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Atopic Dermatitis: Understanding a Difficult Disease
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James P. Rosen, MD FAAAAI, FACAAI, FAAP
Connecticut Asthma and Allergy Center LLC
West Hartford, CT 06119
Triggers of Itch of Atopic Dermatitis
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Some of this information courtesy of the American Academy of Allergy,
Asthma and Immunology, with permission.
General Overview
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Atopic dermatitis (AD) is a chronic or recurrent inflammatory skin disease
that is characterized by an extraordinarily itchy rash that has remissions and
relapses.
The prevalence of atopic dermatitis is increasing with up to 10-15% of the
population being affected during childhood.
Atopic dermatitis is a type of eczema, but all eczemas are NOT always
atopic dermatitis.
Generally begins in the first year of life, with 60% of patients developing
symptoms in the first year with 85% of patients developing symptoms by
age 5.
Earlier onset is associated with a more severe course, as is atopic dermatitis
in an infant affecting the flexural areas of elbows and knees.
Many cases resolve by age 2 with significant improvement at puberty being
common.
The cause of AD is not known, however there is a high association with IgE
mediated allergy; approximately 85% of patients have elevated IgE and
positive immediate skin tests.
More than 50% of patients will go on to develop asthma and up towards
75% of patients will develop allergic rhinitis.
The characteristic symptoms of AD are intense itching of the skin and
skin sensitivity.
The scratching may be severe, worse in the evenings and often interferes
with normal sleep patterns.
Often AD is described as an itch, that when scratched, rashes.
80% of offspring of 2 parents with AD will develop AD, whereas 60% of
offspring will develop AD when one parent has AD and the other has
allergic respiratory disease.
Although the cause is not exactly known, it is hereditary and involves the
immune system in the skin.
There is no cure!
There are many triggers of itch and subsequent rash of AD. These include
but are not limited to:
* Irritants- wool (looks like barbed wire under a microscope)
* Soaps
* Disinfectants
* Dry skin
* Infectious agents; bacteria agents, (although viruses and fungal
infections can be seen in the skin of patients with AD, they are usually
not a cause of itch)
* Heat and Sweating
* Psychological factors
* Contactants
* Foods –IgE mediated allergy and possibly other mechanisms (to be
discussed later)
* Aeroallergens such as pollens, mites and pets* Hormonal factors
* Climatic factors
Complications of Atopic Dermatitis
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Patients with AD often develop bacterial, viral and fungal infections.
The cause of increased skin infections is due to immunological
abnormalities in the skin as well as the excoriations in the skin, which leads
to an increase in infectious colonization and more infections.
Treatment of the bacterial skin infections with topical or oral antibiotics is
often very important to the treatment and successful outcome of the disease.
Treatment of viral infections (most often molluscum cantagiosum and
warts) is often very challenging.
Some viral infections, specifically herpes, can be very serious and life
threatening and are characterized by painful rather than itchy bumps.
Patients are usually ill looking, often with fever. Be aware of painful
lesions. Patients should be seen immediately.
Eye complications associated with AD are 1.Atopic Keratoconjunctivitis
associated with eyelid dermatitis and lid margin dermatitis, 2. Keratoconus
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from severe and persistent itching of the eyes, and 3. Anterior capsular
cataracts can be caused not only by the disease itself, but also by
inappropriate use of topical steroids on the eyelids. Eye examination by an
ophthalmologist is often recommended.
Thickening of the skin, known as lichenifcation, occurs after long standing
AD.
Psychosocial issues and school avoidance.
Sleep disturbances and poor school performance.
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Diagnosis of Atopic Dermatitis
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If it doesn’t itch, it’s not atopic dermatitis.
Lesions of AD are intensely itchy with red bumps and excoriations often
accompanied by a yellowish crust and /or yellowish fluid. They are almost
always bilateral & symmetrical on the body.
Assess age of onset to help with diagnosis. Onset in adults is very very
unusual.
Family or personal history of allergic diseases like asthma and allergic
rhinitis is very supportive evidence of AD.
If there is no personal or family history of atopy, one must rethink the
diagnosis.
The rash is chronic and relapsing.
Presence of other conditions like dry skin and hyperkeratosis pilaris often
helps with diagnosis.
Characteristic location of lesions: infant- checks and extensor surfaces of
arms and legs, also involves chest and where ever the child can scratch.
Older children have lesions located at the flexural areas of elbows and knees
and areas around the neck, wrists, and feet.
Lichenified (thickened) skin is the result of chronic scratching and
inflammation and seen in older children and adults, usually at elbows, knees
and neck.
Increased palm and sole linearity is common in patients affected with AD.
Lower eyelid pleats (Dennie-Morgan lines) are common at all ages,
although usually first presents in early childhood.
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Treatment of Atopic Dermatitis
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Hallmarks of treatment are: 1.avoid triggers that cause
symptoms. 2.Evaluate for allergic triggers (inhalants, contactants, or
foods). 3. Keep skin moist with hydration and moisturizers and 4. Treat
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the affected areas with topical anti-inflammatory creams or ointments and
use antihistamines.
Antihistamines may be valuable in atopic dermatitis because of 1. their
antagonistic effect on histamine released from mast cells with subsequent
itch supression, 2. their mast cell stabilizing effects with their subsequent
effect on the release of inflammatory mediators and 3. their effect of
reducing inflammatory cell trafficking into the skin. In addition, there are
some studies that suggest that antihistamines might downregulate the
allergic expression of certain T lymphocytes.
