Atopic dermatitis

Alternative Names

Infantile eczema; Dermatitis - atopic; Eczema

Definition

Atopic dermatitis is a long-term (chronic) skin disorder that involves scaly and itchy rashes.

Other forms of eczema include:

Causes

Atopic dermatitis is due to a skin reaction (similar to an allergy) in the skin. The reaction leads to ongoing swelling and redness. People with atopic dermititis may be more sensitive because their skin lacks certain proteins.

Atopic dermatitis is most common in infants. It may start as early as age 2 to 6 months. Many people outgrow it by early adulthood.

People with atopic dermatitis often have asthma or seasonal allergies. There is often a family history of allergies such as asthma, hay fever, or eczema. People with atopic dermatitis often test positive to allergy skin tests.However, atopic dermatitis is not caused by allergies.

The following can make atopic dermatitis symptoms worse:

Allergies to pollen, mold, dust mites, or animals
Cold and dry air in the winter
Colds or the flu
Contact with irritants and chemicals
Contact with rough materials, such as wool
Dry skin
Emotional stress
Drying out of the skin from taking too many baths or showers and swimming too often
Getting too hot or too cold, as well as sudden changes of temperature
Perfumes or dyes added to skin lotions or soaps

Symptoms

Skin changes may include:

Blisters with oozing and crusting
Dry skin all over the body or areas of bumpy skin on the back of the arms and front of the thighs
Ear discharge or bleeding
Raw areas of the skin from scratching
Skin coloring changes, such as more or less color than the normal skin tone
Skin redness or inflammation around the blisters
Thickened or leather-like areas (called lichenification), which can occur after long-term irritation and scratching

The type and location of the rash can depend on the age of the patient:

In children younger than age 2, skin lesions begin on the face, scalp, hands, and feet. The rash is often itchy and bubble, ooze, or form crusts.
In older children and adults, the rash is more often seen on the inside of the knees and elbow. It can also appear on the neck, hands, and feet.
Rashes may occur anywhere on the body during a bad outbreak.

Intense itching is common. Itching may start even before the rash appears. Atopic dermatitis is often called the "itch that rashes" because the itching starts, and then the skin rash follows as a result of scratching.

Exams and Tests

The health care provider will give you an exam and look at your skin. A physical exam will be done. You may need a skin biopsy to confirm the diagnosis or rule out other causes of dry, itchy skin.

Diagnosis is based on the:

How the skin looks
Personal and family history

Allergy skin testing may be helpful for people with:

Hard-to-treat atopic dermatitis
Other allergy symptoms
Skin rashes that form only on certain areas of the body after exposure to a specific chemical

Treatment

SKIN CARE AT HOME

Daily skin care make cut down on the need for medicines.

Avoid scratching the rash or skin:

Use a moisturizer, topical steroid cream, or other medicine your doctor prescribes.
Take antihistamine medicines by mouth to reduce severe itching.
Keep fingernails cut short. Wear light gloves during sleep if nighttime scratching is a problem.

Keep the skin moist (called lubricating or moisturizing the skin). Use ointments (such as petroleum jelly), creams, or lotions 2 - 3 times a day. Choose skin products that are free of alcohol, scents, dyes, and other chemicals. A humidifier to keep home air moist will also help.

Avoid things that make your symptoms worse, such as:

Foods that may cause an allergic reaction such as eggs in a very young child (always talk to your doctor first)
Irritants such as wool and lanolin
Strong soaps or detergents, as well as chemicals and solvents
Sudden changes in body temperature and stress, which may cause sweating
Triggers that cause allergy symptoms

When washing or bathing:

Expose your skin to water for as short a time as possible. Short, cooler baths are better then long, hot baths.
Use gentle body washes and cleansers instead of regular soaps.
Do not scrub or dry the skin too hard or for too long.
Apply lubricating creams, lotions, or ointment to the skin after bathing while it is damp. This will help trap moisture in the skin.

MEDICATIONS

At this time, allergy shots are not used to treat atopic dermatitis.

Antihistamines taken by mouth may help with itching or allergies. You can often buy these medicines without a prescription.

Most causes of atopic dermatitis are treated with medicines placed directly on the skin or scalp (called topical medicines):

You will probably be prescribed a mild cortisone (or steroid) cream or ointment at first. You may need a stronger medicine if this doesn't work.
Medicines called topical immunomodulators (TIMs) may be prescribed for anyone over 2 years old. TIMs include tacrolimus (protopic) and pimecrolimus (Elidel). Ask your doctor about concerns over a possible cancer risk with the use of these medicines.
Creams or ointments that contain coal tar or anthralin may be used for thickened areas.
Barrier repair creams containing ceramides may be used.

Wet-wrap treatment with topical corticosteroids may help control the condition but may lead to an infection.

Other treatments that may be used include:

Antibiotic creams or pills if the skin is infected
Drugs that suppress the immune system, such as cyclosporine, methotrexate, or mycophenolate mofetil
Phototherapy, a medical treatment in which your skin is carefully exposed to ultraviolet (UV) light
Short-term use of systemic steroids

Outlook (Prognosis)

Atopic dermatitis is a long-term condition. You can control it with treatment, by avoiding irritants, and by keeping the skin well-moisturized.

In children, the condition often starts to go away around age 5 - 6, but flare-ups will often occur. In adults, the problem is generally a long-term or returning condition.

Atopic dermatitis may be harder to control if it:

Begins at an early age
Involves a large amount of the body
Occurs along with allergic rhinitis and asthma
Occurs in someone with a family history of eczema

Possible Complications

Infections of the skin caused by bacteria, fungi, or viruses
Permanent scars
Side effects from long-term use of medicines to control eczema

When to Contact a Medical Professional

Call your health care provider if:

Atopic dermatitis does not get better with home care
Symptoms get worse or treatment does not work
You have signs of infection (such as fever, redness, or pain)

Prevention

Children who are breast-fed until age 4 months are less likely to get atopic dermatitis.

If a child is not breast-fed, using a formula that contains processed cow milk protein (called partially hydrolyzed formula) may cut down on the chances of developing atopic dermatitis.

References

Atopic Dearmatitis, Eczema, and Noninfectious Immunodeficiency Disorders. In: James WD, Berger TG, Elston DM, eds. Andrews' Diseases of the Skin: Clinical Dermatology. 11th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 5.

Greer FR, Sicherer SH, Burks, W and the Committee on Nutrition and Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121:183-191.

Lewis-Jones S, Mugglestone MA; Guideline Development Group. Management of atopic eczema in children aged up to 12 years: summary of NICE guidance. BMJ. 2007;335:1263-1264.

Ascroft DM, Chen LC, Garside R, Stein K, Williams HC. Topical pimecrolimus for eczema. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005500.

Bath-Hextall FJ, Delamere FM, Williams HC. Dietary exclusions for established atopic eczema. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD005203.