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Child with Atopic Dermatitis

A five-year-old male was being treated atopic dermatitis that started when he was a year old. Over time, the rash became worse and extremely itchy. The child would awaken at night in order to scratch his legs which is where the rash was localized. 

He was started on a four-course medication management plan of prednisone for one week. His mother reported temporary relief with this treatment, but the rash reoccurred soon afterward. The boy was then started on cyclosporine for one month with no improvement reported by his mother. 

What do you recommend for medication management for this patient and why? 

  • 1 day 15 hours
    I would take bacterial cultures of his worst areas, and start weekly bleach baths at 1 tsp/gallon. I would also encourage wet to dry pajamas at night, with triamcinalone ointment 0.1% on the affected areas, supplemented with some tacrolimus oint .03% in the mornings. Treat with antibiotic according based off culture results, along with good skin care and avoidance of environmental triggers. If all else fails, see if we can get him into a dupilumab trial.
  • 3 days 2 hours
    Start oral antibiotic, bleach baths followed by wet/ dry pjs with Eucerin eczema and Triamcinolone ointment mixture
  • from Dermatologist Nation 3 days 4 hours
    I would initiate dilute bleach baths and attempt to reduce the Ph to lower colonization followed by a mid potency steroid bid ointment for one week. Then attempt to maintain the skin barrier function with overzealous use of emollients
  • 4 weeks 1 day
    Highly recommend soak and smear.
    1) soak wraps (onsie pajamas or something similar)
    2) bathe in warm water for 15 minutes (gentle cleanser only)
    3) lightly pat skin with towel
    4) apply TAC .1% ointment within 3 minutes (can also do same with aquaphor)
    5) wring out excess water from wrap and immediately dress child in damp wrap to seal moisture
    6) apply dry later clothing on top
    *do this for 3-5 days*

    If bacterial colonization is present I actually like dilute bleach baths. Easy, cheap and not giving the kid antibiotics. Let him/her sit in bath tub for 3-5 minutes (1/4 cup bleach to full bath tub water) then rinse after.

    Of course everything else should follow normal care we recommend (unscented soaps, thick moisturizing emollients - eucerin, cerave, aveeno etc). All free and clear detergent. Humidifier in bedroom. No scratching. Etc.
  • from Dermatologist Nation 1 month
    I would add Eucrisa Ointment BID and Capriclear spray on moisturizer with fractionated coconut oil daily after baths. If the above Kenalog cream does not help, I would try a 2 week course of Clobetesol ointment under Saran occulsion BID to see if it puts the itch/inflammation under control.
  • from Dermatologist Nation 1 month
    Bacterial colonization most likely cause of flares, contact sensitization can also play a role, especially if distribution is right and pityrosporum can cause flares esp if they involve upper half body. Recommend Topical decolonization w diluted bleach baths and short course oral staph coverage . If in suspicious distribution for contact exacerbation would patch test and consider nizoral shampoo as body wash if involves primarily upper half body
  • from AI Unite 1 month
    Do a complete lab evaluation for eosinophils and allergens.
  • from Dermatologist Nation 1 month
    Bleach baths followed by TAC0.1% ointment and wraps
  • from AI Unite 1 month
    Most likely staphylococcal colonization. Culture and start antibiotics