Atopic dermatitis

Atopic dermatitis also called atopic eczema, is the most common form of eczema (also known as dermatitis) that often begins in infancy or early childhood before their first birthday but can also begin for the first time in young adults or even later in life. The skin is often dry, becomes red, swollen, cracked and very itchy (pruritus). The itchiness may interfere with sleep. Scratching leads to: redness, swelling, cracking, “weeping” clear fluid, crusting and scaling. The inflammation and itchiness wax and wane in severity. Atopic dermatitis is usually a long-term (chronic) condition, although it can improve significantly, or even clear completely, in some children as they get older.

Atopic dermatitis is most common in infants. It may start as early as age 2 to 6 months. In infants, atopic dermatitis often affects the cheeks, scalp, outsides of the arms and legs and the trunk. In children and adults the inflammation involves the creases in the front of the arms and behind the knee, often the wrists, ankles and buttocks.

Atopic dermatitis is due to a skin reaction in the skin. The reaction leads to ongoing itching, swelling and redness. People with atopic dermatitis may be more sensitive because their skin lacks certain proteins that maintain the skin’s barrier to water.

Atopic dermatitis is seen in approximately 10% to 30% of children and 2% to 10% of adults in developed countries ¹⁾. This prevalence has increased two to three-fold in recent decades. Atopic dermatitis has a higher incidence at higher latitudes, which may be related to decreased sun exposure and lower humidity levels. Atopic dermatitis is divided into three subsets based on the age of onset:

1. Early-onset atopic dermatitis (birth to 2 years old): most common type of atopic dermatitis, with approximately 60% of cases starting by age 1. Sixty percent of cases resolve by 12 years old
2. Late-onset atopic dermatitis: symptoms begin after the onset of puberty
3. Senile onset atopic dermatitis: an unusual subset with onset in patients older than 60 years old.

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

• In children younger than age 2, the rash may begin on the face, scalp, hands, and feet. The rash is often itchy and forms blisters that ooze and crust over.
• 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.
• In adults, the rash may be limited to the hands, eyelids, or genitals.
• 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.

Many people outgrow it by early adulthood.

Atopic dermatitis can vary in severity between different individuals. Some children have dry skin and dermatitis that can be kept under control with simple treatments, while others may need a variety of more complex treatments. You will get to know what your child’s dermatitis looks like, what treatments will be needed for flares (when the skin becomes hot, inflamed, itchy and sore) and when your child needs to visit a healthcare professional. However, if the dermatitis gets worse or looks different, you should always ask for medical help.

There are a number of different topical treatments for atopic dermatitis – that is, treatments that can be applied to the skin: emollients (medical moisturizers), topical steroids and topical calcineurin inhibitors. For more severe dermatitis, treatments include phototherapy, oral steroids, oral immunosuppressant drugs, and a biologic drug.

Atopic dermatitis is usually treated with medicines placed directly on the skin or scalp. These are called topical medicines:

• Your doctor will probably prescribe a mild cortisone (steroid) cream or ointment at first. Topical steroids contain a hormone that helps “calm” your child’s skin when it is swollen or inflamed.
• Your child may need a stronger medicine if this does not work.
• Medicines called topical immunomodulators may be prescribed for anyone over 2 years old.
• Creams or ointments that contain coal tar or anthralin may be used for thickened skin areas.
• Moisturizers and creams containing ceramides that restore the barrier of the skin are also helpful.
• A newer medicine called crisaborole (Eucrisa) may also help.

Other treatments that may be used include:

• Antibiotic creams or pills if your child’s skin is infected
• Drugs that suppress the immune system
• Phototherapy, a medical treatment in which your child’s skin is carefully exposed to ultraviolet (UV) light
• Short-term use of systemic steroids (steroids given by mouth or through a vein)
• A biologic injection called dupilumab (Dupixent) may be used for moderate to severe atopic dermatitis.

Your child’s doctor will tell you how much of these medicines to use and how often. DO NOT use more medicine or use it more often than your doctor says.

Figure 1. Atopic dermatitis baby

Figure 2. Atopic dermatitis neck

Figure 3. Atopic dermatitis eyelid

Figure 4. Atopic dermatitis scalp

Is there a cure for atopic dermatitis?

Although there is currently no known cure for atopic dermatitis, when it is well-managed it is possible to limit its impact on day-to-day life.

