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1. The Skinny on
Atopic Dermatitis
Robyn Morrissette, PA-C
Division of Allergy and
Immunology
Pediatric Specialists of Virginia

2. No conflicts of interest to disclose.

3. Learning Objectives:
1. To understand how to recognize and
diagnose atopic dermatitis
2. To learn the clinical presentation of atopic
dermatitis
3. To review common treatments for atopic
dermatitis
4. To review developing treatment for atopic
dermatitis in the pediatric population
5. To review the association with food
allergies.

4. Case: Julia 7 month old female
• Referred to clinic by PMD for evaluation of a
rash and to find the cause, concerned it is a food
allergy
• Rash started around 3mo and has worsened
over last 3 months
• Started on the cheeks initially but is spreading to
trunk
• Seems uncomfortable and itchy
• Has been told not to bathe every day as this will
make the skin worse

5. Case Report: Julia
• Mom has been moisturizing with Aveeno twice a
day
• Given Hydrocortisone 2.5% to use twice a day
sparingly and only for 1 week.
• Medication worked but mom was nervous to use
it again
• Rash seems to get worse if Julia is upset
• Rash seems worse if it is hot outside or if Julia is
hot
• Seems to have difficulty sleeping when the rash
is really bad

7. What is your diagnosis? What
would you do?

8. What is Atopic Dermatitis?
•Chronic pruritic inflammatory skin disease
•Affects about 13% of children and about 7% of
adults in the US alone
•Also known as eczema
•Often called the “itch that rashes”

9. What is Atopic Dermatitis?
•Exact cause is unknown
•Thought to be due to a “leaky” skin barrier
•Do know there is an association with the Filaggrin
gene and increased risk for AD
•Also some link to substances that contain proteins
called proteases – proteases break the link
between the skin cells and make the skin barrier
leaky

10. What is Atopic Dermatitis?
• Sensitization to environmental allergens and
food allergens commonly seen but is not a cause
• Is an allergic spectrum disorder as patients with
moderate to severe disease often have elevated
serum IgE
• About 70% patients have a positive family history
of atopic diseases
– Risk can increase to 3-5 fold if both parents have
atopic disease

11. Clinical Presentation of Atopic Dermatitis
• Presentation varies widely
• Childhood onset begins early in life
– About 50% in first year
– About 85% by age 5
• Can persist into adulthood in anywhere from 20-
50% of patients
• Can have adult onset
– Reported by about 26% of adult patients

12. Clinical Presentation of Atopic Dermatitis
• Dry skin and severe pruritis
• Erythematous maculo-papular rash
• Vesicles that can have exudate and crusting
(acute flare)
• Dry, scaly, excoriated patches (more chronic
lesions)
• Lichenification (chronic)
• Hyper/hypo-pigmentation

13. Clinical Presentation of Atopic Dermatitis
• Excoriations at various stages of healing
• Persistent fidgeting due to pruritis
• Irritability
• Insomnia due to pruritis at night
• Decreased concentration secondary to itching
and being uncomfortable

14. Clinical Presentation of Atopic Dermatitis
•In infants to around age 2: Commonly starts on face
and scalp. Sometimes on extensor surfaces.
– Typically spares the genitalia/diaper area
•Age 2 – teenager: Presents more on the flexor surfaces
– Typical antecubital fossa and popliteal fossa
presentation
– Volar aspect wrists, ankles, neck
•Adults: Continues on flexor surfaces and also on hands

15. Diagnosing Atopic Dermatitis
• Clinical diagnosis based on history and
presentation
• Rule out other dermatologic conditions
• Rule out rare immunodeficiency conditions such
as hyper-IgE syndrome and Omenn syndrome
– Eczema accompanied by other symptom such as
failure to thrive, skin abscesses, cutaneous viral
infection, chronic diarrhea
– In adults need to rule psoriasis and cutaneous T-cell
lymphoma

23. Diagnosing Atopic Dermatitis
• Several sets of criteria have been developed
• Hanifin-Rajka (H-R) criteria considered the gold
standard
• United Kingdom Working Party (UKWP)
abridged version of H-R criteria, tends to work
better for pediatric diagnosis
• Not all allergist/dermatologist use a diagnosing
criteria

