A 16-year-old boy comes to the office due to an itchy rash on his back and shoulders. The rash has been present for the last 3 months, but he has had similar symptoms intermittently in other body areas over the last 10 years. The patient has no fever and has had no recent illnesses. Current medications include daily cetirizine for seasonal allergies and topical benzoyl peroxide for acne. Vital signs are normal. On skin examination, there are excoriated lichenified plaques on the back and right shoulder, as shown in the exhibit.
Which of the following is the most appropriate advice to reduce this patient's symptoms?

Question

A 16-year-old boy comes to the office due to an itchy rash on his back and shoulders.  The rash has been present for the last 3 months, but he has had similar symptoms intermittently in other body areas over the last 10 years.  The patient has no fever and has had no recent illnesses.  Current medications include daily cetirizine for seasonal allergies and topical benzoyl peroxide for acne.  Vital signs are normal.  On skin examination, there are excoriated lichenified plaques on the back and right shoulder, as shown in the exhibit. 
Which of the following is the most appropriate advice to reduce this patient's symptoms?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be70_3dab_8f63_e3fc852122e7_MD0005_00 This patient, with a chronic pruritic rash with excoriations and lichenification, has features typical of atopic dermatitis (AD). AD most often first appears in childhood and is frequently associated with other atopic conditions such as asthma and seasonal or perennial allergies. The foundation of management for AD includes avoidance of factors that contribute to itching, such as excessively hot or dry environments and harsh soaps and detergents. Oral antihistamines are also useful. Regular use of emollients to maintain skin hydration can also relieve pruritus. (Choice A) A gluten-free diet is recommended for patients with dermatitis herpetiformis. This condition is usually associated with celiac disease and is characterized by intensely pruritic papules and vesicles on the extensor surfaces of the elbows and knees as well as on the buttocks and back. dermatitis herpetiformis (Choice B) Cotton clothing is generally recommended for patients with AD, as wool and synthetic fibers may increase the itching. However, care must still be taken as some fabric dyes or bacterial/fungal colonization in the material may cause a hypersensitivity reaction. (Choices D and E) Patients with AD frequently have evidence of hypersensitivity on antigen patch testing, but environmental and food antigen mitigation efforts have shown only minimal utility in the management of AD. Educational objective: Initial management of atopic dermatitis (AD) includes topical emollients and avoidance of excessively hot/dry environments and harsh soaps and detergents. Although patients with AD often have evidence of hypersensitivity on antigen patch testing, mitigation of environmental and food allergens does not have a significant benefit for most patients. References: Skin barrier breakdown: a renaissance in emollient therapy. (http://www.ncbi.nlm.nih.gov/pubmed/19633599) Steroid-free emollient formulations reduce symptoms of eczema and improve quality of life. (http://www.ncbi.nlm.nih.gov/pubmed/24809884)

A 16-Year-Old Boy Comes to the Office Due to an Itchy