Eczema

1. Atopic Dermatitis
DR. SHILPA SONIDR. SHILPA SONI

2. Atopic Dermatitis: Definition
Atopic dermatitis = eczema = itchy skinAtopic dermatitis = eczema = itchy skin
Greek- meaning Greek- meaning

(ec-) over(ec-) over

(-ze) out (-ze) out

(-ma) boiling (-ma) boiling
Infants & small children (affects 1 in 7)Infants & small children (affects 1 in 7)
Atopic dermatitis of childhood may reappear at Atopic dermatitis of childhood may reappear at
different site later in life.different site later in life.

3. Etiology
DECREASED SKIN BARRIER DECREASED SKIN BARRIER
FUNCTION- FUNCTION-
-reduced filaggrin & loricrin ceramide levels reduced filaggrin & loricrin ceramide levels
((loss of FLG gene on chr 1q21loss of FLG gene on chr 1q21))
-Reduced ceramide levelsReduced ceramide levels
-increased levels of endogenous proteolytic increased levels of endogenous proteolytic
enzymesenzymes
-Enhanced TEWLEnhanced TEWL

4. SKIN BARRIER MAY ALSO BE SKIN BARRIER MAY ALSO BE
DAMAGED BY EXOGENOUS DAMAGED BY EXOGENOUS
PROTEASES BY –PROTEASES BY –
-HOUSE DUST MITES HOUSE DUST MITES
-Staphylococcus aureusStaphylococcus aureus

5. Atopic Dermatitis: Cause
The exact cause is unknown. The exact cause is unknown.

6. Atopic Dermatitis: Cause

7. Atopic Dermatitis: Cause
? Inborn skin defect that tends to run in families, e.g. ? Inborn skin defect that tends to run in families, e.g.
asthma or hay feverasthma or hay fever
85% with high serum IgE and + skin tests food & inhalant 85% with high serum IgE and + skin tests food & inhalant

8. Morphology

9. Distribution
In infantsIn infants, the , the faceface is often affected first, is often affected first,
then the hands and feet; dry red patches then the hands and feet; dry red patches
may appear all over the body.may appear all over the body.
In older children,In older children, the the skin foldsskin folds are most are most
often affected, especially the elbow creases often affected, especially the elbow creases
and behind the knees.and behind the knees.
In adultsIn adults, the , the faceface and and handshands are more likely are more likely
to be involved.to be involved.

10. Distribution

14. Hand Eczema

15. Foot Eczema

16. Atopic
Derm
Adults

17. Atopic Derm Adults

18. Atopic Dermatitis:
Associated features
The skin is usually dry, itchy & easily irritated by:The skin is usually dry, itchy & easily irritated by:

soap soap

detergents detergents

wool clothingwool clothing
May worsen in hot weather & emotional stress.May worsen in hot weather & emotional stress.
May worsen with exposure to dust & cats. May worsen with exposure to dust & cats.

19. Associated Findings
Pityriasis albaPityriasis alba

20. Associated Findings
XerosisXerosis

21. Associated Findings
Keratosis PilarisKeratosis Pilaris

22. Associated
Findings
IchthyosisIchthyosis

23. Hyperlinear Palmar Creases

24. Pharmacological & vascular
abnormalities in patients with AD
White dermographismWhite dermographism
Delayed blanch with acetylcholineDelayed blanch with acetylcholine
White reaction to nicotinic acid estersWhite reaction to nicotinic acid esters
Abnormal reactions to histamine in affected Abnormal reactions to histamine in affected
skinskin
Low finger temperatureLow finger temperature
Pronounced vasoconstriction on exposure to Pronounced vasoconstriction on exposure to
coldcold

25. Diagnosis
Major characteristicsMajor characteristics

Pruritus with or without excoriationPruritus with or without excoriation

Typical morphology and distributionTypical morphology and distribution

Chronic relapsing dermatitisChronic relapsing dermatitis

Personal or family history of atopy (asthma, allergy, Personal or family history of atopy (asthma, allergy,
atopic derm, contact urticaria)atopic derm, contact urticaria)
OtherOther characteristics characteristics

