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Aspen Pharmacare Australia Pty Ltd ABN: 51 096 236 985 34–36 Chandos Street, St Leonards NSW 2065 Phone: (61 2) 8436 8300 Fax: (61 2) 9901 3540 Email: [email protected] Web: www.aspenpharma.com.au 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 FERRI’S FAST FACTS IN DERMATOLOGY A Practical Guide to Skin Diseases and Disorders ISBN: 978-1-4377-0847-9 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. is book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. e Publisher Library of Congress Cataloging-in-Publication Data Ferri, Fred F. Ferri’s fast facts in dermatology : a practical guide to skin diseases and disorders / Fred F. Ferri ; associate editors, James S. Studdiford, Amber Tully.—1st ed. p. ; cm. ISBN 978-1-4377-0847-9 Includes index. 1. Skin—Diseases—Handbooks, manuals, etc. 2. Skin—Diseases—Atlases. I. Studdiford, James S. II. Tully, Amber. III. Title. IV. Title: Fast facts in dermatology. [DNLM: 1. Skin Diseases—Handbooks. WR 39 F388f 2011] RL74.F47 2011 616.5—dc22 2009025859 e patient images without a credit line were taken from the following collections: e Honickman Collection of Medical Images in memory of Elaine Garfinkel e Jefferson Clinical Images Collection (through the generosity of JMB, AKR, LKB, and DA) Acquisitions Editor: Jim Merritt Developmental Editor: Nicole DiCicco Project Manager: Bryan Hayward Design Direction: Steven Stave Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 Third Line ■ Pentoxifylline ■ Oral acyclovir Chapter from: Clinical Pearl(s) Ferri’s Fast Facts in Dermatology: A Practical Guide to Skin Diseases and Disorders ■ Some conditions often associated with the minor variant include Behçet’s Atopic Dermatitis syndrome, inflammatory bowel disease, and gluten sensitivity. (Atopic Eczema) 15. ATOPIC DERMATITIS (ATOPIC ECZEMA) FIGURE 03-030. Dry, erythematous, scaling skin on the palm of this patient during a flare of his atopic dermatitis. Also note fissuring and bleeding secondary to pruritus and scratching. FIGURE 03-031. Marked erythema, secondary excoriations, and edema of the skin overlying the lateral neck. Skin crease accentuation (hyperlinear DISEASES AND DISORDERS 71 creases) is also evident. FIGURE 03-032. Thickened, inflamed, scaling skin FIGURE 03-033. Chronically inflamed, pruritic, in the small of the back that was refractory to hyperpigmented skin in the antecubital fossa with treatment. lichenification and excorciations secondary to excessive scratching. General Comments Definition ■ Atopic dermatitis is a genetically determined eczematous eruption that is pruritic, symmetric, and associated with personal family history of allergic manifestations (atopy). ■ Diagnosis is based on the presence of three of the following major features and three minor features. Copyright © 2011 by Saunders an imprint of Elsevier Inc. All rights reserved. Major Features ■ Pruritus 1 Chapter from: Ferri’s Fast Facts in Dermatology: A Practical Guide to Skin Diseases and Disorders 2 FIGURE 03-032. Thickened, inflamed, scaling skin FIGURE 03-033. Chronically inflamed, pruritic, in theAtopic small of the back that was refractory hyperpigmented skin in the antecubital fossa with Dermatitis (Atopic Eczema)to treatment. lichenification and excorciations secondary to excessive scratching. General Comments Definition ■ Atopic dermatitis is a genetically determined eczematous eruption that is pruritic, symmetric, and associated with personal family history of allergic manifestations (atopy). ■ Diagnosis is based on the presence of three of the following major features and three minor features. Major Features ■ Pruritus ■ Personal or family history of atopy: asthma, allergic rhinitis, atopic dermatitis ■ Facial and extensor involvement in infants and children ■ Flexural lichenification in adults Minor Features ■ Elevated IgE ■ Eczema-perifollicular accentuation ■ Recurrent conjunctivitis 72Ichthyosis Atopic Dermatitis (Atopic Eczema) ■ ■ Nipple dermatitis ■ Wool intolerance ■ Cutaneous S. aureus infections or herpes simplex infections ■ Food intolerance ■ Hand dermatitis (nonallergic irritant) ■ Facial pallor, facial erythema ■ Cheilitis ■ White dermographism ■ Early age of onset (after 2 months of age) Etiology ■ Unknown. Elevated T-lymphocyte activation, defective cell immunity, and B-cell IgE overproduction may play a significant role. Keys to Diagnosis Clinical Manifestation(s) ■ There are no specific cutaneous signs for atopic dermatitis, and a wide spectrum of presentations are possible, ranging from minimal flexural eczema to erythroderma. ■ Inflammation in the flexural areas and lichenified skin is a very common presentation in children. Physical Examination ■ The primary lesions are a result of scratching caused