Atopic Dermatitis:

Dr. Francisco Eizayaga, MD; PhD

 Atopic dermatitis is a chronic inflammation of the skin that occurs in

persons of all ages but is more common in children.
 The condition is characterized by intense pruritus and a course marked by
exacerbations and remissions.
 Atopic dermatitis has been reported to affect 10 percent of children.
 In the United States alone, it is estimated that more than $364 million per
year is spent on the treatment of childhood atopic dermatitis.
 Although the symptoms of atopic dermatitis resolve by adolescence in 50
percent of affected children, the condition can persist into adulthood.
 Poor prognostic features include a family history of the condition, early
disseminated infantile disease, female gender and coexisting allergic
rhinitis and asthma.

Diagnostic Features of Atopic Dermatitis*

Major features
Pruritus
Chronic or relapsing dermatitis
Personal or family history of atopic disease
Typical distribution and morphology of atopic dermatitis rash:
Facial and extensor surfaces in infants and young children
Flexure lichenification in older children and adults

Minor features
Eyes
Cataracts (anterior subcapsular)
Keratoconus
Infraorbital folds affected
Facial pallor
Palmar hyperlinearity
Xerosis
Pityriasis alba
White dermatographism
Ichthyosis
Keratosis pilaris
Nonspecific dermatitis of the hands and feet
Nipple eczema
Positive type I hypersensitivity skin tests
Propensity for cutaneous infections
Elevated serum IgE level
Food intolerance
Impaired cell-mediated immunity
Erythroderma
Early age of onset

The diagnosis of atopic dermatitis should be suspected if three major criteria

and three minor criteria are present.

Staphylococcal and streptococcal infections are common complications of

atopic lesions.

TABLE 2
Differential Diagnosis of Atopic Dermatitis

Seborrheic dermatitis
Psoriasis
Neurodermatitis
Contact dermatitis
Scabies
Systemic
Dermatitis herpetiformis
Dermatophyte infection
Immunodeficiency disorder
Cutaneous T-cell lymphoma

 When the disease starts in infancy, it's often called infantile eczema.
o The itchy rash is an oozing, crusting condition that occurs
mainly on the face and scalp, but patches can appear
anywhere.
o Because of the itch, children may rub their head, cheeks,
and other patches with a hand, a pillow, or anything within
reach. Many babies improve before two years of age.
 After infancy, the skin tends to be less red, blistering, oozing, or
crusting.
o Instead, the patches are dry, red to brownish-gray, and may
be scaly or thickened. The intense, almost unbearable
itching can continue, and may be most noticeable at night.
o Some patients scratch the skin until it bleeds and crusts.
When this occurs, the skin can get infected.
 In teens and young adults, the patches typically occur on the hands
and feet.
o Although these are the most common sites, any area such
as the bends of the elbows, backs of the knees, ankles,
wrists, face, neck, and upper chest may also be affected.
 Atopy: In 1923, Coca and Cooke coined the term "atopy" to describe
the clinical presentations of type I hypersensitivity, which they noted
in patients with asthma, hay fever, eczema, urticaria, and food
allergies. Recent immunologic advances render that definition
simplistic and imprecise.
 Lack of an updated official definition for this term may be the major
obstacle in reaching a consensus regarding the diagnosis of AD.
 Non-allergists recognize atopy in those patients with a family or
personal history of asthma, hay fever, or eczema; allergists recognize
atopy as an epiphenomena of immunologic aberrations, distinctive to
a genetically predisposed population.

The Characteristic clinical features of the eczema of AD

 1. Age of onset. Some 60% of patients develop AD within the first year of
life, 85% by age 5. Early onset often indicates a more severe course.

AD affects infants, children, and young adults predominantly.

2. Distribution. AD has been called the itch that erupts, rather than the
rash that itches. This statement is not quite true. In reality AD is the itch that,
when scratched, erupts. Patients with AD whose extremity is placed in a cast
for weeks do not develop eczema under the cast. Thus, scratching or rubbing
itchy, atopic skin characterizes this eczema as being isomorphic. Its
distribution is variable and age-related, with a distribution that corresponds to
areas of the body that are accessible to scratching and rubbing. Yet, the nose is
almost always spared and is referred to as the head-light sign. The diaper area
is usually spared.