Xerosis/Ichthyosis/palmar hyper kerat. pilarisXerosis/Ichthyosis/palmar hyper kerat. pilaris

Early age of onsetEarly age of onset

Cutaneous colonization and/or overt infectionsCutaneous colonization and/or overt infections

Hand/foot/nipple/contact dermatitis, cheilitis, Hand/foot/nipple/contact dermatitis, cheilitis,
conjunctivitis, conjunctivitis, ErythrodermaErythroderma, subcapsular cataracts, , subcapsular cataracts,
dennie morgan folds, allergic shiners, facial pallor.dennie morgan folds, allergic shiners, facial pallor.

26. HANIFIN & RAJKAS DIAGNOSTIC
CRITARIA FOR AD
An itchy skin condition (or parentral report An itchy skin condition (or parentral report
of scrathing or rubbing in a child) of scrathing or rubbing in a child) PLUS PLUS 3
or more than 3 of the following-
-Onset <2 yrs of age.
-H/O skin crease involvement. (including
cheeks in children <10 yrs of age.)
-H/O generally dry skin.
-Personal H/O other atopic disease child
below 4 yrs or FDR +
-Visible flexural dermatitis.

27. UK WORKING PARTY
CRITERIA.
-H/O flexural dermatitis;H/O flexural dermatitis;
-Onset under age of 2 years;Onset under age of 2 years;
-Presence of an itchy rash;Presence of an itchy rash;
-Personal H/O asthma;Personal H/O asthma;
-H/O dry skin; andH/O dry skin; and
-Visible flexural dermatitis.Visible flexural dermatitis.
1 MAJOR + 3 MINOR1 MAJOR + 3 MINOR

29. LABORATORY TESTS
Raised serum IgE levels (70-80%)Raised serum IgE levels (70-80%)
Allergic to food /+ inhalant allergensAllergic to food /+ inhalant allergens
Concomitent rhinitis and asthama Concomitent rhinitis and asthama
Eosinophilia Eosinophilia
Increased histamine levesIncreased histamine leves

30. Differential Diagnosis
Seborrheic Seborrheic
dermatitisdermatitis

31. Differential Diagnosis
Seborrheic dermatitisSeborrheic dermatitis
ScabiesScabies

32. Differential Diagnosis
Seborrheic dermatitisSeborrheic dermatitis
ScabiesScabies
DrugsDrugs

33. Differential Diagnosis
Seborrheic dermatitisSeborrheic dermatitis
ScabiesScabies
DrugsDrugs
PsoriasisPsoriasis

34. Differential Diagnosis
Seborrheic Seborrheic
dermatitisdermatitis
ScabiesScabies
DrugsDrugs
PsoriasisPsoriasis
Allergic contact Allergic contact
dermatitisdermatitis

35. Differential Diagnosis
Seborrheic dermatitisSeborrheic dermatitis
ScabiesScabies
DrugsDrugs
PsoriasisPsoriasis
Allergic contact dermatitisAllergic contact dermatitis
Cutaneous T-cell lymphomaCutaneous T-cell lymphoma
Hyper IgE syndrome(Job’s Hyper IgE syndrome(Job’s
synd.)synd.)
Hypereosinophilic syndHypereosinophilic synd
Wiskott-Aldrich syndWiskott-Aldrich synd
Netherton syndNetherton synd

36. Atopic Dermatitis: Treatment
1. Reduce contact with irritants 1. Reduce contact with irritants (soap substitutes)(soap substitutes)
2. Reduce exposure to allergens2. Reduce exposure to allergens
3. Emollients3. Emollients
4. Topical Steroids4. Topical Steroids
5. Antihistamines5. Antihistamines
6. Antibiotics6. Antibiotics
7. Steroid sparing7. Steroid sparing
8. Other (herbals, soaps)8. Other (herbals, soaps)
9. Systmic therapies9. Systmic therapies
10. Other therapies10. Other therapies

