Eczema

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Eczema/Atopic Dermatitis The Itch that Rashes:

Eczema/Atopic Dermatitis The Itch that Rashes Family Nurse Practitioner I K. Michelle Pendergrass PhD(c), PNP, FNP-BC

Definitions:

Definitions A chronic inflammatory genetically determined disease of the skin marked by increased ability to form reagin ( IgE ), with increased susceptibility to allergic rhinitis and asthma, and hereditary disposition to a lowered threshold for pruritus . It is manifested by lichenification , excoriation, and crusting, mainly on the flexural surfaces of the elbow and knee. In infants it is known as infantile eczema. (MSH) Chronic inflammatory skin disorder in individuals with a hereditary predisposition to a lowered threshold to pruritus ; characterized by extreme itching, leading to scratching and rubbing that result in typical lesions of eczema. (CSP)

Epidemiology:

Epidemiology Hereditary Sensitive Skin Effects 10% children Low itch threshold Provocative factors IgE Antibody response

Eczema:

Eczema Onset: Early Childhood, alt remission, exacerbation, resolves age 30 Allergic triad fam history Atopic dermatitis Allergic rhinitis Asthma Itching may be severe, worse in pm Dry scaly ( xerosis ) patches from scratch trauma Skin fails to hold moisture

3 phases:

3 phases Infant: birth to 2 Childhood: 2-12 Adult: 12-adult

3 phases:

3 phases Infant ~3mo old, esp cold, dry weather Erythema and scaling of cheeks, chin Spares perioral & paranasal and often diaper areas Exudative lesions (oozing, weeping) Location: face (especially cheeks) Scalp Trunk Extensor surface of arms & legs

Severe Eczema:

Severe Eczema http://www.skinsight.com/infant/atopicDermatitisEczema.htm Severe eczema. Large, crusted lesions w/ erosions Severe eczema on eyelids

Childhood phase:

Childhood phase Characteristic flexural area involvement “Hot & sweaty fossa and folds” Area of skin that often is stretched Starts the itch-scratch cycle Plaques, lichenification Foot derm more common in children; eyelids Less Exudative lesions in children

Eczema:

Eczema the rash often is seen as scaly bumps over each hair follicle. multiple small, dark brown bumps typical of atopic dermatitis (eczema) in a person with darker skin. in people with darker skin can cause lighter skin areas ( hypopigmentation ) as seen on the arms of this patient.

Adult phase:

Adult phase New onset rare Puberty may exacerbate Most common-localized inflammation of flexural areas Hand dermatitis more common Eyelids

PowerPoint Presentation:

Chronic itch & rubbing leads to skin thickening and increased prominence of normal skin markings

Provocative Factors:

Provocative Factors Sweating Bacterial colonization Rough clothing Chemical irritants Emotional Stress Foods Cow's milk Wheat Eggs Soy Peanut and tree nuts Fish Environment Dust or mold Cat dander Temperature changes Low humidity

Differential Diagnosis:

Differential Diagnosis Contact Dermatitis Seborrheic dermatitis Nummular dermatitis Scabies Tinea

Complications:

Complications Secondary Infections (Impetigo) Atopic dermatitis (eczema) in body folds coupled with staph bacteria

Plan/Management:

Plan/Management Avoid provocative factors such as: Excessive bathing Rough clothing Excessive sweating (see p 271 U&G k eys to reduce drying factors)) Wear comfortable clothing Add bath emollients such as bath oils Use mild soaps (Dove, Cetaphil ) Pat skin dry, don’t rub Skin barrier protection (skin lubricants-Lubriderm, eucerin , vaseline ) Apply immediately after bathing and throughout day Avoid lotions with alcohol (drying effect) Eliminate Environmental Allergens

Pharmacology Topical Steroids:

Pharmacology Topical Steroids To reduce inflammation: topical steroid preps applied thinly 2x/day (up to 7 days-children, 14 days adults) Infants and Children-Hydrocortisone ointment see prescribing guide for up-to-date information and warnings Adults Triamcinolone ointment .1% Milder cases-steroid cream instead of ointment Lubricants should not be applied over steroid ointment Once inflammation controlled, switch back to lubricants Always use lowest effective potency

Pharmacology Antihistamines:

Pharmacology Antihistamines For pruritis control-oral and topical antipruritis Fexofenadine (Allegra) Loartadine (Claritin) Desloratidine ( Clarinex ) Cetrizine ( Zyrtec ) Hydroxyzine ( Atarax ) Topical antipruritic-prax lotion, cetaphil , doxepin Always use prescriber guide or other up-to-date information for prescriptions

Follow Up:

Follow Up First follow-up 2-4 weeks (determine effectiveness of therapy) Monthly visits for management until able to use lubricants only then 3-6 months Teach patient or family the this is chronic, recurrent disorder Must consider who you can give several refills. Must know patient.

Referral:

Referral When: No response to conventional therapies after a 2-4 week trial Who: dermatologist

References:

References Family Practice Notebook.com http://www.fpnotebook.com/DER/Dry/AtpcDrmts.htm American Osteopathic College of Dermatology http://www.aocd.org/skin/dermatologic_diseases/index.html

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