Basic
information about atopic dermatitis or eczema
Atopy is a term that was introduced years ago to describe
a group of patients who have a personal or family history of
one or more of the following conditions: hay fever (allergic
rhinitis), asthma, dry skin, and eczema. Atopic dermatitis a
type of eczema that is itchy, recurrent, chronic, and occurs
on both sides of the body symmetrically. Atopic dermatitis
causes the skin to become inflamed with redness, swelling,
cracking, weeping, crusting, and scaling.
Atopic Dermatitis Facts
- More than 15 million people in the United States have
symptoms of atopic dermatitis Atopic dermatitis occurs in 5-25
per 1000 people
- Up to 15 % of population may suffer from atopic dermatitis
during childhood
- Males and females are affected equally
- Atopic dermatitis accounts for 10%-20% of referrals to
dermatologists
65% of people who have atopic dermatitis develop symptoms in
the first year of life and 90% develop symptoms before age 5
- People who live in urban areas or low-humidity climates
have a higher risk of atopic dermatitis
Atopic Dermatitis - A Recurrent Condition
Atopic dermatitis most often affects infants and young
children, but it can continue later into life.
An important aspect of atopic dermatitis is its recurrent,
waxing and waning course. Children with atopic dermatitis go
through remissions and progressions. As many children get older,
the frequency and severity of the symptoms decrease until the
condition seems to be gone. However, the skin of a person with a
history of atopic dermatitis as a child often stays dry and is
easily irritated. Environmental factors can bring the symptoms
back at any time in the life of a person with a history of
atopic dermatitis.
Atopic Dermatitis - Itch-Scratch Cycle
People with atopic dermatitis develop the itch-scratch
cycle. The skin itches causing the person to scratch. People
with atopic dermatitis seem to be more sensitive to itching and
need to scratch longer. This scratching and rubbing actually
irritate the skin more and make the inflammation worse. This
causes more itching and more scratching. This cycle continues
while the person is asleep. The itching also gets more
noticeable at night as outside stimuli decrease.
Atopic Dermatitis Cause
Cause of atopic dermatitis is not known, but is believed to
be a combination of environmental and genetic factors. There may
be a relationship between hay fever, asthma, and atopic
dermatitis. Stress can make the symptoms worse but do not cause
the disease. Atopic dermatitis is not contagious. There may be a
defect in a bone marrow-derived cell that causes a variety of
skin and generalized immune abnormalities.
Atopic Dermatitis Skin Changes
In normal skin the outer layer of the epidermis, the
stratum corneum, contains dry, dead, flattened skin cells that
form a barrier protecting the other layers from irritants and
keeping them moist. People with atopic dermatitis loose too much
moisture from the outer layer causing the skin to dry and crack,
thus decreasing the skin's protective ability. A person with
atopic dermatitis is more susceptible to recurring infections
like bacterial infections, warts, herpes simplex, and molluscum
contagiousum.
Atopic Dermatitis Symptoms
The type of rash and its location in atopic dermatitis is
different for different age groups. In infants the rash is most
often seen on the trunk, face, and extensor surfaces. The rash
consists of papules and vesicles that develop into oozing,
crusting blisters. In children the rash is seen on extensor
surfaces, but also in the bend of the arm and behind the knees.
The skin is dry and bumpy with scaly patches. In older children,
adolescents, and adults the rash is seen on the face, neck,
flexor surfaces, hands, and feet, but the skin is dry and thick.
Source: About Health
Atopic Dermatitis information for the patient
Defining Atopic Dermatitis
Atopic dermatitis is a chronic (long-lasting) disease that
affects the skin. It is not contagious; it cannot be passed from
one person to another. The word "dermatitis" means inflammation
of the skin. "Atopic" refers to a group of diseases where there
is often an inherited tendency to develop other allergic
conditions, such as asthma and hay fever. In atopic dermatitis,
the skin becomes extremely itchy. Scratching leads to redness,
swelling, cracking, "weeping" clear fluid, and finally, crusting
and scaling. In most cases, there are periods of time when the
disease is worse (called exacerbations or flares) followed by
periods when the skin improves or clears up entirely (called
remissions). As some children with atopic dermatitis grow older,
their skin disease improves or disappears altogether, although
their skin often remains dry and easily irritated. In others,
atopic dermatitis continues to be a significant problem in
adulthood.
Although atopic dermatitis may occur at any age, it
most often begins in infancy and childhood.
Atopic dermatitis is often referred to as "eczema," which is
a general term for the several types of inflammation of the
skin. Atopic dermatitis is the most common of the many types of
eczema. Several have very similar symptoms. Types of eczema are
described in the box on page 5.