25. Treatments for Atopic Dermatitis

26. Treatments for Atopic Dermatitis
• Accepted for publication June 26, 2019
• Includes newer topical medications like
Crisaborole (Eucrisa)

28. Treatments for Atopic Dermatitis
• Treatment is daily given the chronicity of the
disease
• Multifaceted
• Personalized to the patient and severity
• Often requires review at follow up visits to
ensure compliance

29. Treatments for Atopic Dermatitis
• Atopic Derm myth #1: Baths make AD worse.
• Every patient no matter severity gets daily care
of basic management (bath and moisturizing)
• Daily bath  Soak and seal
– 15-20 minutes warm, clean water
– Infants/small kids place wash cloth over areas not under
water and continue to wet
– Older kids can do shower
– Soaps do not have to be done daily. If used, use at end and
rinse immediately then out of bath.
– Pat dry
– Apply emollients (Aquaphor or Vaseline)

30. Treatments for Atopic Dermatitis
•Recommend moisturizing in the morning and at
bedtime after bath.
•Should do at least 1 more time mid-
day/afterschool
•Can be done as needed
•Infants – easy to tell parents to do with diaper
changes
•Older patients can use non-fragranced lotion
(CeraVe, Aveeno, Cetaphil, Eucerin)

31. Treatments for Atopic Dermatitis
• Avoidance of triggers (allergens and irritants)
– Fragrances
– Wool
– Temperature extremes
– Foods
– Soaps/detergents

32. Treatments for Atopic Dermatitis
• Topical Medications
– Topical corticosteroids (Hydrocortisone, Triamcinolone,
Desonide, etc)
– Topical calcineurin inhibitors (pimecrolimus and
tacrolimus)
– Phosphodiesterase-4 inhibitor (Crisaborole)
– Systemic immunosuppressants (Cyclosporine,
Methotrexate)
• Injectable medications
– Dupilumab
• Oral antihistamines

33. Treatments for Atopic Dermatitis
Topical Steroids
• Atopic Derm Myth #2: Use steroids sparingly and
only for 7 days and no more.
• Topical steroids applied twice a day to flare
• Use a thick layer of the medication
• Prefer ointment over creams/lotions
• Use lowest potency that still controls the symptoms
• Use until area clears then 2-3 more days
• Can use up to 14 days in a row before needing to
take a break

34. Treatments for Atopic Dermatitis
Topical Steroids
• In some patients with severe atopic derm can do
a daily preventive application of topical steroids
– Typically done under supervision of Allergist or
Dermatologist
• Safe to use in infants
• Side effect profile is mild if used appropriately
– Side effect of topical steroids  discoloration of the
skin and thinning of the skin
– Minimal absorption systemically if used appropriately

35. Treatments for Atopic Dermatitis
Topical Calcineurin inhibitor
• Includes Pimecrolimus and Tacrolimus
• Approved in use for patients age 2 years and
older
• Popular for use on eyelid atopic dermatitis and
hand dermatitis
• Can use up to 14 days in a row
• Side effect profile is mild if used appropriately
– Most common side effect is redness initially at the
application site  improves with use
– Can make you more photosensitive

36. Treatments for Atopic Dermatitis
Topical PDE4 inhibitiors
• Crisaborole (brand name Eucrisa)
• Approved December 2016
• Ages 2 and older
• Nonsteriodal topical ointment that inhibits PDE 4
(intracellular mediator of inflammation that
degrades cyclic adenosine monophosphate)
• Can be applied anywhere except in the eyes, in
the mouth, or vaginally

37. Treatments for Atopic Dermatitis
Topical PDE4 inhibitiors
• Applied twice a day
• No limitation in how long it can be used
• Side effect profile is mild
– Most common side effects include redness and pain at application
– In our clinic majority of patients who come in on this medication have
stopped if for these reasons

