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Atopic Dermatitis and Seborrheic Dermatitis Atopic dermatitis and seborrheic dermatitis T. Pozo Román*, B. Mínguez Rodríguez** *Lead of the Dermatology Unit at Río Hortega University Hospital. Valladolid. **Consultant in Pediatrics at San Joan de Deu Hospital. Barcelona Abstract Resumen Atopic dermatitis is a common and frequently La dermatitis atópica es una dermatosis familial inflammatory dermatosis, which inflamatoria común y frecuentemente familiar que, usually appears during infancy or early habitualmente, aparece durante la lactancia o la childhood and is often associated with primera infancia, y se asocia con frecuencia a otras other atopic diseases such as asthma, enfermedades atópicas, como: asma, rinoconjuntivitis allergic rhinoconjunctivitis, food allergies alérgica, alergias alimentarias o esofagitis or eosinophilic esophagitis. It is a complex eosinófilica. Es una enfermedad genética compleja genetic disease with environmental con influencias medioambientales, caracterizada por influences, characterized by intense pruritus un prurito intenso y una evolución crónica en brotes. and a chronic course in flares. En lactantes y niños pequeños, se afectan: In infants and young children, cheeks, scalp mejillas, cuero cabelludo y superficies de extensión and extensor surfaces of the extremities are de las extremidades; y en niños mayores y adultos, affected and in older children and adults the las lesiones suelen localizarse en los pliegues lesions are usually located in the flexion folds, de flexión o en localizaciones específicas, como: or in specific locations such as the perioral zona perioral, párpados, manos o pies. En la mayoría area, eyelids, hands or feet. In most patients de los pacientes, la enfermedad desaparece the disease disappears when puberty arrives, cuando llega la pubertad, pero también puede but it can also appear in adulthood. aparecer en la edad adulta. Seborrheic dermatitis is a common La dermatitis seborreica es una dermatosis inflammatory dermatosis, with an infantile inflamatoria común, con una forma clínica del and an adult clinical form. Lesions are located lactante y otra del adulto. Las lesiones se localizan on the scalp, ears, face, central part of the en: cuero cabelludo, orejas, cara, parte central chest and intertriginous areas. There is an del tórax y áreas intertriginosas. Hay una relación etiological relationship with active sebaceous etiológica con las glándulas sebáceas activas, las glands, alterations in sebum composition and alteraciones en la composición del sebo y el género the genus Malassezia (Pityrosporum). Malassezia (Pityrosporum). Key words: Atopic dermatitis; Eczema; Atopy; Seborrheic dermatitis; Malassezia (Pityrosporum). Palabras clave: Dermatitis atópica; Eczema; Atopia; Dermatitis seborreica; Malassezia (Pityrosporum). Atopic dermatitis Atopic dermatitis (AD) and It is more prevalent in children (10- food allergy have a predilection 20%) than in adults (1-3%) and, in Introduction / definition L for infants and young children; 90% of cases, it appears in childhood whereas, asthma prevails in older chil- (45% during the first 6 months of life Atopic dermatitis is characterized by fla- dren and rhinoconjunctivitis predomi- and 60% before the first year of life). res of inflammatory, itchy lesions, with a nates in adolescents. This characteris- At least 50% of atopic children will characteristic distribution and personal tic age-dependent sequence is called continue to express certain manifesta- and / or family history of atopy (allergic “atopic march”, however, it does not tion of the disease during adolescence rhinoconjunctivitis, asthma, food allergies, always manifest, as these diseases may and 20% also in adult life(1,2). etc.). or may not appear, and do so simulta- Most of the cases can be considered neously or at different ages. mild, but 10% of the patients suffer a Pediatr Integral 2021; XXV (3): 119 – 127 PEDIATRÍA INTEGRAL - EN 119 ATOPIC DERMATITIS AND SEBORRHEIC DERMATITIS Table I. Diagnostic criteria for On the other hand, AD, and espe- of Th1, Th2 and Th22 lymphocytes). atopic dermatitis (Hanifin and cially severe AD, implies a significant Antigens that cross the skin reach Rajka, 1980) economic expense, both direct (medi- the ganglia (via dendritic cells) and Major criteria cal visits, pharmacological cost) and stimulate Th2 response with the con- - Pruritus indirect costs (loss of school hours sequent increase in the production of - Typical morphology and and productivity), and both at a perso- IgE and several other mediators from distribution of lesions nal level as well as for health systems. various inflammatory and epidermal This emphasizes the need to evaluate cells. Immunity mediated by the Th1 • Facial and extensor involvement in children its impact on the