Will my child grow out of atopic dermatitis?

Children often ‘grow out of’ the symptoms of atopic dermatitis, but it can return at any time, unfortunately. If you have atopic dermatitis at an early age, your skin is likely to remain sensitive even if there is no recurrence of dermatitis.

Atopic dermatitis causes

Atopic dermatitis has a complex causes including genetic and environmental factors which lead to abnormalities in the epidermis and the immune system ²⁾. In atopic dermatitis, dry skin is due to a genetically defective skin barrier. Skin without eczema (dermatitis) provides an effective barrier that protects the body from infection and irritation. If you think of the skin as a brick wall, the outer cells are the bricks, while fats and oils are the mortar, holding everything together and acting like a seal. The cells attract and keep water inside, and the fats and oils also help to keep moisture in.

If you have dermatitis, your skin may not produce as many fats and oils and will be unable to retain water. Also, some everyday substances (e.g. soap, bubble bath and detergents) will dry out the skin. Gaps open up between the skin cells as they are not sufficiently plumped up by water. This means that the skin barrier is not as effective as it should be, and bacteria or irritants can more easily pass through. These then trigger an inflammatory response, which causes the redness in dermatitis flares. Although the exact cause of atopic dermatitis is not known, an ‘over-reactive’ immune system is understood to be involved.

Atopic dermatitis is part of the atopic triad (atopic dermatitis, allergic rhinoconjunctivitis, and asthma) which may start simultaneously or in succession in what is known as the “atopic march.” Patients with the atopic triad have a defective barrier of the skin, upper respiratory, and lower respiratory tract which leads to their symptomatology ³⁾. If one parent is atopic, there is more than a 50% chance that their offspring will develop atopic symptoms. If both parents are affected, up to 80% of offspring will be affected. Genetic alterations include loss of function mutations of filaggrin (Filament Aggregating Protein), an epidermal protein that is broken down into natural moisturization factor. Filaggrin mutations are present in up to 30% of atopic dermatitis patients and may also predispose patients to ichthyosis vulgaris, allergic rhinitis, and keratosis pilaris. Food hypersensitivity may also cause or exacerbate atopic dermatitis in 10% to 30% of patients. Ninety percent of such reactions or flares are caused by eggs, milk, peanuts, soy, and wheat ⁴⁾.

Recent studies indicate that there may be an association between smoking and adult-onset atopic dermatitis.

Atopic dermatitis patients have a defective skin barrier that is susceptible to xerosis (dry skin) and environmental irritants and allergens that lead to inflammation, pruritus, and the classic clinical findings of atopic dermatitis. The barrier defect may be caused in part by decreased levels of ceramides, which are sphingolipids in the stratum corneum which play a role in the skin’s barrier function and prevent transepidermal water loss. The defective skin barrier allows irritants and allergens to penetrate the skin and cause inflammation via an overactive Th2 response (with increased IL-4, IL-5 cytokines) in acute lesions and Th1 response (with IFN-gamma and IL-12) in chronic lesions. Scratching of the skin also stimulates keratinocytes to release inflammatory cytokines such as TNF-alpha, IL-1, and IL-6. Decreased anti-microbial peptides (human beta-defensins, cathelicidins) in the epidermis of atopic patients also contribute to Staphylococcus aureus colonization seen in more than 90% of atopic dermatitis patients. Staphylococcus aureus may worsen the inflammation of atopic dermatitis lesions and lead to secondary infection and impetiginization ⁵⁾.

In atopic dermatitis, there is significant water loss across the epidermis, but why there is dysregulation of the epithelial barrier is not fully understood. It is believed that filaggrin, which is critical for epithelial integrity, may be dysfunctional.

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 frequent baths or showers and swimming very often
• Getting too hot or too cold, as well as sudden changes of temperature
• Perfumes or dyes added to skin lotions or soaps

Atopic dermatitis prevention

Moisturization is important on an ongoing basis and may prevent flares. Daily skin care may cut down on the need for medicines.

To help you avoid scratching your rash or skin:

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

Keep your skin moist by using ointments (such as petroleum jelly), creams, or lotions 2 to 3 times a day. Choose skin products that do not contain alcohol, scents, dyes, and other chemicals. A humidifier to keep home air moist will also help.