Incidence and Prevalence of Atopic Dermatitis
Atopic dermatitis is very common. It affects males and
females and accounts for 10 to 20 percent of all visits to
dermatologists (doctors who specialize in the care and treatment
of skin diseases). Although atopic dermatitis may occur at any
age, it most often begins in infancy and childhood. Scientists
estimate that 65 percent of patients develop symptoms in the
first year of life, and 90 percent develop symptoms before the
age of 5. Onset after age 30 is less common and is often due to
exposure of the skin to harsh or wet conditions. Atopic
dermatitis is a common cause of workplace disability. People who
live in cities and in dry climates appear more likely to develop
this condition.
More than 15 million people in the U.S. have
symptoms of atopic dermatitis.
Although it is difficult to identify exactly how many
people are affected by atopic dermatitis, an estimated 20
percent of infants and young children experience symptoms of the
disease. Roughly 60 percent of these infants continue to have
one or more symptoms of atopic dermatitis in adulthood. This
means that more than 15 million people in the United States have
symptoms of the disease.
Types of Eczema (Dermatitis)
Allergic contact eczema (dermatitis): a red, itchy, weepy
reaction where the skin has come into contact with a substance
that the immune system recognizes as foreign, such as poison ivy
or certain preservatives in creams and lotions
Atopic dermatitis: a chronic skin disease
characterized by itchy, inflamed skin
Contact eczema: a localized reaction that includes redness,
itching, and burning where the skin has come into contact with
an allergen (an allergy-causing substance) or with an irritant
such as an acid, a cleaning agent, or other chemical
Dyshidrotic eczema: irritation of the skin on the palms of
hands and soles of the feet characterized by clear, deep
blisters that itch and burn
Neurodermatitis: scaly patches of the skin on the head,
lower legs, wrists, or forearms caused by a localized itch (such
as an insect bite) that become intensely irritated when
scratched
Nummular eczema: coin-shaped patches of irritated skin-most
common on the arms, back, buttocks, and lower legs-that may be
crusted, scaling, and extremely itchy
Seborrheic eczema: yellowish, oily, scaly patches of skin on
the scalp, face, and occasionally other parts of the body
Stasis dermatitis: a skin irritation on the lower legs,
generally related to circulatory problems
Cost of Atopic Dermatitis
In a recent analysis of the health insurance records of 5
million Americans under age 65, medical researchers found that
approximately 2.5 percent had atopic dermatitis. Annual
insurance payments for medical care of atopic dermatitis ranged
from $580 to $1,250 per patient. More than one-quarter of each
patient's total health care costs were for atopic dermatitis and
related conditions. The researchers project that U.S. health
insurance companies spend more than $1 billion per year on
atopic dermatitis.
Causes of Atopic Dermatitis
The cause of atopic dermatitis is not known, but the
disease seems to result from a combination of genetic
(hereditary) and environmental factors.
Children are more likely to develop this disorder if one or
both parents have had it or have had allergic conditions like
asthma or hay fever. While some people outgrow skin symptoms,
approximately three-fourths of children with atopic dermatitis
go on to develop hay fever or asthma. Environmental factors can
bring on symptoms of atopic dermatitis at any time in
individuals who have inherited the atopic disease trait.
Atopic dermatitis is also associated with malfunction of the body s
immune system.
Atopic dermatitis is also associated with malfunction of the
body's immune system: the system that recognizes and helps fight
bacteria and viruses that invade the body. Scientists have found
that people with atopic dermatitis have a low level of a
cytokine (a protein) that is essential to the healthy function
of the body's immune system and a high level of other cytokines
that lead to allergic reactions. The immune system can become
misguided and create inflammation in the skin even in the
absence of a major infection. This can be viewed as a form of
autoimmunity, where a body reacts against its own tissues.
In the past, doctors thought that atopic dermatitis was
caused by an emotional disorder. We now know that emotional
factors, such as stress, can make the condition worse, but they
do not cause the disease.
Skin Features of Atopic Dermatitis
- Atopic pleat (Dennie-Morgan fold): an extra fold of skin
that develops under the eye
- Cheilitis: inflammation of the skin on and around the
lips
- Hyper linear palms: increased number of skin creases on
the palms
- Hyper pigmented eyelids: eyelids that have become darker
in colour from inflammation or hay fever
- Ichthyoids: dry, rectangular scales on the skin
- Keratosis pilaris: small, rough bumps, generally on the
face, upper arms, and thighs
- Lichenification: thick, leathery skin resulting from
constant scratching and rubbing
- Papules: small raised bumps that may open when scratched
and become crusty and infected
- Urticaria: hives (red, raised bumps) that may occur
after exposure to an allergen, at the beginning of flares,
or after exercise or a hot bath
Symptoms of Atopic Dermatitis
Symptoms (signs) vary from person to person. The most common
symptoms are dry, itchy skin and rashes on the face, inside the
elbows and behind the knees, and on the hands and feet. Itching
is the most important symptom of atopic dermatitis. Scratching
and rubbing in response to itching irritates the skin, increases
inflammation, and actually increases itchiness. Itching is a
particular problem during sleep when conscious control of
scratching is lost.
