Atopic Dermatitis

Atopic dermatitis is a chronic eczematous skin disease that usually begins in childhood.

Atopic dermatitis is a common, often persistent skin disease that affects a large percentage of the world's population. Atopy is a special type of allergic hypersensitivity that is associated with asthma, inhalant allergies (hay fever), and chronic dermatitis. There is a known hereditary component of the disease, and it is more common in affected families.

Criteria that enable a doctor to diagnose it include the typical appearance and distribution of the rash in a patient with a personal or family history of asthma and/or hay fever. The term atopic is from the Greek meaning "strange." The term dermatitis means inflammation of the skin. Many physicians and patients use the term eczema when they are referring to this condition. Sometimes it is called neurodermatitis.

In atopic dermatitis, the skin becomes extremely itchy and inflamed, causing redness, swelling, vesicle formation (minute blisters), cracking, weeping, crusting, and scaling. This type of eruption is termed eczematous. In addition, dry skin is a very common complaint in almost all those afflicted with atopic dermatitis.

Although atopic dermatitis can occur at any age, most often it affects infants and young children. Occasionally, it may persist into adulthood or may rarely appear at that time. Some patients tend to have a protracted course with ups and downs. In most cases, there are periods when the disease is worse, called exacerbations or flares, which are followed by periods when the skin improves or clears up entirely, called remissions. Many children with atopic dermatitis enter into a permanent remission of the disease when they get older, although their skin may remain somewhat dry and easily irritated.

Multiple factors can trigger or worsen atopic dermatitis, including low humidity, seasonal allergies, exposure to harsh soaps and detergents, and cold weather. Environmental factors can activate symptoms of atopic dermatitis at any time in the lives of individuals who have inherited the atopic disease trait.

Atopic dermatitis is very common worldwide and increasing in prevalence. It affects males and females equally and accounts for 10%-20% of all referrals to dermatologists (doctors who specialize in the care and treatment of skin diseases).

Atopic dermatitis occurs most often in infants and children, and its onset decreases substantially with age.

• Of those affected, 65% of patients develop symptoms in the first year of life, and 90% develop symptoms before the age of 5.
• Onset after age 30 is uncommon and often occurs after exposure of the skin to harsh conditions.
• About 10% of all infants and young children experience symptoms of the disease.
• Roughly 60% of these infants continue to have one or more symptoms of atopic dermatitis even after they reach adulthood.
• This means that more than 15 million people in the United States have symptoms of the disease.

People who live in urban areas and climates with low humidity seem to be at an increased risk of developing atopic dermatitis.

Some allergens are called aeroallergens because they are present in the air. They may also play a role in atopic dermatitis.

• Common aeroallergens are dust mites, pollens, molds, and dander from animal hair or skin.
• These aeroallergens, particularly the house dust mite, may worsen the symptoms of atopic dermatitis in some people.
• Although some researchers think that aeroallergens are an important contributing factor to atopic dermatitis, others believe that they are insignificant.

No reliable test is available that determines whether a specific aeroallergen is an exacerbating factor in any given individual. If the doctor suspects that an aeroallergen is contributing to a patient's symptoms, the doctor may recommend ways to reduce exposure to the offending agents. For example, the presence of the house dust mite can be limited by encasing mattresses and pillows in special dust-proof covers, frequently washing bedding in hot water, and removing carpeting. However, there is no way to completely rid the environment of aeroallergens.

The cause of atopic dermatitis is not known, but the disease seems to result from a combination of genetic (hereditary) and environmental factors. There seems to be a basic cutaneous hypersensitivity and an increased tendency toward itching. Evidence suggests that the disease is associated with other so-called atopic disorders such as hay fever (seasonal allergies) and asthma, which many people with atopic dermatitis also have.