Avoid Triggers

The following triggers 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
• Taking frequent baths or showers and swimming often, which can dry out skin
• Getting too hot or too cold, as well as sudden changes of temperature
• Perfumes or dyes added to skin lotions or soaps

To prevent flare-ups, try to avoid:

• Foods, such as eggs, that may cause an allergic reaction in a very young child. Always discuss with your provider first.
• Wool, lanolin, and other scratchy fabrics. Use smooth, textured clothing and bedding, such as cotton.
• Sweating. Be careful not to over dress your child during warmer weather.
• Strong soaps or detergents, as well as chemicals and solvents.
• Sudden changes in body temperature, which may cause sweating and worsen your child’s condition.
• Stress. Watch for signs that your child feels frustrated or stressed and teach them ways to reduce stress such as taking deep breaths or thinking about things they enjoy.
• Triggers that cause allergy symptoms. Do what you can to keep your home free of allergy triggers such as mold, dust, and pet dander.
• Avoid using skin care products that contain alcohol.

Using moisturizers, creams, or ointments every day as directed may help prevent flares.

When washing or bathing:

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

Medicines

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

Atopic dermatitis is usually treated with medicines placed directly on the skin or scalp. These are called topical medicines:

• You will probably be prescribed a mild cortisone (steroid) cream or ointment at first. You may need a stronger medicine if this does not work.
• Medicines called topical immunomodulators may be prescribed for anyone over 2 years old. Ask your provider 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, it may lead to an infection.

Other treatments that may be used include:

• Antibiotic creams or pills if your skin is infected
• Drugs that suppress the immune system
• Targeted biologic medicines that are designed to affect parts of the immune system involved in atopic dermatitis
• Phototherapy, a treatment in which your skin is carefully exposed to ultraviolet (UV) light
• Short-term use of systemic steroids (steroids given by mouth or through a vein)

Atopic dermatitis symptoms

Atopic dermatitis affects up to 30% of the childhood population and causes considerable distress and ill health. Its prevalence is greatest in childhood, generally starting in the first few months of life, becoming more severe in infancy and often improving in school years.

Affected sites vary with age. Infantile eczema commonly affects the face, sparing around the mouth and later the hands, feet and elsewhere. Erythrodermic eczema refers to involvement of the entire body at any age.

In older children, eczema tends to affect flexures, particularly antecubital and popliteal fossae. Flexural dermatitis often persists into adult life. Occasionally, a ‘dirty neck’ is observed in teenagers. Irritant hand eczema may be a problem for those who do wet work. Bilateral nipple eczema is not uncommon.

Diagnosis depends on clinical findings, which vary with the age and stage of the disease. The main features are:

• Marked pruritus, frequently resulting in lichenification
• Intermittent exacerbations (acute flare-ups)
• Association with personal or family history of atopic dermatitis, allergic rhinitis and/or asthma
• Dry skin

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 color changes, such as more or less color than the normal skin tone
• Skin redness or inflammation around the blisters
• Thickened or leather-like areas, which can occur after long-term irritation and scratching

A scoring index (SCORAD) combining extent, severity and subjective symptoms, is often used in clinical trials that assess the effectiveness of treatments.

Atopic dermatitis flare-ups may be precipitated by:

• Staphylococcus aureus exotoxins, which act as superantigens
• Irritants, especially skin dehydration by over-washing, woollen clothing
• Inhalant allergens especially house dust mite (which may also be a contact allergen)
• Ingested allergens in some infants (eggs, milk, soybeans, peanuts and wheat account for most of these)
• Emotional stress

Atopic dermatitis baby

• Infants less than one year of age often have widely distributed eczema. The skin is often dry, scaly and red with small scratch marks made by sharp baby nails.
• The cheeks of infants are often the first place to be affected by eczema.
• The napkin area is frequently spared due to the moisture retention of nappies. Just like other babies, they can develop irritant napkin dermatitis, if wet or soiled nappies are left on too long.

Atopic dermatitis toddlers and pre-schoolers

• As children begin to move around, eczema becomes more localised and thickened. Toddlers scratch vigorously and eczema may look very raw and uncomfortable.
• Eczema in this age group often affects the extensor (outer) aspects of joints, particularly the wrists, elbows, ankles and knees. It may also affect the genitals.
• As the child becomes older the pattern frequently changes to involve the flexor surfaces of the same joints (the creases) with less extensor involvement. The affected skin often becomes lichenified i.e. dry and thickened from constant scratching and rubbing,
• In some children, the extensor pattern of eczema persists into later childhood.

