An 18-year-old man has chronic atopic dermatitis. He has been applying a corticosteroid cream daily to the flexural areas of his skin for several years, and the treated areas have been free of pruritus, papules, vesicles, and scales during that time. Medical history is notable for asthma and allergic rhinitis. Punch biopsy of the treated skin would most likely show which of the following findings?

Question

An 18-year-old man has chronic atopic dermatitis.  He has been applying a corticosteroid cream daily to the flexural areas of his skin for several years, and the treated areas have been free of pruritus, papules, vesicles, and scales during that time.  Medical history is notable for asthma and allergic rhinitis.  Punch biopsy of the treated skin would most likely show which of the following findings?

Quizplus · Accepted Answer

This patient's atopic dermatitis has been successfully treated with a topical corticosteroid, leading to suppression of the typical inflammatory features (eg, pruritis, papules, vesicles, scales). However, chronic daily use of topical corticosteroids can cause cutaneous atrophy due to the inhibition of epidermal keratinocyte proliferation and fibroblast function. Fibroblasts synthesize dermal collagens 1 and 3 as well as hyaluronic acid. When these components are diminished in the extracellular matrix of the dermis, indentations, striae, tightening, and thinning of the skin result, making dermal capillaries more visible. In addition, corticosteroids induce nitric oxide release, leading to capillary dilation (ie, telangiectasia). Corticosteroids can also cause degradation and extrusion of follicular epithelium, resulting in corticosteroid-induced acne. High-potency topical corticosteroids can cause adverse effects within 2-3 weeks of daily usage, with less potent corticosteroids taking longer to cause similar effects. Areas with thin skin (eg, flexural surfaces, intertriginous areas, face, genitalia) are more susceptible. Recovery can be expected within weeks to months after cessation of therapy. (Choice A) Chronic topical corticosteroid therapy can cause atrophy, not hyperplasia, of subcutaneous adipose tissue and muscle layers. (Choices C and F) Dermal perivascular lymphocytosis is characteristic of the initial stage of acute atopic dermatitis. Epidermal intercellular edema (ie, spongiosis) is also seen in acute atopic dermatitis and manifests clinically as small vesicles. However, given that the patient is asymptomatic with treatment, these findings would not be expected. (Choices D and E) Epidermal hyperkeratosis (ie, thickening of the stratum corneum) and epidermal hyperplasia (ie, increased cellularity in the stratum spinosum) are characteristic of chronic atopic dermatitis, which manifests with scales and lichenification. Neither finding is present in this patient. Educational objective: Local adverse effects of chronic topical corticosteroid therapy include cutaneous atrophy, telangiectasias, and corticosteroid-induced acne. Effects are more pronounced with high-potency corticosteroids and in areas of thin skin (eg, flexural areas). __________ References: Topical steroid-damaged skin. (http://www.ncbi.nlm.nih.gov/pubmed/25284849)

An 18-Year-Old Man Has Chronic Atopic Dermatitis