Frequently, systemic antibiotics and bleach baths (yes bleach) are needed to
treat bacterial infections and prevent re-occurrence of infection.
Rarely, antiviral and antifungal agents are needed to treat infections, like
molluscum, herpes and warts.
Use of cold compresses is extremely effective in helping to reduce itch.
Cool baths can be very helpful for total body itching.
Wet wraps are very effective in maintaining good skin care.
Long hydrating baths (20-30 min) are very effecting in keeping skin moist.
Use of cotton gloves and trimming nails is helpful to reduce excoriation and
thus helps to reduce bacterial infections.
Data on long term use of Citerizine shows that it might help prevent the
development of asthma in children with AD and positive skin tests to cat,
grass and mites. Looks promising.
Leukotriene modifyers, by their ability to antagonize some of the mediators
of mast cell degranulation, have been used with some success in AD in
conjunction with antihistamines.
Topical immunomodulators: Topical steroids and calcineurin inhibitors
(Protopic and Elidel).
·Use in conjunction with moisturizers.
·Use the least potent topical steroid that gives good control.
·Face, genitalia, axilla, and eyelids are especially susceptible to the side
effects of topical steroids, such as thinning, of the skin, telangiectasia
(spider veins), acne, hypopigmentation, and striae (stretch marks) Be
careful!!
·The use of Calcineurin inhibitors (Protopic and Elidel) appears safe and
free from the side effects of topical steroids. However, they are probably
no more potent than high potency topical steroids, just appear safer
especially for use on the face.
·One needs frequent medical supervision with use of topical antiinflammatories.
Evaluation of inhalant and food allergies is very important for
environmental control and proper food avoidance.
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Regular check ups are important for ongoing evaluation of the
skin and to check on compliance and side effect of treatment.
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Skin Care
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Food Allergy and AD
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Patients with food allergy, as a cause of AD, usually present under the age
of one, often have very difficult to treat AD, have extensive AD and usually
have an atopic familial background.
In moderate to severe AD, ~ 33% of patients have food allergy.
Adults, very low incidence of food allergy.
85% of foods responsible for AD are milk, egg, peanut, tree nuts, wheat and
soy.
It is important to note that in the evaluation of food allergy by skin testing,
many patients with AD have positive skin tests to foods that may not be
clinically relevant. Therefore, it is imperative that a trained allergist assist
the patient in determining the clinical relevance of positive skin tests.
Once a food has been identified as a potential allergen, a systematic diet can
be undertaken to remove such allergens. However, it may not be advisable
to completely avoid the aggravating food as this may reduce tolerance and
potentially cause anaphylaxis upon further ingestion of the food. Please
discuss this with your physician.
It is important to note that if the implicated foods are extensive in number
or represent a significant part of the child’s diet, a dietitian should get
involved to develop a diet so as not to cause caloric deprivation. Vitamin
and mineral supplements may be needed.
For the patients on elimination diets, it is important to weigh and get heights
on children every 4-6 months to ensure proper nutrition and growth.
Re-evaluation of food allergy every 6 months is essential because children
often outgrow their food allergy (milk and egg primarily, peanut and nuts,
rarely).
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Hydration of the skin is extremely important, using prolonged hydrating
baths (20-30 minutes) and moisturizers to be applied within 3 minutes of
exiting the bath.
Avoid skin care products that contain perfumes and alcohol.
Rinse clothes thoroughly after washing.
Avoid fabric softeners.
Wear cotton clothing.
Avoid wool (barbed wire to a child with AD) or other irritating fabrics.
Stress Control
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Stress often triggers the itch-scratch cycle.
Counseling should be considered in patients who have difficulty with
uncontrollable stress.
Poor self esteem and school absenteeism should trigger a psychological
evaluation.
Masqueraders of atopic dermatitis
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Seborrheic dermatitis (cradle cap)
Contact dermatitis (poison ivy)
Scabies
Nummular eczema
Dry skin
Hyperkeratosis pilaris
Psoriasis
“Do’s” in AD
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Use soaps that are not drying .
Use only warm water for the hydrating baths.
Long baths are better than showers.
Wash new clothes before wearing.
Use air conditioners in hot humid times.
Reduce exposure to allergens by removal of offending allergens or
avoidance (egg avoidance, mite control).
Wear sunscreens before exposure.
Keep fingernails short.
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If needed, sleep with cotton socks on feet, cotton gloves on hands.
Sun exposure can be helpful but sweating may cause intense itching.
Chlorinated pools are helpful in reducing staph bacteria on skin.
Be generous with skin moisturizers.
Regular check up with MD is important.
Don’ts in AD
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Don’t use drying soaps.
Don’t wear wool clothing.
Don’t get sunburned.
Don’t take hot baths or showers.
Don’t use topical steroids on face for more than a few days.
Don’t use potent topical steroids on face or eyelids at all.
Don’t wait to long to see your physician if rash is not going away with usual
treatment.
Don’t treat painful lesions with topical immunomodulators.
For more information, contact the National Eczema Association for Science and
Education. Phone: 1-800-818-7546
Fax: 503-224-3363. Web Site: www.eczema-assn.org
JPR/dmc Atopicdermatitis 08/07