The most common symptoms are dry, itchy skin and
rashes on the face, inside the elbows and behind the knees,
and on the hands and feet.
The appearance of the skin that is affected by atopic
dermatitis depends on the amount of scratching and the
presence of secondary skin infections. The skin may be red
and scaly, be thick and leathery, contain small raised
bumps, or leak fluid and become crusty and infected. The box
on page 8 lists common skin features of the disease. These
features can also be found in people who do not have atopic
dermatitis or who have other types of skin disorders.
Atopic dermatitis may also affect the skin around the eyes,
the eyelids, and the eyebrows and lashes. Scratching and
rubbing the eye area can cause the skin to redden and swell.
Some people with atopic dermatitis develop an extra fold of
skin under their eyes. Patchy loss of eyebrows and eyelashes
may also result from scratching or rubbing.
Researchers have noted differences in the skin of people
with atopic dermatitis that may contribute to the symptoms
of the disease. The outer layer of skin, called the
epidermis, is divided into two parts: an inner part
containing moist, living cells, and an outer part, known as
the horny layer or stratum corneum, containing dry,
flattened, dead cells. Under normal conditions the stratum
corneum acts as a barrier, keeping the rest of the skin from
drying out and protecting other layers of skin from damage
caused by irritants and infections. When this barrier is
damaged, irritants act more intensely on the skin.
Atopic dermatitis may also affect the skin around the eyes, the
eyelids, and the eyebrows and lashes.
The skin of a person with atopic dermatitis loses moisture
from the epidermal layer, allowing the skin to become very
dry and reducing its protective abilities. Thus, when
combined with the abnormal skin immune system, the person's
skin is more likely to become infected by bacteria (for
example, Staphylococcus and Streptococcus) or viruses, such
as those that cause warts and cold sores.
Stages of Atopic Dermatitis
When atopic dermatitis occurs during infancy and childhood,
it affects each child differently in terms of both onset and
severity of symptoms. In infants, atopic dermatitis typically
begins around 6 to 12 weeks of age. It may first appear around
the cheeks and chin as a patchy facial rash, which can progress
to red, scaling, oozing skin. The skin may become infected. Once
the infant becomes more mobile and begins crawling, exposed
areas, such as the inner and outer parts of the arms and legs,
may also be affected. An infant with atopic dermatitis may be
restless and irritable because of the itching and discomfort of
the disease. The skin may improve by 18 months of age, although
the infant has a greater than normal risk of developing dry skin
or hand eczema later in life.
In childhood, the rash tends to occur behind the knees and
inside the elbows; on the sides of the neck; around the mouth;
and on the wrists, ankles, and hands. Often, the rash begins
with papules that become hard and scaly when scratched. The skin
around the lips may be inflamed, and constant licking of the
area may lead to small, painful cracks in the skin around the
mouth.
In some children, the disease goes into remission for a long
time, only to come back at the onset of puberty when hormones,
stress, and the use of irritating skin care products or
cosmetics may cause the disease to flare.
It is also possible for the disease to show up
first in adulthood.
Although a number of people who developed atopic dermatitis
as children also experience symptoms as adults, it is also
possible for the disease to show up first in adulthood. The
pattern in adults is similar to that seen in children; that is,
the disease may be widespread or limited to only a few parts of
the body. For example, only the hands or feet may be affected
and become dry, itchy, red, and cracked. Sleep patterns and work
performance may be affected, and long-term use of medications to
treat the atopic dermatitis may cause complications. Adults with
atopic dermatitis also have a predisposition toward irritant
contact dermatitis, where the skin becomes red and inflamed from
contact with detergents, wool, friction from clothing, or other
potential irritants. It is more likely to occur in occupations
involving frequent hand washing or exposure to chemicals. Some
people develop a rash around their nipples. These localized
symptoms are difficult to treat. Because adults may also develop
cataracts, the doctor may recommend regular eye exams.