Atopic dermatitis school-age children

• Older children tend to have the flexural pattern of eczema and it most often affects the elbow and knee creases. Other susceptible areas include the eyelids, earlobes, neck and scalp.
• They can develop recurrent acute itchy blisters on the palms, fingers and sometimes on the feet, known as pompholyx or vesicular hand/foot dermatitis.
• Many children develop a ‘nummular’ pattern of atopic dermatitis. This refers to small coin-like areas of eczema scattered over the body. These round patches of eczema are dry, red and itchy and may be mistaken for ringworm (a fungal infection).
• Mostly eczema improves during school years and it may completely clear up by the teens, although the barrier function of the skin is never entirely normal.

Atopic dermatitis adults

• Adults who have atopic dermatitis may present in various different ways.
  They may continue to have a diffuse pattern of eczema but the skin is often more dry and lichenified than in children.
• Commonly adults have persistent localised eczema, possibly confined to the hands, eyelids, flexures, nipples or all of these areas.
• Recurrent staphylococcal infections may be prominent.
• Atopic dermatitis is a major contributing factor to occupational irritant contact dermatitis. This most often affects hands that are frequently exposed to water, detergents and /or solvents.
• Having atopic dermatitis does not exclude contact allergic dermatitis (confirmed by patch tests) in children and adults)
• Hand dermatitis in adult atopics tends to be dry and thickened but may also be blistered.

Atopic dermatitis complications

Atopic dermatitis may be complicated by microbial colonization or infection:

• Staphylococcus aureus (impetiginised eczema)
• Streptococcus pyogenes
• Herpes simplex (eczema herpeticum)
• Warts
• Molluscum contagiosum
• Malassezia spp.

The pathogenesis appears involve release of vasoactive substances from mast cells and basophils as an IgE-mediated hypersensitivity reaction. There is a TH2 pattern of cytokine release from T helper lymphocytes in the epidermis and dermis with low levels of TH1 lymphocytes and gamma interferon. There is also a non-allergic or intrinsic type of atopic dermatitis. These patients have no associated respiratory diseases, show normal total serum IgE levels, no specific IgE, and have negative skin-prick tests to aeroallergens or foods.

It is not known why the incidence of atopic dermatitis appears to be increasing; theories include increased hygiene and decreased exposure to micro-organisms and greater exposure to house dust mite.

A proportion of patients have been found to be deficient in fillagrin, resulting in abnormal barrier function of the stratum corneum and increased susceptibility to the effect of contact irritants. These individuals have dry skin (ichthyosis vulgaris).

Atopic dermatitis diagnosis

Your health care provider will look at your skin and do a physical exam. You may need a skin biopsy to confirm the diagnosis or rule out other causes of dry, itchy skin. The presence of associated findings (e.g., keratosis pilaris) may facilitate diagnosis. A biopsy will show an eczematous pattern. In childhood cases that are recalcitrant to treatment, fluorescent enzyme immunoassays or skin prick testing can be performed to detect immunoglobulin E (IgE) antibodies against specific allergens, which may or may not be a clinically relevant exacerbating factor ⁶⁾.

Atopic dermatitis diagnosis is based on:

• How your skin looks
• Your personal and family history

In most cases, no specific investigations are required. However, on occasion the following may be useful:

• Skin swabs for bacteriology: to identify methicillin resistant strains of Staphylococcus. Your doctor may order cultures for infection of the skin. If you have atopic dermatitis you may get infections easily.
• Viral culture: to confirm eczema herpeticum
• Iron studies: severe eczema can result in iron deficiency; iron deficiency aggravates pruritus
• Total IgE: elevated IgE confirms atopy but normal levels may occur in non-allergic patients
• RAST tests (specific IgE): negative tests have a high predictive value, positive test results are not so useful
• Prick tests: positive test results may simply confirm an atopic diathesis
• Patch tests: to rule out specific contact allergy for example to an applied medicament

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

Atopic dermatitis treatment

The best way to manage atopic dermatitis is unknown. At present, management of atopic dermatitis in patients of all ages involves:

• Avoidance of aggravating factors: use soap substitutes; don’t wear woollen garments or perfumed cosmetics; ensure adequate rest; reduce stress
• Fans and wet dressings to cool hot and inflamed skin
• Emollients applied as often as is required to keep the skin hydrated and comfortable
• Topical immunomodulators, also known as calcineurin inhibitors (pimecrolimus cream)
• Topical corticosteroid creams and/or ointments for flare-ups
• Oral antibiotics, usually flucloxacillin or dicloxacillin, for bacterial infection
• Non-sedating antihistamines for patients with an element of urticaria.
• Sedative antihistamines at night to allow adequate rest.
• In severe cases, refer for phototherapy, azathioprine, methotrexate or ciclosporin

Treatment of atopic dermatitis may be required for many months and possibly years.