Some of the risk factors of atopic dermatitis include:

• In addition, many children who outgrow the symptoms of atopic dermatitis go on to develop hay fever or asthma.
• Although one disorder does not necessarily cause another, they may be related, thereby giving researchers clues to understanding atopic dermatitis.
• Many of those affected seem to have either a decreased quantity of or a defective form of a protein called filaggrin in their skin. This protein seems to be important in maintaining normal cutaneous hydration.
• It is important to understand that food sensitivities do not seem to be a major inciting factor for most cases of atopic dermatitis.
• This is an area of active research. Patients with atopic dermatitis seem to have mild immune system weakness.
• They are predisposed to developing fungal foot disease and cutaneous staphylococcal infections, and they can disseminate herpes simplex lip infections (eczema herpeticum) and smallpox vaccination (eczema vaccinatum) to large areas of skin.
• While emotional factors and stress may sometimes exacerbate the condition, they do not seem to be a primary or underlying cause of the disorder.

Irritants are substances that directly damage the skin, and when used in high enough concentrations for long enough, cause the skin to become inflamed. Soaps, detergents, and even water may produce inflammation. Some perfumes and cosmetics may irritate the skin. Chlorine and alcoholic solvents, dust, or sand may also aggravate the condition. Cigarette smoke may irritate the eyelids.

Common irritants for atopic dermatitis include:

• Wool or synthetic fibers
• Soaps and detergents
• Some perfumes and cosmetics
• Substances such as chlorine, mineral oil, or solvents
• Dust or sand
• Dust mites
• Cigarette smoke
• Animal fur or dander
• Flowers and pollen

Allergens are substances from foods, plants, or animals that provoke an overreaction of the immune system and cause inflammation (in this case, the skin). The importance of food allergy in atopic dermatitis is controversial. Although not all researchers agree, most experts think that breastfeeding the infant for at least four months may have a protective effect on the child. New lines of evidence even support exposing young children to normal environmental contaminants such as peanuts. Although such exposures may prevent the development of atopic dermatitis, there is no consensus on how to prevent the development of atopic diseases.

If a food allergy is suspected, it may be helpful to keep a careful diary of everything the patient eats, noting any reactions. Identifying the food allergen may be difficult and require supervision by an allergist if the patient is also being exposed to other allergens. One helpful way to explore the possibility of a food allergy is to eliminate the suspected food and then, if the improvement is noticed, reintroduce it into the diet under carefully controlled conditions. A two-week trial is usually sufficient for each food. If the food being tested causes no symptoms after two weeks, a different food can be tested in like manner afterward. Likewise, if the elimination of a food does not result in improvement after two weeks, other foods may be eliminated in turn.

Changing the diet of a person who has atopic dermatitis may not always relieve symptoms. A change may be helpful, however, when a patient's medical history and specific symptoms strongly suggest a food allergy. It is up to the patient and his or her family and physician to judge whether the dietary restrictions outweigh the impact of the disease itself. Restricted diets often are emotionally and financially difficult for patients and their families to follow. Unless properly monitored, diets with many restrictions can also contribute to nutritional problems in children.

Photo of irritant contact eczema on the hands

Although symptoms and signs may vary from person to person, the most common symptoms are dry, itchy, red skin.

• Itch is the hallmark of the disease.
• Typically, affected skin areas include the folds of the arms, the back of the knees, wrists, the face, and the neck.
• Itchiness is an important factor in atopic dermatitis because scratching and rubbing can worsen the skin inflammation that is characteristic of this disease.
• People with atopic dermatitis seem to be more sensitive to itching and feel the need to scratch longer in response.
• They develop what is referred to as the "itch-scratch" cycle.
• The extreme itchiness of the skin causes the person to scratch, which in turn worsens the itch, and so on. Itching is particularly a problem during sleep when conscious control of scratching decreases and the absence of other outside stimuli makes the itchiness more noticeable.

No. Atopic dermatitis itself is not contagious, and it cannot be passed from one person to another through skin contact. There is generally no cause for concern in being around someone with even an active case of atopic dermatitis unless they have active skin infections.

Some patients with atopic dermatitis get secondary infections of their skin with Staphylococcus ("staph"), other bacteria, herpes virus (cold sores), and less commonly yeasts and other fungal infections. These infections may be contagious through skin contact.

