NU 664B Week 11 Discussion 1 Atopic Dermatitis

Sample Answer

Differential Diagnosis

Atopic dermatitis Atopic dermatitis is the most likely diagnosis in this case. Atopic dermatitis is a chronic inflammatory skin condition which typically presents as a pruritic rash. Atopic dermatitis is most commonly seen in children which fits this patients demographics and the pruritus is a common feature of this condition.

This patient has a family history that is significant for asthma, allergic rhinitis, and food allergies which is commonly seen in patients with atopic dermatitis and is the strongest risk factor for development of this condition which makes me highly suspicious that this rash is consistent with atopic dermatitis.

This patient first developed these symptoms at the age of 4 which is consistent with a typical age of onset of atopic dermatitis at age 5 (Howe,2023). Excessively hot or cold environments can trigger an exacerbation of atopic dermatitis so the fact that this patient often has flare ups in the winter and also had exacerbation after returning from a vacation in a tropical climate further supports the diagnosis of atopic dermatitis (Dunphy et al.,2019).

The diagnosis is further supported by the affected body parts of the popliteal and antecubital fossae which is the most common presentation of atopic dermatitis in children (Dunphy et al.,2019). The presence of Dennie-morgan lines also supports the diagnosis of atopic dermatitis and is often seen in this condition (Garzon et al.,2020).

Atopic dermatitis is typically diagnosed based upon clinical presentation and history alone and ruling out other skin conditions (Dunphy et al.,2019)
Impetigo In this patient he may have two skin conditions present as separate issues. On exam he does have Impetigo “crust-like” lesions with serum oozing found on the left elbow (Dunphy et al.,2019).

Impetigo is the most common bacterial skin condition that occurs in the pediatric population and presents as a superficial vesiculopustular infection that is highly contagious (Dunphy et al.,2019). This diagnosis would need to be included on the differential due to the description of the area and how common it is in the pediatric population and even more common in atopic dermatitis due to breaks in the skin from scratching.

Impetigo typically presents with pruritus and is often found on the extremities which fits with this clinical picture (Dunphy et al.,2019). Often impetigo is diagnosed based on clinical presentation and history however, it can be confirmed by culture (Dunphy et al.,2019).

Due to the highly contagious nature of impetigo the diagnosis would further be supported if someone else exposed to the patient had the same presentation, this is not present in the case but doesn’t rule out the condition (Dunphy et al.,2019).

Psoriasis Another condition to consider as part of the differential diagnosis in this patient would be psoriasis. Psoriasis is a skin condition that will also present with erythematous, scaly plaques commonly on the extensor elbows and knees (Dunphy et al.,2019).

The diagnosis of psoriasis should also be considered in this case because like atopic dermatitis it is also triggered by either an excessively cold environment or triggered by prolonged exposure to sunlight which is consistent with this case (Dunphy et al.,2019).

This diagnosis is less likely in this patient because he fits less with the clinical picture of psoriasis which typically has an age of onset either in the late teens to early 20s or late 50s to early 60s (Dunphy et al.,2019). This patient was asked about joint pain because patients with psoriasis may also experience psoriatic arthritis where joints are affected and painful (Dunphy et al.,2019).

In this case the patient has no joint pain. Often a diagnosis of psoriasis can be made based on clinical presentation and history alone. In this case the presentation, history, and demographic features of the patient are more consistent with atopic dermatitis (Dunphy et al.,2019)

Contact dermatitis This is a common skin condition that is either caused by an allergic immune mediated response or caused by irritation after repeated insults to contact with a caustic substance (Dunphy et al.,2019). This condition should be considered because of its prevalence and its typical presentation of a pruritic, erythematous rash.

Four to seven percent of all dermatologic consultation are made due to contact dermatitis (Dunphy et al.,2019). This diagnosis is less likely in this case because the patient does not fit with the typical clinical picture for contact dermatitis which is more common in adult women (Dunphy et al.,2019).

The diagnosis is also less likely as the patient’s parent denies any exposures to any new soaps, lotions or detergents and reports being very careful about what the patient is exposed to. The diagnosis of contact dermatitis is based on the clinical presentation and history which in this case is more consistent with atopic dermatitis (Dunphy et al.,2019)

Plan

Primary Differential Diagnosis Atopic dermatitis and case of impetigo on elbow

Pharmacology

The mainstay of treatment for atopic dermatitis in children is the lowest potency steroid possible for the shortest amount of time possible. Hydrocortisone 2% topically has already been tried which is a lower potency topical steroid.

I would recommend applying a small amount of a higher potency topical steroid of triamcinolone 0.1% ointment twice a day for no more than two weeks. Will re-evaluate in the office in two weeks (Garzon et al.,2020).

