Snapshot A 5-month-old boy is brought to urgent care for a wet rash on his cheeks. His mother reports that he has been dealing with this rash for the past few weeks, though it has gotten much worse in the past few days. She has wrapped his hands in socks to prevent scratching, especially during sleep. Family history includes childhood asthma and eczema. On physical exam, his bilateral cheeks are erythematous with oozing papulovesicles and excoriations. The physician prescribes a topical corticosteroid. Introduction Clinical definition a chronic and pruritic inflammatory skin disease also known as eczema Epidemiology prevalence very common 10-20% prevalence demographics primarily affects children but can affect all ages risk factors family history living in urban setting Western diet Etiology combination of genetic, dietary, and environmental causes Pathogenesis filaggrin deficiency or dysfunction may contribute to decreased water retention, impaired tight-junction formation, and reduced ceramide content cutaneous inflammation with infiltrating T-cells can cause epidermal thickening, contributing to functional impairment of epidermal barrier Genetics mutations loss of function mutation in filaggrin (FLG) gene filaggrin is an epidermal structural protein increases risk for developing atopic dermatitis and other allergic disorders Associated conditions atopic triad eczema (atopic dermatitis) asthma allergic rhinitis food allergy Wiskott-Aldrich syndrome suspect when there is eczema along with recurrent infections and thrombocytopenia selective IgA deficiency suspect when you have eczema and recurrent sinus, pulmonary, and GI infections hyper-IgE syndrome suspect when there is eczema along with recurrent cold abscesses and high serum IgE Prognosis majority of childhood eczema will improve or resolve as they get older adult eczema often evolve into chronic hand eczema Presentation Symptoms pruritus may result in sleep disturbance excoriations from scratching Physical exam dry and rough skin acute flares diffuse erythematous patches and plaques with oozing and crusting papules/vesicles chronic lesions poorly demarcated patches and plaques with scales, excoriation, and lichenification hyperlinearity of palms or soles location commonly on skin flexures in children and adults commonly on the face in infancy Studies Labs may have ↑ serum IgE Biopsy indication to confirm diagnosis findings epidermal intercellular edema (spongiosis) Making the diagnosis most cases are clinically diagnosed Differential Seborrheic dermatitis Contact dermatitis Ichthyosis vulgaris Nutritional deficiency Treatment Conservative emollients and moisturizers indications enhances repair of epidermal barrier to apply soon after bathing Medical topical therapy corticosteroids indication first-line treatment for acute flares types low-potency topical steroids can use on face and neck medium or high-potency topical steroids cannot use on face, neck, or anogenital area adverse effects long-term use carries risk of skin atrophy calcineurin inhibitors indications for use on face, anogenital, and neck area for disease recalcitrant to steroids alternative to steroids drugs tacrolimus systemic therapy indication for severe or refractory atopic dermatitis drugs cyclosporine azathioprine dupilumab Procedural phototherapy indications for severe or refractory atopic dermatitis for patients not willing to take systemic therapy for atopic dermatitis modalities ultraviolet light therapy psoralen plus ultraviolet A (PUVA) Complications Secondary bacterial infection Eczema herpeticum