This document outlines an atopic dermatitis didactic webinar presented by the Pediatric Physicians’ Organization at Children's (PPOC). It includes an agenda for the webinar series, faculty biographies, learning objectives, and credits offered. The webinar on atopic dermatitis focuses on the background, clinical presentation, differential diagnosis, treatment including topical medications and skin care, and complications of atopic dermatitis. It provides several case scenarios to discuss treatment approaches.

1. Atopic Dermatitis Didactic Webinar
Thursday May 4, 2017
Bringing Basic Dermatology Care
to the Pediatric Medical Home 1.2
A PPOC/CHICO Learning Community
& Integration Program
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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We have no financial relationships with
commercial entities producing, marketing, re-
selling, or distributing health care goods or
services consumed by, or used on, patients
relevant to the content we are planning,
developing, presenting, or evaluating.
Disclosure
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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Glenn Focht, MD
Medical Director
Pediatric Physicians’ Organization
at Children’s
Karen R. Barnett, MD, FAAP
LC Medical Director
Pediatric Physicians’ Organization
at Children’s
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu
Madeleine Kuhn, MPH
CHICO Program Manager
Faculty
Stephen E. Gellis, MD
Program Director, Dermatology
Boston Children’s Hospital
Sadaf Hussain, MD
Dermatology
Boston Children’s Hospital
Sophie Delano, MD
Dermatology
Boston Children’s Hospital
Tope Osineye, MBBS MPH
Practice Consultant
Pediatric Physicians’ Organization
at Children’s
Alex Lorenzo
QI Program Coordinator
Pediatric Physicians’ Organization
at Children’s

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Graphs are only commercial payers and only
practices in the PPOC

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Learning Community Schedule
Date Content
Thursday, May 4, 2017 Atopic Dermatitis
Thursday, June 1, 2017 Acne
Thursday, June 29, 2017 Q&A (Optional and open to
past and current participants)
Thursday, August 24, 2017 Warts, Molluscum, Hives
Thursday, September 28,2017 Q&A (Optional and open to
past and current participants
Thursday, October 26, 2017 Wrap-up
Didactic Webinars: 7:30am – 9:00am
Q&A: 7:30am – 8:30am
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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• Materials stored on Blackboard
childrens.blackboard.com and are
posted one day after each session.
• Materials on Blackboard include:
– Syllabus
– Schedule
– Slides
– Handout
– Videos
– Session recordings
– Surveys (MOC/CME)
• Questions email course director:
Madeleine Kuhn at
madeleine.kuhn@childrens.harvard.edu
Course Structure
© 2015 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu
4 Didactic Webinars.
Didactic webinars are online sessions in which
a specialist in dermatology and primary care
lead is present to discuss anatomy and lead
case discussions.
Coursework:
• Qstream
• One Pre- and Post process map for one of
the areas of study (Acne, Atopic Dermatitis,
Warts/Molluscum/Hives) per practice
• Case reviews of past dermatology visits per
practice
• After every session you will receive a follow-
up email with the recording, course handouts
and CME/MOC Survey

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• Physician
o Boston Children’s Hospital designates this live activity for a
maximum of 20.00 AMA PRA Category 1 Credits ™.
Physicians should claim only credit commensurate with the
extent of their participation in this activity.
o Boston Children’s Hospital approves this course for 20 ABP
MOC Part IV credits
• Nurse
Boston Children’s Hospital designates this activity for
10.00 contact hours for nurses. Nurse should only claim
credit commensurate with the extent of their participation
in the activity.
Course Credits
© 2015 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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Atopic Dermatitis
Background
Definition
History
Physical Examination
Treatment
Cases
Special Circumstances
Common Questions

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Key Features of Atopic Dermatitis
• Pruritus
• Comes and goes
• Early age onset
• Characteristic locations

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Atopic Dermatitis Background
● Prevalence increasing with 15-29% children
affected
● Onset usually at 3-6 months of age; 90% develop
before age 5 years
● 1st manifestation of the “atopic march”
● Genetic and environmental factors

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Case Scenario One

13. Collecting the Patient’s History

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History
HPI:
● Onset
● Location
● Symptoms (itching/sleeping problems)
● Bathing Habits
o Frequency
o Duration
o Water temperature
o Soap
● Moisturizing
● Treatments tried
PMH: skin infections, seasonal allergies, asthma, food
allergies
FH: atopy
ROS: growing/feeding well, diarrhea, bloody stools

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Case Scenario 2
6 year old with
history of
intermittent, itchy
rash that began
around age 6
months. It is worse
in the winter.
She bathes once
daily for 20 minutes
with Johnson and
Johnson's cleanser
and moisturizes with
baby lotion.