Picture of nummular eczema on the leg

Yes. Atopic dermatitis may affect the skin around the eyes, the eyelids, the eyebrows, and the lashes. Scratching and rubbing the eye area can cause the skin to change in appearance. Some people with atopic dermatitis develop an extra fold of skin under their eyes, called an atopic pleat or Dennie-Morgan fold. Other people may have hyperpigmented eyelids, meaning that the skin on their eyelids darkens from the inflammation or hay fever (allergic shiners). Patchy eyebrows and eyelashes may also result from scratching or rubbing.

The face is very commonly affected in babies, who may drool excessively, and become irritated from skin contact with their abundant saliva.

The skin of a person with atopic dermatitis loses excessive moisture from the epidermal layer. Some patients with atopic dermatitis lack a protein called filaggrin which is important in retaining moisture. This defective genetic trait allows the skin to become very dry, which reduces its protective abilities. In addition, the skin is very susceptible to infectious disorders, such as staphylococcal and streptococcal bacterial skin infections, warts, herpes simplex, and molluscum contagiosum (which is caused by a virus).

Skin features of atopic dermatitis

• Lichenification: thick, leathery skin resulting from constant scratching and rubbing
• Lichen simplex: refers to a thickened patch of raised skin that results from repeated rubbing and scratching of the same skin area
• Papules: small, raised bumps that may open when scratched, becoming crusty and infected
• Ichthyosis: dry, rectangular scales on the skin, commonly on the lower legs and shins
• Keratosis pilaris: small, rough bumps, generally on the face, upper arms, and thighs. These are also described as gooseflesh or chicken skin and may have small coiled hair under each bump.
• Hyper-linear palms: increased number of skin creases on the palms
• Urticaria: hives (red, raised bumps), often after exposure to an allergen, at the beginning of flare-ups, or after exercise or a hot bath
• Cheilitis: inflammation of the skin on and around the lips
• Atopic pleat (Dennie-Morgan fold): an extra fold of skin that develops under the eye
• Dark circles under the eyes: may result from allergies and atopy
• Hyperpigmented eyelids: scaling eyelids that have become darker in color from inflammation or hay fever
• Prurigo nodules: also called "picker's warts" are not warts at all. These are small thickened bumps of the skin caused by repeated picking of the same skin site.

Picture of xerotic eczema on the leg

Eczema is a nonspecific term for many types of skin inflammation (dermatitis). There are different categories of eczema, which include allergic, contact, irritant, and nummular eczema, which can be difficult to distinguish from atopic dermatitis. These types of eczema are listed and briefly described below.

Atopy is a medical syndrome that includes three associated conditions that tend to occur in the same individual: atopic dermatitis, inhalant allergies, and asthma. All three components need not be present in the same individual simultaneously.

8 Types of eczema

1. Contact eczema: a localized reaction that includes redness, itching, and burning where the skin has come into direct contact with an irritant such as an acid, a cleaning agent, or other chemicals
2. Allergic contact eczema: a red, itchy, weepy reaction where the skin has come into contact with a substance that the immune system recognizes as foreign, such as poison ivy or certain chemicals or antibiotics in creams and lotions like neomycin (Neosporin) or bacitracin (Baciguent)
3. Seborrheic eczema (also called seborrheic dermatitis or seborrhea) is a very common form of mild skin inflammation of unknown cause that presents as yellowish, oily, scaly patches of skin on the scalp, face, ears, and occasionally other parts of the body. Often this is also called dandruff in adults or "cradle cap" in infants.
4. Nummular eczema: coin-shaped (round), isolated patches of irritated skin -- most commonly on the arms and lower legs -- that may be crusted, scaling, and extremely itchy
5. Lichen simplex chronicus (localized neurodermatitis): dermatitis localized to a particular anatomical area induced by long-term rubbing, scratching, or picking the skin. The underlying cause may be a sensitivity or irritation that sets off a cascade of repeated itching and scratching cycles. It may be seen as scratch marks and pick marks. Areas of thickened plaques form on the skin of the neck, shins, wrists, or forearms. This condition has certain similarities to calluses, and it will resolve if the patient stops irritating the area.
6. Stasis dermatitis: a skin irritation on the lower legs, generally related to circulatory problems and congestion of the leg veins. It may have a darker pigmentation, light-brown, or purplish-red discoloration from the congestion and backup of the blood in the leg veins. It's sometimes seen more in legs with varicose veins.
7. Dyshidrotic eczema or pompholyx: irritation of the skin on the palms of hands (mostly) and less commonly soles of the feet characterized by clear, very deep-seated blisters that itch and burn. It's sometimes described as a "tapioca pudding"-like rash on the palms.
8. Xerotic eczema: areas of very dry skin most often seen on the lower legs of the elderly