Diagnosing Atopic Dermatitis
Each person experiences a unique combination of symptoms,
which may vary in severity over time. The doctor will base a
diagnosis on the symptoms the patient experiences and may need
to see the patient several times to make an accurate diagnosis
and to rule out other diseases and conditions that might cause
skin irritation. In some cases, the family doctor or
paediatrician may refer the patient to a dermatologist (doctor
specializing in skin disorders) or allergist (allergy
specialist) for further evaluation.
A medical history may help the doctor better understand the
nature of a patient's symptoms, when they occur, and their
possible causes. The doctor may ask about family history of
allergic disease; whether the patient also has diseases such as
hay fever or asthma; and about exposure to irritants, sleep
disturbances, any foods that seem to be related to skin flares,
previous treatments for skin-related symptoms, and use of
steroids or other medications. A preliminary diagnosis of atopic
dermatitis can be made if the patient has three or more features
from each of two categories: major features and minor features.
Some of these features are listed in the box on page 14.
Currently, there is no single test to diagnose
atopic dermatitis.
Currently, there is no single test to diagnose atopic
dermatitis. However, there are some tests that can give the
doctor an indication of allergic sensitivity.
Pricking the skin with a needle that contains a
small amount of a suspected allergen may be helpful in
identifying factors that trigger flares of atopic dermatitis.
Negative results on skin tests may help rule out the possibility
that certain substances cause skin inflammation. Positive skin
prick test results are difficult to interpret in people with
atopic dermatitis because the skin is very sensitive to many
substances, and there can be many positive test sites that are
not meaningful to a person's disease at the time. Positive
results simply indicate that the individual has (allergic)
antibodies to the substance tested. (immunoglobulin E) controls
the immune system's allergic response and is often high in
atopic dermatitis.
Recently, it was shown that if the quantity of
antibodies to a food in the blood is above a certain level, it
is diagnostic of a food allergy. If the level of a specific food
does not exceed the level needed for diagnosis but a food
allergy is suspected, a person might be asked to record
everything eaten and note any reactions. Physician-supervised
food challenges (that is, the introduction of a food) following
a period of food elimination may be necessary to determine if
symptomatic food allergy is present. Identifying the food
allergen may be difficult when a person is also being exposed to
other possible allergens at the same time or symptoms may be
triggered by other factors, such as infection, heat, and
humidity.
- Major and Minor Features of Atopic Dermatitis
- Major Features
- Intense itching
- Characteristic rash in locations typical of the disease
- Chronic or repeatedly occurring symptoms
- Personal or family history of atopic disorders (eczema,
hay fever, asthma)
- Some Minor Features
- Early age of onset
- Dry skin that may also have patchy scales or rough bumps
- High levels of immunoglobulin E (IgE), an antibody, in
the blood
- Numerous skin creases on the palms
- Hand or foot involvement
- Inflammation around the lips
- Nipple eczema
- Susceptibility to skin infection
- Positive allergy skin tests
Factors That Make Atopic Dermatitis Worse
Many factors or conditions can make symptoms of atopic
dermatitis worse, further triggering the already overactive
immune system, aggravating the itch-scratch cycle, and
increasing damage to the skin. These factors can be broken down
into two main categories: irritants and allergens. Emotional
factors and some infections and illnesses can also influence
atopic dermatitis.
Irritants are substances that directly affect the
skin and, when present in high enough concentrations with long
enough contact, cause the skin to become red and itchy or to
burn. Specific irritants affect people with atopic dermatitis to
different degrees. Over time, many patients and their family
members learn to identify the irritants causing the most
trouble. For example, frequent wetting and drying of the skin
may affect the skin barrier function. Also, wool or synthetic
fibres and rough or poorly fitting clothing can rub the skin,
trigger inflammation, and cause the itch-scratch cycle to begin.
Soaps and detergents may have a drying effect and worsen
itching, and some perfumes and cosmetics may irritate the skin.
Exposure to certain substances, such as solvents, dust, or sand,
may also make the condition worse. Cigarette smoke may irritate
the eyelids. Because the effects of irritants vary from one
person to another, each person can best determine what
substances or circumstances cause the disease to flare.
Allergens are substances from foods, plants,
animals, or the air that inflame the skin because the immune
system overreacts to the substance. Inflammation occurs even
when the person is exposed to small amounts of the substance for
a limited time. Although it is known that allergens in the air,
such as dust mites, pollens, moulds, and dander from animal hair
or skin, may worsen the symptoms of atopic dermatitis in some
people, scientists aren't certain whether inhaling these
allergens or their actual penetration of the skin causes the
problems. When people with atopic dermatitis come into contact
with an irritant or allergen they are sensitive to,
inflammation-producing cells become active. These cells release
chemicals that cause itching and redness. As the person responds
by scratching and rubbing the skin, further damage occurs.
