Overview
Definition:
Atopic dermatitis (AD), also known as atopic eczema, is a chronic, relapsing, inflammatory skin condition characterized by intense pruritus and eczematous lesions
Proactive maintenance therapy aims to prevent flares and maintain skin barrier function between active disease exacerbations.
Epidemiology:
It is the most common chronic inflammatory skin disease in childhood, affecting 15-20% of children globally
Prevalence varies by region, with higher rates in developed countries
There is a strong genetic predisposition, often associated with a personal or family history of asthma and allergic rhinitis (the atopic march).
Clinical Significance:
AD significantly impacts a child's quality of life, leading to sleep disturbances, school absenteeism, and emotional distress for both the child and family
Long-term management is crucial to prevent secondary infections, skin thickening (lichenification), and potential psychological sequelae
Effective maintenance therapy is key to achieving long-term control.
Clinical Presentation
Symptoms:
Intense pruritus, often worse at night
Dry, sensitive skin
Red, inflamed patches of skin
Oozing or crusting of affected areas
Skin thickening (lichenification) in chronic cases
Areas affected vary with age: infants typically present with facial and extensor involvement
older children show flexural pattern.
Signs:
Erythema
Edema
Excoriations due to scratching
Vesiculation in acute flares
Lichenification in chronic lesions
Scaling and dryness
Secondary infection signs like pustules or honey-colored crusts.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the Hanifin and Rajka criteria or the UK Working Party criteria
Key components include: presence of pruritus, typical morphology and distribution, chronic or relapsing course, personal or family history of atopy
Exclusion of other dermatoses is important.
Diagnostic Approach
History Taking:
Detailed history of symptom onset, duration, triggers (food, environmental allergens, irritants, stress), previous treatments and response, presence of associated atopic conditions (asthma, allergic rhinitis), family history of atopy, and impact on quality of life.
Physical Examination:
Systematic assessment of skin for characteristic lesions (erythema, dryness, excoriations, lichenification), distribution pattern according to age, and presence of secondary infection
Assessment of overall skin barrier integrity.
Investigations:
Generally not required for diagnosis in typical cases
Allergy testing (skin prick tests, specific IgE) may be considered in select patients with suspected trigger foods or environmental allergens if immunotherapy is contemplated, but is not routine for diagnosis or management of AD itself
Consider patch testing for contact dermatitis if suspicion arises.
Differential Diagnosis:
Differential diagnoses include: seborrheic dermatitis, allergic contact dermatitis, irritant contact dermatitis, scabies, fungal infections, nymphomania, pityriasis rosea, psoriasis
Features like itch severity, distribution, morphology, and response to therapy help differentiate.
Management
Initial Management:
Identify and avoid triggers (irritants, allergens)
Gentle skin care: lukewarm baths (short duration), mild non-soap cleansers, pat dry
Vigorous application of emollients immediately after bathing is crucial for skin barrier repair.
Medical Management:
Topical corticosteroids (TCS) are the cornerstone for flare treatment, with potency chosen based on age, location, and severity
Low to medium potency TCS for face and intertriginous areas
medium to high potency for trunk and limbs
Topical calcineurin inhibitors (TCIs) like tacrolimus and pimecrolimus are alternatives for sensitive areas or long-term maintenance, especially when steroids are a concern
Antihistamines (sedating at night for itch relief, non-sedating during the day)
Antibiotics for secondary infections.
Proactive Maintenance Therapy:
Application of emollients at least twice daily, even when skin appears clear, to maintain skin hydration and barrier function
Regular, intermittent use of low-potency TCS or TCIs on previously affected areas 2-3 times per week to prevent relapse
Education of parents on trigger avoidance and consistent application of topical therapies is vital
Once-weekly applications of emollients with TCS or TCIs on historically problematic areas have also shown efficacy.
Supportive Care:
Psychological support for child and family
Education on disease, treatment adherence, and trigger avoidance
Sleep hygiene measures
Wet wrap therapy for severe flares
Referral to specialists (allergist, dermatologist) if refractory or complex cases.
Complications
Early Complications:
Secondary bacterial infections (Staphylococcus aureus is common, presenting as worsening eczema, pustules, honey-crusted lesions)
Viral infections (eczema herpeticum, a disseminated herpes simplex infection, is a medical emergency)
Fungal infections.
Late Complications:
Lichenification and thickening of the skin
Post-inflammatory hyperpigmentation or hypopigmentation
Increased risk of asthma and allergic rhinitis (atopic march)
Psychological issues like anxiety and depression.
Prevention Strategies:
Strict adherence to proactive maintenance therapy with emollients and intermittent anti-inflammatory agents
Prompt treatment of secondary infections
Careful identification and avoidance of individual triggers
Education on signs of infection for early intervention.
Prognosis
Factors Affecting Prognosis:
Severity of disease at onset, presence of other atopic comorbidities, adherence to treatment, effectiveness of trigger avoidance, early and consistent management of flares and maintenance therapy
Genetic factors can influence disease persistence.
Outcomes:
Most children experience improvement or remission of AD by adolescence, but a significant proportion may have persistent disease or adult-onset AD
Long-term proactive management can significantly improve quality of life and reduce disease severity.
Follow Up:
Regular follow-up with a pediatrician or dermatologist is recommended, especially during childhood, to monitor disease activity, adjust treatment, reinforce education, and screen for associated atopic conditions
Frequency depends on disease severity, typically every 3-12 months.
Key Points
Exam Focus:
Proactive maintenance therapy is essential to prevent flares and improve quality of life
Key components include consistent emollient use and intermittent anti-inflammatory application (TCS or TCIs)
Recognize age-specific distribution patterns and common triggers
Understand the management of secondary infections and eczema herpeticum.
Clinical Pearls:
Emollients are not just moisturizers
they are a critical part of skin barrier repair therapy
Apply liberally and frequently, especially immediately after bathing
Topical corticosteroids should be used at the lowest effective potency and duration, but fear of their use should not lead to undertreatment
TCIs offer a steroid-sparing option for sensitive areas and maintenance
Always consider secondary infections in recalcitrant or worsening AD.
Common Mistakes:
Inconsistent emollient use
Inadequate use of topical corticosteroids (too weak, too short duration) leading to flares
Over-reliance on bathing without adequate moisturization
Failure to identify and manage secondary infections promptly
Neglecting the psychological impact on the child and family.