ATOPIC DERMATITIS

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cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=110 BGCOLOR="#666699" TEXT="#080000" bgproperties="fixed" background="04a00840erlcjm.gif"> <div> <FONT SIZE="5" COLOR="#FFFFFF" FACE="Arial" ><B>pediatryPART I</B></FONT><B>     |     </B><A HREF="index.htm" TARGET="_top" TITLE="pediatryPART I"><U><B>home</B></U></A></div> <div> <A HREF="id31.htm" TARGET="_top" TITLE="PEDIATRIC PEARLS FOR THE USMLE"><U>PEDIATRIC PEARLS FOR THE USMLE</U></A>   |   <A HREF="id48.htm" TARGET="_top" TITLE="pearls pediatry 2"><U>pearls pediatry 2</U></A>   |   <A HREF="id18.htm" TARGET="_top" TITLE="general"><U>general</U></A>   |   <A HREF="id34.htm" TARGET="_top" TITLE="appendiceal colic"><U>appendiceal colic</U></A>   |   <B>ATOPIC DERMATITIS</B>   |   <A HREF="id19.htm" TARGET="_top" TITLE="Stuttering"><U>Stuttering</U></A>   |   <A HREF="id20.htm" TARGET="_top" TITLE="enuresis"><U>enuresis</U></A>   |   <A HREF="id21.htm" TARGET="_top" TITLE="Conduct Disorder in Children and 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TITLE="Chronic Abdominal Pain in Childhood: Dia"><U><B>Chronic Abdominal Pain in Childhood: Diagnosis and Management </B></U></A></div> <div> <A HREF="id25.htm" TARGET="_top" TITLE="child devlpt"><U><B>child devlpt</B></U></A></div> <div> <A HREF="id26.htm" TARGET="_top" TITLE="ACETAMINOPHEN OVERDOSE"><U><B>ACETAMINOPHEN OVERDOSE</B></U></A></div> <div> <A HREF="id27.htm" TARGET="_top" TITLE="SHAKEN BABY SYNDROME"><U><B>SHAKEN BABY SYNDROME</B></U></A></div> <div> <A HREF="id28.htm" TARGET="_top" TITLE="NEONATAL JAUNDICE (HYPERBILIRUBINEMIA)"><U><B>NEONATAL JAUNDICE (HYPERBILIRUBINEMIA)</B></U></A></div> <div> <A HREF="id29.htm" TARGET="_top" TITLE="Hyaline Membrane Disease (Respiratory Di"><U><B>Hyaline Membrane Disease (Respiratory Distress Syndrome) (HMD) (RDS</B></U></A></div> <div> <A HREF="id30.htm" TARGET="_top" TITLE="infectious disease"><U><B>infectious disease</B></U></A></div> <div> <A HREF="id32.htm" TARGET="_top" TITLE="HEMORRHAGIC DISEASE IN A NEW BORN"><U><B>HEMORRHAGIC DISEASE IN A NEW BORN</B></U></A></div> <div> <A HREF="id33.htm" TARGET="_top" TITLE="OPTIC NERVE GLIOMA"><U><B>OPTIC NERVE GLIOMA</B></U></A></div> <div> <A HREF="id36.htm" TARGET="_top" TITLE="New Born Assessment "><U><B>New Born Assessment </B></U></A></div> <div> <A HREF="id38.htm" TARGET="_top" TITLE="laryngomalacia"><U><B>laryngomalacia</B></U></A></div> <div> <A HREF="id39.htm" TARGET="_top" TITLE="CRANIOSYNOSTOSIS "><U><B>CRANIOSYNOSTOSIS </B></U></A></div> <div> <A HREF="id40.htm" TARGET="_top" TITLE="DANDYWALKER MALFORMATION "><U><B>DANDY-WALKER MALFORMATION </B></U></A></div> <div> <A HREF="id41.htm" TARGET="_top" TITLE="DEJERINESOTTAS DISEASE "><U><B>DEJERINE-SOTTAS DISEASE </B></U></A></div> <div> <A HREF="id42.htm" TARGET="_top" TITLE="DOWN SYNDROME "><U><B>DOWN SYNDROME </B></U></A></div> <div> <A HREF="id43.htm" TARGET="_top" TITLE="Respiratory Syncytial Virus (RSV)"><U><B>Respiratory Syncytial Virus (RSV)</B></U></A></div> <div> <A HREF="id44.htm" TARGET="_top" TITLE="FABRY DISEASE "><U><B>FABRY DISEASE </B></U></A></div> <div> <A HREF="id45.htm" TARGET="_top" TITLE="PRADERWILLI SYNDROME "><U><B>PRADER-WILLI SYNDROME </B></U></A></div> <div> <A HREF="id37.htm" TARGET="_top" TITLE="new born fun"><U><B>new born fun</B></U></A></div> <div> <A HREF="id46.htm" TARGET="_top" TITLE="RETT SYNDROME "><U><B>RETT SYNDROME </B></U></A></div> <div> <A HREF="id47.htm" TARGET="_top" TITLE="Alexander Disease"><U><B>Alexander Disease</B></U></A></div> <div> <A HREF="id49.htm" TARGET="_top" TITLE="leukemia"><U><B>leukemia</B></U></A></div> <div> <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U><B>Contact Me</B></U></A></div> </td> <td valign="top" height=370 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> ATOPIC DERMATITIS</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Characteristically, atopic dermatitis is a chronic disorder with a relapsing course, pruritis, variable presentation, and is associated with an atopic diathesis in 75 to 80% of afflicted patients. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The disorder may present with evidence of acute eczematous changes with micro-vesiculation, erosions and crusts or with more chronic lichenified plaques. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It may present as a generalized dermatitis or a more localized condition affecting the scalp, hands or feet.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This diversity makes the diagnosis of atopic dermatitis and its distinction from other eczematous dermatoses difficult.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Isolated findings and complications which can be associated with atopic dermatitis are misdiagnosed. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Conversely, other patients have eczematous dermatoses which actually represent cutaneous manifestations of systemic disorders which may be associated with malignancies, nutritional/metabolic and immunodeficiency states. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The dermatologist's approach to the differential diagnosis of eczema will be discussed in detail with special emphasis on the distinction of atopic dermatitis.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Attempting to explain the etiology of atopic dermatitis is far from easy.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Its association in families with atopic disorders may relate to the recent isolation of an autosomal dominant gene on chromosome 11q apparently responsible for IgE responsiveness in families with asthma and rhinitis.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The resolution of atopic-like dermatitis following bone marrow transplantation and the transfer of atopic dermatitis to a bone marrow recipient suggest an intrinsic dysregulation of the immune system in these individuals.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Classically atopic dermatitis has been associated with type IV hypersensitivity but the role of IgE mediated or type I hypersensitivity has been suggested for some time.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It is now hypothesized that "late phase reactions" occur in patients with allergic mediated atopic dermatitis, whereby the initial insult, involving mast cell degranulation with subsequent infiltration of neutrophils, basophils, and eosinophils is later replaced by lymphocytes and macrophages.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The presence of prior eosinophil infiltration is substantiated by documented presence of major basic protein in these infiltrates.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The presence of antigen specific IgE receptors on Langerhans cells in these infiltrates in atopic individuals and the mediation by cytokines (specifically IL-4 and gamma interferon) on these receptors provides a possible model to explain how chronic exposure to food and aeroallergens can precipitate a dermatitis.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Staphylococcal infection (or colonization) and superantigens may play a role in prolonging the eczematous changes.</div> <bR> <div> <B><U>The approach to therapy must be individualized to the needs of the patient</U></B></div> <div> <B><U><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">.</U></B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Initially, the restoration of the integrity of the skin as a barrier to infection and allergen exposure requires intensive rehydration and lubrication.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Isolated findings and complications which can be associated with atopic dermatitis are misdiagnosed.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The use of antihistamines to break the itch-scratch cycle' and topical mild corticosteroids are often helpful but caution regarding the use of fluorinated steroid use cannot be overemphasized especially in covered and intertriginous areas and on the face.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When considering the use of mid-potency topical or systemic corticosteroids a dermatologic consultation should be considered.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">One must look for evidence of superinfection or infestation and treat accordingly.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tar, ultraviolet phototherapy, dietary manipulation, and evening primrose oil are considerations.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">One should also consider psychosocial contributing factors in evaluating these patients.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Allergic evaluation and the use of agents like phosphodiesterase inhibitors, immunosuppressants, immune modulators, vitamins C and E and mast cell stabilizers are more controversial</div> <bR> <div> <B>Examples of isolated findings that can be seen in atopic dermatitis:</B></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="627" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="291"><div> .......................................</div> </tD> <tD VALIGN=CENTER WIDTH="329"><div> ............................................</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 56 WIDTH="291"><div> Keratosis pilaris</div> <div> Hand dermatitis<FONT SIZE="3" COLOR="#FFFFFF" FACE="Arial" >...........</FONT></div> <div> Pityriasis alba</div> </tD> <tD VALIGN=CENTER WIDTH="329"><div> Perioroficial dermatitis</div> <div> Plantar juvenile dermatosis</div> <div> Frictional lichenoid dermatitis</div> </tD> </tR> </TABLE></div> <div> <B>Other associated conditions and complications of atopic dermatitis:</B></div> <div> <B>Secondary infections:</B> </div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="628" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 25 WIDTH="95"><div> <B>Bacterial</B></div> </tD> <tD VALIGN=CENTER WIDTH="161"><div> <B>Fungal</B><FONT SIZE="4" COLOR="#FFFFFF" FACE="Arial" ><B>.......</B></FONT> </div> </tD> <tD VALIGN=CENTER WIDTH="362"><div> <B>Viral</B><FONT SIZE="4" COLOR="#FFFFFF" FACE="Arial" >.........</FONT></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 56 WIDTH="95"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="56" ALIGN="bottom" WIDTH="95" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="161"><div> T. rubrum </div> <div> Candida</div> <div> P. ovale</div> </tD> <tD VALIGN=CENTER><NOBR><div> Herpes simplex (Eczema Herpeticum)</div> <div> Verruca vulgaris</div> <div> Molluscum contagiosum</div> </NOBR></tD> </tR> </TABLE></div> <div> <B>Ophthalmologic findings:</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Keratoconus<FONT SIZE="4" COLOR="#FFFFFF" FACE="Arial" >..........................</FONT>Ectropion</div> <div> Conjunctivitis<FONT SIZE="4" COLOR="#FFFFFF" FACE="Arial" >........................</FONT>.Subcapsular cataracts </div> <div> <B>Other:</B></div> <div> Effects of therapy (ie., steroids)<FONT SIZE="4" COLOR="#FFFFFF" FACE="Arial" >)..........</FONT>.Growth retardation</div> <div> Sleep disturbance<FONT SIZE="4" COLOR="#FFFFFF" FACE="Arial" >..............................</FONT>Psychosocial </div> <div> <B>Conditions characterized by eczematous dermatitis:</B></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="627" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="323"><div> <B>Primary conditions:</B></div> </tD> <tD VALIGN=TOP WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="254"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="254" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 150 ><NOBR><div> Atopic dermatitis </div> <div> Asteatotic eczema </div> <div> Non-specific hand dermatitis </div> <div> Contact irritant dermatitis </div> <div> Contact allergic dermatitis </div> <div> Chronic eczema </div> <div> Nummular eczema</div> <div> Lichen simplex chronicus (neurodermatitis)</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="40"><div> .....