What treatment options are available for a 17-year-old with worsening dermatitis on the neck and axillas (armpits) despite dermatological treatment?

Management of Persistent Dermatitis in a 17-Year-Old with Neck and Axillary Involvement

The most effective approach for a 17-year-old with persistent dermatitis on the neck and axillas that is unresponsive to standard treatments is to consider allergic contact dermatitis as a likely cause and proceed with patch testing to identify specific allergens. 1

Diagnostic Considerations

• Recalcitrant dermatitis that persists despite treatment with a dermatologist strongly suggests allergic contact dermatitis (ACD) as a potential cause or complicating factor 1
• The neck and axillary regions are particularly common sites for ACD, with the axillary creases being especially affected in many cases 1
• Recent studies show that ACD is at least as common in patients with atopic dermatitis as in the general population (6-60% of subjects depending on the study) 1
• The most common contact allergens include nickel, neomycin, fragrance, formaldehyde and other preservatives, lanolin, and rubber chemicals 1

Recommended Approach

Step 1: Patch Testing

• Arrange for patch testing with a dermatologist specializing in contact dermatitis 1
• Patch testing should be considered when there is:
  • Disease aggravated by topical medications or emollients
  • Increased severity at specific locations like the neck and axillary regions
  • Persistent/recalcitrant disease not responding to standard therapies 1

Step 2: Allergen Identification and Avoidance

• Once allergens are identified, complete avoidance is the cornerstone of treatment 1, 2
• Replace soaps and detergents with emollients as they can be irritants that compound the condition 1
• Consider substituting different materials both in clothing and personal care products to avoid implicated allergens 1

Step 3: Treatment of Persistent Dermatitis

Topical Treatments

• Topical corticosteroids of appropriate potency for acute flares:

  • Mid- to high-potency topical steroids (such as triamcinolone 0.1% or clobetasol 0.05%) for localized acute lesions 3
  • Limit use to short periods to avoid side effects 2

• Topical calcineurin inhibitors as steroid-sparing agents:

  • Pimecrolimus (Elidel) cream 1% has shown efficacy in treating mild to moderate dermatitis 4
  • Apply twice daily to affected areas 4
  • Particularly useful for sensitive areas like the neck 5

Systemic Treatments for Severe Cases

• If the dermatitis involves an extensive area of skin (greater than 20%), consider systemic steroid therapy for short-term relief 3
• For long-term management of severe recalcitrant cases, consider referral for:
  • Phototherapy (UVB or PUVA) which has been demonstrated to be useful in chronic dermatitis 1
  • Systemic immunomodulators such as methotrexate, mycophenolate mofetil, or azathioprine for severe cases 1

Step 4: Skin Care and Prevention

• Maintain proper skin hydration with regular use of emollients 5
• Replace harsh cleansers with gentle, fragrance-free alternatives 1
• Avoid known irritants that can exacerbate the condition 1
• Consider clothing made of cotton rather than synthetic materials that may trap sweat in the axillary region 1

Important Considerations and Pitfalls

• The diagnosis of ACD requires demonstrated relevance to the patient's active dermatitis and sometimes confirmation by repeat open application testing 1
• Even some cases of generalized dermatitis may involve ACD, such as reactions to fragrances, preservatives, cleansers, and textiles 1
• Avoid empiric food elimination/avoidance diets as they are rarely helpful without specific evidence of food allergy 1
• Be aware that the prognosis for persistent contact dermatitis can be poor - in one study, only 25% of patients with occupational contact dermatitis had completely healed over a 10-year period 1
• Patient education about allergen avoidance is crucial for long-term management 1

By following this systematic approach, you can effectively address the persistent dermatitis affecting your 17-year-old patient's neck and axillas, even when previous treatments have failed.