A 13 month-old female came to clinic with dry itchy skin that has been worsening over 3 days. The mother noticed that it is worse on her arms, legs and face, and she has had dry skin before that she treated with some lotion occasionally. She has been scratching quite a bit and the areas are becoming redder. The family history shows that mother has dry skin also.
The pertinent physical exam reveals a healthy female with generalized dry skin that is mainly papular and red. Excoriation is seen on the cheeks, behind the ears, and in the flexural areas of the elbows and knees. These areas are also more pink-red in color than the surrounding skin. There are no areas that appear infected. The diagnosis of atopic dermatitis was made. Her mother was educated as to the natural history of the disease. She was told to use “thick” emollients such as petrolatum to protect her skin and use them every couple of hours to keep her skin moist. She was also told to use thinner emollients, such as a cream or lotion, if she was going to be in a warm place so she wouldn’t sweat under the emollients and irritate her skin. After bathing with a mild “beauty bar” such as Dove® or a non-soap alternative such as Cetaphil® she could pat her dry and apply the emollients.
Atopic dermatitis or eczema is a common dermatological skin problem which characteristically is a pruritic, papular eruption with erythema. Like most papulosquamous eruptions it often occurs in intertrigenous areas in people with allergic constitutions or with a family history of atopy. It does not have scale which occur in other papulosquamous eruptions such as psoriasis or tinea. Sometimes atopic dermatitis is described as the “itch that rashes.” Rubbing and scratching can lead to excoriation and, over time, lichenification. There can also be secondary infections or changes to the skin pigmentation (hyper- or hypo-) in affected areas. Emollients for skin rehydration are a mainstay of treatment. Topical steroids are commonly used to decrease inflammation in affected areas. Immunosuppressants such as tacrolimus are also used in some cases.
Complications includes secondary bacterial infections with Group A Beta-hemolytic Streptococcus or Staphlococcal species. Oral or intravenous treatment of bacterial infections is common with appropriate agents. Eczema herpeticum is another complication which has an umbilicated appearance of papular, vesicular and pustular lesions. Luckily, eczema vaccinatum (caused by smallpox virus) does not occur anymore because of no circulating virus in most parts of the world.
The differential diagnosis of atopic dermatitis includes:
- Variants include
- Dishydrotic eczema
- Ichthyosis vulgaris
- Keratosis pilaris
- Nummular eczema
- Perioral dermatitis
- Pitaryiasis alba
- Variants include
- Contact dermatitis
- Allergic- papular or papulovesicular that is pruritic
- Irritant contact dermatitis – usually milder, less pruritic, often seen on cheeks/chin because of saliva or areas that are rubbed
- Seborrheic dermatitis – greasy yellow or pink-colored scale with little pruritis. See also this case.
- Scabies – highly pruritic, may or may not see linear burrows. See also this case.
- Tinea corporis – pink papular round lesions with small scale on the edge
- Acrodermatitis enteropathica – papular, vesicular and bullous lesions, has failure to thrive, alopecia, diarrhea and nail changes, associated with zinc deficiency
- Drug eruptions
- Ichythiosis and other keratin disorders
- Lymphoma, cutaneous
- Phenylketonuria – usually diagnosed because of screening, but may have diffuse hypopigmentation, eczema, photosensitivity as dermatological changes.
- Psoriasis – more on extensor surfaces with mica-like scale, has delinated border
- Wiskott-Aldrich syndrome – X-linked recessive, severe eczema with thrombocytopenic purpura and immune deficiencies
Questions for Further Discussion
1. What is the difference between atopic dermatitis and ichythosis?
2. How have immunomodulators changed the treatment of atopic dermatitis?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Eczema
To view current news articles on this topic check Google News.
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Krakowski AC, Eichenfield LF, Dohil MA. Management of atopic dermatitis in the pediatric population. Pediatrics. 2008 Oct;122(4):812-24.
Hebert AA. Atopic Dermatitis. ePocrates.
Available from the Internet at https://online.epocrates.com/u/293587/A. (rev. 1/18/2013, cited 1/28/13).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital