Eczema

• Core 1 (Pre-Clerkship) 
  • Integrative Systems 
    • Dermatology  
      • Intro to Derm 
      • Skin of color 
      • Atopic dermatitis 
      • Pediatric derm 
• Core 2 (Clerkship)  
  • Pediatrics - Rashes Royale in Fever Didactic
• Core 3 (Post-Clerkship)
  • Electives that may further knowledge: Pediatric dermatology, Dermatology 

A 2 year-old female with no significant past medical history presents to your primary care clinic with a rash. 

Mom says that this rash seems to be really itchy, and her daughter scratches at it all the time. She noticed this rash when her daughter was younger – it tends to come and go, particularly in the winter when she has hot baths. 

Onset, location, and progression:  

• How old was the child when the rash first began? Was it under two years old? 
• How long has the rash been present? (acute, subacute, chronic) 
• Does this rash relapse? Does it come and go? 
• Where is the rash? What region(s) of the body is affected? 

Contributing factors:  

• Routine skin care (bathing, shampoo, lotion, detergents)? 
• Exposures/environmental factors (pet dander, new environment, seasonal change)? 
• Current medications (prescribed, OTC, herbal, natural)? 
• Impact on quality of life? 

Past Medical History: 

• Prior diagnosis of eczema or atopic dermatitis? Last flare? 
• History of asthma, allergies (food, seasonal, environmental)? 
• History of frequent skin infections? Immunodeficiency? 

Maternal/Pregnancy/Birth History:  

• Was the baby born full term or preterm?  
• Did the baby need to stay in the NICU for any reason? 

Family history: 

• Any family history of atopy (asthma, allergies, eczema, etc)? 

Source: https://www.chop.edu/clinical-pathway/atopic-dermatitis-history-physical-exam 

Perform total skin examination 

• General Findings 
  • Keratosis pilaris on the upper arms, thighs and cheeks 
  • Hyperlinear palms 
  • Darkening around eyes or scaling 
• Lesions 
  • Note color, size, shape, texture, location 
• Distribution of lesions 
  • Infants, toddlers: cheeks, extensor surfaces (typically spares diaper area) 
  • Older children: flexural creases (especially antecubital and popliteal fossa) 
• Severity 
  • Mild: pink lesions with thin scale 
  • Moderate: thicker, more scale, skin may be darker in these areas, often widespread 
  • Severe: lichenified lesions, often on neck, wrists, ankles 
• Sign of infection 
  • Crusting, scaling, weeping, erythema, increased pain 
  • Systemic symptoms 

Source: https://www.chop.edu/clinical-pathway/atopic-dermatitis-history-physical-exam 

American Academy of Dermatology 

• Essential features (must be present): 
  • Pruritis 
  • Eczema (acute, subacute, chronic) 
    • Typical morphology and age-specific patterns 
  • Chronic or relapsing history 
• Important features (seen in most cases, adding support to diagnosis): 
  • Early age of onset (<2 years of age) 
  • Personal and/or family history of allergic rhinitis, asthma, food allergies, atopic dermatitis, IgE reactivity 
  • Xerosis or dry skin within the last year 
• Associated features (suggestive but non-specific):  
  • Atypical vascular responses (eg, facial pallor, white dermographism, delayed blanch response) 
  • Keratosis pilaris/pityriasis alba/hyperlinear palms/ichthyosis 
  • Ocular/periorbital changes 
  • Other regional findings (eg, perioral changes/periauricular lesions) 
  • Perifollicular accentuation/lichenification/prurigo lesions 
• Exclusionary conditions:  
  • Scabies 
  • Seborrheic dermatitis 
  • Contact dermatitis (irritant or allergic) 
  • Ichthyoses 
  • Cutaneous T-cell lymphoma 
  • Psoriasis 
  • Photosensitivity dermatoses 
  • Immune deficiency diseases 
  • Erythroderma of other causes 

Source: https://www.chop.edu/clinical-pathway/atopic-dermatitis-differential-diagnosis  

Evaluation 

• Perform comprehensive history and physical exam 
• Review differential diagnoses 
• Diagnose atopic dermatitis and determine level of severity (EASI scoring system) 
  • Mild 
  • Moderate 
  • Severe 
• Assess for evidence of secondary infection  
  • Changes in treatment response or worsening/increasing number of patches 
  • Presence of oozing, crusting, punched-out erosions, vesicles, pustules, excessive redness or warmth 
  • Systemic symptoms such as fever or lethargy without another etiology 
• Determine treatment options based on severity of symptoms 
  • Topical steroids 
  • Maintenance medications 
  • Systemic therapies 
  • Antibiotics/Anti-virals  
• Consider subspecialty referral 
  • Dermatology 
  • Allergy/Immunology 

