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Atopic Dermatitis

A Pediatric Guide

Almost 10 million American children suffer from the chronic skin condition of atopic dermatitis (AD). The most common form of eczema, atopic dermatitis’s disruptive symptoms can be life-long, although two-thirds of patients outgrow their symptoms during childhood. There are a variety of treatments that can help ease AD’s symptoms, but no known cure. The Children’s Mercy Dermatology Team offers the following recommendations:

1. Symptoms


Atopic dermatitis has an early age of onset with intermittent symptoms. Pruritus and patterned rashes on the face, neck extensor and flexural surfaces are common.  

  • Dry, rough, itchy skin.
    • 85 percent of people with AD report daily itching.
    • On darker skin, rashes can appear purple, brown, gray or ashy.
    • On lighter skin, rashes appear red or very white and dry.
  • Interrupted sleep from itching.
  • Scratching rashes can lead to infected skin.
  • Lichenification.
  • Symptoms wax and wane.
  • Distribution of dermatitis by age:
    • Infant: Face, scalp, trunk, back, elbows, knees.
    • Child: Neck, antecubital, popliteal fossa, ankles/feet.
    • Adult: Hands, feet.
  • Responds to moisture and topical steroids.
  • Severity Guide (with visual examples).

2. Diagnostic Criteria


Atopic dermatitis is sometimes mistaken for other similar skin conditions. Look for itchy, relapsing rashes in the areas of distribution common to the disease and check the patient’s history for atopy and familial cases.

  • Essential features:

    • Pruritus.
    • Patterns: Fack, neck, extensor (infant) or flexural surfaces.
      • Sparing groin/axillae.
    • Relapsing history.

  • Important features:

    • Early age of onset (often before 6 years of age, but not always).
    • Atopy (allergies, asthma) or family history.
    • Exclusion of other conditions.*

  • *Diagnoses that resemble atopic dermatitis: 

    • Scabies:
      • Often presents as a new rash, not relapsing.
      • Check history to see if close contacts also have symptoms.
      • Pruritis (worse at night time).
      • Papules, nodules, burrows, vesiculopustules.
        • Interdigital space, wrists, ankles, axilla, waist, buttock, groin, palms, soles
    • Psoriasis vulgaris:
      • Presents within areas of traumaCharacteristic rash: round, brightly erythematous, well-marginated plaque with greyish or silvery-white overlying scale
        • Scalp, elbows, knees, lumbosacral, groin (inverse: axilla, groin, umbilicus)
    • Guttate psoriasis:
      • Drop-like, round/oval lesions (2-6 mm).
      • Symmetrical on truck and extremities.
      • Often triggered by Group A Strep infection.
    • Allergic contact dermatitis:
      • Type IV hypersensitive reaction, generally delayed 8-12 hours.
      • Sharp edges, erythema, vesicles, bullae present.
      • Common triggers: poison ivy, nickel, fragrance, dyes, wet wipes, lanolin, antibiotics, rubber, formaldehyde.
    • Papular urticaria:
      • Distribution often on arms and legs.
      • Hypersensitivity to bug bites.
      • Chronic, papular eruption.
      • Highly pruritic.
      • Summer and late spring.
    • Viral exanthum:
      • Diffuse macules and papules.
      • Within setting of fever, headache, fatigue, respiratory or GI symptoms.
    • Juvenile palmar/plantar dermatosis:
      • Smooth, red and glazed with fine scaling (chronicity lichenification).
      • Distal aspects, soles, spares interdigital spaces.
      • Associated with hyperhidrosis.
    • Seborrhea dermatitis:
      • Self-limiting erythematous, scaly or crusting eruption.
      • Thin, dry scales / well-defined red patches with brown, greasy crust.
      • Infants: scalp, intertriginous, flexural, diaper.
      • Adolescents: Scalp, eyebrow, bridge of nose, nasolabial crease, post-auricular.
      • Pruritis: none or minimal.
    • Tinea incognito:
      • Annular, red, scaly, central clearing, sharp border.
      • Superficial fungal infection.
      • Risks: Wresting, kittens, gerbils.
      • Topical steroids spread rash.
    • Perioral (periorificial) dermatitis:
      • Erythematous, discrete, inflammatory papules/pustules; no comedones.
      • Perioral, nasolabial, periocular.
    • Molluscum dermatitis:
      • Small skin-colored papules.
      • Common, contagious viral childhood disease.
      • Benign and self-limited; will resolve within 6 months to several years.
    • Keratosis pilaris:
      • Dry, bumpy skin with no pruritis.
      • Face, extensor arms, lateral legs; can be widespread.
      • Follicular hyperkeratosis.
      • Familial inheritance.
    • Xerosis cutis (dry skin):
      • More rare: Erythema ab igne, chronic T-cell lymphoma, immune deficiency, ichthyosis.

3. Treatment


Treatment for atopic dermatitis includes dry skin care, using dye- and fragrance-free skin care products, bland ointment/creams and topical steroids or other topical medications. Other interventions may be recommended as detailed below. Additional treatment is necessary if the skin is infected, depending on the type and severity of the infection.

