Effective Primary Management of an Exacerbation of Atopic Dermatitis Using a Non-Steroidal Topical Therapy
Case authors Lisa C. Lopez-Sanglay, APRN, FNP-BC and James Q. Del Rosso, DO, FAAD, FAOCD present a case of a 15-year-old male with a flare of atopic dermatitis primarily affecting his hands and feet and a severely pruritic rash.
By James Q. Del Rosso, DO, FAAD, FAOCD and Lisa C. Lopez-Sanglay, APRN, FNP-BC
Case Presentation History Summary
A 15-year-old male presented accompanied by his mother with a flare of atopic dermatitis primarily affecting his hands and feet over the past 2 months. The “rash” was severely pruritic throughout the day and was notably worse in the evening, often interfering with his ability to fall asleep and/or waking him up from sleep on most evenings. The patient and his mother both emphasized that the rash and itching were progressively worsening.
He stated he feels anxious and self-conscious due to his condition. He is embarrassed by the appearance of the “rash”, and actively avoids shaking hands with people or scratching the areas in public, the latter being quite difficult as the itching is often very intense. At times his hands are painful especially with firm grasping of objects due to skin fissuring in areas where the finger joints flex. Additionally, he avoids holding hands with his girlfriend as they are concerned whether there may be some type of “infection”.
Use of over-the-counter (OTC) hydrocortisone 1% cream twice daily and a hypoallergenic moisturizer were not helpful despite compliant use. Due to the persistence and worsening of the “rash” despite 4-6 weeks of attempted OTC treatment, he was seen at an Urgent Care center, was prescribed topical mupirocin ointment and oral cephalexin, was told he likely has “eczema”, and was told to see a dermatologist.
The patient was seen approximately 1 week later after their visit to urgent care reporting that the topical mupirocin and oral cephalexin use provided little change in the “rash” and no improvement in the itching. The rash was noted on the hands and feet as shown in the baseline photographs at the dermatology office. The presence of dry skin was also noted which has been mildly pruritic at times by history.
The patient did have a history of childhood food allergies, diagnosed by a pediatric allergist, to eggs, dairy products, and several nuts which he effectively avoids as they had caused “hives” and “itchy rashes” earlier during childhood. He also has a history of occasional “itchy rashes” in early childhood treated intermittently with various prescription creams, and seasonal nasal allergies over the past 5 years occasionally treated intermittently with OTC nasal sprays and oral antihistamines.
His mother stated that he had some breathing difficulties on a few occasions that may be “asthma” which started around 5-6 years of age, however, this has not recurred for several years. The patient is otherwise healthy, is a good student, and participates in several academic activities but is not active in sports.
There were no known changes in personal use of products, other exposures, or changes in medical history. He has been using the same gentle cleanser and moisturizer for several months. The only potentially exacerbating factor temporally correlated with the flare was a change in climate due to unseasonably much cooler weather requiring the use of dry central heating. His family history is remarkable for seasonal allergies and dry skin in his mother and one older brother.
The patient was cooperative, admittedly anxious about his condition, able to verbally communicate clearly, and with normal vital signs and overall normal general appearance other than the skin findings. As noted in the baseline photographs, the palmar surface of hands was affected diffusely by erythema, xerosis, fine scaling, superficial fissuring, slight swelling, excoriations, lichenification, and hyperlinearity of the palms and soles.
The distal dorsal feet and posterior ankles were affected similarly, with a greater magnitude of crusting and excoriations. Xerosis is noted diffusely, primarily on the trunk and extremities. There was no warmth on palpation at the affected sites on the hands and feet, with absence of purulent exudate, or any signs of cellulitis.
Skin examination shows symmetric subacute and chronic eczematous dermatitis of the hands and feet with associated significant pruritus. The presence of pruritic eczematous dermatitis, chronic xerosis, and hyperlinearity of the palms and soles coupled with a history of recurrent pruritic skin eruptions, seasonal rhinitis, and food allergies, collectively support the diagnosis of atopic dermatitis. A family history of seasonal rhinitis supports a familial atopic diathesis associated with atopic dermatitis.
The affected body surface area affected by eczematous dermatitis during this flare was 3%. Laboratory testing and skin biopsy were not felt to be indicated for this patient.
1. Exacerbation of Atopic Dermatitis of Moderate Severity with Associated Marked Pruritus Involving the Hands and Feet
2. Diffuse Chronic Xerosis
Before & After Photos
Treatment Discussion and Outcome
The diagnosis and management options were discussed. Consideration of allergic contact dermatitis occurring along with atopic dermatitis, with a recommendation for patch testing, was also reviewed.
As the immediate desire was to control the current flare, they opted to delay patch testing and to first achieve rapid control, especially the severe itching. Although they were open to several options, the preference was to avoid use of “cortisones” due to potential side effects they had been warned about in the past.
The importance of specified skin care during and between flares was stressed as an important part of management. They were instructed on the use of a specified cleanser, moisturizer, and trigger recognition and avoidance. Ruxolitinib 1.5% cream was prescribed to be applied to affected areas twice daily with instructions to follow up in 2 weeks.
At the 2-week follow-up visit, the patient reported that he was “very happy” with the improvement in his condition. He noticed a marked reduction in itching within the first few days, with almost complete control of pruritus noted at follow up. A major benefit was he was able to sleep through the night within the first week of starting treatment and felt much happier, less anxious, and much less self-conscious.
As shown in the follow-up photos, the eczematous areas on the hands and feet were almost clear, with some persistence of erythema and focal lichenification on the feet, which were both markedly decreased from baseline. Scaling was significantly decreased and excoriations and crusting were completely resolved.
Which of the following is not true with regard to the use of topical ruxolitinib 1.5% cream for atopic dermatitis?
James Q. Del Rosso, DO Adjunct Clinical Professor of Dermatology Touro University Nevada Henderson, NV
Medical Director, Dermatology Faculty Practice Associate Director, Residency Program Department of Dermatology Icahn School of Medicine at Mount Sinai New York, NY