37. 1. Reduce contact with irritants
Avoid overheating: lukewarm
baths, 100% cotton clothes, &
keep bedding to minimum
Avoid direct skin contact with
rough fibers, particularly wool,
& limit/eliminate detergents
Avoid dusty conditions & low
humidity
Avoid cosmetics (make-ups,
perfumes) as all can irritate
Avoid soap- use soap substitute
Use gloves to handle chemicals
and detergents

38. Soap Substitutes
Cetaphil / moiz - soap substitute- far less drying and
irritating than soap
Cleansing & moisturizing formulations
Lotion, bar, ‘soap’, cream, sunscreen

39. 2. Reduce exposure to
allergens
Keep home, especially bedroom, Keep home, especially bedroom,
free of dust. free of dust.
Allergic reactions include house Allergic reactions include house
dust mite, molds, grass pollens & dust mite, molds, grass pollens &
animal dander. animal dander.
Special diets will Special diets will notnot help most help most
individuals b/c little evidence that individuals b/c little evidence that
food is major culprit. food is major culprit.
If food allergies exists, most likely If food allergies exists, most likely
d/t dairy products, eggs, wheat, nuts, d/t dairy products, eggs, wheat, nuts,
shellfish, certain fruits or food shellfish, certain fruits or food
additives. additives.

40. 3. Emollients
 Emollients soften the skin soft and reduce itching.Emollients soften the skin soft and reduce itching.
 Moisture Trapping effectiveness Moisture Trapping effectiveness

Best:Best: Oils (e.g. Petroleum Jelly) Oils (e.g. Petroleum Jelly)

ModerateModerate: Creams : Creams

Least: Lotions Least: Lotions
 Apply emollients Apply emollients after bathingafter bathing and times when the skin and times when the skin
is unusually dry (e.g. winter months).is unusually dry (e.g. winter months).

41. Emollients (cont’d)
Large variety.Large variety.
Inexpensive emollients include vegetable shortening and Inexpensive emollients include vegetable shortening and
petroleum jelly (Vaseline)petroleum jelly (Vaseline)
Urea creamsUrea creams
OilsOils

42. Emollients: Alpha-Hydroxy acid
 Creams are excellent for relieving dryness, but Creams are excellent for relieving dryness, but cancan
stingsting & & sometimes aggravate eczemasometimes aggravate eczema
 Useful for maintenance when no longer inflamedUseful for maintenance when no longer inflamed
 Forces epidermal cells to produce keratin that is softer, Forces epidermal cells to produce keratin that is softer,
more flexible and less likely to crack more flexible and less likely to crack
 Preparations Preparations

Glycolic Acid (8%) Glycolic Acid (8%)

Lactic Acid or Lac-Hydrin (5-12%) Lactic Acid or Lac-Hydrin (5-12%)

Urea (3-6%)Urea (3-6%)
 Use 1X/ dayUse 1X/ day

43. Emollients: Oils
Consider using bath oil or mineral oil-based Consider using bath oil or mineral oil-based
lotions in lukewarm bath water lotions in lukewarm bath water
Add to tub 15 minutes into bath Add to tub 15 minutes into bath
Bath oil preparations:Bath oil preparations:

Alpha-KeriAlpha-Keri

Aveeno bathAveeno bath

Jeri-Bath Jeri-Bath
Colloidal oatmeal Colloidal oatmeal
reduces itchingreduces itching

44. 4. Corticosteroids
Topical steroids very effective
Ointments for dry or lichenified skin
Creams for weeping skin or body folds
Lotions or scalp applications for hair-areas.