38. 2
FTU
3
FTU
4.5
FTU
6
FTU
(leg)
3
FTU
2.5
FT
U
2 FTU
(arm)
1.5 FTU
(leg)
3 FTU
(front)
2 FTU
(front)
1 FTU
(front)
1.5
FTU
1.5
FTU
2
FTU
2.5
FTU
(Face
& neck)
1 FTU
(hand,
both
sides)
7 FTU
(trunk,
including
buttocks,
front or
back)
3.5 FTU
(front)
5 FTU
(back)
3.5 FTU
(back)
1.5 FTU
(back) 1.5 FTU
(arm)
1 FTU
(arm)
3 FTU
(back)
Topical Ointment Amounts
2 FTU
(foot)
Adolescent/Adult
>12 years
Child
6–10 years
Child
3–5 years
Infant
1–2 years
Infant
3–6 months
1
FTU
Eichenfeld LF, et al. Pediatrics. 2015;136:554-65.
Photo courtesy of Dermnet NZ, https://www.dermnetnz.org/image-licence.
FTU (fingertip unit) = amount of ointment expressed from a tube with
a 5 mm diameter nozzle measured to the tip of the palmar surface of
an adult’s index finger (˜5 g).
1 FTU = adequate amount of ointment for a “thin and even” application
to an area of skin equal to ˜2 adult hands (fingers together).

40. Treatments for Atopic Dermatitis
Additional Therapies
• Oral antihistamines to control itching
– Cetirizine can be used as young as 6 months old
– Hydroxyzine at bedtime to control itch and help sleep
• Topical and oral antibiotics as needed for
superinfection
• Wet wrapping: Intense moisture therapy
involving wrapping affected areas overnight for 5
nights
– https://www.nationaljewish.org/conditions/eczema-
atopic-dermatitis/eczema-treatment/wet-wrap-therapy

41. Treatments for Atopic Dermatitis
Additional Therapies
• Biologics:
– Newest medication approved for treatment of
moderate-severe atopic dermatitis
– Dupilumab (Brand name: Dupixent)
• Monoclonal antibody that targets IL-4 receptor alpha-chain
subunit common to IL-4 and IL-13
• Injectable medication
• Reduction of pruritis
• Reduction in symptoms of anxiety and depression
• Improvement in quality of life
• Approved for 12 years and older
• Done under supervision of Allergist and/or Dermatologist

42. Treatments for Atopic Dermatitis
Additional Therapies
• Bleach bathes
• Phototherapy
• Hospitalization for intense eczema care
• Systemic immunosuppressants

43. Atopic Dermatitis and Food Allergies
•Commonly see patients with AD have food
allergies but as discussed above it is not the cause
•Can be at increased risk for food allergies
•LEAP study – risk factors included severe eczema
– Increased risk of peanut allergy if not introduced early
•NIH study

44. Atopic Dermatitis and Food Allergies
• NIH guidelines regarding peanut introduction

45. Atopic Dermatitis and Food Allergies
• Broad panel serum IgE or skin prick testing is not
recommended in patients with eczema
• Broad panel testing can lead to unnecessary
food avoidances and potential development of
food allergies due to avoidances
• FARE blog post from December 2015 does a
great job discussing research
– http://www.foodallergy.org/about-fare/blog/new-
research-on-food-allergies-and-atopic-dermatitis
• History can help with difference between allergic
reaction and food triggered eczema

46. Back to baby Julia…
•Started daily eczema care plan including:
– Daily bath
– Frequent moisturizing with Vaseline or Aquaphor
– Topical Desonide to face/neck flare ups and topical
Triamcinolone to body flare ups
– Cetirizine in the morning as needed for itching and
Hydroxyzine at bedtime as needed for itching
•Once the eczema was controlled addressed food
allergy concerns
– Skin testing negative to egg and peanut
– Introduction at home

47. Questions??

48. Sources
Fishbein, A, Silverberg, J, Wilson, E, Ong, P. Update on
Atopic Dermatitis: Diagnosis, Severity Assesment, and
Treatment Selection. The Journal of Allergy and Clinical
Immunology: In Practice.
https://doi.org/10.1016/j.jaip.2019.06.044
Weston, W, Howe, William. Atopic dermatitis (eczema):
Pathogenesis, clinical manifestations, and diagnosis.
https://www.uptodate.com/contents/atopic-dermatitis-eczema-
pathogenesis-clinical-manifestations
Photos property of Dermnetnz.org

49. Sources
Schneider, L, Tilles, S, Lio, P, et. al. Atopic Dermatitis: A
Practice Paramater Update 2012
https://www.aaaai.org/aaaai/media/MediaLibrary/PDF%20doc
uments/Practice%20and%20parameters/Atopic-Dermatitis-
2013.pdf