Atopic Dermatitis, Eczema

Atopic Dermatitis, Eczema
Diagnosis/Condition:
Discipline:
ICD-9 Codes:
ICD-10 Codes:
Origination Date:
Review/Revised Date:
Next Review Date:
Due to food ingestion/sensitivity
Due to food in contact with skin
Due to drugs and medicines applied to
skin
ND
691.8, 693.1, 692.5, 692.3
2/2000
11/2007, 01/2008, 05/2010
05/2012
Eczema is a general term for many types of dermatitis. Atopic dermatitis is the most common of
the many types of eczema, especially in the pediatric population. "Atopic" refers to diseases that
are hereditary, tend to run in families, and often occur together. Atopic dermatitis (AD) is a
pruritic disease of unknown origin that usually starts in early infancy and is typified by pruritus,
eczematous lesions, xerosis (dry skin), and lichenification on the skin (thickening of the skin and
increase in skin markings) which is distributed in age-specific patterns. i, ii AD is associated with
other atopic diseases (e.g., asthma, allergic rhinitis, urticaria, acute allergic reactions to foods,
increased immunoglobulin E [IgE] production) in many patients. iii Those with AD are at an
increased risk of developing a latex allergy. iv The prevalence rate in the US is 10-20% in children
and up to 3% in adults. v, vi, vii The incidence of AD appears to be increasing. viii, ix, x
Affected individuals must cope with a significant psychosocial burden, in addition to dealing with
the medical aspects of the disease. Because this is primarily a disease of childhood, family
members, especially parents, are also affected by the condition. Individuals and family members
are burdened with time-consuming treatment regimens for the disease, as well as dietary and
household changes. AD has been associated with parental sleep disturbances, anxiety levels, and
increased maternal depression.x The cost to society is significant, with estimates ranging from less
than $100 to more than $2000 per patient per year. It is estimated that the direct cost of atopic
dermatitis in the United States alone is almost $1 billion per year. Health care provider visits for
contact dermatitis and other eczemas are over 7 million per year. xi,x
Subjective Findings and History
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Acute or chronic skin inflammation with excessive pruritis (excoriations and crusting may
develop)
Often characterized by periods of acute flare up and remission
Episodes generally more severe in first five years of life (early age of onset)
Intermittent acute “wet” inflamed eruptions and chronic dry itching eruptions
Etiologic factors: heredity, other atopic conditions: asthma, otitis media, allergic rhinitis in
first degree relative
Differential Diagnoses
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Scabies
Allergic contact dermatitis
Lichen simplex chronicus
The CHP Group
Atopic Dermatitis Clinical Pathway
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Mycosis fungoides
Nummular dermatitis
Relative zinc deficiency
Tinea corporis
Seborrheic dermatitis (SD)
Mollusca contagiosa with dermatitis
Cutaneous lymphoma
Ichthyosis, psoriasis
Immunodeficiency
Other primary disease entities
Objective Findings
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Labs
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Inflamed, irritated wet lesions, commonly on flexor surfaces, hands, neck, arms, legs and
torso Lichenification and flexural involvement, xerosis, erythema, deposition of amyloid
Common around the mouth and anus in infants
Chronic appearance more commonly dry, lichenified, cracked and inflamed
Appearance can be anywhere in adults, but is most common on the hands
No chemical marker for the diagnosis of atopic dermatitis is known, but testing to rule out
other immunodeficiencies may be helpful
Biopsy shows an acute, subacute, or chronic dermatitis, but no specific findings are
demonstrated
Peripheral blood for elevated eosinophils, basophilia
Swab of infected skin may help with the isolation of a specific organism and antibiotic
sensitivity.
Possible allergy and sensitivity testing often indicates triggers such as food and
environmental agents
Elevated IgE and decreased IgA common
A platelet count for thrombocytopenia helps exclude Wiskott-Aldrich syndrome
Scraping to exclude tinea corporis may be helpful
Assessment
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Laboratory tests if indicated (as above)
Physical exam (pulmonary, EENT, cardiac, GI)
Identification of the triggers through testing, or avoidance and reintroduction
Plan
Treatment goals
• Identification and avoidance of triggers
• Reduction of pruritis and discomfort
• Prevention of secondary infection
• Develop proper skin care habits, bathing and lubricants/emollients to seal in moisture and
allow water to be absorbed through the stratum corneum
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Atopic Dermatitis Clinical Pathway
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Natural Medicine
• Rotation diets, avoidance dietsxii, vegetarian diet xiii; assess overall diet with elimination
and challenge and/or food sensitivity testing.
