Download 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
•
•
•
•
•
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
•
•
•
Scabies
Allergic contact dermatitis
Lichen simplex chronicus
The CHP Group
Atopic Dermatitis Clinical Pathway
1
•
•
•
•
•
•
•
•
•
•
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
•
•
•
•
Labs
•
•
•
•
•
•
•
•
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
•
•
•
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
The CHP Group
Atopic Dermatitis Clinical Pathway
2
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
•
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
•
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
•
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
3
•
Radix angelicae pubescentis combined with UV-A radiation li, lii
Length of Treatment
•
Up to 4 weeks to achieve sustained improvement and longer for chronic cases
Criteria for Referral or Re-evaluation
•
•
•
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: [email protected]
The CHP Group
Atopic Dermatitis Clinical Pathway
4
i
Hanifin JM, Rajka G. Diagnostic features of atopic dermatitis. Acta Derm Venereol. 1980;92:44–47.
Eichenfield LF, Hanifin JM, Luger TA, Stevens SR, Pride HB. Consensus conference on pediatric atopic dermatitis. J
Am Acad Dermatol. 2003;49:1088–1095.
iii
Eichenfield LF, Hanifin JM, Beck LA, et al. Atopic dermatitis and asthma: parallels in the evolution of treatment.
Pediatrics.2003;111:608–616.
iv
Poley GE and Slater JE. "Latex allergy." Journal of Allergy and Clinical Immunology. 2000;105 (6):1054-62.
v
Rudikoff D and Lebwohl M. "Atopic dermatitis." Lancet 351(9117): 1715-21. 1998
vi
Larsen F and Hanikin J. "Epidemiology of Atopic Dermatitis." Immunology and Allergy Clinics of North America. 2002;
22:1-25.
vii
The International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. "Worldwide variation in
prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC." Lancet. 1998; 351:1225-32.
viii
Disease management of atopic dermatitis: An updated practice parameter. Ann Allergy Asthma Immunol. 2004; 93:S1S21.
ix
Matsumoto I et al. "Change in prevalence of allergic diseases in primary school children in Fukuoka City for the last
fifteen years." Arerugi. 1999; Apr 48(4):435-42.
x
Kimberly A. Horii, Stephen D. Simon, Deede Y. Liu and Vidya Sharma. Atopic Dermatitis in Children in the United
States, 1997_2004: Visit Trends, Patient and Provider Characteristics, and Prescribing Patterns. Pediatrics 2007;120;e527e534.
xi
CDC. National Center for Health Statistics. Vital and Health Statistics Series, 1996: Vol. 13, no. 134.
xii
Sampson HA. The evaluation and management of food allergy in atopic dermatitis. Clin Dermatol 2003;21:183-192.
xiii
Tanaka T. Kouda K. Kotani M. et al. Vegetarian diet ameliorates symptoms of atopic dermatitis through reduction of
the number of peripheral eosinophils and of PGE2 synthesis by monocytes. Journal of Physiological Anthropology &
Applied Human Science. 2001;20(6):353-61.
xiv
Lever R, MacDonald C, Waugh P, et al. Randomised controlled trial of advice on
an egg exclusion diet in young children with atopic eczema and sensitivity to
eggs. Pediatr Allergy Immunol 1998; 9: 13-9.
xv
Atherton DJ, Sewall M, Soothill JF, et al. A double-blind controlled cross-over trial
of an antigen-avoidance diet in atopic eczema. Lancet 1978; 25: 401-3.
xvi
Cant AJ, Bailes JA, Marsden RA, et al. Effect of maternal dietary exclusion on
breast fed infants with eczema: two controlled studies. BMJ 1986; 293: 231-3
xvii
Kramer MS. Maternal antigen avoidance during lactation for preventing atopic
disease in infants of women at high risk (Cochrane Review). Available in The
Cochrane Library [database on CD ROM]. Updated quarterly. The Cochrane
Collaboration; issue 2. Oxford: Update Software, 2002.