Common Irritants that lead to dermatitis
- Wool or synthetic fibres
- Soaps and detergents
- Some perfumes and cosmetics
- Substances such as chlorine, mineral oil, or solvents
- Dust or sand
- Cigarette smoke
A number of studies have shown that foods may trigger
or worsen atopic dermatitis in some people, particularly infants
and children. In general, the worse the atopic dermatitis and
the younger the child, the more likely food allergy is present.
An allergic reaction to food can cause skin inflammation
(generally an itchy red rash), gastrointestinal symptoms
(abdominal pain, vomiting, diarrhoea), and/or upper respiratory
tract symptoms (congestion, sneezing, and wheezing). The most
common allergenic (allergy-causing) foods are eggs, milk,
peanuts, wheat, soy, and fish. A recent analysis of a large
number of studies on allergies and breastfeeding indicated that
breastfeeding an infant for at least 4 months may protect the
child from developing allergies. However, some studies suggest
that mothers with a family history of atopic diseases should
avoid eating common allergenic foods during late pregnancy and
breastfeeding.
In addition to irritants and allergens, emotional
factors, skin infections, and temperature and climate play a
role in atopic dermatitis. Although the disease itself is not
caused by emotional factors, it can be made worse by stress,
anger, and frustration. Interpersonal problems or major life
changes, such as divorce, job changes, or the death of a loved
one, can also make the disease worse.
Bathing without proper moisturizing afterward is a
common factor that triggers a flare of atopic dermatitis. The
low humidity of winter or the dry year-round climate of some
geographic areas can make the disease worse, as can overheated
indoor areas and long or hot baths and showers. Alternately
sweating and chilling can trigger a flare in some people.
Bacterial infections can also trigger or increase the severity
of atopic dermatitis. If a patient experiences a sudden flare of
illness, the doctor may check for infection.
Treatment of Atopic Dermatitis
Treatment is more effective when a partnership develops that
includes the patient, family members, and doctor. The doctor
will suggest a treatment plan based on the patient's age,
symptoms, and general health. The patient or family member
providing care plays a large role in the success of the
treatment plan by carefully following the doctor's instructions
and paying attention to what is or is not helpful. Most patients
will notice improvement with proper skin care and lifestyle
changes.
Treatment is more effective when a partnership
develops that includes the patient, family members, and
doctor.
The doctor has two main goals in treating atopic dermatitis:
healing the skin and preventing flares. These may be
assisted by developing skin care routines and avoiding
substances that lead to skin irritation and trigger the
immune system and the itch-scratch cycle. It is important
for the patient and family members to note any changes in
the skin's condition in response to treatment, and to be
persistent in identifying the treatment that seems to work
best.
Medications: New medications known as immuno-modulators have
been developed that help control inflammation and reduce
immune system reactions when applied to the skin. Examples
of these medications are tacrolimus ointment (Protopic*) and
pimecrolimus cream (Elidel). They can be used in patients
older than 2 years of age and have few side effects (burning
or itching the first few days of application). They not only
reduce flares, but also maintain skin texture and reduce the
need for long-term use of corticosteroids.
*Brand names included in this booklet are provided as
examples only, and their inclusion does not mean that these
products are endorsed by the National Institutes of Health
or any other Government agency. Also, if a particular brand
name is not mentioned, this does not mean or imply that the
product is unsatisfactory.
Corticosteroid creams and ointments have been used for many
years to treat atopic dermatitis and other autoimmune
diseases affecting the skin. Sometimes over-the-counter
preparations are used, but in many cases the doctor will
prescribe a stronger corticosteroid cream or ointment. When
prescribing a medication, the doctor will take into account
the patient's age, location of the skin to be treated,
severity of the symptoms, and type of preparation (cream or
ointment) that will be most effective. Sometimes the base
used in certain brands of corticosteroid creams and
ointments irritates the skin of a particular patient. Side
effects of repeated or long-term use of topical
corticosteroids can include thinning of the skin,
infections, growth suppression (in children), and stretch
marks on the skin.
Corticosteroid creams and ointments have been used for many years to
treat atopic dermatitis and other autoimmune diseases
affecting the skin.
When topical corticosteroids are not effective, the doctor
may prescribe a systemic corticosteroid, which is taken by
mouth or injected instead of being applied directly to the
skin. An example of a commonly prescribed corticosteroid is
prednisone. Typically, these medications are used only in
resistant cases and only given for short periods of time.
