Atopic Dermatitis (Eczema) (Clinical)

Overview

Definition

Atopic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) (also known as eczema Eczema Atopic dermatitis, also known as eczema, is a chronic, relapsing, pruritic, inflammatory skin disease that occurs more frequently in children, although adults can also be affected. The condition is often associated with elevated serum levels of IgE and a personal or family history of atopy. Skin dryness, erythema, oozing, crusting, and lichenification are present. Atopic Dermatitis (Eczema)) is a chronic inflammatory skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions condition, characterized by pruritic lesions that are due to skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions barrier dysfunction and immune dysregulation.

Epidemiology^[6,11,15,19]

• Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency:
  • School-aged children: approximately 17%
  • Adults: 2%–10%
• Atopic triad Atopic triad Atopic dermatitis, Allergic rhinitis, Asthma Atopic Dermatitis (Eczema) (present in 30%–50% of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship):
  • Atopic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema)
  • Allergic rhinitis Allergic rhinitis An inflammation of the nasal mucosa triggered by allergens. Rhinitis
  • Asthma Asthma Asthma is a chronic inflammatory respiratory condition characterized by bronchial hyperresponsiveness and airflow obstruction. The disease is believed to result from the complex interaction of host and environmental factors that increase disease predisposition, with inflammation causing symptoms and structural changes. Patients typically present with wheezing, cough, and dyspnea. Asthma
• 30% of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship develop asthma Asthma Asthma is a chronic inflammatory respiratory condition characterized by bronchial hyperresponsiveness and airflow obstruction. The disease is believed to result from the complex interaction of host and environmental factors that increase disease predisposition, with inflammation causing symptoms and structural changes. Patients typically present with wheezing, cough, and dyspnea. Asthma.
• Most cases occur prior to age 5.
• Slight female preponderance
• Previous history of atopy Atopy Atopic Dermatitis (Eczema) is an important risk factor.
• Incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency higher in:
  • Urban areas
  • Developed countries

Etiology^[6,11,15,19]

• Multifactorial and not completely understood
• Genetics Genetics Genetics is the study of genes and their functions and behaviors. Basic Terms of Genetics:
  • Family history Family History Adult Health Maintenance of atopy Atopy Atopic Dermatitis (Eczema)
  • Filaggrin gene Filaggrin Gene Ichthyosis Vulgaris mutations (loss-of-function mutation Mutation Genetic mutations are errors in DNA that can cause protein misfolding and dysfunction. There are various types of mutations, including chromosomal, point, frameshift, and expansion mutations. Types of Mutations):
    • Strongest known genetic risk factor
    • Results in keratinocyte Keratinocyte Epidermal cells which synthesize keratin and undergo characteristic changes as they move upward from the basal layers of the epidermis to the cornified (horny) layer of the skin. Successive stages of differentiation of the keratinocytes forming the epidermal layers are basal cell, spinous or prickle cell, and the granular cell. Erythema Multiforme barrier dysfunction
    • Increased susceptibility to potential antigens
• Immune defects: Th2 Th2 A subset of helper-inducer T-lymphocytes which synthesize and secrete the interleukins il-4; il-5; il-6; and il-10. These cytokines influence b-cell development and antibody production as well as augmenting humoral responses. T cells: Types and Functions disease (T helper cells)
• Prenatal factors: elevated cord blood IgE Cord blood IgE Atopic Dermatitis (Eczema)
• Infection:
  • Staphylococcus aureus Staphylococcus aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Brain Abscess colonization Colonization Bacteriology:
    • Often causes flares
    • Acts as a superantigen Superantigen Microbial antigens that have in common an extremely potent activating effect on T-cells that bear a specific variable region. Superantigens cross-link the variable region with class II mhc proteins regardless of the peptide binding in the t-cell receptor’s pocket. The result is a transient expansion and subsequent death and anergy of the T-cells with the appropriate variable regions. Toxic Shock Syndrome
  • HSV HSV Herpes simplex virus (HSV) is a double-stranded DNA virus belonging to the family Herpesviridae. Herpes simplex virus commonly causes recurrent infections involving the skin and mucosal surfaces, including the mouth, lips, eyes, and genitals. Herpes Simplex Virus 1 and 2
• Hygiene hypothesis Hypothesis A hypothesis is a preliminary answer to a research question (i.e., a “guess” about what the results will be). There are 2 types of hypotheses: the null hypothesis and the alternative hypothesis. Statistical Tests and Data Representation: Early childhood exposure to microbes and allergens prevents atopy Atopy Atopic Dermatitis (Eczema).

Common triggers^[6,10]

• Temperature (especially overheating)
• Humidity
• Contact irritants (e.g., soaps and detergents)
• Stress
• Infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
• Animal dander
• Dust mites Mites Any arthropod of the subclass acari except the ticks. They are minute animals related to the spiders, usually having transparent or semitransparent bodies. They may be parasitic on humans and domestic animals, producing various irritations of the skin (mite infestations). Many mite species are important to human and veterinary medicine as both parasite and vector. Mites also infest plants. Scabies
• Airborne allergens (e.g., pollens)
• Food allergens (seen primarily in young children and infants)

Pathophysiology and Clinical Presentation

Pathophysiology^[11,14,15]

