Children

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Atopic Dermatitis

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Updated by: Dr. Nikita Lakdawala
Updated on: 7/31/2017

Definition

Atopic Dermatitis (AD) or “eczema” is a very common condition in children and can often be seen in association with asthma, allergies and allergic rhinitis.

Diagnosis/symptom

Signs and symptoms

  • Pruritus
  • Eczematous lesions
  • Chronic or relapsing history

Patterns vary depending on age and may include:

  • Facial, neck, and extensor involvement more common in infants
  • Flexural lesions in all ages
  • Sparing of the groin and axillary regions

Supporting features:

  • Early age of onset
  • Atopy
  • Personal and/or family history

Causes

While the exact cause is not known, genetic factors play a role. In atopic dermatitis that barrier is inadequate, and the skin is easily irritated. Immune dysregulation also occurs as a result of the impaired barrier. The natural history of atopic dermatitis is variable, though many children may outgrow AD in adolescence.

Referring provider’s initial evaluation and management:

  • Initial assessment includes detailed history of skin care regimen and physical examination to assess severity of disease.
  • Management includes implementation of preventative measures and treatment for flares.
  • Preventative maintenance therapy includes initiation of topical emollients twice daily and fragrance-free products.
  • A more comprehensive skin care regimen and suggested product list is provided below.

Skin care regimen

  • Ointments are preferred over creams. Lotions should be avoided as they contain alcohol and high quantity of water.
  • Bathing: Daily bathing is recommended with lukewarm water for a maximum of 10 - 15 minutes. After bathing, recommend patting skin dry gently with a towel. Medicines and moisturizers should be applied to damp skin.
    Avoid:
    • Hot, steamy water
    • Scrubbing skin
    • Bubble baths
  • Bath Oils: Recommend use only bath oils that are free of fragrance and dye. Recommend avoidance of baby oils.
  • Bleach Baths: If frequent infections are present, initiation of bleach baths can aid in bacterial decolonization. Bleach baths may be performed once weekly to several times weekly depending on severity. A quarter cup of regular Clorox bleach should be added to a half of a tub full of water. Soak up to ten minutes and then rinse.
  • Soaps: Recommend use of a fragrance-free soap, restricting application of soap only to areas which are dirty including the neck, axillae and groin.
  • Laundry Products: Recommend use of fragrance-free detergent and avoidance of fabric softeners or dryer sheets.
  • Activity: Sweating can exacerbate AD in some children. In this case, recommend avoiding time outdoors during hot temperatures. In winter, a humidifier may be helpful. When swimming, recommend bathing and applying topical moisturizers immediately after.
  • Clothing: Recommend soft natural fabrics, like cotton. Avoid wool, nylon and synthetic fabrics. If metal allergy is suspected in addition to AD, wearing clothing, jewelry, belts, etc. with metal should be avoided.
  • Fingernails: Recommend fingernails are cut short. When possible, socks can be worn on the hands at night to avoid injury from scratching while asleep.
  • Foods: Acidic foods (fruits & vegetables) that come in contact with the skin around the mouth can cause irritant dermatitis, distinct from food allergy. Recommend application of a topical ointment to the skin before eating and washing face and repeat application immediately after eating for barrier protection. 

When to initiate referral/ consider refer to Dermatology Clinic:

  • Not responsive to topical agents
  • Experiencing flares despite use of topical therapy
  • Concern about superinfection with weeping or crusted areas
  • Moderate to severe disease

What can referring provider send to Dermatology Clinic?

1. Using Epic

  • Please complete the external referral order
    In order to help triage our patients and maximize the visit, the following information would be helpful include with your referral order:
  • Urgency of the referral
  • What is the key question you would like answered?
    Note: Our office will call to schedule the appointment with the patient. 

2. Not using Epic external referral order

  • In order to help triage our patients maximize the visit time, please fax the above information to (414-607-5288) • It would also be helpful to include:
  • Chief complaint, onset, frequency
  • Recent progress notes
  • Labs and imaging results
  • Other Diagnoses
  • Office notes with medications tried/failed in the past and any lab work that may have been obtained regarding this patient’s problems.