3. Clinical appearance. The eczema is polymorphic, with acute (oozing,

or crusted, eroded microvesicles on papular, erythematous plaques), subacute
(thicker, paler, somewhat scaly, erythematous, excoriated plaques), and
chronic (lichenified, more scaly, hyperpigmented, excoriated, papular plaques)
forms.

4. Course. AD is a chronic dermatosis, characterized by exacerbations

and remissions. Most exacerbations can be attributed to one of the triggers of
itch.

Localized variants of AD: Separating localized variants of eczema of

AD seems unwarranted, because any eczema that itches in an atopic individual
should be considered part of the spectrum of AD. Localization merely
exemplifies the isomorphic response.

Eyelid dermatitis: Typically, atopic eyelid dermatitis presents as

symmetrical, pruritic, scaly erythematous or hyperpigmented, lichenified,
papulovesicular plaques that are usually first noted at the upper-medial aspect
of the eyelids. With continued scratching, the entire orbital skin becomes
involved. Scratching and rubbing often results in loss of eyelashes or
eyebrows,

Palmar and plantar dermatitis: Atopy has been reported to occur in up

to 57% of patients with juvenile palmar-plantar dermatosis.[113]
 Eczema on the palms and soles presents as a glistening erythema with
varying degrees of scaling and fissuring. Lichenification results from the
constant rubbing of the xerotic palmar and plantar skin. The dorsum of the
hands may or may not be similarly involved. The non-weight-bearing areas of
the soles and interdigital spaces are spared. Sparing of the interidigital spaces
should defer consideration of a possible dermatophytic infection. The
condition runs a chronically relapsing course with worsening in winter, but
persistent lesions are noted in approximately 40% of patients.[114]

Pityriasis alba: Presents as finely scaling, hypopigmented, poorly

demarcated, macular plaques. Initially the patches may be mildly inflamed;
histologically, spongiosis is noted. Sites of predilection include the face,
neck, and upper trunk. It has been reported to occur in 20%–44% of atopic
children, with or without other evidence of AD. These hypopigmented lesions
become more apparent after UV exposure. Mycologic evaluation is
occassionally warranted to rule out tinea versicolor or a dermatophytosis.

Cheilitis: Cheilitis is noted as a persistent scaliness, usually restricted to

the vermilion, but often extending onto the perioral skin. It often starts in the
winter during childhood and appears as dry scaly lips and often attributed to
frequent licking to hydrate the dryness.

Nipple dermatitis: Nipple dermatitis is noted in 12%–23% of patients

with AD. It is most common in postpubertal girls.

Infra-auricular, retro-auricular, and infranasal fissuring: In these

areas AD presents as an asymmetrical plaque of fine, scaly, excoriated,
macular and papular erythema with fissuring in the folds.

Vulvar dermatitis: Vulvar dermatitis presents as a circumscribed, scaly,

erythematous lichenification of the labia and pubic triangle. It is triggered by
the severe pruritus of the very sensitive skin.