The diagnosis is made on the physical examination and visual inspection of the skin. A personal history of inhalant allergies and family history will often support the diagnosis. Although itching is necessary but not sufficient to diagnose atopic dermatitis, consideration of other itchy eruptions is often necessary.

• A skin biopsy (a sample of a small piece of skin that is sent to the lab for examination under the microscope) is rarely helpful to establish the diagnosis. Many patients with the severe atopic disease may have elevated numbers of a certain type of white blood cells (eosinophils) and/or elevated serum IgE levels. These tests can support the diagnosis of atopic dermatitis. Additionally, skin swab (long cotton tip applicator or Q-tip) samples may be sent to the lab to exclude staphylococcal infections of the skin, which may complicate atopic dermatitis.
• Skin scratch/prick tests (which involve scratching or pricking the skin with a needle that contains a small amount of a suspected allergen) and blood tests for airborne allergens generally are not as useful in diagnosing atopic dermatitis. Positive skin scratch/prick test results are difficult to interpret in people with atopic dermatitis and are often inaccurate.

Major and minor features of atopic dermatitis

Major features

• Itching
• Characteristic rash in locations typical of the disease (arm folds and behind knees)
• Chronic or repeatedly occurring symptoms
• Personal or family history of atopic disorders (eczema, hay fever, asthma)

Some minor features

• Early age of onset
• Dry, rough skin
• High levels of immunoglobulin E (IgE), an antibody, in the blood
• Ichthyosis
• Hyper linear palms
• Keratosis pilaris
• Hand or foot dermatitis
• Cheilitis (dry or irritated lips)
• Nipple eczema
• Susceptibility to a skin infection
• Positive allergy skin tests

Atopic dermatitis seems to have a different pattern of involvement depending on the age of a patient.

In infants, atopic dermatitis typically begins around 6 to 12 weeks of age.

• It may first appear around the cheeks and chin as a patchy facial rash, which can progress to red, scaling, or oozing skin.
• The skin may become infected.
• Once the infant becomes more mobile and begins crawling, exposed areas such as the knees and elbows may also be affected.
• An infant with atopic dermatitis may be restless and irritable because of the itching and discomfort.
• Many infants improve by 18 months of age, although they remain at greater than normal risk for dry skin or hand eczema later in life.

In childhood, the rash tends to occur behind the knees and inside the elbows, on the sides of the neck, and the wrists, ankles, and hands.

• Often, the rash begins with papules that become hard and scaly when scratched.
• The skin around the lips may be inflamed, and constant licking of the area may lead to small, painful cracks.
• Severe eczema cases may affect growth, and the child may be shorter than average.

In those with more heavily pigmented skin, especially the face, areas of lighter skin color appear. This condition is called pityriasis alba. It is usually self-limited and the color will eventually normalize.

The disease may go into remission (disease-free period) for months or even years.

• In most children, the disease disappears after puberty.
• Although several people who developed atopic dermatitis as children also experience symptoms as adults, it is less common for the disease to show up first in adulthood. The pattern in adults is similar to that seen in children; that is, the disease may be widespread or limited.
• In some adults, only the hands or feet may be affected and become dry, itchy, red, and cracked. Sleep patterns and work performance may be affected, and long-term use of medications to treat the condition may cause complications.
• Adults with atopic dermatitis also have a predisposition toward irritant contact dermatitis, especially if they are in occupations involving frequent hand wetting, hand washing, or exposure to chemicals.
• Some people develop a rash around their nipples.
• These localized symptoms are difficult to treat, and people often do not tell their doctor because of modesty or embarrassment.
• Adults may also develop cataracts that are difficult to detect because they cause no symptoms. Therefore, the doctor may recommend regular eye exams.

