Diagnosis and Management of Seasonal Atopic Dermatitis
Diagnosis
This clinical presentation is consistent with atopic dermatitis (AD), a chronic inflammatory skin disease characterized by pruritus, xerosis (dry skin), lichenification, and a relapsing course that worsens with environmental triggers like cold, dry weather. 1
The diagnosis is made clinically based on:
- Pruritus (itching) as a hallmark feature 1
- Xerosis (dry, chapped skin) with skin cracking 1
- Lichenification (thickened skin with accentuated markings) indicating chronicity 1, 2
- Chronic or relapsing course with seasonal flares triggered by cold, dry weather 1
- Personal or family history of atopy (asthma, allergic rhinitis, or eczema) if present 1
Treatment Algorithm
Step 1: Immediate Barrier Restoration (Foundation of All Treatment)
Replace all soaps and detergents with dispersible cream cleansers as soap substitutes to prevent stripping natural lipids from already compromised skin. 1, 3
Apply emollients liberally and frequently:
- At least twice daily and as needed throughout the day 1
- Immediately after bathing (within minutes) when skin is most hydrated to lock in moisture 1, 3
- Use ointment or cream formulations during cold, dry weather for maximum occlusion 1
Bathing technique:
- Use lukewarm water only 1
- Limit bath time to 10-15 minutes 1
- Add bath oils according to preference 1, 3
Step 2: Treat Active Inflammation
For lichenified areas and active eczema, apply topical corticosteroids:
- Use the least potent preparation required to control symptoms 1, 3
- Apply once or twice daily to affected areas until significantly improved 1
- For chronic lichenification specifically, moderate potency topical corticosteroids (such as fluticasone propionate or mometasone) are effective and can show improvement within one week 1, 4
- Implement proactive therapy with twice-weekly application of low to medium potency corticosteroids to previously affected areas to prevent flares 1
Alternative for sensitive areas or steroid-sparing:
- Topical calcineurin inhibitors (tacrolimus or pimecrolimus) for face, neck, or areas requiring prolonged treatment 3, 5, 6
- Pimecrolimus 1% cream applied twice daily can improve erythema and infiltration within 8 days and lichenification by day 15 6
- Use only in patients 2 years and older 6
Step 3: Environmental Modifications
Avoid temperature extremes that trigger symptoms 1
Use cotton clothing next to skin and avoid wool or synthetic fabrics 1, 3
Keep fingernails short to minimize damage from scratching 1, 3, 5
Minimize harsh detergents and fabric softeners when laundering clothes 3, 5
Step 4: Manage Complications
For secondary bacterial infection (if crusting, weeping, or honey-colored discharge present):
- Obtain bacterial cultures 3, 7
- Flucloxacillin is the most appropriate antibiotic for Staphylococcus aureus 1, 5
For severe pruritus disrupting sleep:
- Sedating antihistamines at night only 1, 3, 5
- Non-sedating antihistamines have little value in AD 1, 5
For eczema herpeticum (grouped vesicles or punched-out erosions):
Common Pitfalls to Avoid
Do not use topical corticosteroids continuously without breaks to prevent adverse effects including pituitary-adrenal suppression 1
Do not apply emollients less than twice daily or skip post-bathing application—this is when they are most effective 1, 3
Do not continue using soaps or detergents even if "gentle"—they must be completely replaced with soap substitutes 1, 3
Do not use pimecrolimus continuously for prolonged periods due to uncertain long-term safety 6
Avoid sun exposure, tanning beds, or UV therapy while using topical calcineurin inhibitors 6
When to Reassess
If no improvement after 6 weeks of appropriate treatment, consider alternative diagnoses including contact dermatitis and refer for patch testing 3, 7
If deterioration occurs in previously stable disease, suspect secondary bacterial or viral infection or development of contact dermatitis 1, 3