Altered vascular reactivity: Although altered vascular reactivity is a

very characteristic feature of atopic individuals, it is almost always ignored.
This paradoxical vascular reactivity is common. Of AD patients, 50%–60%
have facial pallor, and up to 60% demonstrate white dermatographism, a
paradoxical vasoconstriction elicited by lightly stoking the skin (there is no
wheal formation).
Atopic Dermatitis- Repertory
SKIN; ERUPTIONS; eczema
SKIN; ERUPTIONS; eczema; chronic
SKIN; ERUPTIONS; papular
SKIN; ERUPTIONS; itching
SKIN; ERUPTIONS; scaly
SKIN; ERUPTIONS; scaly; bran, like
SKIN; ERUPTIONS; scaly; ichthyosis
SKIN; ERUPTIONS; scaly; scratching after
SKIN; ERUPTIONS; desquamating
SKIN; ERUPTIONS; discharging, moist
SKIN; ERUPTIONS; discharging, moist; honey, like infection on the skin by
staph or strep
SKIN; ERUPTIONS; discharging, moist; pus
SKIN; ERUPTIONS; discharging, moist; scratching, after
SKIN; ERUPTIONS; dry
SKIN; ERUPTIONS; vesicular
SKIN; ERUPTIONS; vesicular; burning
SKIN; ERUPTIONS; vesicular; itching
SKIN; ERUPTIONS; vesicular; scratching, after
EXTREMITIES; ERUPTION; Joints; bends of
EXTREMITIES; ERUPTION; Joints; bends of; eczema
EXTREMITIES; ERUPTION; Upper Limbs; itching
EXTREMITIES; ERUPTION; Upper Limbs; vesicles
EXTREMITIES; ERUPTION; Elbow; bend of; eczema
EXTREMITIES; ERUPTION; Elbow; bend of; itching
EXTREMITIES; ERUPTION; Elbow; bend of; vesicles
EXTREMITIES; ERUPTION; Wrist; eczema
EXTREMITIES; ERUPTION; Wrist; vesicles
EXTREMITIES; ERUPTION; Hand; eczema
EXTREMITIES; ERUPTION; Hand; itching
EXTREMITIES; ERUPTION; Hand; vesicles
EXTREMITIES; ERUPTION; Hand; back of hand; eczema
EXTREMITIES; ERUPTION; Hand; back of hand; vesicles
EXTREMITIES; ERUPTION; Fingers; eczema
EXTREMITIES; ERUPTION; Fingers; tips of; eczema
EXTREMITIES; ERUPTION; Lower Limbs; eczema
EXTREMITIES; ERUPTION; Knee; hollow of
EXTREMITIES; ERUPTION; Knee; hollow of; eczema
EXTREMITIES; ERUPTION; Leg; eczema
FACE; ERUPTIONS; eczema
FACE; ERUPTIONS; eczema; moist
FACE; ERUPTIONS; eczema; margins of hair
EYE; ERUPTIONS; about eyes
SKIN; ERUPTIONS; alternating with; asthma
RESPIRATION; ASTHMATIC; alternating with; eruptions
RESPIRATION; ASTHMATIC; eruptions; suppressed, after
RESPIRATION; ASTHMATIC; eruptions; with
SKIN; THICK; skin becomes, after scratching
SKIN; DRY
SKIN; ITCHING
SKIN; ITCHING; night
SKIN; ITCHING; bed, in
SKIN; ITCHING; warm, becoming
SKIN; ITCHING; warm, becoming; bed, in
SKIN; ITCHING; warmth amel.
SKIN; ERUPTIONS; washing; agg.
SKIN; ERUPTIONS; washing; agg.; cold water, in
SKIN; ERUPTIONS; washing; amel., warm
SKIN; ERUPTIONS; Winter; agg.
FACE; ERUPTIONS; Cracked lips, corners of mouth.
FACE; ERUPTIONS; eczema.
EYE; ERUPTIONS; around the.
EARS; ERUPTIONS; behind ears.
HEAD; ERUPTIONS; eczema.
GENITALIA MALE; ERUPTIONS; Eczema.
GENITALIA FEMALE; ERUPTIONS; Itching.

MATERIA MEDICA:

SULPHUR:
  The Sulphur patient has all sorts of eruptions, with
much itching, and some of them with discharge and
suppuration.
 So strong is this affinity of Sulphur far the skin that
it seems bent on pushing everything internal out on
the surface (Nash).

 The skin, even without any eruption, itches much,

itches from the warmth of the bed and from wearing
woolen clothing. Many times the Sulphur patient
cannot wear anything except silk or cotton.

 The warmth of the room will drive him to despair if

he cannot get at the itching part to scratch it. After
scratching there is burning with relief of the itching.
After scratching or after getting into the warmth of
the bed great white welts come out all over the body,
with much itching, and these he keeps on scratching
until the skin becomes raw, or until it burns, and
then comes a relief of the itching (Kent).