Non-infected atopic dermatitis


See severity examples.

  • If skin isn’t red/purple or inflamed, provide dry skin care:
  • If skin is red/purple or inflamed:
    • Avoid using oral steroids for all eczema flares.
    • Start bland ointment/cream emollient (see list).
    • Recommend daily bathing
    • Start mildest strength topical steroid (see list) still likely to be effective. (Use low potency topical steroids for young infants.)
      • Face: Class VII-VI, 2x daily to affected area, as needed.
      • Body: Class VII-III, 2x daily to affected area, as needed.
    • Consider first generation oral antihistamines (see dosing) for itch control and sleep.
    • Consider dilute bleach baths (see instructions).
    • For severe, non-infected cases, consider wet wraps (see instructions and video) for up to 72 hours with close follow-up in Dermatology.
    • Follow-up with PCP or clinic referral to Children’s Mercy Kansas City Dermatology as needed.
    • Discharge home.

Infected atopic dermatitis


The skin is infected—presence of crusting, pustules, erosions, vesicles, blisters—and/or the patient is febrile.

See severity examples.

  • Avoid using oral steroids for all eczema flares.
  • Obtain aerobic culture and/or viral culture (see guidelines) from the affected site.
    • If uncertain of infected HSV, obtain both cultures.
  • If the patient has a fever, lethargy, toxic appearance, signs of dehydration, diffuse skin involvement, and/or is under 1 year old, consider:
  • If there is a history or concern of HSV infection or exposure, consider eczema herpeticum (see visual examples):
    • Widespread skin involvement, pain, fever.
    • Rapidly spreading lesions.
    • Likely history of exposure to HSV.
    • Pustules or vesicles rapidly changing into painful erosions.
    • Occasionally vesicles or pustules can evolve into focal deep erosions with crusting.
    • Widespread skin involvement, pain, fever.
    • Rapidly spreading lesions.
    • Likely history of exposure to HSV.
    • Pustules or vesicles rapidly changing into painful erosions.
    • Occasionally vesicles or pustules can evolve into focal deep erosions with crusting.
     
  • OR eczema coxsackium (see visual examples):
    • Rapid spreading of painful vesicles quickly turning into erosions
    • Typically in areas of previous eczema involvement
    • Often follows seasonal presentations
    • Associated features:
      • Perioral vesicles and crusted papules,
      • Erosions on palate
      • Deep vesicles on palms and soles,
      • Crusted papules and vesicles on buttocks and arms/ legs.
      • Fever may be present.
      • May exhibit irritability or fatigue.
      • Cough or rhinorrhea may precede skin involvement.
      • Possible history of previous hand-foot-and-mouth disease exposure.
      • Evaluate for possible mouth lesions (herpangina).
      • Of note: Erosions are not as deep as seen with HSV/eczema herpeticum.
     

  • Treatment for both eczema herpeticum and eczema coxsackium:
    • Start bland ointment (Vaseline®), avoid creams.
    • Hold topical steroids within area of infection.
    • Consider aerobic culture if suspicious for bacterial infection.
    • Start first generation oral antihistamines (see dosing) for itch control and sleep.
      • For eczema herpeticum ONLY:
        • Start oral acyclovir 80 mg/kg/day divided into 4x day for 7 to 10 days (maximum dose of 3200 mg/day).
        • If there are lesions near the eye or eye symptoms obtain an ophthalmology consultation ASAP.
      • Consider consulting Dermatology on-call provider with questions.
      • Discharge home.
      • Close follow-up with PCP or clinic referral to Children’s Mercy Kansas City Dermatology.


  • If there is not a history or concern of HSV infection or exposure, consider impetigo (Staph aureus) (see visual examples):
    • Can be bullous (bullae forming) or non-bullous impetigo.
    • Often from secondary scratching.
    • Non-bullous impetigo: yellow, honey-colored crusting usually within areas of eczema. Typically caused by Staph aureus methicillin sensitive (MSSA), methicillin resistant (MRSA), or group A strep.
    • Bullous impetigo initially presents as thin-walled bullae which quickly rupture (often before seeking medical care) and appear as red annular areas with a fine white collarette of scaling on border of lesions.
    • Rapidly spreads within areas of eczema and to other areas of body.
    •  
  • OR group A Strep (Strep pyogenes) (see visual example):
    • Glazed, bright red appearance, especially in skin folds.
    • Patients may also experience yellow drainage.
    • Rapid onset of flare, rapid development of lesions, fever, increasing pustules.


  • Treatment for impetigo and group A Strep, if several sites are affected/diffuse involvement:

4. Other treatments a Children’s Mercy dermatologist might recommend and/or manage

  • Topical calcineurin inhibitors (TCI): Non-steroidal immunomodulators block T cell pro-inflammatory cytokines. Preferred for recalcitrant areas; sensitive skin areas; areas of steroid atrophy; or after long-term, uninterrupted steroid use. There is an increased risk of secondary infection, so hold during acute infections.
    • Pimecrolimus (Elidel) cream: for mild to moderate AD FDA-approved for 2 years old and up.
    • Tacrolimus (Protopic) .03% ointment: For moderate to severe AD; FDA-approved for 2 years old and up.
    • Tacrolimus (Protopic) 0.1% ointment: For moderate to severe AD; FDA-approved for 16 years old and up.
    • There is a black box warning for a theoretical risk of skin cancer and lymphoma from an oral tacrolimus animal study (25-50x recommended adult dose), but 10-year surveillance studies have not found skin cancer or lymphoma in humans.