Specialist’s workup will likely include:

After referral to Dermatology Clinic:

  • Assessment of severity of disease and impact on quality of life
  • Implementation of changes in home regimen, including use of fragrance free products
  • Assessment for therapy including topical therapy, phototherapy and systemic therapy and implementation based on patient needs

Atopic Dermatitis: Product List

Moisturizers:

Ointments

  • Aquaphor Healing Ointment
  • Petroleum Jelly
  • Vaseline
  • Petrolatum eczema
  • White petrolatum
  • Vaniply Ointment

Creams

  • CeraVe Moisturizing Cream
  • Cetaphil® Moisturizing Cream
  • Aveeno® Eczema Therapy Moisturizing Cream
  • Eucerin® Original Moisturizing Crème
  • Vanicream Cream®

Skin cleansers

  • Dove Sensitive Skin Beauty Bar
  • Aveeno Skin Relief Body Wash
  • Aquaphor Gentle Wash and Shampoo
  • CeraVe Hydrating Cleanser
  • Vanicream Cleansing Bar
  • Cetaphil Gentle Skin Cleanser/ Gentle Cleansing Bar

Laundry detergent

  • All® Free Clear • Tide® Free & Gentle Liquid
  • Cheer® Free & Gentle • Purex® Free & Clear
  • Arm & Hammer® Perfume and Dye Free Liquid

Topical & Oral Therapy

  • Topical corticosteroids are classified according to strength from Class I (very high potency) to Class VII (lowest potency)
    • Maintenance therapy: In the case of diffuse involvement not responding to over-the-counter topical moisturizers, alone a medicated moisturizer may be implemented twice daily as an alternative
      • Medicated moisturizers typically use low potency topical steroid with an ointment or cream, e.g. hydrocortisone 2.5% ointment mixed 1:1 with CeraVe cream
    • Treatment of flares: A stronger topical steroid may be required for flares areas and should be used twice daily until lesions clear. Maintenance therapy should be continued during periods or remission.
      • Therapy based on severity of lesions and distribution of the lesions
      • Face, axillae and groin represent higher risk areas where mid to high potency topical steroids should be avoid due to increased risk of atrophy.
      • Acral areas, including hands and feet, due to thicker skin, may require increased potency topical steroids.
      • Ointments are preferred over creams
  • Non-steroidal topical agents
    • Tacrolimus 0.03% or 0.1% ointment or pimecrolimus 1% cream may be considered in age appropriate patients as an alternative to topical corticosteroids, particularly in areas such as the face, which are at higher risk for atrophy
  • Antihistamines
    • Oral antihistamines may be considered in a dose appropriate manner if significant pruritus is present.

Topical Corticosteroid Potency Classification

Class  Drug Dosage form(s) Strength (%)
I. Very high potency  Augmented betamethasone dipropionate  Ointment  0.05 
Clobetasol propionate  Cream, foam, ointment  0.05 
Diflorasone diacetate  Ointment  0.05 
Halobetasol propionate  Cream, ointment  0.05 
II. High Potency  Amcinonide  Cream, lotion, ointment  0.1 
Augmented betamethasone dipropionate  Cream 

0.05

Betamethasone dipropionate  Cream, foam, ointment, solution  0.05 
Desoximetasone  Cream, ointment  0.25 
Desoximetasone  Gel  0.25 
Diflorasone diacetate  Cream 0.05 
Fluocinonide  Cream, gel, ointment, solution  0.05 
Halcinonide  Cream, ointment  0.1 
Mometasone furoate  Ointment  0.1 
Triamcinolone acetonide  Cream, ointment  0.5 
III-IV. Medium Potency  Betamethasone valerate  Cream, foam, lotion, ointment  0.1 
Clocortolone pivalate  Cream  0.1 
Desoximetasone  Cream  0.05 
Fluocinolone acetonide  Cream, ointment  0.025 
Flurandrenolide  Cream, ointment  0.05 
Fluticasone propionate  Cream  0.05 
Fluticasone propionate  Ointment  0.005 
Mometasone furoate  Cream  0.1 
Triamcinolone acetonide  Cream, ointment  0.1 
V. Lower-Medium Potency  Hydrocortisone butyrate  Cream, ointment, solution  0.1 
Hydrocortisone probutate  Cream  0.1 
Hydrocortisone valerate  Cream, ointment  0.2 
Prednicarbate  Cream  0.1 
VI. Low Potency  Alclometasone dipropionate  Cream, ointment  0.05 
Desonide  Cream, gel, foam, ointment  0.05
Fluocinolone acetonide  Cream, solution  0.01 
VII. Lowest Potency  Dexamethasone  Cream  0.1 
Hydrocortisone  Cream, lotion, ointment, solution  0.25, 0.5, 1 
Hydrocortisone acetate  Cream, ointment  0.5-1

References

“Practice Management Center.” Atopic Dermatitis Clinical Guideline | American Academy of Dermatology, www.aad.org/practicecenter/quality/clinical-guidelines/atopic-dermatitis.

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