45. Corticosteroids
Hydrocortisone 1-2.5% applied to all skin.
Quite safe used even for months
Use intermittently thin areas- (eg-face & genitals)
Stronger potency topical steroids for
nonfacial/genital regions.
Avoid potent/ultrapotent topical steroid preparations
on face, armpits, groins & bottom.

46. Corticosteroids
Once under control, intermittent use of
topical corticosteroid may prevent relapse
Systemic steroids may bring under rapid
control, but may precipitate rebound
Once daily probably most cost effective

47. Steroids and Young Children
FluticasoneFluticasone proprionate cream 0.05% proprionate cream 0.05%
Moderate- severe atopic derm Moderate- severe atopic derm >> 3 months 3 months
Applied bid 3-4 weeks- mean 64% BSAApplied bid 3-4 weeks- mean 64% BSA
No HPA suppression No HPA suppression

48. Corticosteroids: Pearls
Different preparations prescribed for different
parts of body or for different situations
Educate on
potencies & proper usage
write down directions
Bring all topicals each appointment to clarify use

49. 5. Antibiotics
Atopic eczema frequently secondarily
colonized with a bacteria (up to 30%).
Use oral antibiotics in recalcitrant or
widespread cases.

52. 6. Antihistamines
Oral antihistamines can
reduce urticaria & itch
Non-sedating antihistamines
less side effects but more
expensive
Sedative effect of
hydroxyzine &
diphenhydramine helpful

53. 7. Steroid Sparing
Topical calcineurin inhibitorsTopical calcineurin inhibitors

Tacrolimus ointment & pimecrolimus creamTacrolimus ointment & pimecrolimus cream
Oral CyclosporineOral Cyclosporine
Ultraviolet light therapy (phototherapy) Ultraviolet light therapy (phototherapy)
with PUVA (psoralens plus ultraviolet A with PUVA (psoralens plus ultraviolet A
radiation) or combinations of UVA & UVB radiation) or combinations of UVA & UVB

54. Tacrolimus ointment
(0.03%, 0.1% [Protopic])
Mild to moderate eczemaMild to moderate eczema
Steroid dependent or signs of atrophySteroid dependent or signs of atrophy
Non-steroid responsiveNon-steroid responsive
BID x 2-4 weeks to evaluate responseBID x 2-4 weeks to evaluate response
Transient stinging possibleTransient stinging possible
Longer disease-free intervalsLonger disease-free intervals

55. Pimecrolimus cream 1%
(15, 30, 100 gm [Elidel])
Approved Dec. 2001Approved Dec. 2001
Blocks production/release cytokines T-cellsBlocks production/release cytokines T-cells
Moderate eczemaModerate eczema
Steroid sparingSteroid sparing
Transient stinging 8% children, 26% adults Transient stinging 8% children, 26% adults

56. 9. SYSTEMIC THERAPY
SYSTEMIC GLUCOCORTICOIDSSYSTEMIC GLUCOCORTICOIDS
-Rarely indicated in chronic AD.Rarely indicated in chronic AD.
-Short course- taperShort course- taper

57. 9. SYSTEMIC THERAPY
CYCLOSPPORINCYCLOSPPORIN
- Acts on T cell- Acts on T cell
-calcineurin inhibittor -calcineurin inhibittor  supresses cytokine supresses cytokine
transcription.transcription.
-Dose 5mg / kg.Dose 5mg / kg.
-S/E – elevated serum creatinine;S/E – elevated serum creatinine;
renal impairement;renal impairement;
hypertension. hypertension.

