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PROBLEM-BASED LEARNING:
AN INTERACTIVE DISCUSSION
A 2 year-old male with “chronic eczema.”
AAAAI ANNUAL MEETING
SATURDAY, FEB 23, 2013SAN ANTONIO, TX
PECK ONG, MDRUSSELL SETTIPANE, MD
FINANCIAL DISCLOSURES:Dr. Ong has been a consultant for PuraCap and is a co-investigator for Atopic Dermatitis Research Network.
Dr. Settipane has no relevant disclosures.
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HISTORY
James is a 2 year-old male infant who presents to your office for consultation of “chronic eczema.” The onset of his problems began at approximately one year of age, coinciding with the expansion of his diet. At that time, his mother noticed the onset of a dry and erythematous rash on his cheeks and over much of his body.
Triggers for his eczema have not been identified. Although there has been no history of an acute adverse reaction to any specific food, the mother has observed that his skin sometimes becomes more red and itchy after meals.
He has never eaten peanut products or a cooked whole egg; however he has eaten baked foods with egg as an ingredient, such as cake or pancakes.
At his most recent pediatric check-up, the nurse practitioner obtained some blood tests to assess for allergy. The parents were told that the results were positive to peanut, egg and dog. The pediatrician referred James to you for further evaluation. The parents are frustrated and just want his skin to improve.
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HISTORY CONTINUED
MEDICATIONS: current treatment topical triamcinolone 0.025% ointment and diphenhydramine prn; he previously failed to respond to a 6 week trial of pimecrolimus.
BIRTH HISTORY: Unremarkable term birth, vaginal delivery.
REVIEW OF SYSTEMS: SKIN-“He’s always scratching,”
LUNGS- He has h/o asthma, which is well controlled on beclomethasone and montelukast.
PAST MEDICAL HISTORY: Unremarkable.
ENVIRONMENT: No pets or smokers. The mother has cleaned the house thoroughly to make sure that is not a trigger.
DIET: As mentioned above, he has never eaten peanut products or a cooked whole egg; however he has eaten baked foods with egg as an ingredient, such as cake or pancakes; there has been no restriction on dairy, soy or wheat products.
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PHYSICAL EXAM
GENERAL: Well developed, well nourished, Caucasian male child, who is observed to be constantly scratching.
Vital Signs: HR 92 RR 18 Temp 99 °F Ht. 50 % tile Wt 50 %tile
ENT and CV: were unremarkable.Lungs: clear with good air exchangeSkin: Diffusely dry with patchy areas of mild erythema, papules and scaling involving the face, trunk and all extremities, worse in both antecubital and popliteal fossae. On his face, the erythema and scaling are confined to the cheeks with sparing of the perioral and paranasal area. Excoriations are present on his torso and extremities, but no oozing noted.
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LAB EVALUATION: Skin testing could not be performed because of the extensive distribution of his dermatitis.
His pediatrician previously obtained these specific IgE results:
Total IgE = 1099 IU/ml.
ImmunoCAP:
Egg white = 34 Ku/L
Peanut > 100 Ku/L
Cow’s milk = 3 Ku/L
Soy = 2 Ku/L
Wheat = 0.7 Ku/L.
Positive to all inhalant allergens tested: pollens and indoor allergens.
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IMPRESSIONS
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RECOMMENDATIONS
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On return visit, one month later, the parents report that although there was significant improvement which occurred within one week of instituting the new treatment program, the child experienced significant worsening following accidental dog exposure 4 days ago. In the last two days they have observedgeneralized itching and redness as well as the new occurrence of a sticky, yellowish fluid oozing from his antecubital and popliteal areas.
PHYSICAL EXAM
Temp 99 °F Exam unremarkable except for skin findings.Skin: Large patchy areas of bright erythema involving the torso and worse in both the antecubital and popliteal fossae, with excoriation and yellowish crusting and fluid noted in these areas.
IMPRESSION:
RECOMENDATION:
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LEARNING OBJECTIVES
After completing this CME activity the participant should be able to:
1. Identify triggers of atopic dermatitis including food allergy, environmental allergens and infection
2. Assess of atopic dermatitis severity3. Discuss barrier defects and keratinocyte dysfunctions4. Develop a treatment plan for atopic dermatitis
a. Should patient bathe or not bathe?b. How much topical steroid is too much?
i. Fingertip method to apply topical steroidsc. Wet-wrap treatment.
5. Design an action plan to treat worsening of atopic dermatitis
Three-item Severity (TIS) score for AD
- 3 “E’s”- Erythema, edema, excoriations- Each item scored on a scale 0-3- Each item scored on a scale 0-3
Mild Moderate SevereTIS 0–2 3–5 6–9
Oranje AP et al. Br J Dermatol 2007;157:645-8. .
Figertip unit (FTU) method by Long, Mills, Finlay. A practical guide to topical therapy in Children. Br J Dermatol. 1998;138:293-6.
Figertip unit (FTU) method by Long, Mills, Finlay. A practical guide to topical therapy in Children. Br J Dermatol. 1998;138:293-6.
Face/Neck
Arm/Hand
Leg/Foot
Trunk(front)
Back/Buttock)
Age Number of FTUs
3-6 mth 1 1 1.5 1 1.5
1-2 y 1.5 1.5 2 2 3
3-5 y 1.5 2 3 3 3.5
6-10 y 2 2.5 4.5 3.5 5
Wet-Wrap TreatmentTake lukewarm bath for 15 to 20 min; mild soap/cleanser such as Dove or Cetaphil o.k.
Dab the skin dry gently.
Apply a mid-potency topical steroid ointment (eg. Desonide) to affected areas.
Apply an emollient (eg. Vaseline) to unaffected areas.
Soak a clean, long-sleeve cotton sweatshirt, a pair of cotton sweatpants and 2 pairs of Soak a clean, long-sleeve cotton sweatshirt, a pair of cotton sweatpants and 2 pairs of
cotton socks in clean, warm water.
Wring out the above clothing and socks until they are not dripping.
Put the wet clothing on the child and the wet socks on the hands and feet.
Put a dry layer of long-sleeve cotton sweatshirt, sweatpants and socks over the wet layer.
Remove the wet-wrap after two hours and put the emollient over all areas of the skin.
The above procedure is done once to twice daily for 5 to 7 days.