xviii
Lee J., Seto D., Bielory L.: Meta-analysis of clinical trials of probiotics for prevention and treatment of pediatric
atopic dermatitis. J Allergy Clin Immunol. 2008;121. 116-121;e11
xix
Ogden N.S., Bielory L.: Probiotics: a complementary approach in the treatment and prevention of pediatric atopic
disease. Curr Opin Allergy Clin Immunol. 2005; 5:179-184.
xx
Isolauri E. Dietary modification of atopic disease: Use of probiotics in the prevention of atopic dermatitis. Current
Allergy & Asthma Reports. 2004;4(4):270-5.
xxi
Viljanen M, Savilahti E, Haahtela T, et al. Probiotics in the treatment of atopic eczema/dermatitis syndrome in
infants: a double-blind placebo-controlled trial. Allergy. 2005;60:494-500.
xxii
Weston S, Halbert AR, Richmond P, Prescott SL. Effects of probiotics on atopic dermatitis: a randomised controlled
trial. Arch Dis Child. 2005;90:892-897.
xxiii
Donsky H., Clarke D.: Relieva, a Mahonia aquifolium extract for the treatment of adult patients with atopic
dermatitis. Am J Ther. 2007;14. 442-446.
xxiv
Kimata H.: Improvement of atopic dermatitis and reduction of skin allergic responses by oral intake of konjac
ceramide. Pediatr Dermatol 2006; 23:386-389.
xxv
Schempp C.M., Windeck T., Hezel S., Simon J.C.: Topical treatment of atopic dermatitis with St. John's wort
cream—a randomized, placebo controlled, double blind half-side comparison. Phytomedicine. 2003; 10. (suppl 4): 31-37.
xxvi
Matsumoto M., Kotani M., Fujita A., Higa S., Kishimoto T., Suemura M., et al: Oral administration of persimmon
leaf extract ameliorates skin symptoms and transepidermal water loss in atopic dermatitis model mice, NC/Nga. Br J
Dermatol. 2002;146. 221-227.
xxvii
Mainardi T. Kapoor S. Bielory L. Complementary and alternative medicine: herbs, phytochemicals and vitamins and
their immunologic effects. Journal of Allergy & Clinical Immunology. 2009;123(2):283-94.
xxviii
Andreassi M, Forleo P, Lorio AD, Masci S, Abate G, Amerio P. Efficacy of γ-linolenic acid in the treatment of
patients with atopic dermatitis. J Int Med Res. 1997;25:266-274.
ii
The CHP Group
Atopic Dermatitis Clinical Pathway
5
xxix
Biagi PL, Bordini A, Hrelia S, et al. The effect of gamma-linolenic acid on clinical
status, red cell fatty acid composition and membrane microviscosity in infants
with atopic dermatitis. Drugs Exp Clin Res 1994; 20: 77-84.
xxx
Gehring W, Bopp R, Rippke F, Gloor M. Effect of topically applied evening primrose oil on epidermal barrier function
in atopic dermatitis as a function of vehicle. Arzneimittelforschung. 1999;49:635-642.
xxxi
Schalin-Karrila M, Mattila L, Jansen C, Uotila P. Evening primrose oil in the treatment of atopic eczema: effect of
clinical status, plasma phospholipid fatty acids and circulating blood prostaglandins. Br J Dermatol. 1987;117:11-19.
xxxii
Wright S, Burton J. Oral evening-primrose-seed oil improves atopic eczema. Lancet. 1982;2:1120-1122.
xxxiii
Bordoni A, Biagi P, Masi M, et al. Evening primrose oil (Efamol) in the treatment of children with atopic eczema.