58. 9. SYSTEMIC THERAPY
ANTIMETABOLITES ANTIMETABOLITES  Indicated in AD Indicated in AD
resistant to T/T like topical & oral steroids, resistant to T/T like topical & oral steroids,
psoralene and UVA light.psoralene and UVA light.
- Mycophenolate mofetil- Mycophenolate mofetil – purine – purine
biosynthesis inhibitor biosynthesis inhibitor
-Dose - 2 gm daily (as monotherapy)Dose - 2 gm daily (as monotherapy)

59. - Methotrexate - - Methotrexate - inhibits inflammatory inhibits inflammatory
cytokines synthesis & cell chemotaxiscytokines synthesis & cell chemotaxis
-Dosing more frequently than typical weekly Dosing more frequently than typical weekly
dosing is advocated.dosing is advocated.
- Azathioprine - - Azathioprine - purine analogue with anti purine analogue with anti
inflammatory & anti proliferative effect.inflammatory & anti proliferative effect.
-SIDE EFFECTS - SIDE EFFECTS - BONE MARROW BONE MARROW
SUPRESSION.SUPRESSION.

60. 10. OTHER THERAPIES
INTERFERON – INTERFERON – γγ
-Down regulates Th2 cell proliferation & Down regulates Th2 cell proliferation &
functionfunction
-Supresses IgE responces.Supresses IgE responces.
-S/E – influenza like symptomsS/E – influenza like symptoms
OMALIZUMAB OMALIZUMAB monoclonal anti IgE monoclonal anti IgE
- -

61. EXTRACORPOREAL PHOTOPHERESISEXTRACORPOREAL PHOTOPHERESIS
-Passage of psoralen-treated leukocytes Passage of psoralen-treated leukocytes
through an extracorporeal UVA light through an extracorporeal UVA light
system.system.
-PlusPlus topical steroids topical steroids

62. PHOTO THERAPY – PHOTO THERAPY –
- UVA- UVA targets epidermal LCs & eosinophilstargets epidermal LCs & eosinophils
-UVB exerts immunosuppressive effects by UVB exerts immunosuppressive effects by
blocking of function of LCs & altered blocking of function of LCs & altered
keratinocyte cytokine production.keratinocyte cytokine production.
-S/E S/E  short term - erythema, pain, pruritus short term - erythema, pain, pruritus
and pigmentaion and pigmentaion
long term – premature skin aging & long term – premature skin aging &
cutaneous malignancies.cutaneous malignancies.

63. PROBIOTICS
Lactobacillus rhamnosus strain GG
prenatally to mothers for 4 weeks daily before
delivery
postnatally for 6 months to infants or either mother
(breast feeding).
Has reduced the incidence f AD in at-risk children
during first 2 yrs of life.

64. ORAL VITAMIN D
Improves innate immunityImproves innate immunity

65. Other
Psychological support
Alternative treatments
Chinese herbal tea
Variably effective-not very
palatable
 Liver toxicity possible

66. Thank you.

68. Ointments (Tacrolimus) better than cream (Pimecrolimus)

69. Tacrolimus ointment & pimecrolimus
cream
Licensed for patients Licensed for patients >> 2 years old mild-moderate eczema\ 2 years old mild-moderate eczema\
Safety?Safety?

In controlled trials appear safe in adults and children In controlled trials appear safe in adults and children

In 2005, FDA issued warnings about a possible link between the In 2005, FDA issued warnings about a possible link between the
topical calcineurin inhibitors and cancer (? increased risk of topical calcineurin inhibitors and cancer (? increased risk of
lymphoma and skin cancers with topical exposure)lymphoma and skin cancers with topical exposure)

However, no definite causal relationship established However, no definite causal relationship established
FDA recommends that these agents are used only as second-line FDA recommends that these agents are used only as second-line
therapy in patients unresponsive to or intolerant of other treatmentstherapy in patients unresponsive to or intolerant of other treatments

Avoid in children younger than two years of ageAvoid in children younger than two years of age

Use for short periods of time and minimum amount necessaryUse for short periods of time and minimum amount necessary

Avoid continuous use Avoid continuous use

Avoid in patients with compromised immune systems Avoid in patients with compromised immune systems

70. Oral Cyclosporine and PUVA

71. Other
Evening Primrose Oil / Star Flower
Oil
Contains gamma linolenic acid, fatty
acid (deficient some atopic subjects)