Atopic dermatitis treatment nearly always requires:

• Reduction of exposure to trigger factors (where possible)
• Regular emollients (moisturizers)
• Intermittent topical steroids

Daily skin care includes the application of emollients twice daily, with the application within three minutes of exiting lukewarm shower or bath to prevent skin drying. Ointments are the most occlusive but may be more greasy. Topical steroids, which should be applied before emollients to “lock-in” their effect, are first-line agents for acute flares. The potency should be strong enough to control a flare quickly, and consideration should be given for tapering every other day and for maintenance therapy twice weekly (e.g., weekends) in the usual areas of involvement. Reversible side effects of steroid use include skin atrophy and telangiectasia.

Potent topical steroids should be used with caution in infants because of their greater proportional absorption due to higher surface area to body weight ratio. Blistered or weeping eczema is brought under control most rapidly using wet dressings.

Oral corticosteroids are used for crisis intervention but may be followed by a severe rebound flare at discontinuation. It is important to taper the dose and begin intensified skin care with topical steroids and bathing followed by application of emollients.

Sensitive areas (including the intertriginous areas of the axilla and groin, in addition to the face) may require topical nonsteroidal agents including calcineurin inhibitors such as tacrolimus and pimecrolimus. Newer non-steroidal agents include crisaborole, which exerts its effect by blocking PDE-4. When atopic dermatitis is not controlled with topical agents, systemic agents include phototherapy (ultraviolet (UV) A, UVB, and narrow-band UVB), cyclosporine, azathioprine, mycophenolate mofetil, and methotrexate.

A newly FDA-approved biologic therapy is dupilumab, which is a monoclonal antibody that blocks the IL-4 receptor and thus the effect of IL-4 and IL-13. Other complementary therapies include bleach baths (0.5 cup bleach in full 40 gallon tub) one to two times weekly to decrease S. aureus colonization, low allergen maternal diets during breastfeeding, and probiotic and prebiotic use in pregnant mothers and at-risk infants which has shown 50% decreased frequency of atopic dermatitis at ages 1 to 4 years old compared to placebo.[10][11][12]

Recently Crisaborole topic ointment was approved for mild to moderate atopic dermatitis. The drug is a phosphodiesterase inhibitor and shown to improve skin symptoms.

Some patients may benefit from probiotics; it is believed that the bacterial products may enhance the immune system and prevent the development of allergic IgE antibody response. Further, probiotics are recommended during pregnancy and in breast feeding women.

Numerous studies show that bleach baths may help relieve the symptoms of atopic dermatitis by lowering the risk of

In some cases, management may also include one or more of the following:

• Topical calcineurin inhibitors, such as pimecrolimus cream or tacrolimus ointment
• Crisabarole ointment
• Antibiotics
• Antihistamines
• Phototherapy
• Oral corticosteroids

Longstanding and severe eczema may be treated with an immunosuppressive agent.

• Methotrexate
• Ciclosporin
• Azathioprine

New biologics are under investigation. The first to be approved for the treatment of atopic dermatitis is:

• Dupilumab

Atopic dermatitis face

Use light emollients in adolescents and adults to avoid provoking acne or perioral dermatitis. It is safe to use 0.5-2% hydrocortisone cream on active dermatitis indefinitely, although in time it is likely to lose its efficacy. Pimecrolimus cream can also be used as maintenance treatment. Severe dermatitis may require moderate potency topical steroids for a course of 5 to 10 days or as pulse therapy. A trial of antifungal agents may be warranted in adults with prominent facial dermatitis.