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Physical Examination
● General: well-appearing,
appropriate size-for-age, non-
dysmorphic
● Full skin examination
● Rough, red
(hyperpigmented), plaques
● Classic distribution (varies
by age)
● Evidence of infection
(pustules, abscesses,
impetiginized areas, punched
out areas)
Pictures are placeholders for correct
imagery

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Distribution of AD by Age
Infant
(birth-2 years)
Face (cheeks),
scalp, ears
Extensor
extremities
Seborrheic
dermatitis
overlap
Childhood
(2 years-puberty)
Face (cheeks)
Flexural extremities
Teenager-Adult
Localized flexural
extremities
Hands, dorsum feet

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Physical Examination: Other Considerations
● Classic features/location-confirmation
● Evidence of infection
● Distribution that affects my management-topical strength (skin
thickness/site)
● Clues to exacerbators- airborne allergens, irritants (saliva, wet wipes)

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Case Scenario 3
A 16 year-old with known atopic dermatitis presents with worsening skin
lesions in the popliteal fossae. He feels well but the areas are itchy and sore.
What would be your treatment plan?

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Atopic Dermatitis Treatment: Pathogenesis-Directed
● Primary problem in AD is an impaired skin barrier (e.g., filaggrin mutations)
o Water escapes the skin (dryness)
o Irritants, allergens and microbes easily enter the skin (inflammation-redness,
itchiness, serous drainage or impetiginization)
● Immune system “sees” more and reacts more
If the skin isn’t hydrated it isn’t able to block irritants and microbes
from “slipping through the cracks” and causing an infection.

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Treatment
2 Steps to Treat Effectively: Resolve existent inflammation (acute
flare) AND reinforce the skin barrier (maintenance)
1 2

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Skin Care
 Bathe 5-10 minutes with warm, NOT hot, water once every other day
 Sensitive skin soaps: Dove sensitive skin bar soap, Cetaphil cleanser,
Vanicream soap
 Moisturize twice daily every day
 Ointments: Hydrolatum, Vaseline, Aquaphor
 Creams: CeraVe cream, Cetaphil cream, Aveeno cream, Eucerin
cream, Vanicream
 *do not use lotions as they are minimally effective (too thin)
 *avoid “organic” products or ones containing fragrance, plant derivatives
(calendula, cocamidylpropyl betaine)

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Treating the Inflammation
Topical steroids 1st line
*Systemic corticosteroids are not indicated
For itch: sedating antihistamines: diphenhydramine or
hydroxyzine po (0.5-2mg/kg/dose)

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Topical Steroids
Low Potency Cost / all are covered by
insurance and all are generic
Hydrocortisone 2.5% ointment $5.00 - $20.00
Desonide 0.05% ointment $13.00 -$25.00
Triamcinolone 0.025% ointment $4.00

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Topical Steroids
Very High-Potency: (if needed, consider derm eval)
clobetasol, halobetasol, desoximetasone
Mid-Potency Cost / Coverage
FluocinoLONE 0.025% ointment $20 - $40 has a generic and brand
version and is covered by
insurance
Triamcinolone 0.1% ointment $4.00 Is generic and is covered by
insurance
High-Potency Cost / Coverage
Mometasone 0.1% ointment $6-$20 may be covered by
insurance
FluocinoNIDE 0.025% ointment may be covered by insurance

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Topical Steroid (Contd.)
Use ointments; don't burn and are more potent
Most are twice daily; use for 2-3 weeks during flares
(stop treating once skin is completely smooth, flat,
not red and not itchy)
If clearance doesn't happen, may need a higher
potency topical steroid
Lower potency for thin-skinned areas (face, axillae,
groin) and thin plaques
Higher potency for rest of skin, lichenified or thicker
plaques
Try to use “less than half the days of the month”

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Topical Calcineurin Inhibitors
● Thin-skinned areas, periocular disease
● Maintenance therapy
● Safety data does not suggest any malignancy risk
● Prior authorization may be required
● Tend to be costly and not all are generic