72. Alternative medications some
patients may use for eczema
LicoriceLicorice
CalendulaCalendula
EchinaceaEchinacea
Golden SealGolden Seal
Nettle Nettle
OatsOats

73. Other
Laughter May Be Best Medicine...For Allergies
NEW YORK, NY - Although few would consider allergies to be
funny, results of a new study suggest that laughing them off
might actually work. Dr. Hajime Kimata, of Unitika Central
Hospital in Japan, induced allergic responses on the skin of 26
people with allergic dermatitis by exposing them to house dust
mites, cedar pollen and cat hair, and then had them watch
``Modern Times'', featuring Charlie Chaplin. The participants
exhibited a significant reduction in their allergic responses after
watching the classic comedy, according to the report in the
February 14th issue of The Journal of the American Medical
Association. The effect lasted for 4 hours after the viewing

74. Soaps
Mild or Hypoallergenic
Dove (unscented): Contains lotion
Keri
Oil of Olay
Basis
Purpose
Cetaphil Skin Cleanser (non-soap)
Neutrogena bar
Pure Ivory soap is very drying/irritating

75. Antibacterial Soaps
Dial and Lever 2000
Cetaphil antibacterial cleansing bar

76. Evidenced-based review 2002 (BMJ Clinical Evidence)
Positive evidence that:Positive evidence that:

topical corticosteroidstopical corticosteroids relieve symptoms and are safe relieve symptoms and are safe

emollientsemollients & & steroidssteroids better than steroids alone better than steroids alone

excellent control of house dustexcellent control of house dust mite reduces symptoms mite reduces symptoms
if positive mite RAST scores & childrenif positive mite RAST scores & children

bedding covers most effectivebedding covers most effective
Little to no evidence that: Little to no evidence that:

dietary change reduces symptomsdietary change reduces symptoms

77. Systematic review 2000
Positive evidence:Positive evidence:

Topical steroidsTopical steroids

Oral cyclosporineOral cyclosporine

UV lightUV light

Psychological Psychological
approachesapproaches
Insufficient evidenceInsufficient evidence

Ag avoidance pregnancyAg avoidance pregnancy

AntihistaminesAntihistamines

Dietary restrictionDietary restriction

Dust mite avoidanceDust mite avoidance

HypnotherapyHypnotherapy

EmollientsEmollients

MassageMassage

Evening primrose oilEvening primrose oil

Topical coal tarTopical coal tar

Topical doxepinTopical doxepin

Chinese herbsChinese herbs
(Hoare, Health Technol Assess, 2000)

78. Systematic review
Not beneficial: Not beneficial:

Cotton clothingCotton clothing

BiofeedbackBiofeedback

Bid vs qd topical steroidsBid vs qd topical steroids

Bath additivesBath additives

Topical antibiotic/steroids vs steroids Topical antibiotic/steroids vs steroids
alonealone
(Hoare, Health Technol Assess, 2000)

79. Final Pearls
Educate parents that the goal is Educate parents that the goal is
CONTROL not CURECONTROL not CURE
Atopics exposed to herpes virus or smallpox Atopics exposed to herpes virus or smallpox
vaccination may get severe infection with vaccination may get severe infection with
widespread involvement d/t altered skin widespread involvement d/t altered skin
barrier.barrier.

