Atopic Dermatitis in Emergency Medicine Treatment & Management

  • Author: Jamie Alison Edelstein, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP   more...
 
Updated: Apr 11, 2011
 

Emergency Department Care

Many patients with atopic dermatitis (AD) present to the ED during acute exacerbation. Therapy is targeted toward alleviation of pruritus and prevention of scratching. ED physicians must also look for signs and symptoms of bacterial superinfection and treat accordingly.

Practice guidelines on the management of atopic dermatitis are available from the Joint Task Force on Practice Parameters for Allergy and Immunology.[8]

Skin care

In the acute setting patients should be instructed to bathe once-to-twice daily using mild soaps (eg, Dove). There is no preference over showers or baths, whichever makes the patient most comfortable.

The patient should dry quickly and immediately (within 3 min) lubricate the skin. Many creams and lotions are available, and the optimal one is the greasiest the patient can tolerate.

Creams (eg, Eucerin, Cetaphil) are preferred over lotions, as they have lower or no water content and will not evaporate off of the skin during the day. Parents may use petroleum jelly on infants, but most children and adults will not tolerate the texture.

Topical steroids

Acute attacks should be treated by mid-high strength topical steroids for up to 2 weeks. Medium-to-high potency topical steroids should not be used on the face or neck area because of the potential adverse effects. These are preferred over low-mid strength medications, as they better control exacerbations. Patients should apply the ointment within 5 minutes of twice-daily bathing.

Inform the patient about adverse effects of topical steroids (eg, atrophy, hypopigmentation, striae, telangiectasia, thinning of the skin).

Antihistamines

Physicians have been prescribing antihistamines for years to control the pruritus associated with acute atopic dermatitis. Little evidence exists that antihistamines help with the itching in an awake patient; however, the use of sedating antihistamines is supported to control scratching while the patient is asleep.[9]

Systemic steroids

The use of systemic steroids in the treatment of acute exacerbation of atopic dermatitis is controversial. Most authors reserve oral prednisone (at least 20 mg/d for 7 d) for the most severe cases, although it seems the disease quickly relapses once the medication is discontinued. Patients also tend to discontinue topical steroid creams and other treatment as they feel better, which contributes to the relapse after oral steroids are done.

Topical calcineurin inhibitors

Topical calcineurin inhibitors (pimecrolimus 1% and tacrolimus 0.03%, 0.1%) are available for patients older than 2 years. These medications may be used all over skin surfaces (including face, neck, and hairline) because they do not have the side effects seen with topical steroids. Evidence supports the twice-daily use of these creams during acute exacerbation of atopic dermatitis, and some evidence exists to support use up to 4 years. The long-term side effects (including the possibility of increased risk for malignancy) have not fully been elucidated. For these reasons, the US Food and Drug Administration (FDA) does not recommend long-term use yet. Side effects of tacrolimus include burning and stinging on broken skin.

A study by Reitamo and Allsopp determined that twice-weekly tacrolimus ointment was effective in patients with moderate-to-severe atopic dermatitis.[10]

Probiotics

The role of probiotics in the treatment of atopic dermatitis remains controversial. Gerasimov et al determined that the administration of a probiotic mixture containing Lactobacillus acidophilus DDS-1, Bifidobacterium lactis UABLA-12, and fructo-oligosaccharide was associated with significant clinical improvement in children with atopic dermatitis.[11] However, the efficacy of probiotic therapy in adults requires further study.

Oral immunosuppressive agents

Patients with refractory atopic dermatitis may benefit from oral immunosuppressive agents, such as cyclosporine A. This medication is effective in treating severe atopic dermatitis in the acute setting. It is not recommended for long-term use.

Phototherapy

Phototherapy with PUVA, UVA, or UVB is successful in controlling atopic dermatitis but is expensive and may lead to increased risk of melanoma and nonmelanoma skin cancer. Studies evaluating the role of several proposed disease-modifying agents continue to be conducted. Results of studies on IL-4 neutralizing antibody and mast cell depleters are promising, whereas the evidence for probiotics,[12, 13] primrose oil, sodium cromolyn, topical caffeine, and dietary exclusion is inconclusive and requires more research.

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Consultations

In cases of uncertain diagnosis or severe atopic dermatitis that is resistant to conventional therapy, patients may be referred to a specialist such as a dermatologist or an allergist.

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Contributor Information and Disclosures
Author

Jamie Alison Edelstein, MD  Staff Physician, Department of Emergency Medicine, State University of New York, Kings County Hospital Center

Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO  Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert M McNamara, MD, FAAEM  Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine

Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Mark W Fourre, MD  Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Irritation around mouth of an infant with atopic dermatitis.
Typical atopic dermatitis on the face of an infant.
Flexural involvement in childhood atopic dermatitis.
 
 
 
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