ATOPIC DERMATITIS

What Is Atopic Dermatitis?

Atopic dermatitis is a long-term skin disease. "Atopic" refers to a tendency to develop allergy conditions. "Dermatitis" means swelling of the skin. Atopic eczema is sometimes called ‘infantile’ or ‘childhood’ eczema. You may also hear eczema called ‘dermatitis’ – they are both the same thing.

Atopy, or any atopic condition, is where the body’s immune system over-reacts to things that would not normally do any harm – often due to common environmental factors that are all around us.

Eczema improves for most children as they get older, but they may be left with dry and sensitive skin. Some children continue to have problematic eczema throughout life while others may find that their eczema goes away sometime during their childhood, only to come back in adulthood. There is no way we can predict the natural course of your child’s eczema – the important thing is to take and keep control of it.

The most common symptoms of atopic dermatitis are:

• Dry and itchy skin
• Rashes on the face, inside the elbows, behind the knees, and on the hands and feet.

Scratching the skin can cause:

• Redness
• Swelling
• Cracking
• "Weeping" clear fluid
• Crusting
• Thick skin
• Scaling.

Often, the skin gets worse (flares), then it improves or clears up (remissions).

Who Gets Atopic Dermatitis?

Other Types of Skin Problems

What Causes Atopic Dermatitis?

How Is Atopic Dermatitis Diagnosed?

Things That Make Atopic Dermatitis Worse

How Is Atopic Dermatitis Treated?

What Research Is Being Done on Atopic Dermatitis?

Who Gets Atopic Dermatitis?

Atopic dermatitis is most common in babies and children. But it can happen to anyone. People who live in cities and dry climates may be more likely to get this disease. When children with atopic dermatitis grow older, this problem can improve or go away. But the skin may stay dry and easy to irritate. At other times, atopic dermatitis is a problem in adulthood. You can't "catch" the disease or give it to other people.

Other Types of Skin Problems

Atopic dermatitis is often called eczema. "Eczema" is a term for many kinds of skin problems. Atopic dermatitis is the most common kind of eczema. Other types include:

• Allergic contact eczema. The skin gets red, itchy, and weepy because it touches something that the immune system knows is foreign, like poison ivy.
• Contact eczema. The skin has redness, itching, and burning in one spot because it has touched something allergy-causing, like an acid, cleaner, or other chemical.
• Dyshidrotic eczema. The skin on the palms of hands and soles of the feet is irritated and has clear, deep blisters that itch and burn.
• Neurodermatitis. Scaly patches on the head, lower legs, wrists, or forearms are caused by a localized itch (such as an insect bite).
• Nummular eczema. The skin has coin-shaped spots of irritation. The spots can be crusted, scaling, and very itchy.
• Seborrheic eczema. This skin has yellowish, oily, scaly patches on the scalp, face, and sometimes other parts of the body.
• Stasis dermatitis. The skin is irritated on the lower legs, most often from a blood flow problem.

What Causes Atopic Dermatitis?

The cause of atopic dermatitis is not known. It is likely caused by both genetic (runs in the family) and environmental factors. People with atopic dermatitis may go on to develop hay fever and asthma.

How Is Atopic Dermatitis Diagnosed?

Diagnosis is based on the symptoms. Each person has his or her own mix of symptoms that can change over time. Doctors will ask for a medical history to:

• Learn about your symptoms
• Know when symptoms occur
• Rule out other diseases
• Look for causes of symptoms.

There no certain test that can be used to check for this disease. But you may be tested for allergies by a dermatologist (skin doctor).

Things That Make Atopic Dermatitis Worse

Irritants and allergens can make atopic dermatitis worse.

Irritants are things that may cause the skin to be red and itchy or to burn. They include:

• Wool or synthetic fibers
• Soaps and cleansers
• Some perfumes and makeup
• Substances such as chlorine, mineral oil, or solvents
• Dust or sand
• Cigarette smoke.

Allergens are allergy-causing substances from foods, plants, animals, or the air. Common allergens are:

• Eggs, peanuts, milk, fish, soy products, and wheat
• Dust mites
• Mold
• Pollen
• Dog or cat hair

Stress, anger, and frustration can make atopic dermatitis worse, but they haven't been shown to cause it. Skin infections, temperature, and climate can also lead to skin flares. Other things that can lead to flares are:

• Not using enough moisturiser after a bath
• Low humidity in winter
• Dry climate
• Long or hot baths and showers
• Going from sweating to being chilled
• Bacterial infections.

How Is Atopic Dermatitis Treated?

Atopic eczema is a dry skin condition. The skin does not produce enough oil and loses too much water, so it becomes dry and cracked. Replace the oil and treat dry skin with emollients on an ongoing basis. Eczema flares can be treated with prescribed topical treatments, which will be used to reduce the inflammation.

Treatment works best when the patient, family members, and doctor work together. Treatment plans are based on:

• Age
• Symptoms
• General health.

You need to carefully follow the treatment plan. Try to notice what is or isn't helpful. Symptoms usually improve with the right skin care and lifestyle changes.

