Children s Hospital Of Wisconsin
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1 Children s Hospital Of Wisconsin Co-Management Guidelines To support collaborative care, we have developed guidelines for our community providers to utilize when referring to, and managing patients with, the pediatric specialists at Children s Hospital of Wisconsin. These guidelines provide protocols for jointly managing patient cases between community providers and our pediatric specialists. Atopic Dermatitis Atopic Dermatitis (AD) or eczema is a very common condition in children and can often be seen in association with asthma, allergies and allergic rhinitis. Diagnosis/symptom Referring provider s initial evaluation and management: When to initiate referral/ consider refer to Dermatology Clinic: What can referring provider send to Dermatology Clinic? Specialist s workup will likely include: Signs and symptoms Pruritus Eczematous lesions Chronic or relapsing history Patterns vary depending on age and may include 1 : Facial, neck, and extensor involvement more common in infants Flexural lesions in all ages Sparing of the groin and axillary regions Supporting features: Early age of onset Atopy Initial assessment includes detailed history of skin care regimen and physical examination to assess severity of disease. Management includes implementation of preventative measures and treatment for flares. Preventative maintenance therapy includes initiation of topical emollients twice daily and fragrance-free products. A more comprehensive skin care regimen and suggested product list is provided below. Skin care regimen Not responsive to topical agents Experiencing flares despite use of topical therapy Concern about superinfection with weeping or crusted areas Moderate to severe disease 1. Using Epic Please complete the external referral order In order to help triage our patients and maximize the visit, the following information would be helpful include with your referral order: Urgency of the referral What is the key question you would like answered? Note: Our office will call to schedule the appointment with the patient. 2. Not using Epic external referral order: In order to help triage our patients maximize the visit time, please fax the above information to ( ) After referral to Dermatology Clinic: Assessment of severity of disease and impact on quality of life Implementation of changes in home regimen, including use of fragrance free products Assessment for therapy including topical therapy, phototherapy and systemic therapy and implementation based on patient needs
2 Personal and/or family history Ointments are preferred over creams. Lotions should be avoided as they contain alcohol and high quantity of water. Bathing: Daily bathing is recommended with lukewarm water for a maximum of minutes. After bathing, recommend patting skin dry gently with a towel. Medicines and moisturizers should be applied to damp skin. Avoid: o Hot, steamy water o Scrubbing skin o Bubble baths Bath Oils: Recommend use only bath oils that are free of fragrance and dye. Recommend avoidance of baby oils. Bleach Baths: If frequent infections are present, initiation of bleach baths can aid in bacterial decolonization. Bleach baths may be performed once weekly to several times weekly depending on severity. A quarter cup of regular Clorox bleach should be added to a half of a tub full of water. Soak up to ten minutes and then rinse. Soaps: Recommend use of a fragrance-free soap, restricting application of soap only to areas which are dirty including the neck, axillae and groin. Laundry Products: Recommend use of fragrance-free detergent and It would also be helpful to include: Chief complaint, onset, frequency Recent progress notes Labs and imaging results Other Diagnoses Office notes with medications tried/failed in the past and any lab work that may have been obtained regarding this patient s problems.