Atopic dermatitis trunk and limbs

These sites may require thicker emollients (sorbolene cream, white soft paraffin, emulsifying ointment, fatty cream) and moderate potency topical steroid fatty cream or ointment, with potent topical steroids for flare-ups. It is often useful to apply the potent preparation prophylactically on two consecutive days each week (pulse therapy). Ultrapotent products may be required for severe lichenification.

Atopic dermatitis hands and feet

The very thick stratum corneum of palmoplantar sites necessitates the use of ultrapotent topical steroids such as clobetasol propionate, generally in an ointment base, for two to four weeks. Advise frequent use of emollient barrier creams that contain dimethicone and/or petrolatum, and careful protection against irritants.

Atopic dermatitis armpits and groins

Flexures do not generally require emollients. Potent topical steroids are rarely required, and should only be used for a few days. Hydrocortisone cream or pimecrolimus cream is generally adequate.

Atopic dermatitis treatment with topical therapies

Non-pharmacologic interventions such as the role of moisturizers and bathing practices to help with treatment, maintenance, and prevention of flares ⁷⁾.

• Moisturizers: The application of moisturizers should be an integral part of the treatment of patients with atopic dermatitis. They are also important components of maintenance therapy and prevention of flares.
• Bathing practices, including additives: Bathing is suggested in patients with atopic dermatitis as part of treatment and maintenance; however, there is no standard for the frequency or duration of bathing appropriate for those with atopic dermatitis. Moisturizers should be applied soon after bathing to improve skin hydration. Limited use of non-soap cleansers (that are neutral to low pH, hypoallergenic, and fragrance-free) is recommended, and there is no data to support the use of bath water additives (oils, emollients, etc.).
• Wet-wrap therapy with or without topical corticosteroid can be recommended for patients with moderate to severe atopic dermatitis to decrease severity and water loss during flares.

Topical corticosteroids are used on both adults and pediatrics for the management of atopic dermatitis. A variety of factors must be considered to choose the proper topical corticosteroids for treatment, such as patient preference and age. No specific monitoring is required for side effects. However, based on patient risk factors and response some monitoring may be required. Patient education may be key to address misconceptions of topical corticosteroids.

Topical calcineurin inhibitors can be used for the treatment of acute and chronic atopic dermatitis as well as maintenance therapy in both adults and children. They can serve as a steroid-sparing treatment; however, careful considerations must be made before prescribing. Patient education regarding topical calcineurin inhibitor for atopic dermatitis is crucial since there are some adverse effects they may experience. Concomitant use of topical corticosteroid and topical calcineurin inhibitor can be used to treat atopic dermatitis. No specific monitoring is required for topical calcineurin inhibitors; however, based on individual patient risk factors it may be warranted.

Topical antimicrobials and antiseptics: Bleach baths with intranasal mupirocin have been shown to be beneficial for atopic dermatitis patients; however, they are not routinely recommended. This therapy is mostly for patients with clinical signs of secondary bacterial infection to help reduce disease severity. All other forms of antimicrobial and antiseptic therapies have not been shown to be clinically helpful for atopic dermatitis.

Topical antihistamines are not suggested for the treatment of atopic dermatitis due to the risk of absorption and contact dermatitis ⁸⁾.

Other topical agents are currently being studied for their use in treating atopic dermatitis. However, no conclusive data is available.

Complications

If topical corticosteroids are used inappropriately or if superpotent steroids are used in teenagers during rapid growth, striae may occur. Skin thinning can result if steroids are used inappropriately in older patients.

Whether verrucae vulgaris and mollusca contagiosa are more frequent is difficult to assess, but they are more widespread and difficult to eliminate.

Tachyphylaxis to topical steroids occurs if they are not used on a stop-start basis.

Patients may develop other related allergic disorders such as urticaria, food allergy, asthma and allergic rhinitis.

Superinfection with Staphylococcus aureus may require topical and/or systemic antibiotic treatment with antistaphylococcal agents.

Superinfection with herpes simplex virus, referred to as eczema herpeticum, can require admission to the hospital in children for systemic treatment with acyclovir and evaluation of other complications such as herpes keratitis.

Atopic dermatitis treatment with phototherapy and systemic agents

Phototherapy is typically used as a treatment for both acute and chronic atopic dermatitis in pediatric and adult patients. Narrowband ultraviolet-B (NB-UVB) is the most commonly used phototherapy due to its low-risk profile, efficacy, and availability. Phototherapy can be used as monotherapy or in combination with other topical therapies. However, caution must be taken due to drug interactions and increased risk of adverse effects.

