Atopic dermatitis
Patient presentations
Chief Complaint
As stated by the patient’s mother, “My child constantly wants toscratch her skin, and she can’t sleep well during the night.”
HPI
31/2-year-old girl who just started attending daycare about 1month ago. She did not want to go and still exhibits a lot ofclinging behavior when her mother tries to leave; she still crieswhen her mother eventually does manage to leave. Her mother saysthat She has atopic dermatitis has flared up again. she has hadatopic dermatitis since she was about 6 months old. It had beenwell controlled by topical corticosteroids and liberal use ofmoisturizers. Her recent flare-up began about 2–3 weeks ago. Shehas not been sleeping well and is constantly trying to scratch herskin at night. Her mother has been using 100% cotton sheets for herbed since she was an infant. She has sewn mittens on her 100%cotton pajamas to prevent her from scratching, because she hadpreviously caused excoriations from scratching, which then becameinfected. During the day, Julia constantly wants to scratch herskin but has been told to just “pat” the itchy area. The caregiversat the daycare center keep an eye on her scratching behavior aswell but aren’t always able to prevent her from scratching herself.They also inform her mother that Julia likes to eat food shared byother children.
_ PMH
She was breastfed from birth for a total of 8 weeks, when hermother
decided to return to work. she was then cared for at home by ababysitter and fed cow’s milk, with oatmeal cereal being introducedas the first solid food. She was fed some lemon meringue pie (madewith egg white) once, and developed generalized hives, which led tothe recognition that shehas an egg allergy. This was confirmed byallergic skin testing. atopic dermatitis presented at 6 months ofage. The parents have recently become aware that the babysitterleft her alone a lot (sitting on the floor/carpet to play byherself). That was the major reason for sending her to a daycarecenter.
_ SH
she is the only child of a professional couple. Her father is anengineer and her mother is a litigation lawyer who often works longhours. The couple has a stressful lifestyle, and it appears thatthe stress is reflected in Julia’s care. Sometimes Julia would bedriven to one or another babysitter’s homes at the last minute,when something urgent arises that the couple must attend to. Thereis very little family time. Unfortunately, their relatives do notlive in the same city, and there is little social support for Juliaon a day-to-day basis. The parents were hoping that the daycarecenter would be helpful, but so far that has proven to be anotherissue for Julia. She doesn’t want to participate in activitiesthere and has lots of temper tantrums. She doesn’t play well withother children. Julia had been toilet trained but has now lost hertoilet training and is using diapers again. Julia’s mother startedsmoking again due to the recent stress; Julia keeps her up atnight, and she’s having difficulty dealing with Julia’s multipleissues at home and at the daycare center.
_ FH
There is a strong family history of atopy. Julia’s father has asevere allergy to shellfish, and her mother has a history of hayfever. Her father’s sister has multiple food allergies. Hermaternal grandmother had asthma. Her paternal first cousin hadinfantile eczema. Her maternal first cousin has a severe peanutallergy (generalized hives).
_ Meds
Hydrocortisone 1% cream applied to affected areas two to fourtimes a day; although twice daily is her usual maintenance dose,she is currently using it three to four times a day Vaseline ad libDiphenhydramine 1/2 teaspoonful at bedtime as needed (when skin isexcessively itchy, to allow Julia to sleep)
_ Allergies
NKDA. Multiple food allergies: egg (hives, developed allergy asan
infant), strawberries, raspberries, tomatoes.
_ ROS
Not obtained
_ Physical test
Gen
Unhappy, cranky, thin, clinging girl who keeps sucking herthumb
VS
BP 98/50, HR 96, RR 18, T 37°C; Wt 12.2 kg (10th percentile),Ht
98 cm (38.6”; 50th percentile), head circumference 49.5 cm(19.5”;
50th percentile)
Skin
Generally dry. Eczematous skin lesions in flexure areas (behindears, wrist joints, elbows, knees). Likely pruritic papules inflexure areas.
Excoriations from scratching. Some bleeding seen but does notappear infected. Some cracking skin lesions seen behind the earsand knees. There are no lesions on the extensor parts of her body,no lesions on top of her nose, and no lesions in the diaper area.The remainder of the physical test was normal.
Note: References ranges at age 31/2: BUN 8–20 mg/dL, SCr0.2–0.8
mg/dL, AST 20–60 IU/L, ALT 0–37 IU/L, IgE 0–25 IU/mL; WBC
differential: Neutros 20–65%, Eos 0–15%, Basos 0–2%, Lymphs
20–60%, Monos 0–10%
Swab of skin lesion where there is bleeding: No growth
Questions:
Therapeutic Alternatives
3. What feasible nonpharmacologic and pharmacologic alternativesare available to manage this patient’s pruritus and atopicdermatitis?
Optimal Plan
4. What treatment regimen is best suited for this patient?
Outcome Evaluation
5. What efficacy and adverse effects monitoring is needed forthe management strategies you recommended?
Patient Education
6. How would you inform the patient’s caregiver about thetreatment regimen to enhance compliance and ensure successfultherapy?