• Pathogenesis is poorly defined.
• Characterized by spongiosis (epidermal edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema)
• Edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema leads to breaking of intercellular attachments → vesicle Vesicle Primary Skin Lesions formation
• Lymphocytic dermal infiltrates are present.
• Acanthosis and hyperkeratosis Hyperkeratosis Ichthyosis Vulgaris may be present.
• 2 interrelated pathways have been implicated:
  • Primary epithelial barrier disruption Primary Epithelial Barrier Disruption Atopic Dermatitis (Eczema) (outside-in hypothesis Hypothesis A hypothesis is a preliminary answer to a research question (i.e., a “guess” about what the results will be). There are 2 types of hypotheses: the null hypothesis and the alternative hypothesis. Statistical Tests and Data Representation):
    • Disruption of tight junctions Tight junctions Cell-cell junctions that seal adjacent epithelial cells together, preventing the passage of most dissolved molecules from one side of the epithelial sheet to the other. The Cell: Cell Junctions and increased permeability of stratum corneum Stratum corneum Skin: Structure and Functions
    • Increased transepidermal water loss
    • Can be associated with defects in structural proteins Structural proteins Proteins and Peptides (filaggrin is the major one implicated)
    • Barrier disruption can also be caused by microbial colonization Colonization Bacteriology and release of inflammatory cytokines Cytokines Non-antibody proteins secreted by inflammatory leukocytes and some non-leukocytic cells, that act as intercellular mediators. They differ from classical hormones in that they are produced by a number of tissue or cell types rather than by specialized glands. They generally act locally in a paracrine or autocrine rather than endocrine manner. Adaptive Immune Response.
  • Immune-response defect (inside-out hypothesis Hypothesis A hypothesis is a preliminary answer to a research question (i.e., a “guess” about what the results will be). There are 2 types of hypotheses: the null hypothesis and the alternative hypothesis. Statistical Tests and Data Representation):
    • Secondary immunologic dysregulation
    • Defect in toll-like receptors Receptors Receptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell. Receptors has been implicated in the loss of epidermal innate immunity Innate immunity The capacity of a normal organism to remain unaffected by microorganisms and their toxins. It results from the presence of naturally occurring anti-infective agents, constitutional factors such as body temperature and immediate acting immune cells such as natural killer cells. Innate Immunity: Phagocytes and Antigen Presentation ( colonization Colonization Bacteriology with S. aureus S. aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Staphylococcus leads to severe inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation).
    • IgE IgE An immunoglobulin associated with mast cells. Overexpression has been associated with allergic hypersensitivity. Immunoglobulins: Types and Functions–mediated allergic sensitization → increased susceptibility to irritants/allergens secondary to structural epidermal defects

Clinical presentation^[3,6,10,19]

Key features:

• Chronic course with periods of remission Remission A spontaneous diminution or abatement of a disease over time, without formal treatment. Cluster Headaches and exacerbation
• Intense pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema): cardinal symptom
• Cutaneous hyperreactivity to environmental stimuli

Based on age:

• Infants and younger children:
  • Papulovesicular lesions Papulovesicular Lesions Atopic Dermatitis (Eczema)
  • Intense pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema)
  • Erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion
  • Edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
  • Excoriations Excoriations Excoriation is a linear abrasion produced by mechanical means (scratching, rubbing, or picking) that usually involves only the epidermis but can reach the papillary dermis. Secondary Skin Lesions: result of scratching
  • Location: face, scalp, extensor surfaces, with sparing of the diaper area
• Older children and young adults:
  • Chronic lesions with lichenification Lichenification Atopic Dermatitis (Eczema)
  • Location: flexor surfaces of elbows, knees, and sides of the neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess, wrists, and ankles
  • Improves with age, with remission Remission A spontaneous diminution or abatement of a disease over time, without formal treatment. Cluster Headaches seen by 13 years of age in approximately 50% of cases

Based on severity:

• Mild:
  • Areas of dry skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions
  • Pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema): infrequent
  • Minimal impact on activities, sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep, and psychosocial well-being
• Moderate:
  • Areas of dry skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions
  • Pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema): frequent
  • Redness Redness Inflammation
  • Localized skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions thickening with or without excoriation Excoriation Mastitis
  • Moderate impact on activities and psychosocial well-being
  • Sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep frequently disturbed
• Severe:
  • Widespread dry skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions
  • Pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema): incessant
  • Redness Redness Inflammation
  • Extensive skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions thickening, bleeding, oozing, cracking, and pigmentation alteration
  • Severe impact on activities, psychosocial functioning, and sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep

Diagnosis

Atopic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) is primarily a clinical diagnosis. The following information is based on US, European, and UK recommendations.

Diagnostic Criteria
U.K. Working Party’s diagnostic criteria (1994):^[20,22]
According to this set of criteria, the diagnosis can be made with the presence of pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema) PLUS ≥ 3 of the following:

• Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions creases involved:
  • Antecubital fossae
  • Popliteal fossae
  • Neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess
  • Periorbital Periorbital Orbital and Preseptal Cellulitis areas
  • Ankles anteriorly
• Asthma Asthma Asthma is a chronic inflammatory respiratory condition characterized by bronchial hyperresponsiveness and airflow obstruction. The disease is believed to result from the complex interaction of host and environmental factors that increase disease predisposition, with inflammation causing symptoms and structural changes. Patients typically present with wheezing, cough, and dyspnea. Asthma or hay fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever history (or 1st-degree relative if child < 4 years of age)
• Dry skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions in the past year
• Symptoms beginning prior to age 2 (not used if child is < 4 years old)
• Dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) of flexural surfaces (if child < 4 years old, cheeks Cheeks The part of the face that is below the eye and to the side of the nose and mouth. Melasma, forehead Forehead The part of the face above the eyes. Melasma, or outer aspects of extremities)

American Academy of Dermatology’s Diagnostic Criteria (2014):^[15]

