Atopic Dermatitis

Question 1

Atopic Dermatitis overview

Answer 1

-most common form of eczema
-more so in children
-mostly mild
-sleep, depression, anxiety, productivity

Question 2

Atopic dermatitis patho

Answer 2

-genetic predisposition
-skin barrier dysfx
-immune dysregulation
-environmental factors

Question 3

AD genetic predisposition

Answer 3

-mutations in skin barrier protein genes (filaggrin) and immune regulators (IL-4 and IL-13)

Question 4

AD skin barrier dysfunction

Answer 4

-mutations in barrier
=water loss (dryness)
=more susceptible to irritants and allergens
-dysbiosis of skin microbiome can = barrier dysfunction

Question 5

AD immune dysregulation

Answer 5

-overactive immune response esp Th2 cells
-Th2 cells = cytokines (IL-4,5,13)
=inflammation, itching, skin thickening
-mast cells and basophils release histamine and tryptase

Question 6

AD environmental factors

Answer 6

-irritants and allergens (soap, detergent, fragrance, foods)
-staph aureus infections = inflammation

Question 7

AD dysregulation of lipid metabolism

Answer 7

=dec ceramides

Question 8

Atopic triad

Answer 8

-atopic dermatitis
-allergic rhinitis
-asthma

-AD first to develop
-50-75% develop the other two

Question 9

AD clinical presentation

Answer 9

-pruritis
-red papules/plaques
-dry skin
-redness/inflammation
-thick skin
-itching
-trouble sleeping
-PO-SORAD?

Question 10

AD presentation in infant

Answer 10

-red, papular rash on cheeks and skin
-lesions later appear on neck, trunk, groin
-lesions crust over time

Question 11

AD presentation in child

Answer 11

-face, neck, arm/leg creases
-greater risk of skin infections

Question 12

AD presentation in adults

Answer 12

-hands and neck
-arm and leg creases

Question 13

AD triggers

Answer 13

-heat/sweat
-wool
-stress
-vasodilatory foods
-alcohol
-URIs
-dust mites
-extremes in temp
-dry air
-irritants

Question 14

AD complications

Answer 14

-secondary infections
-breakdown of skin integrity
-predisposition to other atopic dx
-negative QOL

Question 15

Step-wise tx of AD

Answer 15

-non-rx
-topical
-systemic
-acute flares
-refractory
-mx

Question 16

Non-rx AD tx

Answer 16

-baths
-emollients
-avoid triggers
-trim nails

Question 17

Topical AD tx options

Answer 17

-corticosteroids
-calcineurin inhibitor
-phosphodiesterase-4 inhibitor
-JAK inhibitor

Question 18

Systemic AD tx

Answer 18

-phototherapy
-oral immunosuppressant
-oral JAK
-inj biologic

Question 19

Acute AD flare tx

Answer 19

-mod-severe
-medium potency TCS BID up to 3 days beyond clearance of lesions

Question 20

Refractory AD tx

Answer 20

-phototherapy
-oral immunosuppresant
-consider emerging biologics if still refractory

Question 21

mx AD tx

Answer 21

-mod-severe
-basic measures
-daily or 2-3x weekly app of low potency TCS or other topical
-written action plan

Question 22

Topical corticosteroid overview

Answer 22

-classified by anti-inflammatory activity and vasoconstricitve potency
-I-VII
-vehicle impacts delivery and potency
-only 2% absorbed on intact skin
-occlusion inc upto 10x

Question 23

Topical corticosteroid side effects

Answer 23

-thinning of skin
-dilated blood vessels
-inc bruising
-skin color changes
-risk HPA suppression
-tolerance (tachyphylaxis)

Question 24

Low potency TCS

Answer 24

-hydrocortisone (OTC)
-use on face, groin, genitalia, axilla
-safest for long-term use

Question 25

mid potency TCS

Answer 25

-betamethasone LOTION -use on most skin surfaces -safe for longer usage than high potency

Question 26

High potency TCS

Answer 26

-betamethasone CREAM (class 2) -betamethasone OINTMENT (class 1) -DO not use on face -avoid using > 2weeks -good for severe lesions and v thick skin

Question 27

Topical calcineurin inhibitors for AD

Answer 27

-2nd line -pimecroliumus -tacrolimus -intermittent use only (risk malignancies, URI in < 2yo) -use any area -equivalent to mid potency TCS -no risk of atrophy -burning sensation -$$$

Question 28

Phosphodiesterase-4 inhibitor

Answer 28

-alt to TCS and TCIs (steroid phobia) -mild-mod AD -BID 28 days -$$

Question 29

Topical JAK inhibitor

Answer 29

-ruxolitinib (opzelura) cream -mid-mod AD uncontrolled w other tx -thin layer BID -short term use -max 60g/week -avoid in immunocompromised pt

Question 30

oral JAK

Answer 30

-upadacitinib (rinvoq) -mod-severe AD uncontrolled w other tx -15-30mg PO qd -well tolerates -higher rates of major CV events and thrombosis

Question 31

Dupilumab (dupixent)

Answer 31

-first biologic for mod-severe AD uncontrolled w other tx -mAb againts IL-4 receptor =inhibits IL-4 and IL-13 signaling (th2 cytokines) -SC q 2 weeks -$$$

Question 32

Approved biologics for AD

Answer 32

-dupilumab (IL-4/13) -tralokinumab (IL-13) -Lebrikizumab (IL-13) -Nemolizumab (IL-31)