Management 

• Treatment goals:  
  • 1) maintain healthy skin barrier 
  • 2) prevent infection 
  • 3) decrease irritation 
• General skin care recommendations 
  • Bathing: Give lukewarm bath every 2-3 days for 5-10 minutes using fragrance-free soap, pat dry and leave skin damp (do not use washcloth, sponge, baby wipes) 
  • Emollients: Moisturize at least twice daily using fragrance-free cream or ointment (not lotion), apply within 3 minutes of bathing 
  • Avoidance of irritants: Wear cotton clothing, avoid perfumes and fragrance, use mild detergent 
  • Wet wraps: Apply emollient, wrap skin with wet bandage or clothing, apply dry bandage or clothing over wet layer 
  • Bleach baths: Perform bleach baths 1-3 times weekly for 5-10 minutes to reduce risk of superinfection 
• Treatment of flares: 
  • Topical steroids: 
    • Potency:  
      • Based on age, severity, location 
        • Use lower potency steroids on less mature, thinner skin to prevent skin atrophy (e.g., age < 3 yrs and face or genital area) 
        • Use higher potency steroids in children > 3 yrs with severe disease 
    • Formulation: 
      • Ointment is the preferred formulation (other options include lotions, creams, gels, foams, etc.) 
    • Frequency: 
      • Apply twice daily to affected areas 
    • Duration: 
      • Two weeks (prolonged topical steroid use not recommended given risk of skin atrophy and infection) 
  • Adjuvant therapies (for itching and/or sleep): 
    • 1st generation anti-histamine (e.g., hydroxyzine) - more sedating 
    • 2nd generation anti-histamine (e.g., cetirizine) - less sedating 
  • Systemic steroids are not typically indicated for the treatment of atopic dermatitis (except in severe cases) and can cause flares once discontinued 
• Maintenance medications: 
  • Topical calcineurin inhibitors (e.g., pimecrolimus, tacrolimus) 
  • PDE4 inhibitor (e.g., crisaborole) 
• Systemic therapies (for severe cases, non-responsive to other therapies):  
  • Biologics (e.g., Dupixent) 
  • Immunosuppressants (e.g., methotrexate, cyclosporine, azathioprine) 
  • Narrowband Ultraviolet Light Therapy 
• Treatment of secondary infection: 
  • Antibiotics for superimposed bacterial infection 
    • Most commonly Staphylococcus or streptococcus 
  • Antivirals for superimposed viral infection  
    • Most commonly HSV (e.g., eczema herpeticum) or enterovirus (e.g., eczema coxsackium) 
• Subspecialty referral 
  • Consider referral to Dermatology and/or Allergy/Immunology if: 
    • Severe/refractory disease 
    • Unclear diagnosis 
    • Suspected food allergy 
    • Suspected immunodeficiency

Source: https://www.chop.edu/clinical-pathway/atopic-dermatitis-clinical-pathway 

• The mainstay of therapy for eczema/atopic dermatitis is routine skin care with avoidance of irritants and frequent moisturization with a topical emollient.  
• Short-term topical steroids are the preferred treatment for atopic dermatitis flares. The potency of topical steroid should be determined based on age, severity, and location of flare.  

• Article  
  • Atopic Dermatitis Clinical Guideline (American Academy of Dermatology) 
  • Translating Atopic Dermatitis Management Guidelines Into Practice for Primary Care Providers  
  • Atopic eczema in children (NICE) 
• Video 
  • Pediatric Atopic Dermatitis: Assessing Disease Severity and Implementing Targeted Treatment 
• Podcast 
  • Episode 28 — Eczema or Atopic Dermatitis in Kids: Causes & Treatments (Healthy Children Podcast) 
• Pathways 
  • Atopic Dermatitis Clinical Pathway (CHOP) 
  • Atopic Dermatitis Clinical Pathway (Nationwide Children’s) 

Answers:

Q1: c. Increase frequency of topical corticosteroid application 

This is a classic presentation of infantile atopic dermatitis (eczema), often affecting the cheeks and extensor surfaces in infants. Key features include: 

• Chronic or relapsing dry, erythematous, itchy patches 

• Common in the first 6 months of life 

• Can worsen with irritants, allergens, or underuse of medications 

In this case, the caregiver was underusing the topical corticosteroid (only once in a month), which is not adequate for managing an active flare. 

The next appropriate step is to increase the frequency of corticosteroid use, typically twice daily during flares.  

Incorrect Answers:

a. Start a non-sedating antihistamine

Antihistamines may reduce itching in older children, but non-sedating agents (like loratadine) have limited effect on eczema and do not address the underlying inflammation. Sedating antihistamines might be used short-term for sleep, but they are not first-line treatment.

b. Discontinue bleach baths

Dilute bleach baths (e.g., 1/4–1/2 cup in a full tub) can help reduce Staphylococcus aureus colonization, a common eczema trigger. They are beneficial in moderate-to- severe cases and should not be stopped if tolerated, especially if infection is suspected or recurrent.

d. Increase potency of the topical corticosteroid

Before escalating potency, providers should ensure that the prescribed steroid is being used consistently and correctly. Increasing frequency is a safer and more appropriate first step, especially in infants with sensitive skin. 

Answer 2

Correct Answer: d. 0.1% triamcinolone ointment twice daily for 14 days 

This patient has atopic dermatitis (eczema) with moderate disease involving flexural surfaces. The best initial pharmacologic treatment is a mid-potency topical corticosteroid such as triamcinolone 0.1% applied twice daily for 2 weeks. 

Incorrect Answers: 

a. Oral hydroxyzine 25 mg nightly

May help with itch at night but does not address inflammation; not first-line monotherapy.

b. 1% hydrocortisone ointment daily for 21 days

Low potency and once daily use is insufficient for moderate eczema. 

c. Oral prednisone 20 mg daily for 7 days

Reserved for severe or refractory cases due to side effects; not initial treatment. 

Basic Dermatology: Atopic dermatitis (Cases and Questions) (American Academy of Dermatology)