• Essential features (must be present):
  • Pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema)
  • Lesions consistent with typical eczema Eczema Atopic dermatitis, also known as eczema, is a chronic, relapsing, pruritic, inflammatory skin disease that occurs more frequently in children, although adults can also be affected. The condition is often associated with elevated serum levels of IgE and a personal or family history of atopy. Skin dryness, erythema, oozing, crusting, and lichenification are present. Atopic Dermatitis (Eczema) morphology, in typical age-specific patterns:
    • Infants and children: face, neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess, and extensor surfaces
    • Any age group: flexural lesions
    • Sparing of the groin Groin The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination and axilla Axilla The axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus: Anatomy
  • Chronic or relapsing history
• Important features (seen in most cases and support the diagnosis):
  • Early age at onset
  • Personal or family history Family History Adult Health Maintenance of atopy Atopy Atopic Dermatitis (Eczema)
  • Xerosis Xerosis Sjögren’s Syndrome
• Associated features (suggest the diagnosis, but are too nonspecific to define the condition):
  • Atypical vascular responses:
    • Facial pallor
    • White dermographism Dermographism Dermatologic Examination
    • Delayed blanch response
  • Perifollicular accentuation/ lichenification Lichenification Atopic Dermatitis (Eczema)
  • Keratosis pilaris Keratosis Pilaris Ichthyosis Vulgaris, pityriasis alba, or hyperlinear palms
  • Ocular or periorbital Periorbital Orbital and Preseptal Cellulitis changes
  • Perioral or preauricular lesions
• Must exclude other causes, such as the following:
  • Psoriasis Psoriasis Psoriasis is a common T-cell-mediated inflammatory skin condition. The etiology is unknown, but is thought to be due to genetic inheritance and environmental triggers. There are 4 major subtypes, with the most common form being chronic plaque psoriasis. Psoriasis
  • Contact dermatitis Contact dermatitis A type of acute or chronic skin reaction in which sensitivity is manifested by reactivity to materials or substances coming in contact with the skin. It may involve allergic or non-allergic mechanisms. Male Genitourinary Examination
  • Seborrheic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema)
  • Scabies Scabies Scabies is an infestation of the skin by the Sarcoptes scabiei mite, which presents most commonly with intense pruritus, characteristic linear burrows, and erythematous papules, particularly in the interdigital folds and the flexor aspects of the wrists. Scabies
  • Ichthyoses
  • Photosensitivity Photosensitivity Tetracyclines dermatoses
  • Immunodeficiency Immunodeficiency Chédiak-Higashi Syndrome disease
  • Cutaneous T-cell lymphoma Cutaneous T-Cell Lymphoma Non-Hodgkin Lymphomas
  • Erythroderma due to other causes

Additional studies^[15]

Atopic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) is a clinical diagnosis; therefore, testing is only to rule out other skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions conditions:

• Serum IgE IgE An immunoglobulin associated with mast cells. Overexpression has been associated with allergic hypersensitivity. Immunoglobulins: Types and Functions:
  • Elevated in 80% of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship
  • Not routinely recommended (including allergen-specific IgE IgE An immunoglobulin associated with mast cells. Overexpression has been associated with allergic hypersensitivity. Immunoglobulins: Types and Functions levels)
• Skin biopsy Skin Biopsy Secondary Skin Lesions
• Potassium Potassium An element in the alkali group of metals with an atomic symbol k, atomic number 19, and atomic weight 39. 10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte that plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. Hyperkalemia hydroxide preparation of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions scrapings to rule out Tinea corporis Tinea corporis Dermatophytes/Tinea Infections
• Patch Patch Nonpalpable lesion > 1 cm in diameter Generalized and Localized Rashes testing to rule out contact dermatitis Contact dermatitis A type of acute or chronic skin reaction in which sensitivity is manifested by reactivity to materials or substances coming in contact with the skin. It may involve allergic or non-allergic mechanisms. Male Genitourinary Examination
• Genetic testing Genetic Testing Detection of a mutation; genotype; karyotype; or specific alleles associated with genetic traits, heritable diseases, or predisposition to a disease, or that may lead to the disease in descendants. It includes prenatal genetic testing. Myotonic Dystrophies

Assessing disease severity

In clinical practice, global assessments are often used—for example, simply classifying disease as mild, moderate, or severe based on clinical presentation.^[15,22]

Several validated scoring systems exist. However, these are primarily used in clinical trials (rather than in day-to-day practice). Some of the most common include SCORAD, EASI, and POEM.^[3,4,15,21]

• Scoring of Atopic Dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) (SCORAD):^[21]
  • Calculator
  • Classic composite scoring system assessing both objective signs (e.g., lesions) and subjective symptoms (e.g., pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema), insomnia Insomnia Insomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking. Insomnia)
  • Total body surface area (BSA) affected by inflammatory lesions (can approximate the affected percentage of each body area (e.g., 25%, 50%, 75%, etc ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (ETC).) and combine that with the rule of 9s to calculate the total affected BSA):
    • Head and neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess (9% of BSA)
    • Upper limbs (each 9% of BSA)
    • Lower limbs (each 18% of BSA)
    • Anterior trunk (18% of BSA)
    • Back (18% of BSA)
    • Genitals (1% of BSA)
  • Intensity items (assesses 6 objective signs of disease, scored as 0 (absent), 1 (mild), 2 (moderate), or 3 (severe)):
    • Erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion
    • Edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
    • Oozing/crusting
    • Excoriations Excoriations Excoriation is a linear abrasion produced by mechanical means (scratching, rubbing, or picking) that usually involves only the epidermis but can reach the papillary dermis. Secondary Skin Lesions
    • Lichenification Lichenification Atopic Dermatitis (Eczema) ( skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions thickening)
    • Dryness
  • Subjective items (assesses 2 subjective symptoms, scored on a scale Scale Dermatologic Examination from 0 (none) to 10 (worst imaginable)):
    • Pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema)
    • Sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep loss
  • Score interpretations:
    • Mild disease: < 25
    • Moderate disease: 25‒50
    • Severe disease: > 50
• Eczema Eczema Atopic dermatitis, also known as eczema, is a chronic, relapsing, pruritic, inflammatory skin disease that occurs more frequently in children, although adults can also be affected. The condition is often associated with elevated serum levels of IgE and a personal or family history of atopy. Skin dryness, erythema, oozing, crusting, and lichenification are present. Atopic Dermatitis (Eczema) Area and Severity Index (EASI):^[15]
  • Assesses only objective signs (lesions), but not subjective symptoms 
  • Calculator
• Patient-Oriented Eczema Eczema Atopic dermatitis, also known as eczema, is a chronic, relapsing, pruritic, inflammatory skin disease that occurs more frequently in children, although adults can also be affected. The condition is often associated with elevated serum levels of IgE and a personal or family history of atopy. Skin dryness, erythema, oozing, crusting, and lichenification are present. Atopic Dermatitis (Eczema) Measure (POEM):
  • Assesses only subjective symptoms^[15]

Management

Management of atopic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) may vary depending on practice location. The following information is based on US, European, and UK recommendations. Refer to local guidelines for additional information.

