ATOPIC DERMATITIS

(INFANTILE AND CHILDHOOD ECZEMA)

 Atopic dermatitis, the most common cause of eczema
in childhood, is a highly pruritic chronic inflammatory skin
disorder affecting 10% to 20% of the pediatric population.
 It is an abnormal immune response to environmental
allergens in a genetically susceptible individual. This
individual tend to have dry skin and a lower threshold for
itching. Many children with atopic dermatitis have a personal
or family history of disorders in the atopic triad (allergic
rhinitis, asthma, and atopic dermatitis).
 Atopic dermatitis has a typical age-related morphology and
distribution and a chronic or chronically relapsing nature. It usually
starts after age 2 months. By age 5, 90% of patients who will develop
atopic dermatitis have already manifested the disease. The appearance
and location of the lesions change with age in a characteristic manner.
Atopic dermatitis usually improves or resolves by adolescence, but can
persist in some form throughout adulthood. Hand dermatitis is a
common finding in adults with a history of atopic dermatitis.
 Etiology
1. Although it has both immunologic and genetic components, the
etiology of atopic dermatitis is unknown.

2. Atopic dermatitis is known as the “itch that rashes”. The skin is dry and
becomes pruritic when exposed to common environmental allergens,
such as wool; occlusive synthetic fabrics, soaps, and detergents;
perspiration; extremes of temperature and humidity; and emotional
stress.

3. Food allergies contribute to atopic dermatitis in up to 30% of infants

and very young children with moderate to severe disease. Eggs, milk,
peanut, soy, wheat, tree nuts, fish and shellfish account for more than
90% of the reactions. The most common offender is eggs.
4. Most children outgrow their allergies to eggs, milk, wheat, and soy in
the first few years of life. Allergies to peanuts, tree nuts, fish and shellfish
are more likely to persist.

5. One-third to one-half of children with atopic dermatitis are allergic to

house dust mites, animal dander, weeds, and molds.

6. Children with atopic dermatitis are at increased risk for developing

allergic rhinitis or asthma.
 Clinical Manifestations

Atopic dermatitis is divided into three phases based on the age of

the patient and the distribution of the lesions. These are referred to as
the infant, childhood, and adult phases.
1. Infant (ages 2 months to 3 years):
a. The onset is between ages 2 and 6 months. One-half of affected
infants have spontaneous resolution by age 2 or 3.
b. Characterized by intense itching, erythema, papules, vesicles,
oozing, and crusting.
c. The rash usually begins on the cheeks, forehead, or scalp and
then extends to the trunk or extremities in scattered, often symmetric
patches. The perioral, perinasal, and diaper areas are usually spared.
2. Childhood (ages 4 to 10 years):
a. Affected people in this age-group are less likely to have exudative
and crusted lesions. Eruptions are characteristically more dry and papular and
commonly occur as circumscribed scaly patches. There is a greater tendency
toward chronicity and lichenification.
b. The typical areas of involvement are the face, including the perioral
and perinasal areas, neck, antecubital and popliteal fossae, wrists, and ankles.

3. Adult (puberty to old age):

a. Predominant areas of involvement include the flexor folds, face,
neck, upper arms, back, dorsa of the hands and feet, fingers, and toes.
b. The eruption appears as thick, dry lesions, confluent papules, and
large lichenified plaques. Weeping, crusting, and exudation can occur, but they
are usually the result of superimposed external irritation or infection.
 Clinical Appearance
Atopic dermatitis is also divided into three stages
based on the clinical appearance of the lesions. The acute,
subacute, and chronic stages can occur in infants, children
and adults.
1. Acute – moderate to intense erythema, vesicles, a wet surface, and severe
itching.

2. Subacute:
a. Erythema and scaling are present in various patterns with indistinct
borders. The redness may be faint or intense. The surface is dry. There are
varying degrees of pruritus.
b. The subacute stage may be an initial stage or may follow an acute
inflammation or exacerbation of a chronic stage. Irritation, allergy, or infection
can covert a subacute process into an acute one.

3. Chronic – the inflamed area thickens and the surface skin markings become
more prominent. Thick plaques with deep parallel skin markings are called
lichenified. Lichenification is the hallmark of chronic eczema. The surface of
the skin is dry and the border of the lesion well defined. There is moderate to
intense itching.
 TREATMENT
Acute
1. Open, wet dressings for 1 to 3 days.
2. Avoidance of known allergen or
trigger.
3. Management of secondary infection.
4. Topical corticosteroids. ADD A SLIDE TITLE - 5
5. Oral medications to relieve itching-
-hydroxyzine (Atarax),
-Diphenhydramine (Benadryl)
-or Promethazine (Phenergan)
 TREATMENT
Subacute and Chronic

1. Prevention of dry skin:

-Diminish the frequency and duration of
bathing
-Use mild soap or hydrophilic lotion
-Lubricate the skin with emollients
-Add tar preparations to the bath water
-Maintain environmental humidity above
40% during winter months.
2. Avoidance of known allergens or triggers.
3. Management of secondary infection.
4. Topical corticosteroids as described
above. Apply the least potent topical
corticosteroid that provides adequate
control.
5. Topical immunomodulators, also
called calcineurin inhibitors, are a new
class of drugs effective for the
treatment of atopic dermatitis.
a. Tacrolimus (Protopic) 0.03%
ointment and Pimecrolimus (Elidel) 1%
cream.
b. These agents do not cause skin
atrophy (which corticosteroids may
cause) and can be used on the face and
neck. However, they are expensive and
their long-term safety is unknown.
c. Active viral, bacterial, or fungal skin
infections must be cleared before use.
d. Topical immunomodulators should
be discontinued if lymphadenopathy of
unknown etiology develops.