The side effects of systemic corticosteroids can include
skin damage, thinned or weakened bones, high blood pressure,
high blood sugar, infections, and cataracts. It can be
dangerous to suddenly stop taking corticosteroids, so it is
very important that the doctor and patient work together in
changing the corticosteroid dose.
Antibiotics to treat skin infections may be applied directly
to the skin in an ointment, but are usually more effective
when taken by mouth. If viral or fungal infections are
present, the doctor may also prescribe specific medications
to treat those infections.
Certain antihistamines that cause drowsiness can reduce
night time scratching and allow more restful sleep when
taken at bedtime. This effect can be particularly helpful
for patients whose night time scratching makes the disease
worse.
In adults, drugs that suppress the immune system, such as
cyclosporine, methotrexate, or azathioprine, may be
prescribed to treat severe cases of atopic dermatitis that
have failed to respond to other forms of therapy. These
drugs block the production of some immune cells and curb the
action of others. The side effects of drugs like
cyclosporine can include high blood pressure, nausea,
vomiting, kidney problems, headaches, tingling or numbness,
and a possible increased risk of cancer and infections.
There is also a risk of relapse after the drug is stopped.
Because of their toxic side effects, systemic
corticosteroids and immunosuppressive drugs are used only in
severe cases and then for as short a period of time as
possible. Patients requiring systemic corticosteroids should
be referred to dermatologists or allergists specializing in
the care of atopic dermatitis to help identify trigger
factors and alternative therapies.
In rare cases, when home-based treatments have been
unsuccessful, a patient may need a few days in the hospital
for intense treatment.
Phototherapy: Use of ultraviolet A or B light waves, alone
or combined, can be an effective treatment for mild to
moderate dermatitis in older children (over 12 years old)
and adults. A combination of ultraviolet light therapy and a
drug called psoralen can also be used in cases that are
resistant to ultraviolet light alone. Possible long-term
side effects of this treatment include premature skin aging
and skin cancer. If the doctor thinks that phototherapy may
be useful to treat the symptoms of atopic dermatitis, he or
she will use the minimum exposure necessary and monitor the
skin carefully.
Treating Atopic Dermatitis in Infants and Children
- Give lukewarm baths.
- Apply lubricant immediately following the bath.
- Keep child's fingernails filed short.
- Select soft cotton fabrics when choosing clothing.
- Consider using sedating antihistamines to promote sleep
and reduce scratching at night.
- Keep the child cool; avoid situations where overheating
occurs.
- Learn to recognize skin infections and seek treatment
promptly.
- Attempt to distract the child with activities to keep
him or her from scratching.
- Identify and remove irritants and allergens.
Skin Care: Healing the skin and keeping it healthy are
important to prevent further damage and enhance quality of life. Developing
and sticking with a daily skin care routine is critical to preventing
flares.
A lukewarm bath helps to cleanse and moisturize the skin
without drying it excessively. Because soaps can be drying to the skin, the
doctor may recommend use of a mild bar soap or nonsoap cleanser. Bath oils
are not usually helpful.
After bathing, a person should air-dry the skin, or pat it
dry gently (avoiding rubbing or brisk drying), and then apply a lubricant to
seal in the water that has been absorbed into the skin during bathing. In
addition to restoring the skin's moisture, lubrication increases the rate of
healing and establishes a barrier against further drying and irritation.
Lotions that have a high water or alcohol content evaporate more quickly,
and alcohol may cause stinging. Therefore, they generally are not the best
choice. Creams and ointments work better at healing the skin.
Another key to protecting and restoring the skin is taking
steps to avoid repeated skin infections. Signs of skin infection include
tiny pustules (pus-filled bumps), oozing cracks or sores, or crusty yellow
blisters. If symptoms of a skin infection develop, the doctor should be
consulted and treatment should begin as soon as possible.
Protection from Allergen Exposure: The doctor may suggest
reducing exposure to a suspected allergen. For example, the presence of the
house dust mite can be limited by encasing mattresses and pillows in special
dust-proof covers, frequently washing bedding in hot water, and removing
carpeting. However, there is no way to completely rid the environment of
airborne allergens.
Changing the diet may not always relieve symptoms of atopic
dermatitis. A change may be helpful, however, when the medical history,
laboratory studies, and specific symptoms strongly suggest a food allergy.
It is up to the patient and his or her family and physician to decide
whether the dietary restrictions are appropriate. Unless properly monitored
by a physician or dietitian, diets with many restrictions can contribute to
serious nutritional problems, especially in children.
Atopic Dermatitis and Quality of Life
Despite the symptoms caused by atopic dermatitis, it is
possible for people with the disorder to maintain a good quality
of life. The keys to quality of life lie in being well-informed;
awareness of symptoms and their possible cause; and developing a
partnership involving the patient or care giving family member,
medical doctor, and other health professionals. Good
communication is essential. (See "Tips for Working With Your
Doctor" on page 26.)
