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