Pediatricians, allergists, and dermatologists care for most patients with atopic dermatitis.

If the disease does not respond to mild local over-the-counter treatment then a physician is required. With proper treatment, most symptoms can be brought under control within three weeks.

• Topical corticosteroid creams and ointments are the most frequently used treatment. Since many of these are quite potent it will be necessary to have frequent physician visits to assure that the treatment is successful.
• Tacrolimus (Protopic) and pimecrolimus (Elidel) are non-steroid topical ointments that contain molecules that inhibit a substance called calcineurin which is important in inflammation. They are rather expensive topical medicated creams that are used for the treatment of atopic dermatitis. They are particularly effective when used on the faces of children since they seem less likely to produce atrophy. These new drugs are referred to as "immune modulators."
• Crisaborole (Eucrisa), a recently approved topical treatment for children and adults with mild to moderate atopic dermatitis (AD) seems to work by inhibiting a different portion of the inflammatory cascade in the skin.
• Dupilumab (Duxipent) was recently approved by the FDA for the treatment of moderate to severe atopic dermatitis in adults. It is an anti-IL-4 antibody that is given by injection twice a month and shows great promise in the control of severe atopic dermatitis.
• A newer class of OTC (over-the-counter) creams has been recently developed which claims to repair and improve the skin's barrier function in both children and adults. They include Atopiclair, MimyX, and CeraVe. These creams may be used in combination with topical steroids and other emollients to help repair the overall dryness and broken skin function.

Additional available treatments may help to reduce specific symptoms of the disease.

• Oral antibiotics to treat staphylococcal skin infections can be helpful in the face of pyoderma.
• Certain antihistamines that cause drowsiness can reduce nighttime scratching and allow more restful sleep when taken at bedtime. This effect can be particularly helpful for patients whose nighttime scratching aggravates the disease.
• If viral or fungal infections are present, the doctor may also prescribe medications to treat those infections.

Phototherapy is treatment with light that uses ultraviolet A or B light waves or a combination of both. This treatment can be an effective treatment for mild to moderate dermatitis in older children (over 12 years old) and adults. Photochemotherapy, a combination of ultraviolet light therapy and a drug called psoralen, can also be used in cases that are resistant to phototherapy alone. Possible long-term side effects of this treatment include premature skin aging and skin cancer. If the doctor thinks that phototherapy may be useful in treating the symptoms of atopic dermatitis, he or she will use the minimum exposure necessary and monitor the skin carefully.

When other treatments are not effective, the doctor may prescribe systemic corticosteroids, drugs that are taken by mouth or injected into a muscle instead of being applied directly to the skin. An example of a commonly prescribed corticosteroid is prednisone. Typically, these medications are used only in resistant cases and are only given for short periods of time. The side effects of systemic corticosteroids can include skin damage, thinned or weakened bones, high blood pressure, high blood sugar, infections, and cataracts. It can be dangerous to suddenly stop taking corticosteroids, so it is very important that the doctor and patient work together in changing the corticosteroid dose.

In adults, immunosuppressive drugs, such as cyclosporine, are also used to treat severe cases of atopic dermatitis that have failed to respond to any other forms of therapy. Immunosuppressive drugs restrain the overactive immune system by blocking the production of some immune cells and curbing the action of others.

• The side effects of cyclosporine can include high blood pressure, nausea, vomiting, kidney problems, headaches, tingling or numbness, and a possible increased risk of cancer and infections.
• There is also a risk of relapse after the drug is discontinued. Because of their toxic side effects, systemic corticosteroids and immunosuppressive drugs are used only in severe cases and then for as short a period of time as possible.
• Patients requiring systemic corticosteroids or immunosuppressive drugs should be referred to a dermatologist or an allergist specializing in the care of atopic dermatitis to help identify trigger factors and alternative therapies.

In extremely rare cases, when no other treatments have been successful, the patient may have to be hospitalized. A five- to seven-day hospital stay allows intensive skincare treatment and reduces the patient's exposure to irritants, allergens, and the stresses of day-to-day life. Under these conditions, the symptoms usually clear quickly if environmental factors play a role or if the patient is not able to carry out an adequate skin care program at home.

