Atopic Dermatitis (AD)

The airway comes with the skin - AD sits in the atopy cluster with allergic bronchial asthma and allergic rhinitis, and those two are atopy's most frequent manifestations. Take a respiratory history aimed at them: wheeze, inhaler and steroid-inhaler use, the date of the last exacerbation and any admission for it, then auscultate for expiratory wheeze before induction. Plan for a reactive airway - adequate depth before instrumentation and a bronchodilator within reach.

IgE and the propensity to react - Atopy is IgE overproduction with an increased propensity to hypersensitivity reactions, so this is the patient who reacts to things. Work through drug, food and material allergies by history rather than trusting the allergy field in the chart, and know what each listed reaction actually looked like.

Choose your sites by looking at them - Eczematous skin is broken and prone to recurrent infection. Examine the skin over the planned IV, arterial line and neuraxial sites before you prep, and use the least involved skin available rather than picking by habit.

Eczema herpeticum stops an elective case - Disseminated cutaneous herpes simplex on top of AD shows up as sudden monomorphic vesicles and punched-out erosions with hemorrhagic crusts over eczematous areas, often with fever, lymphadenopathy and malaise. It is potentially life-threatening. Find that pattern on the preoperative skin exam and the elective case waits for treatment.

Know what is treating it - Topical corticosteroids such as triamcinolone and topical calcineurin inhibitors such as pimecrolimus cover mild to moderate disease. Dupilumab is a subcutaneous injectable for moderate to severe AD that has not responded to conventional therapy including topical corticosteroids. Ask which agents are running, how much body surface they cover and for how long, because that answers both the immunosuppression and the steroid-cover questions.

Tape, electrodes and positioning - Inflamed and excoriated skin is what you have to work with, so plan securement rather than improvising it. Put ECG electrodes and the grounding pad on intact skin, use the gentlest securement that will reliably hold the tube and the lines, and pad pressure points before draping.

Atopic dermatitis (AD) is a specific form of eczema and the most common chronic inflammatory skin disease. Genetic and environmental factors combine to produce abnormalities in both the epidermis and the immune system: the barrier fails and the immune response is misdirected. AD is the cutaneous face of atopy, which is a predisposition to mount an immune response against diverse antigens and allergens, driving CD4+ Th2 differentiation and overproduction of IgE, with the clinical consequence of an increased propensity to hypersensitivity reactions. Allergic bronchial asthma and allergic rhinitis are the most frequent manifestations of atopy, followed by AD and food allergy.

Two things follow the patient into the operating room. The airway belongs to an atopic patient and behaves like one, and the skin is broken, inflamed, and prone to recurrent infection at exactly the sites you want to use.