• Exclusion of cow’s milk and eggs xiv,xv
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Maternal dietary exclusions in pregnancy and lactation xvi,xvii
• Anti-inflammatory nutritional supplements and nutritional support for the GI tract;
antihistamine effects anti-oxidant effects
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Probiotics xviii,xix,xx,xxi,xxii
• Botanicals: anti-inflammatory, liver support, GI support, anti-infective, skin tonics, antihistamine and anti-allergic herbs
• Mahonia aquifolium ointment xxiii, oral Konjac ceramide xxiv, topical St John’s Wort xxv,
topical Persimmon leaf.xxvi, xxvii
• Topical and oral γ-linolenic acid (GLA)xxviii, evening primrose (EPO) xxix and borage oil
have mixed results. xxx,xxxi, xxxii, xxxiii, xxxiv,xxxv, xxxvi, xxxvii, xxxviii, xxxix. Therapeutic doses of EPO were
500 g/day for 8 weeks xl
• Constitutional homeopathic prescription
Physical Therapy
• Hydrotherapy. Avoid hot baths. Lukewarm baths followed by the application of a
moisturizer to avoid moisture evaporation. Baths can be taken with added oils.
• Local topical poultices to decrease irritation
• Castor oil packs
• Phototherapy (ultraviolet light (ultraviolet B, narrow-band ultraviolet B, and highintensity ultraviolet A) xli. Avoid long-term use.
Relaxation Techniques and Behavioral Modification
• Improved skin hygiene
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Autogenic training xlii
• Hypnotherapy xliii
• Behavioral therapyxli
• Parental training xliv
• Allergen and dust mite avoidancexli
• Clothing should be soft next to the skin (e.g. cotton) and washed in a mild detergent with
no bleach or fabric softener.
• Cool temperatures to reduce sweating which can exacerbate irritation and itch. A
humidifier (cool mist) prevents excess skin drying.
Pharmaceuticals
• Topical corticosteroids
• Emollient adjunct, xlv wet wrap dressing adjunct xlvi
• Topical calcineurin inhibitors (for patients over 2 y.o.)
• Topical antibiotic treatment if secondary infection
Traditional Chinese Medicine (TCM)
• Botanicals and Chinese herbs xlvii (Potentilla chinensis, Tribulus terrestris, Rehmannia
glutinosa, Lophatherum gracile, Clematis armandii, Ledebouriella saseloides, Dictamnus
dasycarpus, Paeonia lactiflora, Schizonepeta tenuifolia, and Glycyrrhiza glabrae.) xlviii, xlix, l
The CHP Group
Atopic Dermatitis Clinical Pathway
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Radix angelicae pubescentis combined with UV-A radiation li, lii
Length of Treatment
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Up to 4 weeks to achieve sustained improvement and longer for chronic cases
Criteria for Referral or Re-evaluation
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Ongoing acute symptoms without resolution after 4 weeks
Secondary infection not responding to treatment
Chronic - failure to resolve or repeated acute outbreaks over a period of several months
Provider Resources
Williams H. Atopic Dermatitis. N Engl J Med 2005;352:2314-24.
http://content.nejm.org/cgi/content/full/352/22/2314
Hanifin JM, et.al. Guidelines of care for atopic dermatitis. J Am Acad Dermatol 2004
Mar;50(3):391-404. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=4361&nbr=3286
Krafchik, BR. Atopic Dermatitis. 2010.,http://emedicine.medscape.com/article/1049085-print
Guidelines of care for atopic dermatitis. American Academy of Dermatology - Medical Specialty
Society. 2004 Mar.
Patient Resources:
MedicineNet.com is an online, healthcare media publishing company. It provides easy-to-read,
in-depth, authoritative medical information for consumers via its robust, user-friendly, interactive
web site. Atopic Dermatitis.
http://www.medicinenet.com/atopic_dermatitis/page7.htm
The American Academy of Dermatology. Eczema/Atopic Dermatitis.
http://www.aad.org/public/publications/pamphlets/skin_eczema.html
The National Eczema Association. http://www.nationaleczema.org/
The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Atopic
Dermatitis. 2009. http://www.niams.nih.gov/Health_Info/Atopic_Dermatitis/default.asp
Created by The Nemours Foundation's Center for Children's Health Media, the award-winning Kids
Health provides families with accurate, up-to-date, and jargon-free health information they can
use.
http://www.kidshealth.org/parent/infections/skin/eczema_atopic_dermatitis.html
Clinical Pathway Feedback
CHP desires to keep our clinical pathways customarily updated. If you wish to provide additional
input, please use the e-mail address listed below and identify which clinical pathway you are
referencing. Thank you for taking the time to give us your comments.
Chuck Simpson, DC, CHP Medical Director: csimpson@chpgroup.com
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Atopic Dermatitis Clinical Pathway
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i
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iii
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iv
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v
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viii
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x
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xi
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xii
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xiii
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xiv
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xv
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xvi
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xvii
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xviii
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xix
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xx
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xxi
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xxii
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xxiii
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xxiv
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xxv
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xxvi
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xxvii
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xxviii
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ii
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xxix
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xxx
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xxxi
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xxxii
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xxxiii
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xxxiv
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xxxv
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xxxvi
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xxxvii
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xxxviii
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xl
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xli
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xlii
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xlv
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xlvi
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xlviii
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xlix
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l
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li
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lii
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