 The skin of a Sulphur patient ulcerates and

suppurates easily. The skin is rough and unhealthy.

 The whole face in Sulphur is covered at times with

patches of moist, scaly, itching, eczematous
eruptions. Eruptions in bend of joints and elbows.

 Excoriation, especially in folds

 Pruritus, especially from warmth, is evening, often

recurs in spring-time, in damp weather.

 The orifices of the body are red, as if pressed full of

blood. The lips are red as vermilion, ears very red;
eyelids red, anus red, urethra red (Nash).

 Alternating with rhinitis or asthma.

Modalities.—
  Aggravates: at rest, when standing, warmth in bed,
washing, bathing. Itching, burning; worse scratching
and washing.
o The Sulphur patient is aggravated from, bathing.
He dreads a bath. He does not bathe himself and
from his state in general he belongs to "the great
unwashed." He cannot take a bath without
catching "cold."(Kent).

o Ameliorates: in dry, warm weather, from drawing

up affected limbs.

Eruptions alternating with asthma or asthma after

supressed eruptions.

Sensations: Itch, burn and sting.

PSORINUM:

Psorinum strongly resemble Sulphur

Leading skin symptoms.

 Itching when the body becomes warm.

 Itching, intolerable in warmth of bed.

 Itching scratches until it bleeds.

 Itching between fingers and in bends of joints.

 Dry, scaly eruptions which disappear summers and

return winters (Nash).

 Offensiveness, foetid odors, foetid breath discharges

and oozing from the skin smelling like carrion

 Repeated outbreaks of eruptions.

 The patient dreads to be washed (Kent). Skin has a dirty dingy
look, as if the patient never washed, and the body has a filthy
smell even after a bath.

This remedy resembles Graphites in many points.

There is one valuable diagnostic difference between them,

although the remedies are so much alike, and that is that the
Graphites moisture from the eruption is glutinous or sticky and
not markedly so with Psorinum (Nash).

Modalities.-

 Worse, coffee; changes of weather, in hot sunshine,

from cold. Dread of least cold air or draft.
o In the skin: from bathing and from the warmth
of the bed. The skin itches when warm; itches
when wearing wool clothing. Itching when
warm in bed; he scratches until the part
becomes raw, and then it becomes scabby

 Better, heat, warm clothing, even in summer.

GRAPHITES:

 Rough, hard, persistent dryness of portions of skin

unaffected by eczema

 Eruptions, oozing out a sticky exudation, yellow like

honey.

 Rawness in bends of limbs, groins, neck, behind ears.

 Unhealthy skin; every little injury suppurates. Ulcers

discharging a glutinous fluid, thin and sticky.

 Swelling and induration of glands.

  Cracks in nipples, mouth, between toes, anus. Fissures
on ends of fingers.

 Constitutionally fat, similar to Calc.

 Modalities.—

o Worse, warmth, at night, during and after

menstruation. The patient is very sensitive to cold
and needs warm clothing; he is sensitive to the
cold in winter and to the heat in summer; he is
sensitive to a warm room and desires open air.

o Worse in a warm bed; complaints come on from

becoming cold or heated; the headaches are
worse in a warm room and better in the open air.

o Worse for anticipation, anger, grief, fright.

o Better, in the dark, from wrapping up.

MEZEREUM:

 Eczema; intolerable itching; worse in summer with erratic itch.

Vesicular eruptions.
 Chilliness with pruritus; worse in bed.

 Ulcers itch and burn, surrounded by vesicles and shining, fiery-red

areola.

 Eruptions ulcerate and form thick scabs under purulent matter exudes.
“Head covered with thick, leather-like crusts, under which thick, white
pus collects here and there, and glues the hair together” (Kent).

 The outer surfaces of the body are in a constant state of irritation;

nervous feelings, biting, tingling, itching, changing place from
scratching. Even when there is nothing to be seen, there is violent
 itching and the patient rubs and scratches until the part becomes raw
and then burns (Kent).

