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Atopic Dermatitis/Eczema

DEFINITION:

Atopic dermatitis is a chronic and relapsing skin disorder characterized by itching, rash, scaling, thickening, and inflammation of the skin.

INCIDENCE:

Atopic dermatitis is the most common skin disorder in children. It affects 10%-15% of all children and adolescents. Over 60% of children will have their first symptom by 1 year of age and over 90% of children will show symptoms by 7 years of age. Asthma, allergies, and atopic dermatitis frequently occur together and 75% of children with this skin condition have family members with the same disorder. The yearly cost of treating this skin condition is said to be in excess of 400 million dollars per year.

SYMPTOMS:

CAUSES:

The exact cause of this disorder is not known. It does tend to run in families and it is associated with allergies or asthma in many cases. Triggers can include irritants and pollutants, dietary changes, allergic reactions, stress, and frequent bathing.

DIAGNOSIS:

Atopic dermatitis/eczema can mimic many other disorders making the diagnosis difficult in many cases. Other common disorders that mimic eczema include scabies, fungal rashes, poison ivy, and seborrhea. The diagnosis is made by excluding other causes, taking a family history, taking a history of the appearance of the rash, and by looking at the appearance of the rash. If this is a chronic, recurrent rash involving the face in newborns or the face, elbows, and knees in older children, then eczema is more likely. If there is a family history of allergies, asthma, or eczema and the rash follows the symptoms described above, then eczema is more likely. Sometimes the diagnosis can only be confirmed by looking at the response to treatment. If the rash responds to typical eczema treatment then eczema is the more likely diagnosis. There is no lab test or skin test that can confirm the diagnosis.

CONTAGION:

This is not a contagious illness.

TREATMENT:

There is an old expression in dermatology that applies here; if it is wet, dry it and if it is dry, wet it. Eczema is a dry rash so the mainstay of treatment is to keep the area moist. The simplest measures are to avoid baths in hot water, which can remove the natural oils from the skin, avoid things that are known to irritate a particular person's skin, to use mild soaps, and to apply gentle moisturizing agents. Ointments, creams, and lotions can be used frequently to keep the skin moist. These moisturizers are absorbed quickly and will probably need to be applied at least 2-3 times per day. Ointments and creams are the thickest and last the longest but they tend to be greasy when applied. Typical ointments and creams include petrolatum, Cetaphil, Moisturel, Aquaphor, and Eucerin. Lotions are the easiest to wipe on but tend to dissipate more quickly. The mainstay of treatment for atopic dermatitis/eczema is topical corticosteroids. These are not the same thing as the anabolic steroids that are sometimes abused by athletes. There are 7 levels of potency of topical steroid cream. Below is a table of the different potency creams. Group 1 is the most potent, and Group 7 is the least potent.

 

The goal of treatment with steroids is to use the lowest potency steroid that will give relief. If a lower potency does not work, then a higher potency can be used. For bad flare-ups, a high potency can be used for a short period of time followed by daily application of a lower potency steroid. The location of the eczema also needs to be taken into consideration. High potency steroids are rarely needed on the face but may be needed frequently on the hand or foot where there is thicker skin.

Also, higher potency halogenated steroids should never be used in occluded areas such as the diaper since these can cause skin atrophy and striae (lines on the skin). When the appropriate steroid is used, it should be applied generously once or twice a day. For severe cases, oral steroids in short-term dosages can be very beneficial. Side effects are uncommon but when they do occur, it is usually due to the higher potency steroids used for long periods of time. The side effects can include striae, skin atrophy, acne, loss of pigmentation of the skin, wrinkling, and absorption of the steroid in to the blood stream, which can lead to growth suppression.

Bathing can cause problems in some children with eczema because the water can be very drying to the skin. To combat this, treatment should be applied to the skin within minutes after leaving the water. Bathing every other day may be beneficial as well. Oral antihistamines can be very useful for eczema. These can prevent some of the itching and relieve the itch-scratch cycle that leads to the rash. Diphenhydramine (Benadryl), hydroxyzine (Atarax), and cetirizine (Zyrtec) have been very helpful for this.

Because of the itching associated with this skin condition, many children may scratch and cause a bacterial infection of the skin such as impetigo. In these instances it is very important to receive treatment with oral or topical antibiotics prescribed by the physician. Triggers should be prevented. Infections, stress, allergens, pollutants, and irritants should be removed or avoided as much as possible. If there are allergies that cannot be avoided, skin testing and allergy shots may be helpful.

Newer therapy for atopic dermatitis can be helpful in some of the more severe cases. There have been treatment plans including steroid wet-wrap therapy, and ultraviolet light therapy. Tacrolimus (Protopic) is an immunosuppressive drug that has been shown to be beneficial in the topical treatment of the more poorly controlled eczema.

OUTCOMES:

Atopic dermatitis/eczema is a chronic condition. All of the treatments are suppressive and not curative. This condition seems to happen in a chronic relapsing mode. Although some children will improve as time goes on, there will always be some manifestations of having "sensitive" skin. Proper therapy can provide a lot of relief but cannot cure this skin condition.

DISCUSSION:

Atopic dermatitis/eczema can be a mild or severe condition. In some cases it is easily controlled and treated and in other cases it can be a very frustrating condition. The first thing to be sure of is to get the proper diagnosis. Very frequently, fungal rashes or scabies are present but look like eczema. Sometimes you have to try a steroid cream and if it isn't working, treat for scabies or fungus.

Most physicians won't do a skin scraping of the rash to look for the scabies or fungus, although most textbooks will suggest this for proper treatment. Sometimes the scraping won't show the fungus or the scabies mite and the lab result will give us a false sense of security that we are treating the right thing. It seems to be much easier to try treatment and then choose the next step by looking at the response to that treatment. That is why good follow up is important for this condition.

The initial treatment will depend on the severity of the initial presentation. For mild cases an over the counter lotion or cortisone cream can be used. For the more severe presentations, a higher potency topical prescribed steroid and even an oral steroid may be necessary. Once the flare-up is under control, a lower potency steroid can then be used for longer-term suppression. If the eczema seems to appear after certain foods are ingested or it seems to be seasonal, then a visit to the allergist for allergy testing may be indicated. There are times when allergy shots can be useful.

If none of the topical steroids are working then my next step is usually to use a medicine such as Protopic for prevention. Also, I use oral antihistamines for the more chronic cases. Education about this illness is very important. Treatment should be started at the beginning of a flare-up to prevent it from getting to a point where stronger treatment is needed.

Fear of the word 'steroid' should be addressed since the steroids used for this have nothing to do with the anabolic steroids that are sometimes abused. You wouldn't want a parent to avoid treatment because they don't like the word 'steroid'. I wish these could be called anti-inflammatories instead to avoid this confusion but that just isn't the case. Any bacterial infection should be aggressively treated since this will not improve until that is taken care of. Once this condition is understood, avoidance of any triggers are in place, proper treatment is provided, and secondary infections are quickly treated, then hopefully this condition will not cause too much distress or harm.