Head-and-Neck Atopic Dermatitis

Steroid-induced rosacea and periorificial dermatitis can mimic HNAD, as both can present as refractory dermatitis due to chronic topical steroid use. These 2 conditions can be distinguished from true HNAD by lesional morphology and areas of involvement. Steroid-induced rosacea tends to occur over sebaceous areas, such as the glabella, cheeks, nose, and chin, and presents as red papules on a background of diffuse erythema and occasionally telangiectasia. Periorificial dermatitis tends to involve areas around the eyes, nose and mouth, and presents as small non-folliculocentric papules and pustules. Periorificial dermatitis can be seen in nearly 3% of asthmatic children who use inhaled steroids.³ On the other hand, true head-and-neck AD is less likely to present as papules and pustules unless impetiginized. Furthermore, AD is a sebostatic condition with sebaceous hypofunction, and therefore is less likely to occur over sebaceous areas.

Treatment of HNAD can be challenging for several reasons. Firstly, long-term topical corticosteroid (TCS) use carries the risks of facial skin atrophy and TCS withdrawal.⁴ Additionally, topical therapies are often greasy and occlusive, and are therefore impractical and cosmetically unpleasant for head-and-neck use, resulting in poor patient compliance.

For steroid-induced rosacea and periorificial dermatitis, prompt discontinuation of topical steroids is necessary, and treatment with nonsteroidal alternatives should be initiated. Protective barrier products such as petrolatum, waxes, or zinc oxide paste can be applied to the face and around the mouth of young children before eating to prevent food-related irritant and allergen entry. Areas around the mouth and cheeks should be cleaned and moisturized after feeding. It is important to advise caregivers to avoid using commercial wet-wipes due to risk of developing allergic contact dermatitis from preservatives and fragrances.⁵ If rinsing is not possible, a soft towel dampened with tap water can be used. The same should be done for the lower face and neck areas in asthmatic children with AD after inhaled corticosteroid use to prevent periorificial dermatitis.

Vasomotor instability is also a contributor to HNAD. This is especially prominent at night, leading to nocturnal exacerbation and sleep disturbance. Cool water or thermal water spray can be used during the day for cooling. At night, a chilling pillow can be used to decrease head-and-neck vasomotor instability and nocturnal itch. Rice paper facial masks can be used alone or as an occlusive membrane over moisturizers or topical medications to increase penetration and skin barrier repair. The link below provides a brief tutorial on how to make a rice paper mask: https://www.learnskin.com/courses/eczema/rice-paper-mask-for-eczema-tutorial

Dr Shi is an assistant professor of medicine and dermatology at the University of Arizona and Banner University Medical Center in Tucson, AZ.

Ms Hendricks is a medical student in the College of Medicine at the University of Arizona in Tucson, AZ.