Phototherapy can be used in children; however, additional factors such as their psychological perspective may need to be considered when administering therapy.

Various factors must be considered when prescribing systemic agents, such as previous therapy failure or contraindications, as well as quality of life and disease severity. When using systemic agents, the minimal effective dose should be used, because there is no optimal dosing, duration, or monitoring protocol due to the lack of data. Treatment is highly individualized and based on patient response, comorbidities, and history.

The following systemic therapies can be used off-label to treat atopic dermatitis. Some should only be considered as an alternative when other more commonly used off-label systemic therapies are not an option:

• Cyclosporine: off-label use for atopic dermatitis
• Azathioprine: off-label use for atopic dermatitis
• Methotrexate: off-label use for atopic dermatitis
• Mycophenolate Mofetil: alternative off-label use for atopic dermatitis
• Interferon Gama: alternative use for atopic dermatitis

Systemic steroids should be avoided when possible for the treatment of atopic dermatitis. They mainly serve for short-term bridge therapy to other systemic therapies or for acute severe exacerbations.

There is insufficient data to make proper recommendations for the use of the following systemic therapies for the treatment of atopic dermatitis ⁹⁾:

• Omalizumab
• Oral Calcineurin Inhibitors
• Other systemic therapies (TNF-alpha inhibitors, IV immunoglobulin, theophylline, papaverine, or thymopentin)

The use of systemic antibiotics is not encouraged unless there is clinical evidence of bacterial infection or eczema herpeticum.

There is no data to support the use of oral antihistamines as a treatment of atopic dermatitis, they can be used to help with pruritus and some sedating antihistamines can help (short-term) with sleep loss due to atopic dermatitis.

Prevention of atopic dermatitis flares

Continued use of topical corticosteroids or topical calcineurin inhibitors after disease stabilization can help prevent relapse or flares ¹⁰⁾.

Patient education is important to inform the patient about atopic dermatitis and can be done through educational programs, video training, or nurse-led workshops. Education should always be an adjunct to conventional therapy.

Overall, allergy testing without a history of allergies in atopic dermatitis patients is not supported since atopic dermatitis can be affected by other non-allergic factors such as diet and the environment. If a patient does have a history of allergies or signs of contact dermatitis then it may be helpful to test for allergies (food allergies, inhalant/aeroallergens, allergic contact dermatitis).

Dietary interventions based solely on food allergies are not supported due to atopic dermatitis being affected by different non-food allergy/diet-based factors.

• In children < 5 years of age with persistent atopic dermatitis despite optimized treatment or history of reaction to certain foods can be considered for food allergy tests.
• If a food avoidance diet is being undertaken, then it should be done with the assistance of a dietician.

The following dietary supplements are NOT supported by data for the treatment of atopic dermatitis:

• Probiotics/prebiotics
• Fish oils, primrose oil, borage oil, multivitamin supplements, zinc, vitamin D, E, B12, or B6

Environmental modifications are not supported by the currently available data and more studies are needed.

• Measures to avoid and reduce contact with house dust mites may be helpful in patients with high sensitivity to house dust mites.
• Modification of laundering techniques such as double rinsing or use of certain detergents and laundry products is not supported by the current data.
• There is limited data supporting the use of certain clothing fabrics and fibers to help reduce irritation, further studies are needed.

Other allergen-based interventions such as immunotherapy or sublingual immunotherapy for the treatment of atopic dermatitis are not supported by the currently available data.

There is insufficient evidence to support the use of complementary alternative therapies for the treatment of atopic dermatitis such as the following: traditional Chinese medicine, acupuncture, aromatherapy, homeopathy, naturopathy, acupressure, autologous blood injections.

Allergens

Dermatologists rarely recommend dietary manipulation for atopic dermatitis because it is troublesome, expensive and not often helpful. However, about 30% of children with dermatitis also have food allergies causing urticaria and anaphylactic responses. In some of these, certain foods may consistently aggravate their dermatitis. The most well established food allergies associated with dermatitis are to egg, milk, peanut, wheat, and soy.

If there is a strong suspicion of food allergy, a specific RAST test reaction or positive prick test may be supportive but should be confirmed with controlled food challenges and a limited elimination diet that results in consistent clinical improvement. Extensive elimination diets can be nutritionally deficient and are useless. Most affected children outgrow their food hypersensitivity.