80. Severe herpes infections in children with eczema

81. Atopic Derm and Smallpox Vaccine
(Ann Intern Med 2003;139)

82. Costs
H/C 1%H/C 1% Bid-tid Bid-tid 30 gm30 gm $3.00$3.00
TAC 0.1%TAC 0.1% BidBid 30 gm30 gm $8.00$8.00
Fluticasone Fluticasone
propionate 0.05%propionate 0.05%
QdQd-bid-bid 30 gm30 gm $42.00$42.00
Mometasone Mometasone
furoate 0.1%furoate 0.1%
Qd Qd 30 gm30 gm $45.00$45.00
Betamethasone Betamethasone
dipropionate dipropionate
0.05%0.05%
BidBid 30 gm30 gm $20.00$20.00
Clobetasol Clobetasol
propionate 0.05%propionate 0.05%
BidBid 30 gm30 gm $15.00$15.00
Halobetasol Halobetasol
propionate 0.05%propionate 0.05%
QdQd-bid-bid 30 gm30 gm $72.00$72.00
Pimecrolimus 1%Pimecrolimus 1%BidBid 30 gm30 gm $56.00$56.00
Tacrolimus 0.1%Tacrolimus 0.1%BidBid 30 gm30 gm $60.00$60.00
Drugstore.com 2004

83. CASE 1
3 year old female with h/o eczema since 4 months old.
Had done well on hydrocortisone 2.5% ointment when
flared last winter. Parents ran out of the ointment and have
been using vaseline and OTC hydrocortisone 0.5% without
improvement. Child is now waking at night and constantly
scratching.
What do you want to do?What do you want to do?

84. Case Treatment strategy:
Review mild skin care regimen
Confirm use of
•mild cleanser
•daily moisturizers &
•mild laundry detergent
Prescribe sufficient potency & quantity of
topical corticosteroids
Which steroid class(es) would you px?

85. Objectives
Improve ability to accurately diagnose and Improve ability to accurately diagnose and
manage 90% of cases of atopic dermatitismanage 90% of cases of atopic dermatitis
Recognize differences in infant, childhood Recognize differences in infant, childhood
and adult presentations of atopic dermatitisand adult presentations of atopic dermatitis
Improve ability to diagnose and manage Improve ability to diagnose and manage
conditions associated with and sometimes conditions associated with and sometimes
confused with atopic dermatitisconfused with atopic dermatitis

86. Case- topical steroid choices
TAC 0.1% oint. bid worse areas x 7-14
days
Switch to H/C 2.5% ointment BID
Taper over 4 weeks to emollients if possible

Confirm parents understand dangers of
prolonged steroid use and not to use potent
steroids on face

87. F/U 2 weeks later:
Only slightly improved- now what?

88. Now...
Add oral antistaphylococcal agent for 7-14 days.
REVIEW mild skin care regimen
Follow-up in 2 weeks and SUCCESS!

89. CASE 2
34 yo female with h/o hand eczema diagnosed by former MD for 6 years.
Seems to get worse in winter, but never goes away entirely. A friend
told her it could be a fungus. She was given fluocinonide (lidex)
0.05% cream and it helps some. She wants a refill.

90. CASE 2
Not likely fungus given chronicity
May have secondary staph infection
May need more potent Class I steroid initially, e.g.
clobetasol propionate (temovate) ointment
Class II Fluocinonide (lidex) 0.05% cream ok less severe

91. Case 3
75 YO male with chronic itchy spots-
Using hydrocortisone cream 2.5% bid to ankle- minimal
improvement
Using Class II Fluocinonide (lidex) 0.05% ointment under
occlusion to hip area- “only thing that works”

92. Case 3
2.5% H/C too weak
Fluocinonide (lidex) 0.05% ointment under
occlusion causing atrophy
Good case for topical tacrolimus

93. Patient Education
National Eczema AssociationNational Eczema Association

www.eczema-assn.orgwww.eczema-assn.org

94. (Charman, Arch Dermatol,
2004)
The patient-
oriented eczema
measure
Self
Monitoring