When a child has atopic dermatitis, the entire family may be
affected. It is helpful if families have additional support to
help them cope with the stress and frustration associated with
the disease. A child may be fussy and difficult and unable to
keep from scratching and rubbing the skin. Distracting the child
and providing activities that keep the hands busy are helpful
but require much effort on the part of the parents or
caregivers. Another issue families face is the social and
emotional stress associated with changes in appearance caused by
atopic dermatitis. The child may face difficulty in school or
with social relationships and may need additional support and
encouragement from family members.
Adults with atopic dermatitis can enhance their quality of
life by caring regularly for their skin and being mindful of the
effects of the disease and how to treat them. Adults should
develop a skin care regimen as part of their daily routine,
which can be adapted as circumstances and skin conditions
change. Stress management and relaxation techniques may help
decrease the likelihood of flares. Developing a network of
support that includes family, friends, health professionals, and
support groups or organizations can be beneficial. Chronic
anxiety and depression may be relieved by short-term
psychological therapy.
Recognizing the situations when scratching is most likely to
occur may also help. For example, many patients find that they
scratch more when they are idle, and they do better when engaged
in activities that keep the hands occupied. Counselling also may
be helpful to identify or change career goals if a job involves
contact with irritants or involves frequent hand washing, such
as kitchen work or auto mechanics.
Atopic Dermatitis and Vaccination Against
Smallpox
Although scientists are working to develop safer vaccines,
persons diagnosed with atopic dermatitis (or eczema) should not
receive the current smallpox vaccine. According to the Centres
for Disease Control and Prevention (CDC), a U.S. Government
organization, persons who have ever been diagnosed with atopic
dermatitis, even if the condition is mild or not presently
active, are more likely to develop a serious complication if
they are exposed to the virus from the smallpox vaccine.
People with atopic dermatitis should exercise caution when
coming into close physical contact with a person who has been
recently vaccinated, and make certain the vaccinated person has
covered the vaccination site or taken other precautions until
the scab falls off (about 3 weeks). Those who have had physical
contact with a vaccinated person's unhealed vaccination site or
to their bedding or other items that might have touched that
site should notify their doctor, particularly if they develop a
new or unusual rash.
During a smallpox outbreak, these vaccination
recommendations may change. Persons with atopic dermatitis who
have been exposed to smallpox should consult their doctor about
vaccination.
Tips for Working With Your Doctor
- Provide complete, accurate medical information.
- Make a list of your questions and concerns in advance.
- Be honest and share your point of view with the doctor.
- Ask for clarification or further explanation if you need
it.
- Talk to other members of the health care team, such as
nurses, therapists, or pharmacists.
- Don't hesitate to discuss sensitive subjects with your
doctor.
- Discuss changes to any medical treatment or medications
with your doctor.
- Additional information about atopic dermatitis and
smallpox vaccination is available from CDC. (See "Additional
Resources" section of this booklet.)
Current Research on Dermatitis
Researchers supported by the National Institute of
Arthritis and Musculoskeletal and Skin Diseases and other
institutes of the National Institutes of Health are gaining a
better understanding of what causes atopic dermatitis and how it
can be managed, treated, and, ultimately, prevented. Some
promising avenues of research are described below.
Genetics: Although atopic dermatitis runs in families, the
role of genetics (inheritance) remains unclear. It does appear
that more than one gene is involved in the disease.
Research has helped shed light on the way atopic dermatitis
is inherited. Studies show that children are at increased risk
for developing the disorder if there is a family history of
other atopic disease, such as hay fever or asthma. The risk is
significantly higher if both parents have an atopic disease. In
addition, studies of identical twins, who have the same genes,
show that in an estimated 80 to 90 percent of cases, atopic
disease appears in both twins. Fraternal (no identical) twins,
who have only some genes in common, are no more likely than two
other people in the general population to both have an atopic
disease. These findings suggest that genes play an important
role in determining who gets the disease.
Biochemical Abnormalities: Scientists suspect that changes
in the skin's protective barrier make people with atopic
dermatitis more sensitive to irritants. Such people have lower
levels of fatty acids (substances that provide moisture and
elasticity) in their skin, which causes dryness and reduces the
skin's ability to control inflammation.
Other research points to a possible defect in a type of
white blood cell called a monocyte. In people with atopic
dermatitis, monocytes appear to play a role in the decreased
production of an immune system hormone called interferon gamma
(IFN-γ), which helps regulate allergic reactions. This defect
may cause exaggerated immune and inflammatory responses in the
blood and tissues of people with atopic dermatitis.