 Eruptions after vaccination

 Modalities:

o The Mez. patient is sensitive to warm air as far as the skin and
eruptions are concerned, but very sensitive to damp or cold
weather as to the neuralgias.

o After the eruptions have given place to internal manifestations,

the patient is chilly, sensitive to the changes of the weather,
worse in stormy weather.

o Worse after a bath, because he takes cold and his internal

complaints are aggravated. The eruptions are aggravated after
washing.

o The itching is aggravated from bathing in warm water.

o Better, open air.

o When the eruptions are not out, the skin is hot and he wants
something to cool it; he is better from cool water; there is simply
a redness at this time.

PETROLEUM:

 Eczemas, on scalp, behind ears, scrotum, anus, hands, feet, legs; hands
chap and bleed; all < in winter; get better in summer. (Nash).
 Vesicles which are isolated, tendency of the vesicles to form thick
yellow crusts, with considerable moisture. These vesicles break early.
Vesicles about the fingers, scrotum, face and scalp. Special tendency to
produce vesicular eruptions about the back of the neck.

 The skin is rough, ragged, exfoliates, cracks, bleeds; the tissues are
hardened, especially about the palms of the hands and nails.

 All eruptions itch violently. He can not rest until he scratches the skin
off, when the part becomes moist, bloody, raw and inflamed.
  The eruptions on the surface and the state of induration are like
Graphites, but the oozing in Petroleum is thin and watery, and in
Graphites it is gluey, honey like, sticky, viscid.

 Petroleum and Rhus are the most common remedies for eruptions on the
scrotum and genitals.

 Modalities.—

o Worse in damp weather, before and during a thunder-storm, in

winter, in contact with clothing.

o Better in warm air; dry weather. Skin eruptions become cured in

summer warm weather.

RHUS TOXICODENDRON:

 Large blisters form upon the skin either with or without erysipelas.
 The incessant itching is sometimes relieved by "scalding" the parts,
with water as hot as it is possible to bathe the parts in.

 Humid eczema with raw surfaces; excoriated; oozing much.

 Intolerable itching of the skin; tingling in the skin; eruptions burn and
itch violently; much moisture with eruptions upon the skin.

 Eczemas of the vesicular type are often cured by it; there is much
itching which is not greatly relieved by scratching.

 Modalities.—

o Worse, during sleep, cold, wet rainy weather and after rain; at
night, during rest; scratching the affected part.

o Better, warm, dry weather, motion; walking, change of position,

rubbing, warm applications, from stretching out limbs.
CALCAREA CARBONICA:

 Eczema capitis or milk crusts, in children of the Calcarea type.

Extending to face and behind the ears.
 The skin of the Calcarea subject is generally cold, soft and flabby. Skin
unhealthy; readily ulcerating, flaccid. Small wounds do not heal readily.

 The Calcarea patient is constitutionally fat, over-fat or strongly inclined

to obesity. The color of the skin is white, watery or chalky pale. Of
torpid disposition (especially children), sluggish or slow in its
movements.

 Head sweats profusely while sleeping, wetting pillow far around (Sil.,
Sanic.). Profuse perspiration, mostly on back of head and neck, or chest
and upper part of body (Sil.). Difficult and delayed dentition and open
fontanelles.

 Frequent upper respiratory symptoms, asthma.

o Modalities.--Worse, from exertion, mental or physical;

ascending; cold in every form; water, washing, moist air, wet
weather.

o Better, dry climate and weather; lying on painful side. Sneezing

(pain in head and nape).

More useful for seborrheic dermtitis

ARSENICUM ALBUM:

 Eczema alternating with rhinitis and asthma.

 The skin troubles of this remedy are mostly dry and scaly, and almost
always burning. Affections caused by suppressed exanthemata, also for
suppressed chronic eczema

 Eruption, papular, dry, rough, scaly; worse cold and scratching.

  Burning vesicles, confluent, aggravated at night and ameliorated from
heat.

 Itching aggravated by scratching.

 A general tendency to pick at roughened places in the skin until they

bleed.