Drugs Exp Clin Res. 1988;14:291-297.
xxxiv
Biagi PL, Bordoni A, Masi M, Ricci G, Fanelli C, Patrizi A, Ceccolini E. A long-term study on the use of evening
primrose oil (Efamol) in atopic children. Drugs Exp Clin Res. 1988;14:285-290.
xxxv
Humphreys F, Symons H, Brown H, Duff G, Hunter J. The effects of gamma-linolenic acid on adult atopic eczema
and premenstrual exacerbation of eczema. Eur J Dermatol. 1994;4:598-603.
xxxvi
Berth-Jones J, Brown G. Placebo-controlled trial of essential fatty acid supplementation
in atopic dermatitis. Lancet. 1993; 341: 1557-60.
xxxvii
Whitaker DK, Cilliers J, de Beer C. Evening primrose oil (Epogam) in the treatment
of chronic hand dermatitis: disappointing therapeutic results. Dermatology
1996; 193: 115-20.
xxxviii
Hederos CA, Berg A. Epogam evening primrose oil treatment in atopic dermatitis
and asthma. Arch Dis Childhood. 1996; 75: 494-7.
xxxix
Ernst E, Pittler MH, Stevinson C. Complementary/alternative medicine in dermatology: evidence-assessed efficacy of two
diseases and two treatments. Am J Clin Dermatol. 2002;3(5):341-8.
xl
Biagi P, Bordoni A, Hrelia S, et al. The effect of gamma-linolenic acid on clinical status, red cell fatty acid composition
and membrane microviscosity in infants with atopic dermatitis. Drugs Exp Clin Res. 1994;20:77-84.
xli
Hoare C, Li Wan Po A, Williams H. Systematic review of treatments for atopic eczema. Health Technol Assess
2000;4:1-191.
xlii
Ehlers A, Stangier U, Gieler U. Treatment of atopic dermatitis: a comparison of psychological and dermatological
approaches to relapse prevention. J Consult Clin Psychol. 1995; 63: 624-35.
xliii
Sokel B, Christie D, Kent A, et al. A comparison of hypnotherapy and biofeedback
in the treatment of childhood atopic eczema. Contemp Hypnosis. 1993; 10: 145-54.
xliv
Staab D, von Rueden U, Kehrt R, et al. Evaluation of a parental training program for the management of childhood
atopic dermatitis. Pediatr Allergy Immunol. 2002;13:84-90.
xlv
Lucky AW. Leach AD. Laskarzewski P. Wenck H. Use of an emollient as a steroid-sparing agent in the treatment of
mild to moderate atopic dermatitis in children. Pediatric Dermatology. 1997;14(4):321-4.
xlvi
Devillers AC. de Waard-van der Spek FB. Mulder PG. Oranje AP. Treatment of refractory atopic dermatitis using
'wet-wrap' dressings and diluted corticosteroids: results of standardized treatment in both children and adults.
Dermatology. 2002; 204(1):50-5.
xlvii
John Koo, MD; Sumaira Arain, BA. Traditional Chinese Medicine for the Treatment of Dermatologic Disorders. Arch
Dermatol. 1998;134:1388-1393.
xlviii
Sheehan MP, Atherton DJ. A controlled trial of traditional Chinese medicinal plants in widespread non-exudative
atopic eczema. Br J Dermatol. 1992;126:179-184.
xlix
Sheehan MP, Rustin MHA, Atherton DJ, et al. Efficacy of traditional Chinese herbal therapy in adult atopic
dermatitis. Lancet. 1992;340:13-17.
l
Latchman Y, Whittle B, Rustin M, Atherton DJ, Brostoff J. The efficacy of traditional Chinese herbal therapy in atopic
eczema. Int Arch Allergy Immunol. 1994;104:222-226.
li
Li FQ, Fang FY, Jian ZY, et al. Cases suffering from psoriasis treated with traditional Chinese medicine and long wave
ultraviolet. Chin J Phys Ther. 1983;6:144-145.
lii
Zhang GW, Wang HJ, Zhou YH, et al. Treatment of psoriasis by photochemotherapy: a comparison between the
photosensitizing capsule of Angelica dahurica and 8-MOP. Natl Med J China. 1983;63:16-19.
The CHP Group
Atopic Dermatitis Clinical Pathway
6