Atopic dermatitis treatment goals are to heal the skin and prevent flares. Your doctor will help you:

• Develop a good skin care routine
• Avoid things that lead to flares
• Treat symptoms when they occur.

You and your family members should watch for changes in the skin to find out what treatments help the most.

Medicines for atopic dermatitis include:

• Skin creams or ointments that control swelling and lower allergic reactions
• Corticosteroids
• Antibiotics to treat infections caused by bacteria
• Antihistamines that make people sleepy to help stop nighttime scratching
• Medicines that suppress the immune system.

Other treatments include:

• Light therapy
• A mix of light therapy and a drug called psoralen
• Skin care that helps heal the skin and keep it healthy
• Protection from allergens.

Emollients

Emollients are an essential treatment for all children with atopic eczema to moisturize the skin by soothing and softening. There is a wide range of emollients to choose from and you mayneed to try quite a few until you find the right ones for your child. Emollients come in various forms, including lotions, gels, creams, ointments and sprays (known as leave-on emollients).Some leave-on emollients can be used as soap substitutes. Emollient washes, bath and shower products are available for washing and cleansing. When you find one that suits your child, ask them to prescribe it in large amounts – for example, a 500-g tube and 200-ml bottle. Try to use a new emollient for at least a month, unless you can see it is making the eczema worse. Remember that a stinging sensation is always likely when applying emollients to very dry skin. However, if irritation occurs, consider using a different one.

Bath oils

Bathing your child every day is good practice, as this can prevent infection, but find a bathing routine that suits your child’s skin and your daily routine. Some bath oils have an ingredient that helps with itching or that can help to deal with infection. Avoid using bubble bath and ordinary baby oil as they dry out the skin.

Soap substitutes

Ordinary soaps should not be used as they can dry the skin. Some wash, bath and shower products are especially designed for eczema skin. Remember to ask the pharmacist if a product is designed for eczema, as some products may appear eczema friendly but contain detergent and are not suitable. You can also use most leave-on emollients as soap substitutes. Getting used to is essential as they do not foam like ordinary soaps but are just as good at getting you clean. Apply a soap substitute onto your child’s skin before they get into the bath, or whilst they are sitting in the bath, and simply let the child soak in the water. After washing, bathing or showering, rinse off the emollient, pat the skin dry and then re-apply the leave-on emollient.

Leave-on emollients (lotions, gels, creams and ointments)

The best way to put on emollients is to rub them directly onto the skin in the direction that the hairs grow. You can use as much emollient as you wish – even if you can still see the emollient on the skin, it will soon sink in. The most important thing is to use an emollient that your child likes and use it several times a day. If your child will not use an ointment but will happily put on a cream, then choose the cream or gel. Creams are good for using during the day as they are easy to put on and sink into the skin. As creams and lotions contain water, they also have preservatives, and these can cause skin reactions in some people. If you feel that this may be the case with your child, stop using the cream and try an ointment. Ointments are the best thing to use on very dry skin, though they can be difficult to put on and can look greasy on the skin. They can be good to use last thing at night and first thing in the morning. Ointments can seal the skin but may block hair follicles causing red bumps, especially in hot weather. Some newer creams contain natural moisturising factors, producing similar hydrating qualities to ointments with the same consistency as creams. Lotions are the ‘lightest’ emollient. They are good for areas of ‘wet’ eczema, or for veryhairy areas. Remember to keep your leave-on emollients clean – pump dispensers are very helpful. If you use a tub, do not put fingers in the pot – use a spoon to decant and apply what you need. If you need more advice on the differences between the formulations of leave-on emollients, it is best to ask a dermatologist. A few handy tips for emollient use include:

• Apply in a smooth, stroking action, rather than rubbing in, to prevent blockage of hair follicles and irritation.

• If you use pots, decant before application, so fingers are not constantly in pots, which will cause contamination. A good way to prevent this is to use pumps.

• Ask for emollients in large quantities (200 ml for bath oils / wash products and 500 g for leave-on emollients). Small dispensers or tubes are useful for taking to school.

• Mix and match different types of emollients (creams, ointments and gels) depending on skin dryness, seasons, activity and lifestyle.

• Bandages and clothing in contact with ointments (paraffin based products) can easily catch fire with a naked flame or cigarette. So please take care near naked flames.

• Baths and showers will require daily cleaning to prevent slipping and build-up of oil.

• In some situations – like cold weather or feeding time for babies and small children – eczema can get much worse on the face and hands, so apply plenty of emollient to protect the skin before feeding or going out in the cold.

• Apply emollients before swimming, and shower and reapply after swimming.