Atopic dermatitis and quality of life

Despite the symptoms caused by atopic dermatitis, it is possible for people with the disorder to maintain a high quality of life. The keys to an improved quality of life are education, awareness, and developing a partnership among the patient, family, and doctor. Good communication is essential for all involved. It is important that the doctor provides understandable information about the disease and its symptoms to the patient and family and demonstrate any treatment measures recommended to ensure that they will be properly carried out.

When a child has atopic dermatitis, the entire family situation may be affected. It is important that families have additional support to help them cope with the stress and frustration associated with the disease. The child may be fussy and difficult and often is unable to keep from scratching and rubbing the skin. Distracting the child and providing as many activities that keep the hands busy is key but require effort and work on the part of the parents or caregivers. Another issue a family may face is the social and emotional stress associated with disfigurement caused by atopic dermatitis. The child may face difficulty in school or other social relationships and may need additional support and encouragement from family members.

Treatment involves a partnership between the doctor and the patient and family members. The doctor will suggest a treatment plan based on the patient's age, symptoms, and general health. The patient and family members play a large role in the success of the treatment plan by carefully following the doctor's instructions. Some of the primary components of treatment programs are described below. Most patients can be successfully managed with proper skin care and lifestyle changes and do not require the more intensive treatments discussed.

Skincare

A simple and basic regimen is key. Staying with one recommended soap and one moisturizer is very important. Using multiple soaps, lotions, fragrances, and mixes of products may cause further issues and skin sensitivity.

Lifestyle changes

Healing the skin and keeping it healthy is of primary importance both in preventing further damage and enhancing the patient's quality of life. Developing and following a daily skincare routine is critical to preventing recurrent episodes of symptoms. The key factor is proper bathing and the application of an emollient to wet skin without towel drying. Generally, an effective emollient is a reasonably stiff ointment or cream (one that does not move out of an opened inverted jar). People with atopic dermatitis should avoid hot baths and showers. A lukewarm bleach bath with a capful of chlorine bleach (Clorox) helps to cleanse and disinfect the skin. The doctor may recommend limited use of a mild bar soap or non-soap cleanser because soaps can be drying to the skin. Oatmeal baths are often helpful. Red, irritated areas can be treated with 1% hydrocortisone cream (two to three times a day), which can be obtained at most pharmacies and does not require a physician's prescription.

Once the bathing is finished, apply an emollient immediately without towel drying. This restores the skin's moisture and inhibits the evaporation of water, increasing the rate of healing, and establishing a barrier against further drying and irritation. Lotions generally are discouraged because they have a high water or alcohol content and evaporate quickly. Creams and ointments work better at healing the skin. Tar preparations can be very helpful in healing very dry, lichenified areas. Whatever preparation is chosen, it should be as free of fragrances and chemicals as possible.

Another key to protecting and restoring the skin is taking steps to avoid repeated skin infections. Although it may not be possible to avoid infections altogether, the effects of infection may be minimized if they are identified and treated early. Patients and their families should learn to recognize the signs of skin infections, including tiny pustules (pus-filled bumps) on the arms and legs, the appearance of oozing areas, or crusty yellow blisters. If symptoms of a skin infection develop, the doctor should be consulted to begin treatment as soon as possible.

Treating atopic dermatitis in infants and children

• Give lukewarm baths.
• Apply an emollient immediately following the bath.
• Keep a child's fingernails filed short.
• Select soft cotton fabrics when choosing to clothe.
• Consider using antihistamines to reduce scratching at night.
• Keep the child cool; consider a humidifier.
• Learn to recognize skin infections and seek treatment promptly.
• Attempt to distract the child with activities to keep him or her from scratching.

• Although symptoms of atopic dermatitis can be very difficult and uncomfortable, the disease can be successfully managed.
• People with atopic dermatitis, as well as their families, can lead healthy, normal lives.
• Long-term management may include treatment with an allergist to control inhalant allergies and a dermatologist to monitor the skincare component.

Patients with atopic dermatitis should limit exposure to environmental and chemical factors known to cause exacerbations. These include dry skin, quick changes in temperature, the low humidity encountered during cold weather, and wool clothing.