Benadryl can help with pruritus and also help with sleeping at night due to its sedative properties. However, I would recommend discontinuing the Benadryl because sedating antihistamines are not generally recommended for children because they can cause daytime drowsiness which can negatively impact school performance and they can also have a paradoxical effect of causing hyperactivity in some children (Dunphy et al.,2019)
Would prescribe mupirocin 2% ointment topically twice a day for 5 days for the area of impetigo on the elbow ( Garzon et al.,2020).
Would recommend decreasing the Zyrtec to 5 mg daily which is the pediatric dosage.

Non-Pharmacology

A mild emollient such as Cetaphil should be used as substitute for soap.
Soak baths should be used instead of showering followed by liberal application of moisturizers after the skin is partially patted dry.
Any products containing strong scents, coloring agents, or perfumes should be avoided (Dunphy et al.,2019)

Diagnostics Would order an allergy panel ; would culture the oozing lesions for bacterial sensitivities.

Consults/Referrals Referral to dermatology

Referral to allergist  (Dunphy et al.,2019)

Patient education

• The impetigo is contagious until 24 hours of antibacterial treatment has been completed so need to avoid exposure to others (Garzon et al.,2020).
  2. Thorough cleansing of any skin breaks will help prevent impetigo (Garzon et al.,2020).
  
• Need to avoid any contact with persons with active herpetic lesions to prevent development of eczema herpeticum (Dunphy et al.,2019)
  
• Discuss how to monitor for secondary signs of bacterial infections that require evaluation (Dunphy et al.,2019)
  
• Discuss need to avoid triggers such as dust mites, pollen, and animal dander (Dunphy et al.,2019)
  
• Discuss ways to reduce sweating such as light bedclothes at night and avoiding occlusive garments (Dunphy et al.,2019)
  
• Fingernails need to be kept short and clean to avoid colonization with S. aureus to open skin areas from scratching (Dunphy et al.,2019).
  
• Need to upgrade moisturizers during the fall to petroleum jelly (Dunphy et al.,2019)
  
• I would discuss the use of bleach baths once or twice a week (Dunphy et al.,2019)
  
• I would discuss that the triamcinolone cream needs to be used for the shortest amount of time possible in order to reduce the risk of potential side effects such as thinning of the skin (Dunphy et al.,2019).
  
• I would discuss that triamcinolone cream should not be used on the face (Dunphy et al.,2019)
  
• Would discuss that topical steroids need to be used for shortest period of time possible because systemic absorption can lead to growth impairment, and cataract formation (Dunphy et al.,2019)

Follow up I would recommend two week follow up appointment for evaluation if treatment has been effective.

Health Maintenance An important item for health maintenance related to dermatology would be discussing sun protection including the use of sunscreen and protective clothing including wide brimmed hats when outside to protect the skin. This will help prevent flares of atopic dermatitis due to the fact that excessive sun exposure can cause flare ups (Dunphy et al.,2019).

Social Determinants of Health Severe eczema is associated with denial of eczema prescriptions by insurance carriers or a lack of health insurance (Buckstein et al.,2022). The health care provider needs to think of the cost of medications and what insurance will cover when making treatment decisions.

If an effective medication is prescribed but insurance will not cover or it is expensive then the patient is less likely to comply with treatment as they may not be able to afford to pick up the prescription. In this case, triamcinolone topical cream was prescribed because this is a medication that will likely be covered by insurance.

There is a newer medication crisaborole that has been approved for the treatment of moderate atopic dermatitis that is effective in reducing itching that I would consider if the current treatment regimen is ineffective (Howe, 2023). However, due to the fact that the patient’s financial resources need to be taken into account this would not be in the primary treatment plan

References

• Bukstein, D. A., Friedman, A., Gonzalez Reyes, E., Hart, M., Jones, B. L., & Winders, T. (2022).
  Impact of social determinants on the burden of asthma and eczema
• Results from a US patient survey. Advances in therapy, 39(3), 1341–1358. https //doi.org/10.1007/s12325-021-02021-0
  
• Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care (5th ed.). F. A. Davis Company.
  
• Garzon, M. D. L., Starr, N. B., Brady, M. A., Gaylord, N. M., Driessnack, M., & Duderstadt, K. (2020). Burns’ Pediatric Primary Care (7th ed.). Elsevier.
  Howe, W. (2023) Atopic dermatitis (eczema) Pathogenesis, clinical manifestations, and
  diagnosis . Uptodate.Retrieved March 18, 2023 from https //www-uptodate-com.regiscollege.idm.oclc.org/contents/atopic-dermatitis-eczema-pathogenesis-clinical-manifestations-and-diagnosis