Topical steroids

When something is ‘topical’ it means that it is applied to the skin. The human body produces its own steroids and these keep down any swelling, redness and inflammation. The steroids that are used to treat eczema are very like the ones that the body produces. Topical steroids come in creams, ointments, gels and in different strengths, and the chance of any side effect increases as the steroid gets stronger. For example, hydrocortisone is mild, Eumosone is moderate and Betnovate is a potent strength. Be aware that topical steroids have a generic (drug) name and product name. The potency is indicated in the patient information leaflet and not on the packaging. Your doctor will choose the appropriate potency steroid depending on how severe the eczema is, how long it will be used for, the age of the child and areas of skin affected. Dermatologists will normally use the lowest strength that they can, but sometimes a short course of a stronger one may be needed to bring the eczema under control. Always follow the instructions. You should always apply steroids in small amounts, usually just once or twice a day and enough so that you can see a sheen on the skin. Topical steroids have been used to treat atopic eczema for 40 years and, although you need to use them carefully, they can be very safe and effective for treating eczema flares. Always apply topical steroids and emollients separately. It does not really matter which you put on first – you will find what suits your child best – but try to leave about half an hour in between an emollient and prescribed treatment. Never apply an emollient and prescribed treatment at the same time or dilute a topical steroid with an emollient.

Practical management

There are many other things that you can do to make your child more comfortable and less itchy. Here are a few tips:

• Try not to tell them to stop scratching – instead, use play as a distraction technique.

• Keep their nails short and hand gloves or socks on hands or all-in-one sleepsuits at night.

• Keep your home (and especially the child’s bedroom) cool as overheating makes the itching worse.

• Use cotton clothing as much as you can as it is cool and comfortable. Wool can make the skin itch.

• Avoid substances that can affect the skin, such as soap and detergents. Some people find non-biological products cause fewer problems than biological ones.

Doctor may prescribe antihistamines for your child to help them sleep at night. These are meant to be used for a short time when the eczema has flared up and not as a longterm measure. In some situations – like cold weather or feeding time for babies and small children – eczema can get much worse on the face and hands, so apply plenty of emollient.

Avoiding allergens

Atopic eczema seems to be linked to certain things that can cause an allergic reaction. These are called allergens. Children with atopic eczema may have allergy to any number of things in our environment. Allergy testing is generally not helpful and high-street allergy tests should be avoided. A common sense approach to minimising your child’s exposure to some of the more common allergens known in atopic eczema is probably the best course of action. The house-dust mite is a common allergen, or rather its droppings are. It lives in all our homes, and – because it loves warm,damp conditions – it is most at home in our mattresses and carpets, where it feeds on our dead skin. Regular vacuuming, dusting with a damp cloth and using special anti-house-dust-mite bedding covers can help to cut down their numbers. Pets can be a problem for children with eczema. If you do not have a pet, do not get a pet that has fur, hair or feathers. Goldfish are all right! If you already have a family pet, you should try to cut down the contact between the pet and your child, and keep pets out of the bedroom. Allergy to food in children with atopic eczema is a very difficult subject. There has been a lot of research published about it and for a long time there were no real answers. However, it now seems that food allergy can affect a small number of young children, but is usually less of a problem over one year of age. Some foods also cause irritation around children’s mouths, rather than allergic reactions. You should not try to change a child’s diet without first seeing a specialist (doctor) and dietitian – you need to be very sure of a link between food and eczema before considering it as part of your child’s treatment.

Infection

Infection in eczema can be a common problem and can be the reason why eczema flares up. Once your child has broken the skin by scratching, it is very easy for germs to get into the broken areas. Infection can cause the skin to change, making it look more red, itchy and swollen and may even cause it to weep and form a yellow covering. The skin may also feel hot to the touch and may be more difficult to control with your usual treatments. This may indicate a bacterial infection. Other skin infections include viral infections, such as eczema herpeticum and molluscum. Eczema herpeticum can be caused by the cold sore virusand spread very quickly in atopic eczema. If you think your child has this, you should seek medical advice urgently. If you think your child’s eczema may be infected, you should see your doctor as soon as possible. If your child has several infections in a short period of time, a skin swab may be taken to identify the bacterium or virus that may be causing the problem and to ensure that they receive the correct treatment.

Other treatments

There are other specialist treatments for eczema that can be safely used for babies and small children. These include bandaging, wet wraps and therapeutic clothing. Other topical treatments, such as topical calcineurin inhibitors, can be used as alternatives to topical steroids or can be used in conjunction with topical steroids, with specialist guidance. There are a number of other treatments available for more severe eczema that seem to have some success in managing eczema. Generally, these treatments will be started by a dermatologist. 

Eczema can be managed but even in a mild form requires time and commitment. It is important to use a good skin-care routine. It is also essential that children with eczema are not made to feel that they are different. Brothers and sisters need to be involved as much as possible in the care of the child with eczema. It can be hard to find a balance between giving too much attention and too little to both the child with eczema and any of their brothers or sisters. You may begin to feel like your child’s eczema is taking over your family life, especially if everyone is losing sleep. However, you can manage it well if you approach it in a positive way. By talking to your doctor.

What Research Is Being Done on Atopic Dermatitis?

Research is being done into what causes atopic dermatitis, and how it can be managed, treated, and prevented.

Research includes:

• Genetics
• Biochemical changes in skin and white blood cells
• Immune factors
• Light therapy
• New medications
• Supplements, herbs, and plant extracts.