</div> </tD> <tD VALIGN=CENTER><NOBR><div> Fungal infections</div> <div> Infestations (ie., scabies, lice)</div> <div> Autoeczematization</div> <div> Dyshidrotic eczema</div> <div> Air<FONT SIZE="3" COLOR="#800000" FACE="Arial" >born</FONT> contact dermatitis</div> <div> Photoeczematous</div> <div> Prurigo nodularis</div> <div> Stasis dermatitis</div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <B>Pruritic diseases with secondary eczematous changes:</B> </div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="628" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 75 WIDTH="297"><div> Hodgkin's </div> <div> Thyroid disease </div> <div> Iron deficiency anemia </div> <div> Delusions of parasitosis</div> </tD> <tD VALIGN=CENTER WIDTH="61"><div> .....</div> </tD> <tD VALIGN=CENTER WIDTH="260"><div> Hepatic/renal disease</div> <div> Polycythemia vera</div> <div> Chronic urticaria</div> <div> Neurotic excoriations</div> </tD> </tR> </TABLE></div> <bR> <div> HIV infection </div> <div> <B>Non-eczematous masqueraders of eczema: </B></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="628" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="261"><div> Localized </div> </tD> <tD VALIGN=CENTER WIDTH="39"><div> ....</div> </tD> <tD VALIGN=CENTER WIDTH="318"><div> Generalized</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 206 ><NOBR><div> Bowen's </div> <div> Paget's </div> <div> Juvenile psoriasis </div> <div> Hypertrophic lichen planus </div> <bR> </NOBR></tD> <tD VALIGN=CENTER WIDTH="39"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="206" ALIGN="bottom" WIDTH="39" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="318"><div> Erythroderma</div> <div> Rapid:</div> <div> Drug<FONT SIZE="3" COLOR="#FFFFFF" FACE="Arial" >......... </FONT>Lymphoma</div> <div> Contact (ie., T cell) </div> <div> SSSS<FONT SIZE="3" COLOR="#FFFFFF" FACE="Arial" >...... </FONT>Leukemia</div> <div> Gradual:</div> <div> Psoriasis<FONT SIZE="3" COLOR="#FFFFFF" FACE="Arial" >...... </FONT>Atopic dermatitis</div> <div> Pityriasis rubra pilaris</div> <div> Mycosis fungoides</div> <div> Histiocytosis X</div> <bR> </tD> </tR> </TABLE></div> <bR> <div> <B>Other conditions associated with "atopic-like" dermatitis:</B> </div> <div> <B>Immunologic</B></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="628" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 168 ><NOBR><div> Acquired immunodeficiency (HIV)</div> <div> Severe combined immunodeficiency</div> <div> Wiskott-Aldrich syndrome</div> <div> Ataxia telangiectasia</div> <div> X-linked agammaglobulinemia</div> <div> Hyper-IgE syndrome</div> <div> X-linked immunodefiency with hyper IgM</div> <div> Episodic lymphopenia with lymphocytotoxins</div> <bR> </NOBR></tD> <tD VALIGN=CENTER WIDTH="31"><div> ....</div> </tD> <tD VALIGN=CENTER><NOBR><div> Selective IgA deficiency</div> <div> DiGeorge syndrome</div> <div> Nezelhoff's syndrome</div> <div> Letter-Siwe disease (histiocytosis X)</div> <div> Chronic granulomatous disease</div> <div> Leiner's disease</div> <div> Alopecia areata ?</div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="628" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 224 ><NOBR><div> <B>Metabolic/nutritional </B></div> <div> Phenylketonuria</div> <div> Histidinemia</div> <div> Celiac sprue/gluten sensitive enteropathy</div> <div> Acrodermatitis enteropathica</div> <div> Hurler's syndrome</div> <div> Anhydrotic ectodermal dysplasia Hartnup's disease</div> <div> Pellagra</div> <div> Essential fatty acid deficiency</div> <div> Biotin deficiency</div> <div> Protein caloric malnutrition</div> <bR> </NOBR></tD> <tD VALIGN=CENTER WIDTH="31"><div> ....</div> </tD> <tD VALIGN=CENTER><NOBR><div> <B>Other</B></div> <div> Ichthyoses</div> <div> Ichthyosis vulgaris </div> <div> Netherton's syndrome</div> <bR> <div> Anhydrotic ectodermal dysplasia</div> <bR> <bR> <div> Dubowitz syndrome</div> <bR> <div> Migraine ?