Management overview based on disease severity^{[1‒5,16‒18,22]}

All patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship:

• Emollients Emollients Oleaginous substances used topically to soothe, soften or protect skin or mucous membranes. They are used also as vehicles for other dermatologic agents. Pityriasis Rosea and moisturizers (Note: These may not be tolerated well on acutely inflamed skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions.) 
• Avoid triggers.
• Topical antiseptics may be considered if bacterial superinfection or strong colonization Colonization Bacteriology is suspected.
• Wet wraps may be used for flare-ups and/or oozing/erosive lesions:^[16]
  • Typically, a topical agent is applied and then covered with wet bandages (and a top layer of dry bandages).
  • Worn for several hours (up to 24 hours) at a time 
  • Typically worn for several days, up to 2 weeks in a row
• Antihistamines Antihistamines Antihistamines are drugs that target histamine receptors, particularly H1 and H2 receptors. H1 antagonists are competitive and reversible inhibitors of H1 receptors. First-generation antihistamines cross the blood-brain barrier and can cause sedation. Antihistamines may help control itching and assist with sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep.

Mild/transient disease:

• Topical lower-potency corticosteroids Corticosteroids Chorioretinitis during flares are applied to affected areas once daily for up to 2‒4 weeks.
• If symptoms do not improve, consider switching agents (both applied twice daily during flares) to:
  • Topical calcineurin inhibitors Calcineurin Inhibitors Compounds that inhibit or block the phosphatase activity of calcineurin. Immunosuppressants
  • Topical crisaborole Crisaborole Phosphodiesterase Inhibitors
• Maintenance therapy: daily emollients Emollients Oleaginous substances used topically to soothe, soften or protect skin or mucous membranes. They are used also as vehicles for other dermatologic agents. Pityriasis Rosea 

Moderate/recurrent disease:

• Medium- to high-potency topical corticosteroids Corticosteroids Chorioretinitis are applied to affected areas during flare-ups once or twice daily for up to 2‒4 weeks.
• Maintenance therapy on affected areas 2 consecutive days/week:
  • Topical corticosteroids Corticosteroids Chorioretinitis
  • Topical calcineurin inhibitors Calcineurin Inhibitors Compounds that inhibit or block the phosphatase activity of calcineurin. Immunosuppressants
• Consider phototherapy Phototherapy Treatment of disease by exposure to light, especially by variously concentrated light rays or specific wavelengths. Hyperbilirubinemia of the Newborn.

Severe/persistent disease:

• Consider hospitalization Hospitalization The confinement of a patient in a hospital. Delirium.
• Specialist consultation can help guide management options.
• Systemic immunosuppression:
  • Prescribe until remission Remission A spontaneous diminution or abatement of a disease over time, without formal treatment. Cluster Headaches is achieved, then transition to maintenance therapy.
  • Options:
    • Phototherapy Phototherapy Treatment of disease by exposure to light, especially by variously concentrated light rays or specific wavelengths. Hyperbilirubinemia of the Newborn
    • Cyclosporin A
    • Biologic agents Biologic Agents Immunosuppressants (e.g., dupilumab Dupilumab Asthma Drugs)
    • Oral glucocorticoids Glucocorticoids Glucocorticoids are a class within the corticosteroid family. Glucocorticoids are chemically and functionally similar to endogenous cortisol. There are a wide array of indications, which primarily benefit from the antiinflammatory and immunosuppressive effects of this class of drugs. Glucocorticoids (short course as bridging therapy)
    • Methotrexate Methotrexate An antineoplastic antimetabolite with immunosuppressant properties. It is an inhibitor of tetrahydrofolate dehydrogenase and prevents the formation of tetrahydrofolate, necessary for synthesis of thymidylate, an essential component of DNA. Antimetabolite Chemotherapy
    • Azathioprine Azathioprine An immunosuppressive agent used in combination with cyclophosphamide and hydroxychloroquine in the treatment of rheumatoid arthritis. According to the fourth annual report on carcinogens, this substance has been listed as a known carcinogen. Immunosuppressants
    • Mycophenolate Mycophenolate Immunosuppressants mofetil
    • Janus kinase (JAK) inhibitors 
• Maintenance therapy on affected areas 2 consecutive days/week:
  • Topical calcineurin inhibitors Calcineurin Inhibitors Compounds that inhibit or block the phosphatase activity of calcineurin. Immunosuppressants
  • Topical corticosteroids Corticosteroids Chorioretinitis

In this approach, the designated interventions can also be added to the measures listed in the severity level below.

• Acute interventions: Treat acute flares.
• Reactive interventions: Initiate treatment as a reaction to a change in disease severity.
• Proactive interventions: Administer intermittent therapy to a previously affected area.

Supportive/prophylactic measures^{[2‒4,10,16,22]}

Patient education:

• Avoid triggers and exacerbating factors.
• Keep skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions well hydrated with emollients Emollients Oleaginous substances used topically to soothe, soften or protect skin or mucous membranes. They are used also as vehicles for other dermatologic agents. Pityriasis Rosea and moisturizers.
• Use gentle cleansers.
• No standard for bathing frequency or duration
• No restrictions on physical exercise, though sweating may induce flares:
  • Allow for progressive adaptation to exercise.
  • Shower and apply emollients Emollients Oleaginous substances used topically to soothe, soften or protect skin or mucous membranes. They are used also as vehicles for other dermatologic agents. Pityriasis Rosea immediately after exercise.
• Discuss safe use of topical corticosteroids Corticosteroids Chorioretinitis.

