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General Considerations
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Atopic dermatitis looks different at different ages and in people of different races Because most patients have scaly dry skin at some point, this disease is being discussed under scaly dermatoses However, acute flares may present with red patches that are weepy, shiny, or lichenified (ie, thickened, with more prominent skin markings) and plaques and papules Diagnostic criteria for atopic dermatitis must include pruritus, typical morphology and distribution (flexural lichenification in adults), and a tendency toward chronic or chronically relapsing dermatitis Also helpful are (1) a personal or family history of atopic disease (asthma, allergic rhinitis, atopic dermatitis), (2) xerosisichthyosis, (3) facial pallor with infraorbital darkening, (4) elevated serum IgE, (5) fissures under the ear lobes, (6) a tendency toward nonspecific hand dermatitis, (7) a tendency toward repeated skin infections, and (8) nipple eczema
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Treatment
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Treatment of melanoma consists of excision After histologic diagnosis, the area is usually reexcised with margins dictated by the thickness of the tumor Thin low-risk and intermediate-risk tumors require only conservative margins of 1 3 cm More specifically, surgical margins of 05 cm for melanoma in situ and 1 cm for lesions less than 1 mm in thickness are recommended Sentinel lymph node biopsy (selective lymphadenectomy) using preoperative lymphoscintigraphy and intraoperative lymphatic mapping is effective for staging melanoma patients with intermediate risk without clinical adenopathy and is recommended for all patients with lesions over 1 mm in thickness or with high-risk histologic features -Interferon and vaccine therapy may reduce recurrences in patients with high-risk melanomas Referral
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Clinical Findings
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A Symptoms and Signs
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Itching may be severe and prolonged Rough, red plaques usually without the thick scale and discrete demarcation of psoriasis affect the face, neck, and upper trunk ( monk s cowl ) The flexural surfaces of elbows and knees are often involved In chronic cases, the skin is dry, leathery, and lichenified Pigmented persons may have poorly demarcated hypopigmented patches (pityriasis alba) on the cheeks and extremities In black patients with severe disease, pigmentation may be lost in lichenified areas
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Dermatologic Disorders B Laboratory Findings
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Food allergy is an uncommon cause of flares of atopic dermatitis in adults Blinded food challenges are the most reliable method of diagnosing suspected food allergy Radioallergosorbent tests (RASTs) or skin tests may suggest dust mite allergy Eosinophilia and increased serum IgE levels may be present but are nonspecific
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Differential Diagnosis
Atopic dermatitis must be distinguished from seborrheic dermatitis (less pruritic, frequent scalp and face involvement, greasy and scaly lesions, and quick response to therapy) Contact dermatitis and impetigo may exacerbate atopic dermatitis, especially during hyperacute, weepy flares of atopic dermatitis Patients with active lesions are almost always colonized with Staphylococcus aureus, and impetiginization of atopic skin should be considered and treated when an acute flare is present Since virtually all patients with atopic dermatitis have skin disease before age 5, a new diagnosis of atopic dermatitis in an adult should be made cautiously and only after consultation
Treatment
Treatment is most effective if the patient is instructed about the general principles of skin care and exactly how to use medications
A General Measures
Atopic patients have hyperirritable skin Anything that dries or irritates the skin will potentially trigger dermatitis Atopic individuals are sensitive to low humidity and often get worse in the winter Adults with atopic disorders should not bathe more than once daily Soap should be confined to the armpits, groin, scalp and feet Washcloths and brushes should not be used After rinsing, the skin should be patted dry (not rubbed) and then immediately within three minutes covered with a thin film of an emollient such as Aquaphor, Eucerin, Vaseline, or a corticosteroid as needed Ceratopic cream, a therapeutic moisturizer, will reduce inflammation as well as moisturize without a greasy or occlusive feel It is much more expensive than traditional moisturizers Atopic patients may be irritated by scratchy fabrics, including wools and acrylics Cottons are preferable, but synthetic blends also are tolerated Other triggers of eczema in some patients include sweating, ointments, hot bathing, and animal danders To determine the potential effect of foods, the patient may eliminate one food at a time for several months and monitor the severity of the disease Dairy products and wheat are the most common offenders Foods that are a problem typically cause itching within minutes to a few hours after ingestion
one should begin with triamcinolone 01% or a stronger corticosteroid then taper to hydrocortisone or another slightly stronger mild corticosteroid (Aclovate, Desonide) It is vital that patients taper corticosteroids and substitute emollients when the dermatitis clears to avoid the side effects of corticosteroids Tapering is also important to avoid rebound flares of the dermatitis that may follow their abrupt cessation Doxepin cream 5% may be used up to four times daily and is best applied simultaneously with the topical corticosteroid Stinging and drowsiness occur in 25% Tacrolimus ointment (Protopic 003% or 01%) and pimecrolimus ointment (Elidel 1%) can be effective in managing atopic dermatitis when applied twice daily Burning on application occurs in about 50% of patients using Protopic and in 10 25% of Elidel users, but it may resolve with continued treatment These medications do not appear to cause skin atrophy, striae, or other topical corticosteroid-associated side effects and are safe for application on the face and even the eyelids The US Food and Drug Administration (FDA) has issued a black box warning for both topical tacrolimus and pimecrolimus due to concerns about the development of T-cell lymphoma The agents should be used sparingly and only when less expensive corticosteroids cannot be used Tacrolimus and pimecrolimus should be avoided in patients at high risk for lymphoma (ie, those with HIV, iatrogenic immunosuppression, prior lymphoma) The treatment of atopic dermatitis is dictated by the stage of the dermatitis 1 Acute weeping lesions Use water or aluminum subacetate solution (Domeboro tablets, one in a pint of cool water) or colloidal oatmeal (Aveeno; dispense one box, and use as directed on box) as soothing or astringent soaks, baths, or wet dressings for 10 30 minutes two to four times daily Lesions on extremities particularly may be bandaged for protection at night Use high-potency corticosteroids after soaking but spare the face and body folds Tacrolimus may not be tolerated at this stage Systemic corticosteroids may be required (see below) 2 Subacute or scaly lesions At this stage, the lesions are dry but still red and pruritic Mid- to high-potency corticosteroids in ointment form should be continued until scaling and elevated skin lesions are cleared and itching is decreased substantially At that point, patients should begin a 2- to 4-week taper from twice-daily to daily to alternate-day dosing with topical corticosteroids to reliance on emollients, with occasional use of corticosteroids on specific itchy areas Instead of tapering the frequency of usage of a more potent corticosteroid, it may be preferable to switch to a low-potency corticosteroid Tacrolimus and pimecrolimus are more expensive alternatives and may be added if corticosteroids cannot be stopped to avoid the complications of long-term topical corticosteroid use 3 Chronic, dry, lichenified lesions Thickened and usually well-demarcated, they are best treated with highpotency to ultra-high-potency corticosteroid ointments Nightly occlusion for 2 6 weeks may enhance the initial
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