Faulty Regulation of Immunoglobulin E (IgE): As already
described in the section on diagnosis, IgE is a type of antibody
that controls the immune system's allergic response. An antibody
is a special protein produced by the immune system that
recognizes and helps fight and destroy viruses, bacteria, and
other foreign substances that invade the body. Normally, IgE is
present in very small amounts, but levels are high in 80 to 90
percent of people with atopic dermatitis.
Controlling Atopic Dermatitis
Prevent scratching or rubbing whenever possible.
Protect skin from excessive moisture, irritants, and rough
clothing.
Maintain a cool, stable temperature and consistent humidity
levels.
Limit exposure to dust, cigarette smoke, pollens, and animal
dander.
Recognize and limit emotional stress.
In allergic diseases, IgE antibodies are produced in
response to different allergens. When an allergen comes into
contact with IgE on specialized immune cells, the cells release
various chemicals, including histamine. These chemicals cause
the symptoms of an allergic reaction, such as wheezing,
sneezing, runny eyes, and itching. The release of histamine and
other chemicals alone cannot explain the typical long-term
symptoms of the disease. Research is underway to identify
factors that may explain why too much IgE is produced and how it
plays a role in the disease.
Immune System Imbalance: Researchers also think that an
imbalance in the immune system may contribute to the development
of atopic dermatitis. It appears that the part of the immune
system responsible for stimulating IgE is overactive, and the
part that handles skin viral and fungal infections is
underactive. Indeed, the skin of people with atopic dermatitis
shows increased susceptibility to skin infections. This
imbalance appears to result in the skin's inability to prevent
inflammation, even in areas of skin that appear normal. In one
project, scientists are studying the role of the infectious
bacterium Staphylococcus aureus (S. aureus) in atopic
dermatitis.
Researchers also think that an imbalance in the
immune system may contribute to the development of atopic
dermatitis.
Researchers believe that one type of immune cell in the
skin, called a Langerhans cell, may be involved in atopic
dermatitis. Langerhans cells pick up viruses, bacteria,
allergens, and other foreign substances that invade the body
and deliver them to other cells in the immune defence
system. Langerhans cells appear to be hyper-active in the
skin of people with atopic diseases. Certain Langerhans
cells are particularly potent at activating white blood
cells called T cells in atopic skin, which produce proteins
that promote allergic response. This function results in an
exaggerated response of the skin to tiny amounts of
allergens.
Scientists have also developed mouse models to study
step-by-step changes in the immune system in atopic
dermatitis, which may eventually lead to a treatment that
effectively targets the immune system.
Drug Research: Some researchers are focusing on new
treatments for atopic dermatitis, including biologic agents,
fatty acid supplements, and new forms of phototherapy. For
example, they are studying how ultraviolet light affects the
skin's immune system in healthy and diseased skin. They are
also investigating biologic agents, including several aimed
at modifying the response of the immune system. A biologic
agent is a new type of drug based on molecules that occur
naturally in the body. One promising treatment is the use of
thiopental to re-establish balance in the immune system.
Researchers also continue to look for drugs that suppress
the immune system. In this regard, they are studying the
effectiveness of cyclosporine A. Clinical trials are
underway with another drug called FK506, which is applied to
the skin rather than taken orally. Also, anti-inflammatory
drugs have been developed that affect multiple cells and
cell functions, and may prove to be an effective alternative
to corticosteroids in the treatment of atopic dermatitis.
Several experimental treatments are being evaluated that
attempt to replace substances that are deficient in people
with atopic dermatitis. Evening primrose oil is a substance
rich in gamma-linolenic acid, one of the fatty acids that is
decreased in the skin of people with atopic dermatitis.
Studies to date using evening primrose oil have yielded
contradictory results. In addition, dietary fatty acid
supplements have not proven highly effective. There is also
a great deal of interest in the use of Chinese herbs and
herbal teas to treat the disease. Studies to date show some
benefit, but not without concerns about toxicity and the
risks involved in suppressing the immune system without
close medical supervision.
Several experimental treatments are being
evaluated that attempt to replace substances that are
deficient in people with atopic dermatitis.
Hope for the Future
Although the symptoms of atopic dermatitis can be difficult
and uncomfortable, the disease can be successfully managed.
People with atopic dermatitis can lead healthy, productive
lives. As scientists learn more about atopic dermatitis and
what causes it, they continue to move closer to effective
treatments, and perhaps, ultimately, a cure.
Source: National Institute of Arthritis and Musculoskeletal
and Skin Diseases.
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