ATOPIC DERMATITIS   1A

A 30-year-old woman presents to her primary care provider with an itchy rash on her hands, wrists, and arms. She states she has had similar rashes before that had gone away with over-the-counter hydrocortisone cream. The first episode occurred when she was very young. Her past medical history includes asthma. She takes loratadine occasionally for allergic rhinitis. Physical examination reveals plaques on the hands, wrists, and antecubital folds that are mildly exudative and without scale. Laboratory testing shows eosinophilia and an elevated serum IgE level.

What are the salient features of this patient’s problems? How do you think through her problems?

Salient features: Pruritic rash in distribution of hands, wrists, antecubital folds; similar symptoms starting in childhood; personal history of atopic conditions (asthma, allergic rhinitis); plaques with exudates and without scale; eosinophilia and elevated serum IgE level

How to think through: It is important to think broadly about possible causes of rash in this patient despite her strong atopic history. Might this be seborrheic dermatitis? (Seborrheic dermatitis typically involves the face and scalp.) A fungal infection? (Prior similar manifestations have resolved with topical corticosteroid treatment, making this unlikely.) Psoriasis? (The distribution and absence of silvery scale makes this unlikely.) Contact dermatitis? (This is a reasonable consideration. Contact dermatitis can be indistinguishable from atopic dermatitis, and in this case, the rash is similarly confined to exposed areas of the body.) What would raise your suspicion for contact dermatitis? (A history of new potential allergen or irritant exposure.) After considering the above, a diagnosis of atopic dermatitis is most likely given the prior atopy (asthma and allergic rhinitis), recurrence of similar symptoms since childhood, eosinophilia, and elevated IgE. How should she be treated? (Midpotency topical corticosteroids twice daily with subsequent tapering to low-potency corticosteroids with emollient applied frequently. This patient’s presentation is unlikely to require oral corticosteroid treatment. An oral antihistamine for itching may be helpful.) How would you counsel this patient to prevent future flares? (Avoid excessive bathing and hand washing. Use mild soaps. Apply emollient after washing. Trim fingernails and wrap affected areas at night to prevent scratching.)

ATOPIC DERMATITIS   1B

What are the essentials of diagnosis and general considerations regarding atopic dermatitis?

Essentials of Diagnosis

Pruritic, exudative, or lichenified eruption on the face, neck, upper trunk, wrists, hands, antecubital and popliteal folds

Personal or family history of allergies or asthma with a tendency to recur

Onset in childhood in most patients; onset after age 30 years is very uncommon

General Considerations

Also known as eczema

Looks different at different ages and in people of different races

Diagnostic criteria include pruritus, onset in childhood, chronicity, and typical morphology and distribution (flexural lichenification; hand, nipple, and eyelid eczema in adults)

Also helpful diagnostically are a personal or family history of atopic disease such as asthma, atopic dermatitis or allergic rhinitis, xerosis–ichthyosis, facial pallor with intraorbital darkening, elevated serum IgE, and repeated skin infections

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