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Eucrisa (Crisaborole 2%) Ointment
•FDA Approval December 2016
•PDE-4 inhibitor
•Ages 2+ mild-to-moderate atopic dermatitis
•Side effects: hypersensitivity,
stinging/burning/pain
•1522 participants from 2-79 years
•Clear/almost clear: 32.8% vs. 25.4%
(placebo); 31% vs. 18% (placebo)
•Utility-yet to be determined

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Complications
Infections
Bacterial
● Perform a bacterial culture for identification and sensitivities
● Cephalexin po or clindamycin po
● Bleach baths 2-3 times per week for maintenance (also helps with
Inflammation)
Herpes Simplex Virus
Coxsackie Virus
Molluscum
Eczema herpeticum requires emergent dermatologic
treatment

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http://www.wider.es/casosclinicos/index.php/eczema-coxsackium-
causado-por-coxsackievirus-a6-caso-600/

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35. Treatment Cases

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Algorithm
Adapted from Perman M, Yan A. Getting 'ADEPT' at Atopic Dermatitis. Dermped.org. 1:1 (2012)

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Algorithm Continued

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How would you treat?
Questions Based on the Algorithm
Is this atopic dermatitis?
Infection?
Mild/Mod/Severe (thick or thin plaques)?
Thin skinned area?
Affecting sleep?
Triggers?

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WebEx Questions
• You will get the first 4 questions of each case. They are multiple
choice and most are yes or no. You will have a total of 30
seconds to answer the 4 questions on each case. Once you have
submitted your answers, the speaker will go over the right
answers and see how the group did.
• If you don't have the question feature you can write your
answers in the chat box or listen along.
• If you have technical issues during this portion, email the
course directors after the course.

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Case 1
● Is this atopic dermatitis?
● Infection?
● Mild/Mod/Severe?
● Thin Skin?
● Affecting Sleep?
● Triggers?
YES
NO
MILD
YES
YES; SALIVA,
FOOD, WIPES
NO
How would you treat?
Plan: Sensitive skin care
Low potency-desonide 0.05% ointment BID x1-2 weeks
Thick layer of vaseline, hydrolatum, aquaphor before meals, before naps,
before bedtime
Antibiotics and antihistamines are not necessary

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Case 2
● Is this atopic dermatitis?
● Infection?
Mild/Mod Severe?
● Thin Skin?
● Affecting Sleep?
● Triggers?
YES
NO
MOD
NO
?
YES
How would you treat?
Plan: Sensitive skin care
Mid-potency-fluocinolone 0.025 ointment BID x2-3 weeks
Avoid fragrances and chemicals
Antibiotics are not necessary
Hydroxyzine 0.5mg/kg/dose at bedtime

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Case 3:
● Is this atopic dermatitis?
● Infection?
● Mild/Mod/Severe?
● Thin Skin?
● Affecting Sleep?
● Triggers?
YES
NO; culture if not sure
Mild-Mod
NO
NONE APPARENT
YES
Patient has history of skin infection. How would you treat?
Plan: Sensitive skin care
Mid-potency-triamcinolone 0.1 ointment BID x2 weeks
Bleach baths 2-3 times per week
Hydroxyzine 0.5mg/kg/dose at bedtime

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Case 4:
● Is this atopic dermatitis? NO! This is
Scabies!!!
How would you treat?
Plan: Permethrin 5% cream
aad.org

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Case 5:
● Is this atopic dermatitis?
● Infection?
● Mild/Mod/Severe?
● Thin Skin?
● Affecting sleep?
● Triggers?
YES
YES
MOD-SEV
NO
NO
How would you treat?(With evidence of infection, do we treat infection and
inflammation at the same time?)
Plan: Sensitive skin care
Bacterial culture; po cephalexin
(Maintenance-bleach bath)
Med-potency-triamcinolone 0.1 ointment daily x2 weeks
(wrap with plastic wrap)
NO

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Case 6:
● Is this atopic dermatitis?
● Infection?
● Mild/Mod/Severe?
● Thin Skin?
● Affecting sleep?
● Triggers?
YES
NO
MILD
YES
NO
Plan: Sensitive skin care
Avoid fragrances
Low-potency-hydrocortisone 2.5 ointment daily x3-5 days, then switch to
protopic ointment BID x2-3 weeks
Apply a thick layer of moisturizer to act as a protective layer against contactant
YES; FRAGRANCES,
AIRBORNE
Picture courtesy of Dr. Gellis

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Case 7:
● Is this atopic dermatitis?
● Infection?
● Mild/Mod/Severe?
● Triggers?
YES but hmmm
YES
SEVERE
HSV
How would you treat?
Plan: Emergent referral (eczema herpeticum)
Abrupt rash in child with history of
eczema and cold sores.

