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Atopic dermatitis

Atopic dermatitis, a relapsing eczematous condition, is seen more commonly in infants and children. It is one of the most common types of eczema. Atopy translates to meaning “abnormal hypersensitivity”. It primarily occurs because of an overactive immune system. These changes in the immune system lead to inflammation of the skin, causing it to become dry and itchy with changes in skin colour. In atopic dermatitis, the protein filaggrin, which is responsible for maintaining the skin barrier, is affected because of genetic mutation, leading to a break in the skin barrier, thus predisposing these individuals to become itchy, and dry and vulnerable to infections. Note that ~50% of patients develop this condition by the first year of life and another 30% develop it within 1–5 years. Initially, it was considered that these children would outgrow this eczema by adolescence; however, because of changes in our lifestyle, atopic dermatitis is seen in adults.

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Types

As per the age when individuals are affected, atopic dermatitis is of the following types.


  • Infantile atopic dermatitis - This is primarily seen in infants. It occurs at the age of two months to four years.

  • Childhood atopic dermatitis - This occurs from early childhood and may continue till puberty. This type is known for its intense itching and progression to hard, eczematous lesions.

  • Adolescent and adult atopic dermatitis - The intensification of dermatitis-related symptoms characterizes it. Severe itching on the extremities and a speckled appearance on the neck and upper chest are observed.

Symptoms

Eczema may affect any area of your skin; however, it typically appears on the fold of the elbows and behind the knees. It tends to flare up and then subsides periodically. Excessive itching and redness of the skin are the primary symptoms that are observed.

The skin condition can be divided into three phases based on certain characteristic clinical features: infantile, childhood and adulthood phases. However, exact categorisation may be difficult at times because of overlapping features and they often do not follow the sequential evolution.

In infants, the cheeks and perioral areas (near the lips) are affected first, perhaps because of the dripping of saliva and smearing of liquid foods on these areas. As the infant crawls, the eczematous process tends to get localised to the hands and legs.

Itching may be intermittent but becomes worse by evening and night. Vigorous scratching can lead to skin abrasions and thickening in that area. Small, raised bumps may appear that leak fluid and form crust when scratched.

Childhood atopic dermatitis presents with plaques, cracks and intense itching of the skin.

Adolescent and adult atopic dermatitis is characterized by severe spread and enlargement of plaques, thinning of the eyebrow, intense redness on the face, a spotted appearance on the neck and upper chest, and intense itching on the extremities.

If atopic dermatitis becomes chronic, the skin may become thick and leathery. An extra skin fold below the lower eyelid may develop. Moreover, an additional number of skin creases on the palms may show up.

Affected skin is prone to secondary bacterial infection; hence, if there are signs of infection such as redness, yellow crust formation, and oozing of pus, a visit to the dermatologist is recommended.

Causes And Risk Factors

Causes


History of atopic dermatitis amongst family members is considered to be the primary risk factor for this disease. Moreover, the activation of the immune system, genetics, certain environmental triggering factors, and stress can cause atopic dermatitis.

Certain immune system changes that result in hyperactivity and hypersensitivity of the immune system lead to inflammatory changes in the skin because of the presence of minor allergens. Specific genetic changes such as the family history of dermatitis, susceptibility to allergies, or a mutation in genes, which results in deficiency of the protein filaggrin (which helps maintain skin barrier), can predispose an individual to atopic dermatitis. Triggering factors within the environment such as tobacco smoke, dry air, heat, or high humidity can worsen dryness and itchiness of the skin. Mental or physical stress can worsen one’s atopic dermatitis. Unlike other diseases, urbanisation and improved quality of life have contributed to the increased incidences of eczema.

Children with the early onset of atopic dermatitis can develop allergic rhinitis or asthma later.

Risk factors


Factors that aggravate atopic dermatitis are listed below:

  • Dry skin

  • Long, hot baths or showers

  • Stress

  • Excessive sweating

  • Rapid changes in temperature

  • Low humidity

  • Solvents, cleaners, soaps or detergents

  • Wool or man-made fabrics/clothing

  • Dust or sand

  • Smoking

  • Urbanisation


Certain foods such as eggs, milk, fish, soy or wheat, and shellfish

Prevention

Though atopic dermatitis is genetic, there are certain measures that can be taken to prevent atopic dermatitis.


  • Follow a skincare routine as recommended by your dermatologist.

  • Wear gloves when dealing with water-based activities.

  • Using a mild soap during the bath, pat dries rather than rubbing, and moisturizing skin two to three times can help prevent flares of atopic dermatitis.

  • Avoid showering with hot water.

  • Keep skin hydrated by consuming six to eight glasses of water a day.

  • Avoid performing activities that cause you to sweat too much.

  • Avoid wearing woollen clothes. Wearing clothes of cotton and natural fibres is beneficial in preventing atopic dermatitis. Remember to wash new clothes before using them.

  • Utilize stress reduction techniques such as yoga, meditation, getting a hobby, and exercising to prevent stress.

  • Identify irritants and allergens and avoid them.

  • In infants born to parents with an existing allergic condition, the liberal use of emollients has been seen to enhance their skin barrier function.

  • Maternal diet – The inclusion of oily fish in a pregnant mother’s diet has been found to have preventive benefits on infants who have a predisposition to atopy. Limiting the intake of meat can have beneficial effects on infants in preventing the risk of atopic dermatitis in them. Low intake of vitamin D during pregnancy can predispose infants to atopic dermatitis. Therefore, vitamin D supplementation will help.

  • Breastfeeding has been reported to reduce the risk of atopic dermatitis in infants till the age of four years.

