Dermatology Facts—Atopic Dermatisis

Dermatitis means inflammation of skin. Atopic dermatitis (commonly known as eczema) is a particular type of skin barrier defect that is marked by dryness, associated itching, and a characteristic pattern of rash on the body. The condition is fairly common and may occur in as many as 20% of children.

The exact cause of atopic dermatitis is unknown, although increasing evidence suggests that a genetic defect in proteins and lipids that result in a compromised skin barrier is a critically important component of the disease process. In many patients, there is a family history of sensitive skin, atopic dermatitis, asthma or hay fever. Rarely, atopic dermatitis in infants may be related to food sensitivity; however, in the majority of cases, no meaningful food or allergic triggers can be found.

Atopic dermatitis usually starts early in life, from the ages of two months to two years. The skin is dry and the rash is quite itchy, so infants may be restless and rub against the sheets or scratch, if able. The rash may involve the face or it may cover a large part of the body. As the child gets older, the rash may become more localized. In early childhood, the rash is commonly on the legs, feet, hands and arms. Later, the rash may be limited to the bend of the elbows and knees. As the rash becomes more established, the dry itchy skin may become thickened, leathery and sometimes darker in coloration. The more the person scratches, the worse the rash gets and the thicker the skin becomes. Many children with atopic dermatitis outgrow the condition during school age; although some continue to have problems as an adolescent or even as an adult.

Many factors influence the severity of the condition. All of the patients have sensitive and dry skin. Many will find that during the winter months when the humidity is very low, the dryness and itchiness will be worse. On the other hand, some people are easily irritated by sweat and thus experience more problems during the summer months. Most patients note an increase in itching at times when there are sudden changes in temperature. Other irritants easily affect the skin of a patient with atopic dermatitis. Use of harsh soaps and detergents and exposure to wool are common problems.

Sometimes atopic dermatitis may become infected by bacteria, yeast or viruses. This is called "secondary infection". Bacterial secondary infection is most common and often occurs as the result of scratching. In this case, the rash becomes very red with pus filled pimples and scabs or erosions. If this occurs, your doctor will prescribe an antibiotic to control the infection. More serious complications can be caused by certain viruses. The "cold sore" virus (herpes simplex) may cause a severe rash. If this is suspected, contact your doctor immediately. Molluscum is caused by another virus that tends to spread more rapidly in patients with atopic dermatitis.

What can i expect from treatment?

Unfortunately, there is no "magic cure" that will cure atopic dermatitis. The main objective in treating atopic dermatitis is to restore the compromised skin barrier, decrease the skin inflammation, and relieve the itching, thereby controlling the disease and improving the quality of life.

Treatment is directed in four primary ways:

Lubricating the skin:
Because the skin is usually excessively dry, lubricants will be prescribed that will effectively decrease the dryness. All soaps are drying and should therefore be used sparingly. Patients should use mild soaps such as Dove, Aveeno and Cetaphil. Daily bathing is a useful way to get water into the skin, and can be as frequent as every day if desired. Effective lubricants should be applied immediately after bathing or showering to trap moisture in the skin. Examples are Aquaphor, Eucerin, Aveeno, Vasoline and Cetaphil. Lubriderm lotion may be used for milder dryness. Daily or twice-daily lubrication is the mainstay of atopic dermatitis treatment and will decrease the need for topical cortisones.

Restoring the Skin barrier:
There are several barrier repair products available in the marketplace by prescription or over the counter. An effective skin barrier repair product will restore water balance to the skin as well as protect the skin from outside pathogens, allergens and irritants. For chronic active atopic dermatitis, the barrier repair creams may used regularly for maintenance or at the first sign of a flare.

Controlling the skin inflammation:
Cortisone derived ointments or creams are very important in controlling the inflammation and decreasing the itching. Non-cortisone anti-inflammatory creams such as the topical immunomodulatory products are FDA approved for those over the age of 2 years. The cortisone ointments may be used for "rescue" if a flare-up occurs despite your maintenance regimen. Your doctor will tailor a treatment that is most appropriate for the severity and location of the dermatitis. When the area is clear, it is best to discontinue the treatment, but continue the daily use of lubrication or a barrier repair product to try to prevent new areas of dermatitis from occurring. Of course, if itching or a new rash begins, the anti-inflammatory preparation may have to be reintroduced.

Relieving itch:
Oral antihistamines, such as Benadryl and Atarax (hydroxyzine), may help control itching. They primarily help with the itching by causing drowsiness and allowing the child to sleep at night.

Other important forms of treatment:

Avoid contact with substances that you know cause itching. These may include soaps, detergents, certain perfumes, dust, grass weeds, wools and other types of scratchy clothing. In the winter, for example, cotton underwear or a cotton shirt may be worn under the sweater. Don't use bubble bath, as it dries the skin. Don"t use fabric softener sheets that are added to the drier (liquid fabric softeners that are used in the wash cycle are rinsed off and therefore acceptable).

Try to keep the temperature and humidity in the home fairly constant. Use a bedroom air conditioner in the summer and a vaporizer in winter. It is very important that the vaporizer or humidifier be cleaned well and frequently, since molds may grow and cause allergic manifestations.

Try to avoid scratching. Atopic dermatitis is often called "the itch that rashes" and it is known that scratching plays a very important role in making the dermatitis worse. Keeping the nails short and well-filed and using other measures to help prevent scratching are helpful.

The National Eczema Association is a wonderful organization. It distributes a very informative quarterly newsletter. National Eczema Association for Science and Education, 1220 SW Morrison, Ste. 433, Portland, OR 97205 (www.eczema-assn.org).