Rosen & Barkin's 5-Minute Emergency Medicine Consult (234 page)

Dermatitis, located on areas of trauma or motion such as hands and feet and flexural areas

• Epidermal compromise:
  
  • Dry skin
    
  • Weeping
    
  • Oozing
    
  • Finally crusting
    
• Inflammation:
  
  • Maculopapular erythema
    
  • Edema
    
• Scratching leads to:
  
  • Excoriation
    
  • Cracking
    
  • Lichenification
    
  • Hyperkeratosis
    
• Additional findings:
  
  • Icthyosis, palmar hyperlinearity, keratosis pilaris
    
  • Hand or foot dermatitis
    
  • Nipple eczema
    
  • Cheilitis
    
  • Dennie–Morgan infraorbital fold
    
  • Orbital darkening
    
  • Facial pallor or facial erythema
    
  • Pityriasis alba
    
  • Perifollicular accentuation
    
  • White dermographism or delayed blanch
    

• 70% of all cases begin during the 1st 5 yr of life
  
• Only 10% of cases start in adulthood
  
• 30% of children with atopic dermatitis develop asthma, 35% develop allergic rhinitis
  
• Infant distribution is classically extensor surfaces and head and face
  

History and physical exam

• Clinical diagnosis
  
• IgE commonly elevated but does not usually need to be tested
  

Generally reserved for settings outside of the ED:

• Radioallergosorbent test (RAST) sometimes used to identify allergic triggers
  
• Patch testing used if contact dermatitis is suspected
  

• Seborrheic dermatitis
  
• Neurodermatitis (lichen simplex chronicus)
  
• Allergic contact dermatitis
  
• Irritant dermatitis
  
• Psoriasis
  
• Dyshidrosis
  
• Ichthyosis
  
• Scabies
  

TREATMENT

• Mild disease or disease of the head and neck:
  
  • Low-potency corticosteroids such as hydrocortisone 1–2.5%
    
  • Eucerin cream: Apply to affected areas BID
    
• Moderate or severe disease of the trunk and extremities:
  
  • Higher-potency corticosteroids such as triamcinolone 0.1% (moderate potency) or fluocinonide 0.05% ointment (high potency)
    
• Severe disease of the head and neck:
  
  • Topical calcineurin inhibitors such as pimecrolimus and tacrolimus
    
• 1st-generation antihistamines:
  
  • Diphenhydramine, hydroxyzine are used for relief of itching but are only weakly effective
    
• Behavioral interventions:
  
  • Avoid excessive bathing
    
  • Use of tepid water and mild soaps
    
  • Frequent use of emollients (Eucerin cream, Aquaphor ointment)
    
• Bacterial superinfection: Cephalexin, cefazolin:
  
  • Consider MRSA
    

• Aquaphor ointment: Apply to affected areas BID
  
  • Contains lanolin alcohol
    
• Cephalexin: 500 mg (peds: 25–100 mg/kg/24h) PO q6h
  
• Diphenhydramine: 25–50 mg (peds: 5 mg/kg/24h) PO or IV q6h
  
• Eucerin cream: Apply to affected areas BID
  
  • Contains lanolin alcohol
    
• Fluocinonide 0.05% ointment: Apply to affected areas of body BID for the duration of the flare (high potency)
  
• Hydrocortisone 2.5% ointment: Apply to affected areas of body/face BID for the duration of the flare (low potency)
  
• Hydroxyzine: 25–100 mg (peds: 2 mg/kg/24h) PO q4–6h
  
• Pimecrolimus 1% cream: Apply to affected areas BID (peds: >2 yr of age) for the duration of the flare
  
• Tacrolimus ointment: 0.1% (peds: >2 yr of age: 0.03%) apply to affected areas BID for the duration of the flare
  
• Triamcinolone 0.1% ointment: Apply to affected areas of body BID for the duration of the flare (mid potency)
  

• Hydrocortisone 2.5% ointment: Apply to affected areas of body/face BID for the duration of the flare (low potency)
  
• Aquaphor ointment: Apply to affected areas BID
  

• Triamcinolone 0.1% ointment: Apply to affected areas of body BID for the duration of the flare (mid potency)
  
  • Avoid the face and eyelids
    
• Fluocinonide 0.05% ointment: Apply to affected areas of body BID for the duration of the flare (high potency)
  
  • Avoid the face and eyelids
    
• Tacrolimus ointment: 0.1% (peds: >2 yr of age: 0.03%) apply to affected areas BID for the duration of the flare
  
  • Can be used on the face
    
• Pimecrolimus 1% cream: Apply to affected areas BID (peds: >2 yr of age) for the duration of the flare
  
  • Can be used on the face
    

FOLLOW-UP

Dermatology referral for problematic cases

• Patients should be warned of adverse consequences of treatment:
  
  • High-potency steroids can cause thinning of the skin
    
  • Tacrolimus and pimecrolimus cause a stinging sensation for the 1st wk of therapy. Long term use can increase risk of cancer
    

• Consider secondary cellulitis, as 90% of patients with atopic dermatitis are eventually colonized with S. aureus
  
• Use tacrolimus and pimecrolimus for moderate to severe disease of the head and neck
  
• Consider in any patient with a severely pruritic rash
  
• Lotions have low lipid content and can cause drying
  
  • Heavy creams are preferred
    
• Do not use triamcinolone or fluocinonide on face or eyelids
  

• Beltrani VS. Suggestions regarding a more appropriate understanding of atopic dermatitis.
  Curr Opin Allergy Clin Immunol
  . 2005;5:413–418.
  
• Bieber T. Atopic dermatitis.
  N Engl J Med
  . 2008;358:1483–1494.
  
• Wasserbauer N, Ballow M. Atopic dermatitis.
  Am J Med
  . 2009;122:121–125.
  
• Williams HC. Clinical practice: Atopic dermatitis.
  N Engl J Med
  . 2005;352:2314–2324.
  
• Zheng T, Yu J, Oh MH, et al. The atopic march: Progression from atopic dermatitis to allergic rhinitis and asthma.
  Allergy Asthma Immunol Res
  . 2011;3:67–73.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Cellulitis
  
• CA-MRSA
  

CODES

• 691.8 Other atopic dermatitis and related conditions
  
• 692.9 Contact dermatitis and other eczema, unspecified cause
  

BASICS

• Clinically apparent accumulation of extravascular fluid due to a derangement in the balance of oncotic and hydrostatic forces:
  
  • Increase in venous/capillary hydrostatic pressure
    
  • Decrease in plasma oncotic pressure
    
  • Increase in interstitial oncotic pressure
    
  • Increase in capillary permeability
    
  • Increase in lymphatic pressure due to obstruction
    
  • Combination of these factors
    
• Generalized, as with CHF or nephrotic syndrome
  
• Localized, as with deep vein thrombosis
  
• Increased venous hydrostatic pressure or decreased oncotic pressure results in pitting edema
  
• Protein-rich extravasated fluid results in nonpitting edema
  
• In certain disorders, there is no clear relation to Starling forces:
  
  • Idiopathic (cyclic) edema:
    
    • Worsened with heat
      
    • More common in women
      
    • Not necessarily related to menses