Elimination Elimination The initial damage and destruction of tumor cells by innate and adaptive immunity. Completion of the phase means no cancer growth. Cancer Immunotherapy of exacerbating factors:

• Avoid triggers:
  • Heat Heat Inflammation
  • Low humidity
  • Excessive bathing (without moisturization)
  • Stress and anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder
  • Exposure to solvents and detergents
  • Xerosis Xerosis Sjögren’s Syndrome (dry skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions)
  • Overheating of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions
  • Harsh detergents
  • Exposure to allergens (somewhat controversial):
    • Food
    • Inhalant
    • Contact
• Treat associated skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease:
  • S. aureus S. aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Staphylococcus
  • Herpes simplex Herpes Simplex A group of acute infections caused by herpes simplex virus type 1 or type 2 that is characterized by the development of one or more small fluid-filled vesicles with a raised erythematous base on the skin or mucous membrane. It occurs as a primary infection or recurs due to a reactivation of a latent infection. Congenital TORCH Infections

Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions hydration (mainstay of treatment to reduce itching and episodes of inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation):

• Emollients Emollients Oleaginous substances used topically to soothe, soften or protect skin or mucous membranes. They are used also as vehicles for other dermatologic agents. Pityriasis Rosea:
  • Thick creams or ointments (low or no water content) preferred
  • Apply to the whole skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions at least twice a day.
  • Immediately after bathing/showering or handwashing
  • Increase use in cold weather.
• Moisturizers containing:
  • Glycyrrhetinic acid
  • Urea Urea A compound formed in the liver from ammonia produced by the deamination of amino acids. It is the principal end product of protein catabolism and constitutes about one half of the total urinary solids. Urea Cycle
  • Glycerol
• Bath additives:
  • Controversial:
    • Recommended in Europe and by the American Academy of Allergy Allergy An abnormal adaptive immune response that may or may not involve antigen-specific IgE Type I Hypersensitivity Reaction, Asthma Asthma Asthma is a chronic inflammatory respiratory condition characterized by bronchial hyperresponsiveness and airflow obstruction. The disease is believed to result from the complex interaction of host and environmental factors that increase disease predisposition, with inflammation causing symptoms and structural changes. Patients typically present with wheezing, cough, and dyspnea. Asthma, and Immunology
    • Not recommended by the American Academy of Dermatology, which cites a lack of evidence.
  • Potential options:
    • Oils
    • Colloidal oatmeal

Medications

Topical treatments:^{[1‒5,16‒18,22,23]}

• Corticosteroids Corticosteroids Chorioretinitis:
  • Typically considered 1st-line agents
  • Prolonged use may cause skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation or other adverse effects.
  • Avoid daily use on the face for > 1 month.
  • Strategies:
    • Use lowest- or low-potency agents 1st, and increase potency if these fail.
    • Use shorter courses of higher-potency steroids Steroids A group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus. Benign Liver Tumors (followed by a taper) to achieve more rapid control.
• Calcineurin inhibitors Calcineurin Inhibitors Compounds that inhibit or block the phosphatase activity of calcineurin. Immunosuppressants:
  • Used for both acute and maintenance therapy:
    • Effective at treating itching and pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
    • May cause irritation when applied to inflamed skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions (reason why it is often used after topical corticosteroids Corticosteroids Chorioretinitis)
  • Preferred over topical steroids Steroids A group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus. Benign Liver Tumors in the following cases:^[16]
    • Recalcitrance to steroids Steroids A group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus. Benign Liver Tumors
    • Steroid-induced atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation and/or long-term topical steroid use
    • Sensitive areas: face, anogenital areas, skinfolds
  • Options:
    • Tacrolimus Tacrolimus A macrolide isolated from the culture broth of a strain of streptomyces tsukubaensis that has strong immunosuppressive activity in vivo and prevents the activation of T-lymphocytes in response to antigenic or mitogenic stimulation in vitro. Immunosuppressants 0.03% or 0.1% ointment
    • Pimecrolimus Pimecrolimus Immunosuppressants 1% cream 
  • Application:
    • During flares, apply twice daily.
    • Maintenance: once daily for 2 consecutive days each week
• Phosphodiesterase 4 (PDE4) inhibitors:
  • Reduce itching and inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation by reducing IL-4 and IL-31
  • Used in mild to moderate disease^[23]
  • May be an alternative to topical corticosteroids Corticosteroids Chorioretinitis or calcineurin inhibitors Calcineurin Inhibitors Compounds that inhibit or block the phosphatase activity of calcineurin. Immunosuppressants
  • Option: crisaborole Crisaborole Phosphodiesterase Inhibitors 2% ointment applied to affected areas twice daily
  • Note: Crisaborole Crisaborole Phosphodiesterase Inhibitors is not available in the UK or Europe.
• Topical antimicrobials:^[5,16]
  • “Bleach baths” (e.g., diluted 0.005% sodium Sodium A member of the alkali group of metals. It has the atomic symbol na, atomic number 11, and atomic weight 23. Hyponatremia hypochlorite) can be considered for:
    • Clinical signs of bacterial superinfection
    • Chronic, treatment-resistant disease
  • Silver-coated textiles
• Note: The AAD recommends against using topical antihistamines Antihistamines Antihistamines are drugs that target histamine receptors, particularly H1 and H2 receptors. H1 antagonists are competitive and reversible inhibitors of H1 receptors. First-generation antihistamines cross the blood-brain barrier and can cause sedation. Antihistamines.

