atopic dermatitis - Nursing Case Study

Pathophysiology

• Primary mechanism: Atopic dermatitis is primarily driven by a dysfunctional skin barrier. This can stem from mutations in the gene encoding filaggrin, a protein vital for maintaining skin integrity. The compromised barrier allows allergens and pathogens to penetrate the skin, triggering an immune response.

• Secondary mechanism: Overactive immune response is another key factor. In response to invaders, immune cells release inflammatory cytokines, causing chronic inflammation and itching in the skin. Th2 lymphocytes play a significant role, promoting IgE production and eosinophil activation, further exacerbating inflammation.

• Key complication: Chronic inflammation and repeated scratching can lead to lichenification, or thickening of the skin, further worsening the symptoms and potentially leading to bacterial or viral skin infections.

Patient Profile

Demographics:

58-year-old male, office worker

History:

• Key past medical history: Diagnosed with Atopic Dermatitis at age 40, Hypertension

• Current medications: Topical corticosteroids for Atopic Dermatitis, Lisinopril for Hypertension

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Intense itchiness, difficulty in sleeping due to discomfort, worsening skin condition despite medication

• Key symptoms: Dry, scaly skin, red to brownish-gray patches, raised bumps which are leaking fluid and crust over when scratched, thickened, cracked, and scaly skin, raw and sensitive skin from scratching

• Vital signs: Blood Pressure 160/95 mmHg, Pulse Rate 90 bpm, Respiratory Rate 18 breaths per minute, Body Temperature 37.1°C

Section 1

Change in Patient Status:

The patient's condition continues to deteriorate despite the ongoing treatment. He reports an intensification of the itchiness, and skin examination reveals an increase in the number and size of the red to brownish-gray patches, particularly on the arms and legs. Some of these patches have become oozy and crusted, indicating possible secondary bacterial infection. The skin over these areas is visibly thickened and lichenified, suggesting chronic scratching. The patient also presents with signs of fatigue and irritability, which he attributes to persistent sleep disturbances caused by the itch-scratch cycle.

Vital signs are as follows: Blood Pressure 165/100 mmHg, Pulse Rate 92 bpm, Respiratory Rate 20 breaths per minute, Body Temperature 37.8°C. The rise in temperature and blood pressure could be indicative of an underlying infection. Also, the patient's elevated pulse rate and respiratory rate might be due to discomfort and anxiety related to his deteriorating skin condition. These findings indicate a need for further diagnostic tests, including skin swabs for culture and sensitivity, complete blood count, and an assessment of the patient's emotional wellbeing. The patient may also benefit from a review of his current treatment regimen.

Section 2

New Diagnostic Results:

Lab results return showing a significantly elevated white blood cell count of 15,000 cells/mcL, indicating an infection. The skin swab results identify impetigo caused by Staphylococcus aureus, a common secondary infection in patients with atopic dermatitis. The bacteria are sensitive to flucloxacillin, suggesting that this antibiotic could be included in the treatment regimen.

The patient's serum IgE level is also notably high at 500 IU/mL, which is consistent with an ongoing allergic response often seen in atopic dermatitis. His Hemoglobin levels are slightly low at 11 g/dL, possibly suggesting anemia due to chronic disease. The elevated blood pressure persists, which may be due to stress, pain, or could be an indication of an underlying hypertensive disorder. Given these findings, medication adjustments may be necessary, and further monitoring of the patient's blood pressure is recommended.

Section 3

Change in Patient Status:

Over the next few days, the patient's condition continues to fluctify. Despite the administration of flucloxacillin for the staphylococcal infection, there is little improvement in the skin lesions, and they appear to be spreading. The patient reports increased itching and discomfort, particularly at night, which is interfering with his sleep. The patient's blood pressure remains elevated, averaging 145/95 mmHg, despite non-pharmacological interventions such as stress management and rest.

Upon physical examination, the patient's skin appears dry and flaky with red, inflamed patches, particularly in the folds of the arms and behind the knees. The skin in these areas is cracked and oozing, indicating persistent infection. The patient's hemoglobin level has dropped slightly to 10.5 g/dL, and his white blood cell count has risen to 16,000 cells/mcL. These findings suggest that the patient's body is still fighting off an infection, and his ongoing anemia may be exacerbating his fatigue and overall feeling of malaise.

Given these changes in the patient's status, it may be necessary to reevaluate the effectiveness of the current treatment plan and consider alternative therapies. A consultation with a dermatologist may be beneficial to help manage the atopic dermatitis and associated complications. Furthermore, dietary modifications may be explored due to the possible links between certain foods and eczema flare-ups. It is also important to ensure that the patient's blood pressure is closely monitored and managed, potentially with pharmacological intervention if it remains consistently high.

Section 4

Change in Patient Status:

Over the course of the next several days, the patient's condition appears to further deteriorate. The persistent itching has started to cause significant sleep disturbances, leading to daytime fatigue and decreased appetite. His blood pressure readings have also started to spike, reaching 155/100 mmHg, despite continued non-pharmacologic interventions.

On physical examination, the skin lesions have spread to the trunk and neck, appearing more red, inflamed, and oozing. His hemoglobin level has further decreased to 9.8 g/dL, suggesting worsening anemia. The white blood cell count has now escalated to 18,000 cells/mcL, indicating an ongoing infection despite antibiotic treatment. The patient also reports increasing malaise and a subjective feeling of fever, suggesting that the infection may be spreading.

These changes indicate a need to reassess the patient's current treatment plan and consider more aggressive interventions. The worsening anemia, persistent infection, and uncontrolled hypertension pose significant risks to the patient's overall health and wellbeing. It is crucial to consider a multidisciplinary approach involving a dermatologist, dietitian, and possibly a cardiologist to manage the patient's multiple health issues. The team should be keen on monitoring the patient's vital signs, lab values, and response to interventions to ensure optimal patient outcomes.

Section 5

Change in Patient Status:

Despite the multidisciplinary approach to his care, the patient's condition continues to worsen. He now presents with a persistent high-grade fever of 38.9°C, in spite of ongoing antipyretics. His blood pressure remains elevated at 160/105 mmHg, and his pulse rate has increased to 110 beats per minute, suggesting ongoing cardiovascular stress. This increased cardiovascular demand, combined with his worsening anemia, is causing him to experience episodes of lightheadedness and shortness of breath. His appetite continues to decline, and he has lost 4kg over the past week. The patient also reports increased pain, rating it as an 8 on a scale of 1-10, centered around the inflamed skin lesions.

New Diagnostic Results:

The patient's worsening clinical picture prompts further diagnostic testing. A blood culture reveals the presence of Staphylococcus aureus, indicating a systemic bacterial infection. His C-reactive protein (CRP) level has also risen to 30 mg/L, supporting the presence of ongoing inflammation and infection. A skin biopsy of one of the lesions confirms the diagnosis of severe atopic dermatitis with secondary bacterial infection. An echocardiogram is suggested to assess the impact of the prolonged hypertension on his heart function.

The escalating infection, uncontrolled hypertension, and severe atopic dermatitis necessitate an urgent reassessment of the patient's treatment plan. The team must consider more aggressive pharmacologic interventions to manage the hypertension and the infection, along with urgent dermatological interventions to manage the atopic dermatitis. The patient's nutritional status should also be addressed, as the persistent loss of appetite and weight loss may further compromise his health status.