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. The patient returns to the office in 4 weeks with only modest improvement. The rash continues to itch and is disrupting his sleep. Examination findings are largely unchanged. Which of the following is the most appropriate next step in management of 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. The patient returns to the office in 4 weeks with only modest improvement.  The rash continues to itch and is disrupting his sleep.  Examination findings are largely unchanged.  Which of the following is the most appropriate next step in management of this patient's symptoms?

Quizplus · Accepted Answer

Explanation: The foundation of management for atopic dermatitis (AD) includes oral antihistamines, emollients to maintain skin hydration, and avoidance of excessively hot or dry environments. However, many patients continue to have significant pruritus despite these measures. Most patients with AD will benefit from topical glucocorticoids. Low-potency agents (eg, hydrocortisone) may be adequate for mild symptoms. More significant symptoms may warrant moderate- to high-potency glucocorticoids (eg, triamcinolone, betamethasone). Topical glucocorticoids are relatively contraindicated for AD on the face, eyelids, or flexural areas; calcineurin inhibitors (eg, tacrolimus) may be considered for use in these areas (Choice D). Severe AD may require ultraviolet phototherapy or systemic immunosuppressants. (Choice A) Doxycycline is frequently used in a variety of dermatologic conditions, including acne, rosacea, and hidradenitis suppurativa. It is not beneficial for AD. (Choice B) Clotrimazole is indicated for superficial fungal dermatoses such as tinea corporis. Concurrent tinea infections may contribute to AD symptoms, but clotrimazole is otherwise not useful for AD. tinea corporis (Choice C) Oral antihistamines are useful to control itching in AD. However, topical antihistamines are less effective and may contribute to hypersensitivity. Educational objective: Topical glucocorticoids are effective treatment for most cases of atopic dermatitis. Topical calcineurin inhibitors (eg, tacrolimus) are an alternate therapy for areas in which glucocorticoids are relatively contraindicated (eg, face, eyelids). Severe atopic dermatitis may require phototherapy or systemic immunosuppressants. References: Atopic dermatitis: an overview. (http://www.ncbi.nlm.nih.gov/pubmed/22962911)

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