Immunomodulatory agents:^[1,3,17]

• Cyclosporin A:
  • 1st-line option for severe/refractory disease
  • Suppresses T cells T cells Lymphocytes responsible for cell-mediated immunity. Two types have been identified – cytotoxic (t-lymphocytes, cytotoxic) and helper T-lymphocytes (t-lymphocytes, helper-inducer). They are formed when lymphocytes circulate through the thymus gland and differentiate to thymocytes. When exposed to an antigen, they divide rapidly and produce large numbers of new T cells sensitized to that antigen. T cells: Types and Functions and IL-2
  • Dosing:
    • 2.5‒6 mg/kg/day (children and adults) → typically 150‒300 mg/day for adults
    • Higher doses → more rapid control of disease
  • Requires blood pressure and basic lab monitoring (CBC, comprehensive metabolic panel Comprehensive metabolic panel Primary vs Secondary Headaches (CMP), lipids Lipids Lipids are a diverse group of hydrophobic organic molecules, which include fats, oils, sterols, and waxes. Fatty Acids and Lipids)
  • Recurrence common upon discontinuation of treatment

• Biologics:
  • Options:
    • Dupilumab Dupilumab Asthma Drugs (inhibits IL-4 and IL-13)
    • Tralokinumab (inhibits IL-13)
    • Additional agents are in development.
  • Dosing:
    • Adult dosing (for both agents): 600 mg subcutaneously loading dose Loading Dose Dosage Calculation, followed by 300 mg every 2 weeks
    • Pediatric dupilumab Dupilumab Asthma Drugs dosing (15‒60 kg): 300 mg subcutaneously on days 1 and 15, and then every 4 weeks
• Azathioprine Azathioprine An immunosuppressive agent used in combination with cyclophosphamide and hydroxychloroquine in the treatment of rheumatoid arthritis. According to the fourth annual report on carcinogens, this substance has been listed as a known carcinogen. Immunosuppressants:
  • Purine analog preferentially affecting highly proliferative cells, including B and T cells T cells Lymphocytes responsible for cell-mediated immunity. Two types have been identified – cytotoxic (t-lymphocytes, cytotoxic) and helper T-lymphocytes (t-lymphocytes, helper-inducer). They are formed when lymphocytes circulate through the thymus gland and differentiate to thymocytes. When exposed to an antigen, they divide rapidly and produce large numbers of new T cells sensitized to that antigen. T cells: Types and Functions, during inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation
  • Slower onset of action compared to cyclosporin A
  • Dosing (children and adults): 1‒3 mg/kg/day
  • Consider discontinuation if no improvement is seen within 3 months.
• Methotrexate Methotrexate An antineoplastic antimetabolite with immunosuppressant properties. It is an inhibitor of tetrahydrofolate dehydrogenase and prevents the formation of tetrahydrofolate, necessary for synthesis of thymidylate, an essential component of DNA. Antimetabolite Chemotherapy:
  • Antifolate agent blocking synthesis Synthesis Polymerase Chain Reaction (PCR) of DNA DNA A deoxyribonucleotide polymer that is the primary genetic material of all cells. Eukaryotic and prokaryotic organisms normally contain DNA in a double-stranded state, yet several important biological processes transiently involve single-stranded regions. DNA, which consists of a polysugar-phosphate backbone possessing projections of purines (adenine and guanine) and pyrimidines (thymine and cytosine), forms a double helix that is held together by hydrogen bonds between these purines and pyrimidines (adenine to thymine and guanine to cytosine). DNA Types and Structure, RNA RNA A polynucleotide consisting essentially of chains with a repeating backbone of phosphate and ribose units to which nitrogenous bases are attached. RNA is unique among biological macromolecules in that it can encode genetic information, serve as an abundant structural component of cells, and also possesses catalytic activity. RNA Types and Structure, and purines Purines A series of heterocyclic compounds that are variously substituted in nature and are known also as purine bases. They include adenine and guanine, constituents of nucleic acids, as well as many alkaloids such as caffeine and theophylline. Uric acid is the metabolic end product of purine metabolism. Nucleic Acids and negatively affecting T cell function
  • Slower onset of action compared to cyclosporin A
  • Dosing:
    • Adults: 5‒25 mg/wk
    • Children: 0.3‒0.5 mg/kg/wk
  • Requires lab monitoring
• Mycophenolate Mycophenolate Immunosuppressants mofetil:
  • Inhibits purine synthesis Synthesis Polymerase Chain Reaction (PCR) → affects B and T cells T cells Lymphocytes responsible for cell-mediated immunity. Two types have been identified – cytotoxic (t-lymphocytes, cytotoxic) and helper T-lymphocytes (t-lymphocytes, helper-inducer). They are formed when lymphocytes circulate through the thymus gland and differentiate to thymocytes. When exposed to an antigen, they divide rapidly and produce large numbers of new T cells sensitized to that antigen. T cells: Types and Functions
  • Considered an alternative agent for severe disease
  • Dosing:
    • Adults: 1.0‒1.5 g twice daily
    • Children: 30‒50 mg/kg/day 
  • Requires lab monitoring
• Oral corticosteroids Corticosteroids Chorioretinitis:
  • Routine use is discouraged.
  • Short courses (up to 1 week) can be considered during acute flares (as a bridge to alternative therapies).
  • Should be limited to adults with severe disease
  • Typical dosing: 0.5 mg/kg
  • Long-term use is not recommended.
• Janus kinase (JAK) inhibitors:
  • Affect inflammatory processes through alterations in intracellular signaling
  • Newest class of agents → least data on safety and efficacy
  • Licensed for ≥ 30 kg of body weight
  • Options:
    • Baricitinib Baricitinib Targeted and Other Nontraditional Antineoplastic Therapy 4 mg daily → may be reduced to 2 mg/day
    • Upadacitinib 15 or 30 mg once daily
• Oral antihistamines Antihistamines Antihistamines are drugs that target histamine receptors, particularly H1 and H2 receptors. H1 antagonists are competitive and reversible inhibitors of H1 receptors. First-generation antihistamines cross the blood-brain barrier and can cause sedation. Antihistamines:

• Opt for H1-blocking agents.
• Beneficial when sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep disturbed by pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema)
• Options:
  • Diphenhydramine Diphenhydramine A histamine h1 antagonist used as an antiemetic, antitussive, for dermatoses and pruritus, for hypersensitivity reactions, as a hypnotic, an antiparkinson, and as an ingredient in common cold preparations. It has some undesired antimuscarinic and sedative effects. Antihistamines
  • Hydroxyzine Hydroxyzine A histamine h1 receptor antagonist that is effective in the treatment of chronic urticaria, dermatitis, and histamine-mediated pruritus. Unlike its major metabolite cetirizine, it does cause drowsiness. It is also effective as an antiemetic, for relief of anxiety and tension, and as a sedative. Antihistamines
  • Cyproheptadine Cyproheptadine A serotonin antagonist and a histamine h1 blocker used as antipruritic, appetite stimulant, antiallergic, and for the post-gastrectomy dumping syndrome, etc. Serotonin Syndrome

Phototherapy Phototherapy Treatment of disease by exposure to light, especially by variously concentrated light rays or specific wavelengths. Hyperbilirubinemia of the Newborn^[3,6,17,22]

• Used in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with diffuse pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema) not controlled with topical therapy alone
• Reduced production of histamine from mast cells Mast cells Granulated cells that are found in almost all tissues, most abundantly in the skin and the gastrointestinal tract. Like the basophils, mast cells contain large amounts of histamine and heparin. Unlike basophils, mast cells normally remain in the tissues and do not circulate in the blood. Mast cells, derived from the bone marrow stem cells, are regulated by the stem cell factor. Innate Immunity: Phagocytes and Antigen Presentation and basophils Basophils Granular leukocytes characterized by a relatively pale-staining, lobate nucleus and cytoplasm containing coarse dark-staining granules of variable size and stainable by basic dyes. Innate Immunity: Phagocytes and Antigen Presentation
• Options:
  • Narrowband ultraviolet B (NBUVB) → most commonly recommended
  • Broadband ultraviolet B
  • Ultraviolet A1 (UVA1)
• Large variations in treatment protocols (dose and schedule); protocols are specific to the type of UV used
• Dosage Dosage Dosage Calculation is typically determined according to Fitzpatrick skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions type.