Extended avoidance of house dust mites in sensitised patients with atopic dermatitis is reported to be helpful but is difficult to achieve. Avoidance measures include use of house dust mite-proof encasings on pillows, mattresses, and duvets; washing bedding in hot water weekly; removal of bedroom carpets; and decreasing indoor humidity levels.

Immunotherapy has not been found to be useful.

Atopic dermatitis treatment over the counter

Antihistamines taken by mouth may help if allergies cause your child’s itchy skin. These medicines are often available over the counter and do not require a prescription. Ask your child’s doctor what kind is right for your child.

Help for itching and scratching

Severe 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.

To help your child avoid scratching:

• Use a moisturizer, topical steroid cream, barrier repair cream, or other medicine the child’s doctor prescribes.
• Keep your child’s fingernails cut short. Have them wear light gloves while sleeping if scratching at night is a problem.
• Give antihistamines or other medicines by mouth as prescribed by your child’s doctor.
• As much as possible, teach older children not to scratch itchy skin.

Day-to-day skin care

Daily skin care with allergen-free products may cut down on the need for medicines.

Use moisturizing ointments (such as petroleum jelly), creams, or lotions. Choose skin products that are made for people with eczema or sensitive skin. These products do not contain alcohol, scents, dyes, and other chemicals. Having a humidifier to keep air moist will also help.

Moisturizers and emollients work best when they are applied to skin that is wet or damp. After washing or bathing, pat the skin dry and then apply the moisturizer right away. Your provider may also recommend placing a dressing over these skin moisturizing ointments.

When washing or bathing your child:

• Bathe less often and keep water contact as brief as possible. Short, cooler baths are better than long, hot baths.
• Use gentle skin care cleansers rather than traditional soaps, and use them only on your child’s face, underarms, genital areas, hands, and feet.
• Do not scrub or dry the skin too hard or for too long.
• Right after bathing, apply lubricating cream, lotion, or ointment while skin is still damp to trap moisture.

Dress your child in soft, comfortable clothing, such as cotton clothes. Have your child drink plenty of water. This may help add moisture to the skin.

Teach older children these same tips for skin care.

The rash itself, as well as the scratching, often causes breaks in the skin and may lead to infection. Keep an eye out for redness, warmth, swelling, or other signs of infection. Call your child’s doctor at the first sign of infection.

Atopic dermatitis prognosis

Atopic dermatitis affects 10–30% of children but is much less common in adults. One third of patients develop allergic rhinitis. One third of patients develop asthma. It is impossible to predict whether atopic dermatitis will improve by itself or not in an individual. Sensitive skin persists life-long. A meta-analysis including over 110,000 subjects found that 20% of children with atopic dermatitis still had persistent disease 8 years later. Fewer than 5% had persistent disease 20 years later. Children who developed atopic dermatitis before the age of 2 had a much lower risk of persistent disease than those who developed atopic dermatitis later in childhood or during adolescence.

In a longitudinal study of 7157 children and adolescents with atopic dermatitis from the Pediatric Eczema Elective Registry ¹¹⁾, researchers found that symptoms of mild to moderate atopic dermatitis are likely to persist into the teen years or beyond. Approximately two-thirds of the patients were followed for at least 2 years and the rest were followed for at least 5 years. From ages 2 to 26 years, more than 80% of patients reported having continued symptoms and/or use of topical medications to control symptoms. By age 20, approximately half of the patients had experienced at least one 6-month symptom- and medication-free period. Living in southern states, having a relative with an atopic illness, and exposure to pollen, wool, pets, cigarettes, fumes, some foods or drinks, and soaps/detergents were linked to persistent symptoms ¹²⁾.

It is unusual for an infant to be affected with atopic dermatitis before the age of four months but they may suffer from infantile seborrheic dermatitis or other rashes prior to this. The onset of atopic dermatitis is usually before two years of age although it can manifest itself in older people for the first time.

Atopic dermatitis is often worst between the ages of two and four but it generally improves after this and may clear altogether by the teens.

Certain occupations such as farming, hairdressing, domestic and industrial cleaning, domestic duties and care-giving expose the skin to various irritants and, sometimes, allergens. This aggravates atopic dermatitis. It is wise to bear this in mind when considering career options — it is usually easier to choose a more suitable occupation from the outset than to change it later.