Atopic Dermatitis or Eczema

Atopic Dermatitis or Eczema is a common rash that often affects young children beginning in their first year of life. The rash is very itchy, often scaling and red and usually symmetrical. It can affect the scalp, arms, legs and trunk. As the child grows, the rash will often prominently affect the folds between the bends of the arm and forearm and the skin along the back of the knee (bend of the knee). The rash may be mild, or the skin can break down and weep and crust, or over time areas of the skin can become thick and darkly pigmented and leather like (lichenified) from chronic scratching. Although most children will outgrow the rash of atopic dermatitis as they get older, a small percent of children will retain some elements of symptoms as teenagers and even adults. For example, many women who suffer from hand dermatitis have a history of childhood eczema.

Many individuals with atopic dermatitis have a family history of eczema, allergy, asthma and other allergic diseases. Most have dry sensitive skin. The IgE level is often elevated. Symptoms may be triggered by food, wool or rough clothing, heat and sweating, or exposure to harsh soaps/detergents.

The underlying cause of atopic dermatitis is very sensitive or irritable skin with a tendency toward dryness and micro cracks. When the skin breaks down it can become infected by the common resident bacteria, staphylococcus aureus. Some individuals actually develop allergy antibodies to staph aureus, thus compounding the problem.

Treatment for Atopic Dermatitis

Treatment begins with avoidance of irritants and triggers, along with moisturizing to prevent drying of the skin and anti-inflammatory treatment to suppress the disease process from flaring.

In general bathing should be limited to once a day in lukewarm water for a brief period of time using a gentle nonirritating soap. Avoid irritating the skin with over soaping or unnecessary rubbing of the sensitive skin with a wash cloth. Gentle nondrying, nonirritating soaps include Dove, Aveeno, Basis, Eucerin, Alpha Keri and Neutrogena. Soapless cleansers such as Cetaphil or Aquanil are alternative for those too sensitive to use soap. After bathing, pat dry with a double rinsed soft towel, and quickly apply moisturizer to trap moisture in the skin in order to retain hydration.

Common moisturizers include: Eucerin, Cetaphil moisturizer, Aquaphor and Vaseline.
Inflamed patches of eczema can then be treated with topical corticosteroids. Using antihistamines will often suppress itching.

Avoiding wool, rough clothing, overheating and sweating helps prevent unnecessary worsening of the rash. Finally exposure to allergens and irritants based on observation including effects of foods, direct contact with pets, grass, dust, etc. can also be effective in preventing flares of eczema.

Young children often damage their skin by vigorous scratching. This can be controlled in part by cutting nails short and filing down rough edges. Infants and young children with severe night itching may benefit from movement limitation by the use of arm boards and/or gloves which will limit the ability to scratch themselves.

Creams contain medicine in a water soluble base, while ointments are more petrolatum based and occlusive, leading to a longer contact of medication with the skin and therefore greater penetration. For even greater penetration, an occlusive dressing (non permeable wrap) can be applied over the topical cream or ointment and kept in place over night.

Corticosteroid creams and ointments (triamcinalone, Lidex, Acclovate) are the mainstays for treatment of inflamed skin in individuals with atopic dermatitis. They come in varying potencies from mild to very strong. A thin coat of the corticosteroid should be applied twice a day and well rubbed in to the affected skin. For lichenified skin the more potent corticosteroid ointments should be used.

The chronic use of topical steroids can lead to changes in skin pigment, atropy to the skin as well as the side effects of systemic absorption.

Severe itching may be tempered with the addition of a topical antihistamine cream such as Doxepin up to 4 times per day. This medication can lead to downiness in some individuals.

Alternatives to topical corticosteroids are Protopic and Elidel which are applied twice a day. Because the FDA has issued a warning about the development of a form of cancer in animal models from these products, the use of these medications should be reserved for those that have failed the use of corticosteroid creams.

For Acute Weeping lesions that are inflamed and often covered in crusting exudates of infecting bacteria, it is recommended that debris be removed with gauze pads soaked in saline or Domeboro solution or by soaking the area in colloidal oatmeal (Aveeno). Bathing or soaking in wet dressing for up to 30 minutes will usually remove the crusting and bacteria leaving a clean lesion that can be treated with corticosteroids and antibiotics. Open lesions can be protected with gauze dressing. Arm boards and restraints can be placed on infants at night to prevent further damage to the lesions. Potent topical steroids are helpful in suppressing inflammation, however in severe or generalized flares of atopic dermatitis, systemic administration or corticosteroids may be required.

Evidence of systemic infection can be treated with anti-staphylococcus antibiotics such as dicloxacillin or some cephalolosporins. Oral steroids may also be required in severe flares. As the lesions begin to heal, potent topical corticosteroids are gradually tapered over a number of weeks to less potent steroids. Eventually individuals can be weaned off of these medications when lesions heal and itching is controlled. The use of oral antihistamines including hydroxyzine and Zyrtec can be helpful in controlling itching.

Complications

Individuals with atopic dermatitis appear to have some defects in their cellular immune system with a weakness in their defense against certain viruses including herpes and small pox. As a result individuals with atopic dermatitis should avoid direct contact with anyone with an active herpes infection (cold sore) and small pox and avoid small pox vaccination should they become available in the future.

Herpes infection in eczema can spread like wild fire and is know as Eczema Herpeticum which can be fatal. Treatment with Acyclovir is usually successful.