  • Phototherapy: Used to treat AD since 1948, light therapy works through photo-immunosuppression and immunomodulation. Narrowband UVB phototherapy (NBUVB) is the most common AD treatment, used as a second-line treatment after failure of emollients, topical steroids and TCIs. Phototherapy can be difficult to access and might not be covered by insurance. Risks include sun damage, skin aging and skin cancer.

  • Crisaborole (Eucrisa) Ointment: A phosphodiesterase-4 (PDE4) inhibitor that decreases inflammation without the possible risks of topical steroids and the TCI’s black box warning. Good for mild AD for patients over 6 months ; good alternative for topical steroids on sensitive skin areas. Studies show it safely improves itching, disease severity and AD symptoms (erythema, excoriation, lichenification) with a low adverse effects frequency.
    • o Application site pain: Number one complaint. Parents can try applying ice, an emollient (Vaseline or Aquaphor), hydrocortisone ointment, or a numbing cream (Pramoxine) before Eucrisa.

  • Dupilumab (Dupixent): First and only biologic approved for AD. For moderate to severe AD; approved for ages 6 months and older. Dupilumab is a human monoclonal antibody that targets IL-4 and IL-13; it has minimal side effects, and no lab screening or monitoring is needed (unlike other systemics used off-label to treat severe AD). Studies have shown improvement in lesion extent and severity and itch reduction. Referral to a dermatology provider or allergy provider is highly recommended.
    • Good candidates have moderate to severe AD affecting their quality of life who:
      • Are unable to tolerate or have contraindications to other systemic immunosuppressants.
      • Are unresponsive to other systemic therapies.
      • Are transitioning off methotrexate or cyclosporine after large cumulative doses.
      • And/or also have asthma: The medication is approved to treat moderate to severe asthma for ages 12+.
    • Subcutaneous injection every 2 weeks:
      • Children <30 kg: 600 mg loading dose then 300mg every 4 weeks.
      • Children 30 to60kg: 400 mg loading dose then 200mg every 2 weeks.
      • Adolescents <60 kg: 400 mg loading dose then 200 mg every other week.
      • Adolescents >60 kg: 600 mg loading dose then 300 mg every other week.
    • Possible side effects: Conjunctivitis and keratitis, injection site reaction, cold sores on the mouth/lips, or facial erythema.
    • May influence the body’s response to parasite infections; treat any pre-existing prior to starting.

5. Considerations for parents

  • Many parents are concerned about adverse effects of topical steroids (72.5 percent in one recent study), including skin thinning and delaying growth or development. Ask parents to clarify their concerns about topical steroid treatments. Some parental concerns aren’t warranted. For example, many are concerned about skin lightening or darkening, but that is a sign of improvement called post-inflammatory hyper- or hypopigmentation. Although adverse effects are real (telangiectasias, striae, atrophy), they are rare. Share current, correct information with parents and help them understand that the benefits of treatment outweigh the risks.
    • Topical steroids have been used for more than 60 years and have 110+ randomized controlled trials showing their safety.
    • In a study of mild-potency (class VII-VI) topical steroids used twice a week to prevent AD flares, no adverse effects were noted.
    • The risk of hypothalamic-pituitary-adrenal axis suppression is low except in cases where very potent (Class II-I) steroids are used for long periods of time.

  • Eczema Action Plan for Parents: Customize this take-home sheet with your recommendations.

6. When to refer


Most cases of atopic dermatitis can be treated in the primary care setting. Referral to a pediatric dermatologist is recommended when:

  • Patient is responding to standard treatments (needing to escalate beyond Class III topical steroids).
  • Generalized AD may require more intensive treatment with systemic immunosuppressive therapy, phototherapy or newly FDA approved dupilumab (IL-4 receptor antagonist).
  • Patient has recurrent infections.
  • Patient presents with atypical features and diagnosis is in question.
  • Parent crisis.

Referral instructions

  • Step 1: Complete the New Patient Appointment Form online. For best results, please use Google Chrome.

  • Step 2: Review and Schedule. The Children’s Mercy Contact Center will call the patient within 2 business days to schedule an appointment. Scheduled and requested appointment status can be found on the Wednesday referral reports.

  • Follow-up appointments: Scheduled by the patient by calling the Dermatology Clinic at (816) 960-4051.

DISCLAIMER: This content gives you general information about the described health conditions. This information does not take the place of a healthcare provider's training, experience, or judgment. You should not rely on this information in place of the advice of a healthcare provider. NO WARRANTY WHATSOEVER, WHETHER EXPRESS OR IMPLIED BY LAW, IS MADE WITH RESPECT TO THE CONTENT.

Created 7/22/2022

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