 Very sensitive to cold.

 Modalities:

o Worse, wet weather, after midnight; from cold, cold drinks, or

food. Seashore.

o Better: from heat; warm drinks, warm applications.

MERCURIUS SOLUBILIS:

 Scurfy eruptions, vesicular eruptions, eruptions discharging pus (Kent).

 Almost constantly moist. Persistent dryness of the skin contra indicates
mercury (Boericke).

 Vesicles burn and smart, with excoriating discharges, especially on the

head. Crusta lactea; yellowish-brown crusts, considerable suppuration.
Fissures at commissures, at the corners of the mouth and eyes

 Itching of the skin, violent, in all parts of the body, as from fleas,
especially when warm in bed at night.

 Rawness between the thighs and between the scrotum and thighs;
rawness and bleeding of the perineum rendering walking difficult.

 Deep cracks in hands, fingers and joints, bleeding. Worse in winter.

 Modalities.
 o Worse, at night, wet, damp weather, perspiring; warm room and
warm bed.

o With: Excessive odorous viscid perspiration; worse, night.

General tendency to free perspiration, but patient is not relieved
thereby.

SEPIA:

 Sepia, like Sulphur, has many forms of eruption on the skin, and indeed
there is great general resemblance between these two antipsorics. They
follow each other well (Nash).
 Itching often changes to burning when scratching (Sulph.). Soreness of
skin; humid places in bend of knees.

 Itching; not relieved by scratching. Redness, smarting and burning.

 Ichthyosis with offensive odor of skin

 Modalities.—

o Worse: forenoons and evenings; washing, laundry-work,

dampness, after sweat; cold air, before thunder-storm. Itch
aggravated for the warmth of bed.

o Better, by exercise, pressure, warmth of bed, hot applications,

drawing limbs up, cold bathing, after sleep.

DULCAMARA:

 It is a wonderfully eruptive medicine, producing vesicles, crusts, dry,

brown crusts, humid crusts, herpes. Dulcamara produces eruptions so
nearly like impetigo that it has been found a useful remedy in that
condition. i.e., multiple little boil-like eruptions; it produces little boils,
and the boils spread (Kent).
 Eruptions upon the scalp, like crusta lactea or thick, brown-yellow
crusts . Extreme soreness, itching, and the itching is not relieved by
 scratching, and the scratching goes on, until bleeding - and rawness take
place.

 Pruritus, always worse in cold, wet weather

 Humid eruptions on face, genitals, hands, etc, suppurating after

scratching.

 Modalities:

o Worse, at night; from cold in general, damp, rainy weather. Itch

aggravated from cold.

o Better, from external warmth.

OLEANDER:

 Nocturnal burning. Very sensitive skin; slightest friction causes

soreness and chapping. Violent itching eruption, bleeding, oozing; want
of perspiration. Pruritus, especially of scalp, which is sensitive.
 Corrosive itching, most on occiput and behind ears, on beginning to
scratch, but then it burns and smarts which soon passes into biting and
eating, on undressing.

 Corrosive itching on forehead and edge of hair; worse, heat.

 Humid, fetid spots behind ears (Graph; Petrol).

 Modalities.--Worse, undressing, rest, friction of clothes.

MORGAN PURE:

 Congestion of the skin with itching eruption, worse from heat.

 The type of eruption which characterises this can be ascertained from a
study of the "provings" of well known skin remedies found among the
list of remedies associated with the Bacillus Morgan, e. g. Sulphur,
Graphites, Petroleum and Psorinum.
NATRUM MURIATICUM:

 Greasy, oily, especially on hairy parts.

 Dry eruptions, especially on margin of hairy scalp and bends of joints

 Itch and burn.

 Crusty eruptions in bends of limbs, margin of scalp, behind ears

 Eczema; raw, red, and inflamed; worse, eating salt, at seashore.

PULSATILLA:

 Itchy eruptions with characteristics similar to Sulph. Worse at night and

in the evening and for warmth.
 Scratches until the skin is raw.

 Itch aggravated when undressing.