by severe and chronic pruritus. The repeated scratching modifies the skin surface, producing lichenification, dry and scaly skin (Fig. 03-030), and redness. ■ Lesions are typically found on the neck (Fig. 03-031), face, upper trunk, and bends of elbows and knees (symmetric on flexural surfaces of extremities). Copyright © 2011 by Saunders an imprint of Elsevier Inc. All rights reserved. ■ There is dryness, thickening of the involved areas (Fig. 03-032), discoloration, blistering, and oozing. ■ Papular lesions are frequently found in the antecubital and popliteal fossae. Food intolerance Hand dermatitis (nonallergic irritant) ■ Facial pallor, facial erythema ■ Cheilitis Chapter■ from: White dermographism ■ Early age of onset (after 2 months of age) Ferri’s Fast Facts in Dermatology: A Practical ■ ■ Guide to Skin Diseases and Disorders Etiology Atopic Dermatitis (Atopic Eczema) Atopic Dermatitis (Atopic Eczema) 3 ■ Unknown. Elevated T-lymphocyte activation, defective cell immunity, and B-cell IgE overproduction may play a significant role. Keys to Diagnosis Clinical Manifestation(s) ■ There are no specific cutaneous signs for atopic dermatitis, and a wide spectrum of presentations are possible, ranging from minimal flexural eczema to erythroderma. ■ Inflammation in the flexural areas and lichenified skin is a very common presentation in children. Physical Examination ■ The primary lesions are a result of scratching caused by severe and chronic pruritus. The repeated scratching modifies the skin surface, producing lichenification, dry and scaly skin (Fig. 03-030), and redness. ■ Lesions are typically found on the neck (Fig. 03-031), face, upper trunk, and bends of elbows and knees (symmetric on flexural surfaces of extremities). ■ There is dryness, thickening of the involved areas (Fig. 03-032), discoloration, blistering, and oozing. ■ Papular lesions are frequently found in the antecubital and popliteal fossae. ■ In children, red scaling plaques are often confined to the cheeks and the perioral and perinasal areas. ■ Constant scratching may result in areas of hypopigmentation or hyperpigmentation (Fig. 03-033) (more common in African Americans). ■ In adults, redness and scaling in the dorsal aspect of the hands or around the fingers are the most common expression of atopic dermatitis; oozing and crusting may be present. ■ Secondary skin infections may be present (S. aureus, dermatophytosis, herpes simplex). Diagnostic Tests DISEASES AND DISORDERS 73 ■ Skin biopsy can be performed. ■ Laboratory tests are generally not helpful. ■ Elevated IgE levels are found in 80% to 90% of patients with atopic dermatitis. ■ Blood eosinophilia correlates with disease severity. Differential Diagnosis ■ ■ ■ ■ ■ ■ ■ ■ Scabies Psoriasis Dermatitis herpetiform Contact dermatitis Photosensitivity Seborrheic dermatitis Candidiasis Lichen simplex chronicus Treatment First Line ■ Avoidance of triggering factors: Copyright © 2011 by Saunders an imprint of Elsevier Inc. All rights reserved. ● Sudden temperature changes, sweating, low humidity in the winter ● Contact with irritating substance (e.g., wool, cosmetics, some soaps and detergents, tobacco) 3 Chapter from: Ferri’s Fast Facts in Dermatology: A Practical Guide to Skin Diseases and73Disorders DISEASES AND DISORDERS 4 ■ ■ Atopic Dermatitis Eczema) Elevated IgE levels (Atopic are found in 80% to 90% of patients with atopic dermatitis. Blood eosinophilia correlates with disease severity. Differential Diagnosis ■ ■ ■ ■ ■ ■ ■ ■ Scabies Psoriasis Dermatitis herpetiform Contact dermatitis Photosensitivity Seborrheic dermatitis Candidiasis Lichen simplex chronicus Treatment First Line ■ Avoidance of triggering factors: ● Sudden temperature changes, sweating, low humidity in the winter ● Contact with irritating substance (e.g., wool, cosmetics, some soaps and detergents, tobacco) ● Foods that provoke exacerbations (e.g., eggs, peanuts, fish, soy, wheat, milk) ● Stressful situations ● Allergens and dust ● Excessive hand washing ■ Clip nails to decrease abrasion of skin. ■ Emollients can be used to prevent dryness. Severely affected skin can be optimally hydrated by occlusion in addition to application of emollients. ■ Topical corticosteroids may be helpful. Second Line ■ Topical immunomodulators pimecrolimus and tacrolimus are effective steroid-free treatments. ■ Oral antihistamines can help with itching. Third Line ■ Oral prednisone, intramuscular triamcinolone, Goeckerman regimen, and PUVA are generally reserved for severe cases. Clinical Pearl(s) ■ The highest incidence is among children (5%-10%). More than 50% of children with generalized atopic dermatitis develop asthma and allergic rhinitis by age 13 years. Copyright © 2011 by Saunders an imprint of Elsevier Inc. All rights reserved.