Differential Diagnosis

• Contact dermatitis Contact dermatitis A type of acute or chronic skin reaction in which sensitivity is manifested by reactivity to materials or substances coming in contact with the skin. It may involve allergic or non-allergic mechanisms. Male Genitourinary Examination: an erythematous, papular dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema), often with areas of vesiculation. Occurs due to direct skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions exposure to an offending irritant with a direct cytotoxic Cytotoxic Parvovirus B19 effect. Diagnosis is made by history and physical exam findings. Treatment is with avoidance of offending irritants and adoption of protective measures as well as emollients Emollients Oleaginous substances used topically to soothe, soften or protect skin or mucous membranes. They are used also as vehicles for other dermatologic agents. Pityriasis Rosea and moisturizers. Topical steroids Steroids A group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus. Benign Liver Tumors are the 1st-line intervention.
• Seborrheic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema): a chronic, relapsing, and usually mild form of dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) with a biphasic incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency in infants and adults. The condition is characterized by well-demarcated, erythematous plaques with greasy-appearing, yellow-like scales Scales Dry or greasy masses of keratin that represent thickened stratum corneum. Secondary Skin Lesions in sebaceous gland-rich areas. The cause is unknown, but sebaceous glands appear to be necessary for the development of the disorder. The diagnosis is made clinically. Treatment is with topical antifungal Antifungal Azoles, antiinflammatory, and over-the-counter agents.
• Diaper dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema): a form of irritant dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) most common in infants and children. Excessive moisture, friction, increased pH pH The quantitative measurement of the acidity or basicity of a solution. Acid-Base Balance, and high enzymatic activity contribute to local disruption of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions barrier. The condition is limited to the groin Groin The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination area and often spares folds where urine/feces do not contact the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions. The diagnosis is made clinically. Treatment involves general skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions care measures (frequent diaper changes, exposure to air, and cleaning), topical steroids Steroids A group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus. Benign Liver Tumors, and antifungals (in severe cases of superinfection by Candida Candida Candida is a genus of dimorphic, opportunistic fungi. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis, and meningitis). Candida/Candidiasis).
• Psoriasis Psoriasis Psoriasis is a common T-cell-mediated inflammatory skin condition. The etiology is unknown, but is thought to be due to genetic inheritance and environmental triggers. There are 4 major subtypes, with the most common form being chronic plaque psoriasis. Psoriasis: a common chronic inflammatory skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions disorder characterized by erythematous papules and plaques with a silver scale Scale Dermatologic Examination. Psoriasis Psoriasis Psoriasis is a common T-cell-mediated inflammatory skin condition. The etiology is unknown, but is thought to be due to genetic inheritance and environmental triggers. There are 4 major subtypes, with the most common form being chronic plaque psoriasis. Psoriasis is a complex immune-mediated disease whereby T lymphocytes T lymphocytes Lymphocytes responsible for cell-mediated immunity. Two types have been identified – cytotoxic (t-lymphocytes, cytotoxic) and helper T-lymphocytes (t-lymphocytes, helper-inducer). They are formed when lymphocytes circulate through the thymus gland and differentiate to thymocytes. When exposed to an antigen, they divide rapidly and produce large numbers of new T cells sensitized to that antigen. T cells: Types and Functions, cytokines Cytokines Non-antibody proteins secreted by inflammatory leukocytes and some non-leukocytic cells, that act as intercellular mediators. They differ from classical hormones in that they are produced by a number of tissue or cell types rather than by specialized glands. They generally act locally in a paracrine or autocrine rather than endocrine manner. Adaptive Immune Response, dendritic cells Dendritic cells Specialized cells of the hematopoietic system that have branch-like extensions. They are found throughout the lymphatic system, and in non-lymphoid tissues such as skin and the epithelia of the intestinal, respiratory, and reproductive tracts. They trap and process antigens, and present them to T-cells, thereby stimulating cell-mediated immunity. They are different from the non-hematopoietic follicular dendritic cells, which have a similar morphology and immune system function, but with respect to humoral immunity (antibody production). Skin: Structure and Functions, and tumor Tumor Inflammation necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage factor play a predominant role. Previously, it was viewed as a disease of hyperproliferation. Diagnosis is made by physical exam. Management is with topical corticosteroids Corticosteroids Chorioretinitis, phototherapy Phototherapy Treatment of disease by exposure to light, especially by variously concentrated light rays or specific wavelengths. Hyperbilirubinemia of the Newborn, retinoids Retinoids Retinol and derivatives of retinol that play an essential role in metabolic functioning of the retina, the growth of and differentiation of epithelial tissue, the growth of bone, reproduction, and the immune response. Dietary vitamin A is derived from a variety of carotenoids found in plants. It is enriched in the liver, egg yolks, and the fat component of dairy products. Fat-soluble Vitamins and their Deficiencies, methotrexate Methotrexate An antineoplastic antimetabolite with immunosuppressant properties. It is an inhibitor of tetrahydrofolate dehydrogenase and prevents the formation of tetrahydrofolate, necessary for synthesis of thymidylate, an essential component of DNA. Antimetabolite Chemotherapy, cyclosporin, or biologic immune modifying agents.
• Scabies Scabies Scabies is an infestation of the skin by the Sarcoptes scabiei mite, which presents most commonly with intense pruritus, characteristic linear burrows, and erythematous papules, particularly in the interdigital folds and the flexor aspects of the wrists. Scabies: a cutaneous infestation caused by the mite Sarcoptes scabiei Sarcoptes scabiei A species of mite that causes scabies in humans and sarcoptic mange in other animals. Specific variants of s. Scabiei exist for humans and animals, but many have the ability to cross species and cause disease. Scabies. Scabies Scabies Scabies is an infestation of the skin by the Sarcoptes scabiei mite, which presents most commonly with intense pruritus, characteristic linear burrows, and erythematous papules, particularly in the interdigital folds and the flexor aspects of the wrists. Scabies is an intensely pruritic eruption with small erythematous papules on the fingers, wrists, axillae, areolae, waist, genitalia, and buttocks areas. Diagnosis is by history and physical exam along with detection of mites Mites Any arthropod of the subclass acari except the ticks. They are minute animals related to the spiders, usually having transparent or semitransparent bodies. They may be parasitic on humans and domestic animals, producing various irritations of the skin (mite infestations). Many mite species are important to human and veterinary medicine as both parasite and vector. Mites also infest plants. Scabies, eggs, or fecal pellets under microscopic evaluation. Treatment is aimed at both the patient and close contacts. Topical permethrin Permethrin A pyrethroid insecticide commonly used in the treatment of lice infestations and scabies. Scabies and oral ivermectin Ivermectin A mixture of mostly avermectin h2b1a (rn 71827-03-7) with some avermectin h2b1b (rn 70209-81-3), which are macrolides from streptomyces avermitilis. It binds glutamate-gated chloride channel to cause increased permeability and hyperpolarization of nerve and muscle cells. It also interacts with other chloride channels. It is a broad spectrum antiparasitic that is active against microfilariae of onchocerca volvulus but not the adult form. Anthelmintic Drugs are the mainstays of therapy.
• Mycosis fungoides Mycosis fungoides A chronic, malignant T-cell lymphoma of the skin. In the late stages, the lymph nodes and viscera are affected. Non-Hodgkin Lymphomas: a type of cutaneous T cell lymphoma Lymphoma A general term for various neoplastic diseases of the lymphoid tissue. Imaging of the Mediastinum. The disease presents in the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions but also can involve the lymph nodes Lymph Nodes They are oval or bean shaped bodies (1 – 30 mm in diameter) located along the lymphatic system. Lymphatic Drainage System: Anatomy, blood, and viscera. Mycosis fungoides Mycosis fungoides A chronic, malignant T-cell lymphoma of the skin. In the late stages, the lymph nodes and viscera are affected. Non-Hodgkin Lymphomas often involves sites beneath undergarments and is uncommon in children. The disease presents with persistent progressive skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions lesions of varying shapes and sizes and can be localized or widespread plaques or tumors, or generalized erythroderma. Pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema) is common. Diagnosis is clinical along with skin biopsy Skin Biopsy Secondary Skin Lesions with routine histology. Treatment involves topical agents, including steroids Steroids A group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus. Benign Liver Tumors, chemotherapy Chemotherapy Osteosarcoma, retinoids Retinoids Retinol and derivatives of retinol that play an essential role in metabolic functioning of the retina, the growth of and differentiation of epithelial tissue, the growth of bone, reproduction, and the immune response. Dietary vitamin A is derived from a variety of carotenoids found in plants. It is enriched in the liver, egg yolks, and the fat component of dairy products. Fat-soluble Vitamins and their Deficiencies, imiquimod Imiquimod A topically-applied aminoquinoline immune modulator that induces interferon production. It is used in the treatment of external genital and perianal warts, superficial carcinoma, basal cell; and actinic keratosis. Hypertrophic and Keloid Scars, local radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma, and phototherapy Phototherapy Treatment of disease by exposure to light, especially by variously concentrated light rays or specific wavelengths. Hyperbilirubinemia of the Newborn.