Updated: 9/8/2019

Atopic Dermatitis (Eczema)

Topic
Review Topic
0
0
Questions
6
0
0
Evidence
6
0
0
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
 

Please rate topic.

Average 4.2 of 11 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (6)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(M1.MK.75) A pathologist is reviewing a number of old dermatologic histology slides that were never labeled with the proper patient identifiers. He is trying to match the slides up with the correct patients and diseases. Upon examining one such slide, he observes that there is significant epidermal accumulation of edematous fluid in the intercellular spaces and intraepidermal edema. Which are the following patient photographs is most likely to correspond to this finding? Review Topic

QID: 106743
FIGURES:
Type in at least one full word to see suggestions list
1

Figure A

2%

(3/136)

2

Figure B

38%

(52/136)

3

Figure C

46%

(63/136)

4

Figure D

5%

(7/136)

5

Figure E

7%

(9/136)

M1

Select Answer to see Preferred Response

SUBMIT RESPONSE 2
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(M1.MK.12) A mother brings her 8-month-old child to your pediatric clinic with concerns of a rash. Physical exam reveals an erythematous, weeping rash involving bilateral cheeks and scalp. You prescribe a topical agent that is considered the first-line pharmacological treatment for this condition. What is a common concern that the mother should be alerted to regarding long-term use of this topical agent? Review Topic

QID: 103805
Type in at least one full word to see suggestions list
1

Hyperpigmentation

20%

(35/178)

2

Skin atrophy

66%

(117/178)

3

Paresthesia

4%

(8/178)

4

Increased risk of melanoma

3%

(5/178)

5

Hypoglycemia

4%

(7/178)

M1

Select Answer to see Preferred Response

SUBMIT RESPONSE 2

You have 100% on this question.
Just skip this one for now.

(M1.MK.1) A 2-year-old male is brought to your office by his mother for evaluation. The patient develops a skin presentation similar to Image A on his cheeks and chin when exposed to certain food products. This patient is most likely predisposed to develop which of the following? Review Topic

QID: 101310
FIGURES:
Type in at least one full word to see suggestions list
1

Fingernail pitting

2%

(2/101)

2

Arthralgias

5%

(5/101)

3

Wheezing

55%

(56/101)

4

Gluten hypersensitivity

34%

(34/101)

5

Cyanosis

1%

(1/101)

M1

Select Answer to see Preferred Response

SUBMIT RESPONSE 3
ARTICLES (6)
Topic COMMENTS (16)
Private Note