3 avoidance of fabric softeners or dryer sheets. Activity: Sweating can exacerbate AD in some children. In this case, recommend avoiding time outdoors during hot temperatures. In winter, a humidifier may be helpful. When swimming, recommend bathing and applying topical moisturizers immediately after. Clothing: Recommend soft natural fabrics, like cotton. Avoid wool, nylon and synthetic fabrics. If metal allergy is suspected in addition to AD, wearing clothing, jewelry, belts, etc. with metal should be avoided. Fingernails: Recommend fingernails are cut short. When possible, socks can be worn on the hands at night to avoid injury from scratching while asleep. Foods: Acidic foods (fruits & vegetables) that come in contact with the skin around the mouth can cause irritant dermatitis, distinct from food allergy. Recommend application of a topical ointment to the skin before eating and washing face and repeat application immediately after eating for barrier protection. Causes While the exact cause is not known, genetic factors play a role. In atopic dermatitis that barrier is
4 inadequate, and the skin is easily irritated. Immune dysregulation also occurs as a result of the impaired barrier. The natural history of atopic dermatitis is variable, though many children may outgrow AD in adolescence. Atopic Dermatitis: Product List Moisturizers: Ointments Aquaphor Healing Ointment Petroleum Jelly Vaseline Petrolatum eczema White petrolatum Vaniply Ointment Creams CeraVe Moisturizing Cream Cetaphil Moisturizing Cream Aveeno Eczema Therapy Moisturizing Cream Eucerin Original Moisturizing Crème Vanicream Cream Skin cleansers: Dove Sensitive Skin Beauty Bar Aveeno Skin Relief Body Wash Aquaphor Gentle Wash and Shampoo CeraVe Hydrating Cleanser Vanicream Cleansing Bar Cetaphil Gentle Skin Cleanser/ Gentle Cleansing Bar
5 Laundry detergent: All Free Clear Tide Free & Gentle Liquid Cheer Free & Gentle Purex Free & Clear Arm & Hammer Perfume and Dye Free Liquid Topical & Oral Therapy Topical corticosteroids are classified according to strength from Class I (very high potency) to Class VII (lowest potency) o Maintenance therapy: In the case of diffuse involvement not responding to over-the-counter topical moisturizers, alone a medicated moisturizer may be implemented twice daily as an alternative Medicated moisturizers typically use low potency topical steroid with an ointment or cream, e.g. hydrocortisone 2.5% ointment mixed 1:1 with CeraVe cream o Treatment of flares: A stronger topical steroid may be required for flares areas and should be used twice daily until lesions clear. Maintenance therapy should be continued during periods or remission. Therapy based on severity of lesions and distribution of the lesions Face, axillae and groin represent higher risk areas where mid to high potency topical steroids should be avoid due to increased risk of atrophy. Acral areas, including hands and feet, due to thicker skin, may require increased potency topical steroids. Ointments are preferred over creams Non-steroidal topical agents o Tacrolimus 0.03% or 0.1% ointment or pimecrolimus 1% cream may be considered in age appropriate patients as an alternative to topical corticosteroids, particularly in areas such as the face, which are at higher risk for atrophy Antihistamines o Oral antihistamines may be considered in a dose appropriate manner if significant pruritus is present. Topical Corticosteroid Classification 1 Class Drug Dosage Form(s) Strength (%) I. Very High Augmented betamethasone dipropionate Ointment 0.05 Clobetasol propionate Cream, foam, ointment 0.05
6 Diflorasone diacetate Ointment 0.05 Halobetasol propionate Cream, ointment 0.05 Amcinonide Cream, lotion, ointment 0.1 Augmented betamethasone dipropionate Cream 0.05 Betamethasone dipropionate Cream, foam, ointment, solution 0.05 Desoximetasone Cream, ointment 0.25 Desoximetasone II. High Gel 0.05 Diflorasone diacetate Cream 0.05 Fluocinonide Cream, gel, ointment, solution 0.05 Halcinonide Cream, ointment 0.1 Mometasone furoate Ointment 0.1 Triamcinolone acetonide Cream, ointment 0.5 Betamethasone valerate Cream, foam, lotion, ointment 0.1 Clocortolone pivalate Cream 0.1 III-IV. Medium Desoximetasone Cream 0.05 Fluocinolone acetonide Cream, ointment Flurandrenolide Cream, ointment 0.05 Fluticasone propionate Cream 0.05
7 Fluticasone propionate Ointment Mometasone furoate Cream 0.1 Triamcinolone acetonide Cream, ointment 0.1 Hydrocortisone butyrate Cream, ointment, solution 0.1 V. Lower- Medium Hydrocortisone probutate Cream 0.1 Hydrocortisone valerate Cream, ointment 0.2 Prednicarbate Cream 0.1 VI. Low VII. Lowest Alclometasone dipropionate Cream, ointment 0.05 Desonide Cream, gel, foam, ointment 0.05 Fluocinolone acetonide Cream, solution 0.01 Dexamethasone Cream 0.1 Hydrocortisone Cream, lotion, ointment, solution 0.25, 0.5, 1 Hydrocortisone acetate Cream, ointment References 1. Practice Management Center. Atopic Dermatitis Clinical Guideline American Academy of Dermatology,
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