Atypical Wounds - Atopic Dermatitis

AD is a chronic skin disorder that can become chronic and debilitating if not managed appropriately in the early stages. It is characterized by pruritis, dry skin, and diffuse lesions, with frequent recurrence. Although more prevalent in children, it can affect adults as well.

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Atopic dermatitis (AD) is a chronic, non-contiguous, exudative eczema/dermatitis that affects 20-30% of all children and 7-10% of all adults.[1],[2]  It is totally different from, and should not be diagnosed as, acne.  AD is a complex, multi-factorial skin disorder that involves an impairment of the stratum corneum barrier, resulting in altered skin function, an increase in trans-epidermal water loss, and dehydration.  It is a T helper type 2 lymphocyte-mediated disease which causes inflammatory processes characterized by the production and release of several cytokines, chemokines, and interleukens with an increase in inflammation levels and subsequent risk of infections.AD has both heritable and environmental factors, as evidenced by changes in the commensal skin microorganisms on the skin where symptoms are noted.  For example, individuals who present with more severe disease tend to have lower measures of diversity in skin microbes, with an overgrowth of S aureus and a decrease in the relative numbers of other microbes (Streptococcus, Corynebacterium, Propionibacterium).  S aureus contributes to the pathogenesis of AD through its virulence factors, including superantigen production which in turn promotes inflammatory pathways through the activation of interleukin-mediated T-cell responses.[3]  Resolution of an acute flare-up correlates with the return to a normal balance of microorganisms.

The initiating characteristic of AD is pruritus which becomes chronic and at times debilitating, along with dry skin, eczematous lesions, and frequent recurrence.  AD is the first evidence of atopic diseases in early childhood, which frequently develops into what is termed the “atopic march” of allergic rhinitis, asthma, and food allergies.2

Both medical and wound management is directed toward re-establishing the bacterial balance on the skin, relieving the symptoms, and preventing further infection.  The following treatments were reported in the literature:

Medical managment

  • Topical creams (over 2 years of age)
    • Corticosteroids
    • Calcineurin inhibitors (tacrolimus, pimecrolimus)2
    • Glycerol 85%[4]
  • Oral antihistamines
  • Short-term oral antibiotics if needed
  • Oral corticosteroids for most severe cases
  • Dupilumab (an injectable biologic)2
  • Anti-IgE medication (omalizumab), for pediatric population per the ADAPT study[5]
  • Some Janus kinase 1 inhibitors (e.g. upadacitinib) for adult moderate to severe cases[6]

Wound management

  • Topical ointments to hydrate the skin, e.g. glycerol 85>#sup###4
  • Narrow-band Ultraviolet B therapy3
  • Antimicrobial dressings (e.g. cellulose with silver or nanocrystalline silver) for open wounds with exudate6
  • Infants
    • Avoid any skin irritants
    • Avoid extreme temperatures
    • Give warm baths followed by skin lubrication with lipid-based ointment[7],[8]

In summary, AD is a chronic skin disorder that can become chronic and debilitating if not managed appropriately in the early stages.  It is characterized by pruritis, dry skin, and diffuse lesions, with frequent recurrence.  Although more prevalent in children, it can affect adults as well.

[1] Damiani G, Eggenhoffner R, Pigatto PDM, Bragazzi NL. Nanotechnology meets atopic dermatitis: Current solutions, challenges and future prospects.  Insights and implications from a systematic review of the literature.  Bioactive Materials. 2019;4:380-386.

[2] Saini S, Pansare M, New insights and treatments in atopic dermatitis.  Pediatr Clin N Am. 2019;661021-1033.

[3] Woo TE, Sibley CD. The emerging utility of the cutaneous microbiome in the treatment of acne and atopic dermatitis.  J Am Acad Derm. Sept 6, 2019. Available at https://doi.org/10.1016/j.jaad.2019.08.078.  Accessed 3/12/2020.

[4] Youssef R, Hafez V, Elkholy Y, Mourad A.  Glycerol 85% efficacy on atopic skin and its microbiome: A randomized controlled trial with clinical and bacteriological evaluation.  J Dermatolog Treat. 2020.  doi:  10.1080/09546634.2019.1708246.  Accessed 3/11/2020.

[5] Chan S, Cornelius V, Cro S, Harper JI, Lack G.  Treatment effect of omalizumab on severe pediatric atopic dermatitis: The ADAPT randomized clinical trial.  JAMA Pediatr. 2019;11.  Doi: 10.1001/jamapediatrics.2019.4476.  Accessed 3/11/2020.

[6] Guttman-Yassky E, Thaci D, Pangan AL, Hong HC, Papp KA, Reich K, et al. Upadacitinib in adults with moderate to severe atopic dermatitis: 16-week results from a randomized, placebo-controlled trial.  J Allergy Clin Immunol.  2020;145(3):877-884.

[7] https://www.mayoclinic.org/diseases-conditions/atopic-dermatitis-eczema/diagnosis-treatment/drc-20353279.  Accessed 3/12/2020.

[8] Cardona ID, Kempe EE, Lary C, Ginder JH, Jain N.  Frequent versus infrequent bathing in pediatric atopic dermatitis: A randomized clinical trial.  J Allergy and Clin Immunol.  2020;8(3):1014-1021.

Rose Hamm

Physical Therapy, University of Southern California

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