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When to Refer to Dermatology?
EMERGENT:
• Fevers
• Eczema herpeticum
• Widespread redness with peeling of the skin
(erythroderma)
Widespread atopic dermatitis, especially with other
types of atopy (food allergy, etc.) or complicated history
(immunosuppression, nutritional issues)
Limited response to topical steroid therapy

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Common Questions
 How can I tell the difference between atopic dermatitis and
psoriasis?
 But I've seen the diaper area involved in children with
atopic dermatitis. What is going on?
 Is it safe to use topical steroids on eczema that looks
infected?
 When should I test for food allergies?
 Should I be worried about systemic absorption of topical
steroids? What about the side effects?

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Psoriasis
Medicinenet.com

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Common Questions
 How can I tell the difference between atopic dermatitis and
psoriasis?
 But I've seen the diaper area involved in children with
atopic dermatitis. What is going on?
 Is it safe to use topical steroids on eczema that looks
infected?
 When should I test for food allergies?
 Should I be worried about systemic absorption of topical
steroids? What about the side effects?

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Seborrheic Diaper Dermatitis
Skinsight.org

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Baby Wipe Contact Dermatitis
(Methylchloroisothiazinolone)
http://pediatrics.aappublications.org/content/133/2/e434

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Blue Dye Diaper Dermatitis

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Common Questions
 How can I tell the difference between atopic dermatitis and
psoriasis?
 But I've seen the diaper area involved in children with
atopic dermatitis. What is going on?
 Is it safe to use topical steroids on eczema that looks
infected?
 When should I test for food allergies?
 Should I be worried about systemic absorption of topical
steroids? What about the side effects?

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Common Questions
 How can I tell the difference between atopic dermatitis and
psoriasis?
 But I've seen the diaper area involved in children with
atopic dermatitis. What is going on?
 Is it safe to use topical steroids on eczema that looks
infected?
 When should I test for food allergies?
 Should I be worried about systemic absorption of topical
steroids? What about the side effects?

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Common Questions
 How can I tell the difference between atopic dermatitis and
psoriasis?
 But I've seen the diaper area involved in children with
atopic dermatitis. What is going on?
 Is it safe to use topical steroids on eczema that looks
infected?
 When should I test for food allergies?
 Should I be worried about systemic absorption of topical
steroids? What about the side effects?

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Postinflammatory Pityriasis
Hypopigmentation Alba
Pediatricsconsultant360.com Dermnetz.org

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Algorithm
© 2015 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu
On Blackboard and in follow-up email after this session

60. 60© 2015 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu
Coursework
• You are assigned a team and will receive an email from
Qstream to answer 12 questions over 4 weeks. If you
get the question right twice the question will retire
and you will get a new question.

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Key Terms
 “atopic march”
 Hyperpigmented
 Evidence of infection (pustules, abscesses, impetiginized areas, punched
out areas)
 Seborrheic dermatitis overlap
 Xerosis
 lichenification
 filaggrin mutations
 Impetiginization
 Eczema Herpeticum
 Eczema coxsackium
 Molluscum dermatitis
 Red Flags

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Learning Community Schedule
Date Content
Thursday, May 4, 2017 Atopic Dermatitis
Thursday, June 1, 2017 Acne
Thursday, June 29, 2017 Q&A (Optional and open to
past and current participants)
Thursday, August 24, 2017 Warts, Molluscum, Hives
Thursday, September 28,2017 Q&A (Optional and open to
past and current participants
Thursday, October 26, 2017 Wrap-up
Didactic Webinars: 7:30am – 9:00am
Q&A: 7:30am – 8:30am
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu
Recordings will be sent out in follow-up email

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Your Feedback Helps Us Succeed!
Please take a moment to fill out the session
evaluation survey you will receive via email and
provide us with your feedback so that we can continue
to improve and meet your expectations!
Survey is also a CME / MOC requirement
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

64. Thank you!

65. Appendix

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Atopic Dermatitis: Definition