family environment pathway (which is attenuated) and the • Flexural lichenification in adults and on the patients’ caregivers. Hence, innate immune system contribute to - Chronic and relapsing course it should be recognized as a “family” skin inflammation with the release of - Family history of atopy (asthma, disease, rather than as an individual cytokines and a deficiency of antimi- allergy, rhinitis and atopic one and, as such, it must be evalua- crobial peptides. dermatitis) ted(4). Patients with AD show important Minor criteria changes in skin microbiome, mainly - Dry skin (xerosis) Etiopathogenesis involving a decrease in Staphylococcus - Ichthyosis / palmar fold Epidermidis and a dominant coloniza- A deficient skin barrier action, an abnor- exaggeration / keratosis pilaris tion of Staphylococcus Aureus (in up to mal immune response, alteration of the - Immediate positive skin test 90% of the lesions), which correlates cutaneous microbiome and an important reactivity (type I) with the severity of the disease. Con- psychosomatic influence are the main etio- - Elevated serum IgE values versely, recovery of microbiome diver- pathogenic factors. - Early age of onset sity precedes resolution of flare-ups. - Tendency toward non-specific All these abnormalities interact hands and feet dermatitis It is a complex genetic disease, with with each other; so that: barrier dys- - Susceptibility to cutaneous interactions between different genes function alters the skin’s microbiome infections (S. aureus and herpes and of these with the environment. and immune response; the skin micro- simplex) and deficit of cell- In patients with AD, the lesional biome alters the immune response and mediated immunity skin and, to a lesser extent, the non- the skin barrier; and, lastly, immune - Nipple eczema lesional skin, present a defective cuta- dysregulation also alters the cutaneous - Recurrent conjunctivitis neous barrier, with: increased transe- microbiome and the skin’s barrier - Cheilitis pidermal water loss, alteration of skin function(5). - DennieMorgan infraorbital fold lipids, increased epidermal prolifera- - Keratoconus tion, reduction of Filaggrin expression, Manifestations and diagnosis - Anterior subcapsular cataracts inflammation, and increased number The diagnosis of AD is mainly clinical and - Orbital or facial darkening of IgE receptors on Langerhans cells. - Facial pallor or facial erythema remains based on the classical criteria des- The uninjured skin also shows cribed by Hanifin and Rajka(6): 3 or more - Pityriasis alba different immunological profiles to major criteria, and 3 or more minor criteria - Anterior neck folds normal skin (17% more T cells than (Table I). - Itch caused by sweating normal skin and increased expression - Intolerance to wool and lipid solvents - Perifollicular accentuation - Intolerance to certain foods - White dermographism - Course influenced by environmental and emotional factors severe form which is more prevalent in the adult population. The prevalence of severe atopic dermatitis in adults in Spain is estimated to be 0.08%(3). In the most severe forms, the sleep cycle is disturbed leading to irritabi- lity, which affects school and sport performance, self-esteem, social rela- tionships, as well as routine and leisure activities. Figure 1. Atopic dermatitis in the acute phase. Figure 2. Impetiginized eczema. 120 EN - PEDIATRÍA INTEGRAL ATOPIC DERMATITIS AND SEBORRHEIC DERMATITIS Figure 4. Labial and perioral eczema. Figure 3. Retroauricular eczema with fissuring. Differential diagnosis In some cases, it may be necessary The symptoms of AD are highly characte- to perform biopsies (cutaneous T-cell lymphomas and psoriasis) or to per- The diagnosis of AD is primarily ristic, thus most of the possible differential diagnoses can be excluded by the medical form contact tests (allergic contact or clinical (Figs. 1-5). Characteristically, airborne dermatitis), or special studies the typical lesions of atopic eczema history (scabies, seborrheic dermatitis, irritant contact dermatitis and ichthyosis). (photosensitive diseases, diseases due are erythematous areas of skin, often to deficiencies of the immune system, poorly defined, with intense itching, although their distribution and charac- teristics vary with age. There are also Table II. Clinical forms of atopic dermatitis some characteristic clinical manifesta- tions that must be known (Table II). According to age It is also important to distinguish From 3 - 6 months Lesions are located on: cheeks, trunk, and extensor between acute, subacute and chronic to 2 years old surfaces of extremities forms, as the topical treatment differs From 2 to Lesions are typically located in: popliteal fossa and (Table II) and to identify other clinical 12 years old anterior surface
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