95. References
Drake LA, et al. Guidelines of Care For Atopic Dermatitis. J Am Acad Drake LA, et al. Guidelines of Care For Atopic Dermatitis. J Am Acad
Dermatol 1992;26:485-8. Dermatol 1992;26:485-8.
Atopic eczema. In Atopic eczema. In Clinical EvidenceClinical Evidence British Medical Journal 2001. British Medical Journal 2001.
Available online at www.clinicalevidence.orgAvailable online at www.clinicalevidence.org
Correale CE, Walker C, Murphy L, Craig TJ. Atopic Dermatitis: A Correale CE, Walker C, Murphy L, Craig TJ. Atopic Dermatitis: A
Review of Diagnosis and Treatment. J Fam Pract 1999; available at Review of Diagnosis and Treatment. J Fam Pract 1999; available at
http://www.aafp.org/afp/990915ap/1191.htmlhttp://www.aafp.org/afp/990915ap/1191.html
Ruzicka T, Bieber T, Schopf E, et al. A short-term trial of tacrolimus Ruzicka T, Bieber T, Schopf E, et al. A short-term trial of tacrolimus
ointment for atopic dermatitis. European Tacrolimus Multicenter ointment for atopic dermatitis. European Tacrolimus Multicenter
Atopic Dermatitis Study Group. N Engl J Med 1997; 337(12): 816-21.Atopic Dermatitis Study Group. N Engl J Med 1997; 337(12): 816-21.
Eichenfield LF, LuckyAW, Boguniewicz M, et al. Safety and efficacy Eichenfield LF, LuckyAW, Boguniewicz M, et al. Safety and efficacy
of pimecrolimus cream 1% in the treatment of mild and moderate of pimecrolimus cream 1% in the treatment of mild and moderate
atopic dermatitis in children and adolescents. J A Acad Dermatol atopic dermatitis in children and adolescents. J A Acad Dermatol
2002; 46; 495-504 .2002; 46; 495-504 .

96. References
Charlesworth EN . Pruritic dermatoses: overview of etiology and therapy. Am Charlesworth EN . Pruritic dermatoses: overview of etiology and therapy. Am
J Med 2002; 113S, 9A: 25S-33S.J Med 2002; 113S, 9A: 25S-33S.
Wahn U, et al. Efficacy and safety of pimecrolimus cream in the long-term Wahn U, et al. Efficacy and safety of pimecrolimus cream in the long-term
management of atopic dermatitis in children. Pediatrics 2002; 110 (1 Pt 1): e2. management of atopic dermatitis in children. Pediatrics 2002; 110 (1 Pt 1): e2.
Friedlander SF, et al. Safety of fluticasone proprionate cream 0.05% for the Friedlander SF, et al. Safety of fluticasone proprionate cream 0.05% for the
treatment of severe and extensive atopic dermatitis in children as young as 3 treatment of severe and extensive atopic dermatitis in children as young as 3
months. J Am Acad Dermatol 2002; 46: 387-394.months. J Am Acad Dermatol 2002; 46: 387-394.
Hoare C, et al. Systematic review of treatments for atopic eczema. Health Hoare C, et al. Systematic review of treatments for atopic eczema. Health
Technol Assess 2000; 2: 1-191.Technol Assess 2000; 2: 1-191.
Green C, Colquitt JL, Kirby J, Davidson P. Topical corticosteroids for atopic Green C, Colquitt JL, Kirby J, Davidson P. Topical corticosteroids for atopic
eczema: clinical and cost effectiveness of once-daily vs. more frequent use. Br eczema: clinical and cost effectiveness of once-daily vs. more frequent use. Br
J Dermatol 2005; 152: 130-41. J Dermatol 2005; 152: 130-41.
Charman CR, Venn AJ, Williams HC. The patient-oriented eczema measure: Charman CR, Venn AJ, Williams HC. The patient-oriented eczema measure:
development and initial validation of a new tool for measuring atopic eczema development and initial validation of a new tool for measuring atopic eczema
severity from the patients' perspective. Arch Dermatol 2004; 140: 1513-9. severity from the patients' perspective. Arch Dermatol 2004; 140: 1513-9.

97. Other
Coal tar or less messy preps (liquid carbonis
detergent 5-10%) in Eucerin or Aquaphor
Chronic lichenified eczema patches
Coal tar smells & stains clothes so apply
qhs using old clothes and old linens
Coal tar can provoke a folliculitis.