eight weeks



pimecrolimus topical 

<2 years: Safety and efficacy not established
>2 years: Apply a tiny coating to the afflicted region every 12 hours, limiting the application to that area, and continuing as long as the symptoms remain



tacrolimus topical 

<2 years: Not recommended
2-15 years: Apply 0.03% ointment in a thin layer to the affected area every 12 hours
>15 years: Apply 0.03% and 0.1% ointment in a thin layer to the affected area every 12 hours; stop therapy after the symptoms have subsided
If there is no improvement after six weeks, the diagnosis should be reconsidered



tacrolimus ointment 

Age 2-15 years- (0.03% ointment): apply every 12 hours
Age >15 years- apply 0.03% or 0.1% ointment every 12 hours to the affected area
cease medical intervention once symptoms have subsided
If there is no observable progress within a span of 6 weeks, reevaluate the initial diagnosis



 

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References

Atopic Dermatitis

Updated : January 31, 2024




Atopic dermatitis, also known as eczema, is a chronic skin condition that causes inflammation, redness, and itching. It is a common condition often seen in individuals with a personal or family history of allergies, such as asthma or hay fever. Atopic dermatitis can appear anywhere on the body but is most commonly found on the face, arms, and legs.

People with atopic dermatitis often have a deficiency in the skin’s natural barrier function, making their skin more susceptible to irritation and infection. Symptoms of atopic dermatitis can range from mild to severe and may include dry, itchy skin; red, inflamed patches of skin; and small bumps that may leak fluid and crust over.

Atopic dermatitis tends to appear in early childhood. It is more common in developed countries and is often accompanied by other allergic conditions, such as asthma and hay fever.

Atopic dermatitis, also known as eczema, is a common condition that affects people of all ages and races. The global prevalence of atopic dermatitis varies by region and age group. According to the World Health Organization (WHO), the prevalence of atopic dermatitis in children is highest in developed countries and has been increasing in many parts of the world.

It is estimated that up to 20% of children in developed countries have atopic dermatitis, while the prevalence in developing countries is generally lower, ranging from 1% to 10%. In adults, the prevalence of atopic dermatitis is lower than in children, but it can still affect a significant portion of the population. The prevalence of atopic dermatitis in adults varies by region, but it is estimated to affect 2-10% of adults globally.

In atopic dermatitis, there is a deficiency in the skin’s natural barrier function, which can make the skin more susceptible to irritation and infection. The skin barrier is the outermost layer of the skin, known as the stratum corneum, which protects the body from external substances and environmental factors. The stratum corneum is made up of dead skin cells held together by a protein called keratin.

In individuals with atopic dermatitis, the stratum corneum is often impaired, leading to a deficiency in the skin’s natural barrier function. Various factors, including genetics, environmental triggers, and inflammation, can cause this deficiency. When the skin barrier is impaired, it becomes more permeable, allowing substances and irritants to enter the skin more easily. This can lead to dryness, itching, redness, inflammation, and an increased risk of infection.

The exact etiology of AD is still unknown; however, genetic and environmental factors play an essential role. Genetic studies have identified several genes associated with AD, including filaggrin, FLG, ORMDL3, IL4, and CD14. Environmental factors such as allergens, irritants, and pollutants have also been linked to atopic dermatitis development.

Risk factors for AD include a family history of allergic diseases, living in an urban environment, and having a personal history of allergies. Staphylococcus and streptococcus skin infections are another risk factor for atopic dermatitis patients.

In general, many patients with atopic dermatitis get better over time. However, individuals may also have allergic rhinitis and asthma, which may worsen. The condition lasts for decades in the majority of instances of AD with childhood onset. Relapses and remissions of the disease are common, and medication is frequently required to prevent relapses.

Individuals exposed to tobacco, smoking, pet dander, pollen fumes, soap, wool, and detergent regularly may experience ongoing symptoms, and their general quality of life will be poor. In addition to having irritating, persistent, and recurrent itching, it is expensive to treat.

Clinical History

The symptoms vary significantly from person to person and may range from mild to severe. Common symptoms include dry, sensitive skin, itching, red, inflamed skin, papules, and plaques. The rash is usually found on the face, neck, and extremities, but it can also affect the trunk and other areas of the body. The severity can vary over time, with flare-ups occurring periodically.

Physical Examination

The appearance of the skin lesions can vary depending on the age of the person with atopic dermatitis. In infants, the skin lesions may appear as edematous papules and plaques with vesicles or crusts on the scalp, face, and extensor extremities. Children with atopic dermatitis may have less exudative patches and plaques on the antecubital and popliteal fossae on the elbow and the back of the knee, respectively.

Adults with atopic dermatitis may have chronic thickened lesions that tend to affect the hands. Atopic dermatitis lesions may also be classified as acute (swollen, red papules and plaques with vesicles or crusts), subacute (red, scaly skin with variable crusting), or chronic (thick plaques and scaling).

