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Atopic Dermatitis

by Carlo Raj, MD
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    00:01 Here, we’ll take a look at atopic dermatitis.

    00:03 Now, this is extremely common, and must be spoken of why, because when you talk about atopic type of issues, you’ve heard of asthma.

    00:13 With asthma, majority of your asthma is of what type? Oh yeah, it’s atopic, isn’t it? There is intrinsic as well but you focus on atopic.

    00:22 The point is this.

    00:23 When you talk about atopy or atopic, what does that mean to you? You’re talking about a patient in environment that has been exposed to certain allergens.

    00:31 And obviously, in the U.S., we have pollen, pollen, pollen, whatever it may be, huh? When you’re exposed to that type of allergen, there is every possibility that you might then elicit a type 1 hypersensitivity.

    00:42 And therefore, you would have release of histamine working on H1 receptors bringing about bronchoconstriction that gives you your atopic asthma.

    00:49 In such patients, you might also have development of atopic dermatitis.

    00:56 Familial maybe, maybe unknown.

    00:58 Associated with asthma.

    00:59 Let me stop there and make sure that you’re crystal clear about that association.

    01:05 Oftentimes, as I told you earlier, if your patient is experiencing asthma-like symptoms, there’s every possibility that atopic dermatitis is also part of this.

    01:15 Also, allergic type of rhinitis.

    01:16 This is called your atopic triad; asthma, rhinitis, and dermatitis.

    01:24 Obviously, immunologically, this is your type 1 hypersensitivity involvement of your helper type 2 T-cells.

    01:34 Demographics: increasing incidence, especially in the U.S.

    01:39 Most common in childhood, and growing out of it is luckily what happens to the child.

    01:45 So, if there is atopic asthma and there is atopic dermatitis and rhinitis or whatnot, then the patient, the child, as he or she is growing up, will no longer suffer from it.

    01:56 That’s always good news.

    01:58 What about the morphology? Highly pruritic as you can examine, highly pruritic as you examine.

    02:05 And eczematous type of plaque as you take a look at this closer, and by that, we mean that the lesion that you’re seeing here, these plaques are eczematous, we call this weeping type of plaques.

    02:18 And it’s itchy, right, upon examination.

    02:22 Further history, the patient is going to say -- or the child is going to itch, itch, itch.

    02:27 And if it’s itchy enough, at some point, my goodness gracious, the plaque, that eczema is going to then offer resistance, or should I say adaptation, and that type of adaptation we’ll talk about is called lichenification.

    02:42 So, it’s a story that we’ll talk about.

    02:44 At this point, our topic is atopic dermatitis, just discussed demographics, highly pruritic and eczematous.

    02:53 The location of plaque changes with advancing age, and this is huge.

    02:57 So, if you’re a child, then think about your aunt who’s squeezing you in the cheeks.

    03:04 “Oh, it’s been so long since I’ve seen you my boy, or my girl.” So, face and extensor surfaces in infants.

    03:12 Think about cheeks and such in a child.

    03:15 The eczema that you find in an adult, you’re thinking about the flexural areas in older children and some adults.

    03:23 The location of your particular eczema with atopic dermatitis, which is extremely pruritic, is going to change based on age.

    03:34 That’s important for you to take out of this.

    03:39 Associations: With atopic dermatitis, associations are common conditions we’ll talk about soon enough.

    03:46 In Greek, we have ichthyosis, and by that we mean ichthy-, means fishy scaling of the skin.

    03:55 Other association is keratosis pilaris.

    03:59 Then another one called Dennie-Morgan lines.

    04:02 Now, if you take a look at the morphology here of the eczema that I’m showing you, we have residual eczema on the cheek of this patient, and then obviously, the flexural areas that you see here.

    04:12 And these are your weeping type of vesicles, and keep in mind that this is itchy.

    04:18 Atopic dermatitis.

    04:20 Further morphology here, if you’d take a look at atopic dermatitis, would be more of your weeping vesicle type of appearance in the flexural region, extremely itchy.

    04:31 The management: education, meaning what? Well, if that particular patient or the parents of the child in which the child is developing atopic dermatitis/rhinitis and asthma, the atopic triad, then educate the parents, or maybe the child to say, “Okay. Well, maybe perhaps, you want to try to avoid such environments or be careful about exposure to that particular antigen.” Right? Education, gentle bathing, and generous emollient.

    05:04 Remember, it’s itchy, itchy, itchy.

    05:07 And if you keep itching this and you do not apply any type of, let’s say, ointment or emollient, then at some point in time, that particular plaque might then react or adapt and then may become extremely -- well, I don’t want to use the word scarred because in medicine, we have to call it lichenified or lichenification.

    05:27 Topical steroids, and obviously, antihistamines for that itch because we’re dealing with our type 1 hypersensitivity.

    05:36 The differentials quickly: Contact dermatitis.

    05:39 Be careful.

    05:40 What’s the difference? Atopic dermatitis, exposure to allergens, if that helps you, huh? Allergens, where? Most likely in the environment.

    05:50 Hence, in the U.S., it’s a growing field.

