The store-and-forward feature of teledermatology allows patient medical information (including history and visual data) obtained from one provider's location to be electronically transferred to a provider in another location (Roman & Jacob, 2015). The construct of the TeleDermViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.
HISTORY
Chief Complaint
Presenting for diagnosis and therapeutic options.
History of Present Illness
A 9-year-old girl presents with red, dry, itchy plaques on her arms, which she says have been worsening over the last 2 years. She is noted to have had eczema as an infant. Prior treatment for skin condition: topical emollients and over-the-counter hydrocortisone cream three times a day. Her primary symptom: itch. Prior biopsy: no.
IMAGE QUALITY ASSESSMENT
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT1
There is one image provided with this consult (Figure 1). The image shows two large symmetrical fine-scaled, eczematous, erythematous patches on the bilateral antecubital fossae.
INTERPRETATION OF IMAGES
Findings
The erythematous patches are highly consistent with the characteristics of atopic dermatitis (AD).
RECOMMENDATIONS
Skin Care and Treatment Recommendations
Recommend nonalkaline soaps with a pH < 6 (Panther & Jacob, 2015). Recommend dilute vinegar wash, apple cider vinegar (ACV), by mixing ACV with water (1:84 ratio based on California tap water pH of 7.4). For example, in a standard-sized bath, use 32 oz (four cups) of ACV with a half-filled bath (21 gallons of water) to attain an ideal pH of 4.5 (or two tablespoons of ACV in five cups of water). Proceed with cool water rinse, pat dry, and apply prescription salve followed by a ceramide-containing emollient.
Medication Recommendations
Triamcinolone ointment 0.1% should be applied twice daily to the affected areas for a maximum of 6 weeks. There should be gradual reduction in the frequency of use as the inflammation improves. Continued use of emollients is recommended, with use of the triamcinolone only during inflammatory flares. Topical steroid use should be limited, as long-term use has been associated with potential skin atrophy, steroid dependence, striae, bruising, and increased hair growth. (Coondoo, Phiske, Verma, & Lahiri, 2014). Hydroxyzine oral dosage of 2 mg/kg per day (for ages 6-12 years) is recommended for pruritus, nightly as needed.
RECOMMENDED FOLLOW-UP
Type of Visit
Return to primary care to initiate management plan. Refer to dermatology if no improvement in 6-8 weeks.
CLINICAL PEARL
AD is a chronic inflammatory skin condition commonly seen in infants and children. It is currently estimated that almost 6% of Americans meet the clinical diagnostic criteria for AD (Jacob, Miller, & Herro, 2011). Although classic AD typically begins in childhood and regresses by adolescence, it is important to note that AD can continue into adulthood and can present its initial onset in adulthood (Spergel & Paller, 2003).
AD typically manifests as intensely pruritic, erythematous plaques in the flexural areas, such as the antecubital fossae and popliteal fossae, but can also affect the face, neck, hands, and extensor surfaces (Jacob et al., 2011).
The course of AD may be continuous or marked by alternating periods of remission and flares. Flares in affected patients may be attributed to specific triggers, such as food allergens and dust mites (Leung, Boguniewicz, Howell, Nomura, & Hamid, 2004), or by concurrent allergic contact dermatitis (Yoshihisa & Shimizu, 2012).
Barrier repair and maintenance is an important target for treatment, which includes acidification of the skin barrier for optimal antimicrobial properties and the reduction of Staphyloccocus colonization using aseptic soaks (Panther & Jacob, 2015). Anti-inflammatory salves, such as topical corticosteroids and topical immune modulators, may be needed to alleviate flares (Jacob et al., 2011).
Prolonged treatment with topical steroids may introduce side effects featured through striae, atrophy, bruising, and increased hair growth (Coondoo et al., 2014). The use of recommended antihistamines (hydroxyzine) is multipurpose in relieving itching and promoting healing of skin lesions.
REFERENCES