Differential Diagnoses

Allergic contact dermatitis

Dermatophytosis

Lichen planus

Lichen simplex

Psoriasis

Scabies

Seborrheic dermatitis

Oral corticosteroids such as prednisone, methylprednisolone, and dexamethasone are effective in reducing inflammation and controlling other symptoms.

Topical corticosteroids are applied directly to the skin and can help to reduce inflammation. Hydrocortisone is a mild corticosteroid often used as a first-line treatment for mild atopic dermatitis. fluticasone is a medium-strength corticosteroid often used to treat moderate to severe atopic dermatitis. betamethasone, clobetasol, and triamcinolone are potent corticosteroids used to treat severe atopic dermatitis or when other treatments are ineffective.

Topical calcineurin inhibitors (TCIs) are medications used for mild to moderate cases of atopic dermatitis. They may be used as an alternative to corticosteroids. They work by inhibiting calcineurin, an enzyme that plays a role in the activation of immune cells, which can contribute to inflammation. There are two TCIs that are commonly used to treat atopic dermatitis. Tacrolimus and Pimecrolimus are often used to treat moderate to severe atopic dermatitis that does not respond to other treatments or in areas of the body where topical corticosteroids cannot be used.

Antihistamines used in treatment of atopic dermatitis are diphenyhydramine, cetirizine, hydroxyzine, loratadine.

Antibiotics are not typically used as a primary treatment for atopic dermatitis. However, they may be used in some instances to treat or prevent infections that can occur as a result of atopic dermatitis. Atopic dermatitis can cause the skin to become dry, cracked, and inflamed, making it more susceptible to infection. Bacteria, such as Staphylococcus aureus, and fungi, such as Candida, can sometimes infect the skin in people with atopic dermatitis. Antibiotics include penicillin, amoxicillin, cephalexin, cefadroxil, azithromycin, doxycycline, and minocycline.

Biologic agents

Monoclonal antibodies are proteins produced in a laboratory and designed to bind to specific targets on cells. Examples of monoclonal antibodies used in the treatment of atopic dermatitis include dupilumab and tralokinumab. Interleukin inhibitors help regulate the immune system.

Interleukin inhibitors, such as crisaborole, block the action of specific interleukins, which may help reduce inflammation and improve symptoms of atopic dermatitis. Janus kinase (JAK) inhibitors block the activity of specific enzymes involved in the inflammation process. Examples of JAK inhibitors used in the treatment of atopic dermatitis include tofacitinib and baricitinib.

abrocitinib 

100

mg

Tablet

Orally 

every day initially


can increase up to 200mg



diphenhydramine 

Off-label:

25 - 50

mg

Orally 

3-4 times a day


Do not exceed 300 mg per day



ruxolitnib topical 

Apply a thin coating of cream to affected regions of up to 20% body surface area twice a day; do not exceed >60 g/week or one 100-gram tube/2 weeks
After the signs and symptoms of atopic dermatitis (such as itching, rash, and redness) have subsided, discontinue the use



pimecrolimus topical 

Apply a tiny coating to the affected region every 12 hours, limiting the application to that area and continuing as long as the symptoms remain



tacrolimus topical 

Apply a slight coating to the affected region every 12 hours; stop therapy after the symptoms have subsided
If there is no improvement after six weeks, the diagnosis should be reconsidered



fluocinonide 

Apply a small layer topically to the afflicted regions each day



tacrolimus ointment 

0.1% or 0.03% ointment- apply every 12 hours
Cease therapy once indications have resolved
If no progress within a span of 6 weeks, reevaluate the diagnosis



rocatinlimab 

Pending for FDA approval for moderate-to-severe atopic dermatitis rocatinlimab has shown promising results in a Phase 2b clinical trial in terms of efficacy and safety for this specific indication.



diphenhydramine 

Age >12 years:

25 - 50

mg

Orally 

every 4-6 hours as required



ruxolitnib topical 

<12 years: Safety and efficacy not established
≥12 years: Apply a thin coating of cream to affected regions of up to 20% of body surface area twice a day; do not exceed >60 g/week or one 100-gram tube/2 weeks
After the signs and symptoms of atopic dermatitis (such as itching, rash, and redness) have subsided, discontinue use
Re-examine the patient if signs and symptoms do not improve after eight weeks



pimecrolimus topical 

<2 years: Safety and efficacy not established
>2 years: Apply a tiny coating to the afflicted region every 12 hours, limiting the application to that area, and continuing as long as the symptoms remain



tacrolimus topical 

<2 years: Not recommended
2-15 years: Apply 0.03% ointment in a thin layer to the affected area every 12 hours
>15 years: Apply 0.03% and 0.1% ointment in a thin layer to the affected area every 12 hours; stop therapy after the symptoms have subsided
If there is no improvement after six weeks, the diagnosis should be reconsidered



tacrolimus ointment 

Age 2-15 years- (0.03% ointment): apply every 12 hours
Age >15 years- apply 0.03% or 0.1% ointment every 12 hours to the affected area
cease medical intervention once symptoms have subsided
If there is no observable progress within a span of 6 weeks, reevaluate the initial diagnosis