  • Probiotic and prebiotic supplementation has been reported to be useful in preventing and reducing the occurrence of atopic dermatitis in infants.

Diagnosis

There is no diagnostic test for atopic dermatitis. The dermatologist will diagnose the condition based on medical, and family history and physical examination. However, it is found that serum IgE levels are elevated in such patients. A blood count can be performed to check their eosinophil cell count.

A Phadiatop test can be performed to determine to what the patient’s body is allergic to and those allergens should be avoided entirely.

A skin biopsy may be performed to distinguish different types of dermatitis and to confirm the diagnosis.

Many skin diseases such as psoriasis, ichthyosis, and seborrheic dermatitis, resemble atopic dermatitis. Hence, parents should visit a dermatologist when such symptoms appear.

Lifestyle/management

Because there is no cure for atopic dermatitis, certain lifestyle changes can help keep symptoms at bay.


  • Skincare - The application of moisturizers, emollients, non-alcohol based, non-fragrant lotions, keeping bath time to not >15 min, avoiding extreme temperatures while bathing and pat drying can help prevent flaring up of this disease.

  • Avoid common skin irritants such as paints, chemicals, soaps, detergents, alcohol-containing skin products, woollen or synthetic clothes, and cosmetics.

  • Maintaining a consistent temperature by minimizing outdoor activity, particularly during cold weather. Hydrating skin with moisturizers and wearing clothing that protects you from the sun can help. After exercising, avoid hot baths.

  • Limiting exposure to allergens - Identify allergens in your environment and avoid exposure to dust, pests, and animal dander. You should maintain a clean and dry home and work environment.

  • Identify and limit stressful situations - Utilize counselling, and relaxation techniques such as deep breathing and meditation; in fact, yoga can be helpful too.

  • Avoid scratching or rubbing - Moisturize skin to prevent itching sensation. Excess itching and scratching can lead to a thick, leather-like appearance of the skin; therefore, this should be minimized.


What to eat and What not to eat

There is no clear relation between atopic dermatitis and food. Identifying food allergies (evidenced by flaring up symptoms on the consumption of certain foods) is important. Certain foods such as dairy, peanuts, egg, and sugar are common allergic foods. However, if there are no food allergies identified, no foods will cause the flaring up of symptoms.

Prognosis And Complications

Prognosis


Atopic eczema is a chronic, relapsing condition; it cannot be cured. However, with appropriate lifestyle management techniques, preventive measures and medications, flare-ups of this disease can be minimized. Children who have atopic dermatitis will improve or outgrow it by puberty. A few may still persist in suffering from it. In adults, emphasis on good skincare is pertinent in the prevention of flare-ups.

Complications


Patients with this skin condition often have the following:

  • Viral infections (herpes simplex), bacterial infections and fungal infections.

  • Eyelid dermatitis (blepharitis), allergic conjunctivitis, and keratoconjunctivitis.

  • Hand eczema

  • Psychological problems such as depression are commonly observed.

Alternative Treatment

Note that before considering any alternative treatment for atopic dermatitis, the identification of triggering factors for your condition is essential.


  • Vitamin D intake has been reported to prevent atopic dermatitis in winter.

  • Coconut oil and sunflower oil have been reported to be useful in reducing symptoms of eczema.

  • Vitamin E foods or pills can be taken to reduce symptoms associated with atopic dermatitis.

  • Mind-body practices that aid in relaxation such as yoga, tai chi and qigong have been reported to be useful in reducing stress, lowering inflammation and distracting one from the constant feeling of itching.

  • Acupressure, which involves an application of a certain amount of pressure to special points on the body, has been reported to be helpful in relieving itching associated with atopic dermatitis and reducing the thick leathery skin, known as lichenification.


References



  1. Atopic Dermatitis. National Eczema Foundation. Available at: https://nationaleczema.org/eczema/types-of-eczema/atopic-dermatitis/. (https://nationaleczema.org/eczema/types-of-eczema/atopic-dermatitis/.)

  2. Shimizu. Textbook of Dermatology. Japan: Hoikaddo University Publications; 2006.p.98-101.

  3. Symptoms of Eczema. Winchester Hospital. Available at: https://www.winchesterhospital.org/health-library/article?id=19382. (https://www.winchesterhospital.org/health-library/article?id=19382)

  4. Eczema. Cleveland Clinic. Available at: https://my.clevelandclinic.org/health/diseases/9998-eczema. (https://my.clevelandclinic.org/health/diseases/9998-eczema)

  5. Williams HC, et al. NCBI. 2012;4(24): doi: 10.3410/M4-24
    Trikamjee T, et al. Frontiers in Pediatrics. 2021;8(577413):1-8.

  6. Lifestyle changes to manage eczema. Winchester Hospital. Available at: https://www.winchesterhospital.org/health-library/article?id=19375#:~:text=Apply%20emollients%20or%20moisturizers%20immediately,not%20as%20effective%20for%20moisturizing.  (https://www.winchesterhospital.org/health-library/article?id=19375#:~:text=Apply%20emollients%20or%20moisturizers%20immediately,not%20as%20effective%20for%20moisturizing)

  7. Complementary and Alternative Treatments. National Eczema Association. Available at: https://nationaleczema.org/eczema/treatment/complementary-and-alternative/.  (https://nationaleczema.org/eczema/treatment/complementary-and-alternative/)

  8. Eczema. Winchester Hospital. Available at: https://www.winchesterhospital.org/health-library/article?id=21529. (https://www.winchesterhospital.org/health-library/article?id=21529)

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