</div> </NOBR></tD> </tR> </TABLE></div> <bR> <bR> <div> <B><U>Phases of Atopic Dermatitis</U></B><U> </U></div> <div> Infant phase: birth to 2 yrs (mean 7.9 mos) cheeks, abdomen, ext surfaces of legs, irritabel and aggitated at night, prutitus, generalized papular eruption can erupt sparing the diaper area</div> <div> Childhood phase: 2-12 yr, papules coalesce to plaques in flexural areas like neck, antecubital and popliteal fosae, and wrists and ankles. with extensive excoriations and lichenification</div> <div> Adult phase: dorsal aspect of hands, upper eyelids, fexural extremities, more diffuse with increased scaling and decreased excoriations</div> <div> Diagnostic Features of Atopic Dermatitis</div> <div> Must have three or more major features:</div> <div> Pruritus </div> <div> Typical morphology and distribution</div> <div> flexural lichenification or linearity in adults</div> <div> facial and extensor involvement in infants and children</div> <div> Chronic or chronically relapsing course</div> <div> Personal or family history of atopy (asthma, allergic rhinitis, or atopic dermatitis)</div> <div> Must also have three or more minor fatures:</div> <div> Xerosis ( 50%) esp if humidity < 60%</div> <div> Ichthyosis 37%, /*palmar hyperlinearity 1/3-1/2 /*keratosis pilaris </div> <div> Immediate (type I) skin test reactivity 80%</div> <div> Elevated serum IgE</div> <div> Early age of onset</div> <div> Tendency toward cutaneous infections (est. Staphyloccocal aureus and Herpes simplex)/impaired cell-mediated imnmunity</div> <div> Tendency toward nonspecific hand or foot dermatitis</div> <div> +Nipple eczema</div> <div> +Cheilitis</div> <div> Recurrent conjunctivitis</div> <div> Dennie-Morgan infraorbital fold</div> <div> Keratoconus</div> <div> +Anterior subcapsular cataracts</div> <div> Orbital darkening</div> <div> Facial pallor/facial erythema</div> <div> *Pityriasis alba</div> <div> Itch when sweating</div> <div> Intolerance to wool and lipid solvents</div> <div> Perifollicular accentuation (generalized is pathognomonic)</div> <div> Food hypersensitivity</div> <div> Course influenced by environmental/emotional factors</div> <div> *White dermatographism/delayed blanch 70% </div> <div> Adapted from Hanifin and Rajka Acta DermVenereol (Suppl).1980;92:44-7.</div> <div> * = common; +=uncommon but specific </div> <bR> <bR> <div> ERYTHROMYCIN DRUG INTERACTIONS</div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="528" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 19 ><NOBR><div> INCREASED ACTIVITY </div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="49"><div> ....</div> </tD> <tD VALIGN=CENTER><NOBR><div> DECREASED ACTIVITY</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 168 WIDTH="241"><div> Theophylline </div> <div> Carbamazepine</div> <div> Cyclosporine </div> <div> Na warfarin</div> <div> Digoxin</div> <div> Disopyramide</div> <div> Methylprednisone</div> <div> Trazolam</div> <div> Alfentanil </div> </tD> <tD VALIGN=CENTER WIDTH="49"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="168" ALIGN="bottom" WIDTH="49" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="228"><div> Clindomycin</div> <div> Lincomycin</div> <div> Sulfonamides</div> </tD> </tR> </TABLE></div> <div> THERAPEUTIC CONSIDERATIONS</div> <div> Standard therapy:</div> <bR> <div> Discuss realistic expectations </div> <div> Keep the plan as simple as possible.</div> <div> Write out instructions for patients on an education handout.</div> <div> Must control xerosis and itching </div> <div> Avoid harsh soaps</div> <div> Liberal use of moisturize</div> <div> Oral antihistamines</div> <div> If oozing or infected:</div> <div> Consider secondary bacterial, fungal and/or herpes infection</div> <div> Soaks with wet compress, remove them and allow areas to air dry</div> <div> Control inflammatation if above is ineffective: </div> <div> Topical corticosteriods</div> <div> Consider advanced therapy if above is ineffective: </div> <div> Systemic steroids</div> <div> Occlusive suits ("Sauna suit")</div> <div> Tars</div> <div> Ultraviolet V phototherapy</div> <div> Evaluation for psychosocial, dietary and/or environmental factors</div> <div> Caution against dietary restriction without proof as this is usually not necessary!</div> <div> Controversial:</div> <div> Evening primrose oil </div> <div> Eicosapentenoic Acid</div> <div> Cyclosporin</div> <div> Phosphodiesterase inhibitors</div> <div> Investigational: </div> <div> TP-5 (thymopoietin)</div> <div> Thymostimulin (TP-1) injection</div> <div> Interferon</div> <div> IL-2</div> <div> Chloroquin</div> <div> Vitamin C and/or E</div> <div> Ketotifen </div> <bR> <bR> </td> </tr></table></body>