    05:54 So, those of you that wish to go into allergy or you want to become an allergist, your practice is going to be filled, filled, because you have tons of patients that are suffering from that atopic triad.

    06:06 Now, a differential will be contact.

    06:09 What does that mean? Usually revealed by history.

    06:11 What kind of history? Well, maybe there was unusual pattern with sharp demarcation, but the history here literally, let’s say that you have coins in your pocket and you are “allergic” to that nickel in the coin.

    06:27 You’re wearing your jeans, and the jeans are pressing the nickel in the coins upon the skin, huh? Contact.

    06:34 And therefore, it may result in a type 4 hypersensitivity, resulting in contact dermatitis.

    06:40 Hopefully, that’s clear.

    06:41 We’ll talk more.

    06:43 Quickly, as soon as hear seborrheic dermatitis, close your eyes.

    06:46 Dermatitis.

    06:48 Where? Good.

    06:50 On the face.

    06:51 If it’s in adult, tell me about the nasolabial fold.

    06:55 Is there or is there not involvement of the nasolabial fold in seborrheic dermatitis? You’re going to tell me.

    07:04 Yes, there is, very good.

    07:06 When is it not? Your malar rash seen with SLE.

    07:10 Are we getting better at this? If it’s an infant, where would you find this? Oh yeah, cradle cap.

    07:17 Hopefully, if it’s mild in an infant, because of the flaking of skin on the scalp, good, dandruff.

    07:27 With dermatitis, it’s more likely to involve in the diaper area as well.

    07:30 Keep that in mind, okay? Seborrheic dermatitis.

    07:34 Other differentials: diaper dermatitis, limited to the groin area, where atopic dermatitis is unusual.

    07:43 Groin area is unusual in atopic dermatitis.

    07:47 Often spares the body folds where feces and urine does not contact the skin.

    07:56 We’ll talk about a condition called mycosis fungoides.

    08:00 Let’s just put it this way.

    08:01 I am dissatisfied with the name as should you be.

    08:05 It has nothing to do with fungi, nothing.

    08:08 It is a T-cell type of cancer.

    08:12 It’s a cancer.

    08:14 So, when the time is appropriate, this is the first time that I’m introducing this to you.

    08:19 But mycosis fungoides has nothing to do with fungi.

    08:22 In fact, these are cancerous, or should I say, a T-cell type of cancer that is then limited to the tissue.

    08:29 You’ve heard of Sézary syndrome.

    08:31 When the time is right, we’ll talk about two conditions.

    08:34 At this point, keep it as a differential because of -- what are you going to find with atopic dermatitis? Eczema, it’s erythematous.

    08:42 You might also find this with mycosis fungoides.

    08:45 Obviously, atopic dermatitis is not at all cancer.

    08:48 And on top of that, it’s uncommon in children, mycosis fungoides.

    08:53 Often involves the double protected sites beneath the undergarments.

    08:59 We’ll talk further about that, double protected.

    09:01 So in other words, something that you feel is though will be protected and would be then immune to such changes.

    09:08 Here in this cancer, seriously, everything is susceptible to damage.


    About the Lecture

    The lecture Atopic Dermatitis by Carlo Raj, MD is from the course Inflammatory Skin Diseases.


    Included Quiz Questions

    1. Type I hypersensitivity
    2. Type II hypersentivity
    3. Type III hypersensitivity
    4. Type IV hypersensitivity
    5. Delayed hypersensitivity reaction
    1. Pruritic and eczematous
    2. Ulcerative and non-healing
    3. Clearly demarcated and hypopigmented
    4. Scaly and dry
    5. Maculopapular rash in the groin and scalp
    1. Antihistamines and steroids
    2. Methotrexate and steroids
    3. Fluconazole and antihistamines
    4. Ketoconazole and methotrexate
    5. Acetaminophen and steroids
    1. Difficulty in breathing
    2. Hair fall
    3. Constipation
    4. Difficulty in falling asleep
    5. Blurred vision
    1. Symptoms change with age
    2. Presence of perianal lesions
    3. Facial "butterfly rash" over the nasal bridge
    4. Typically seen in pediatric age group
    5. Increased incidence in children wearing diapers

    Author of lecture Atopic Dermatitis

     Carlo Raj, MD

    Carlo Raj, MD


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    Smoothly presented lecture, good content, could use some additions
    By George L. on 14. May 2017 for Atopic Dermatitis

    Good lecture. The talking is very smooth and continuous not robotic like it sometimes tends to be the case with Dr.Raj. Excellent! Good explanation of the terms and the difference between atopic and contact dermatitis! Some more elaboration on treatment options, including non-pharmacologic and the role of allergen testing (should you do it or not?) would be a good addition.

     
    Good, need more information
    By Febelia Devina S. on 19. April 2017 for Atopic Dermatitis

    Easy to understand. I recommend adding more information regarding medication such as what kind of systemic seroid we are using.

     
    Non-pharmacological options
    By Hamed S. on 07. April 2017 for Atopic Dermatitis

    Fantastic talk but would have liked further information on non-pharmacological treatment and also the role of allergen testing