Atopic dermatitis is a chronic (long-lasting) disease that affects the skin. The word "dermatitis" means inflammation of the skin. "Atopic" refers to diseases that are hereditary, tend to run in families, and often occur together. These diseases include asthma, hay fever, and atopic dermatitis. In atopic dermatitis, the skin becomes extremely itchy and inflamed, causing redness, swelling, cracking, weeping, crusting, and scaling.
Atopic dermatitis most often affects infants and young children, but it can continue into adulthood or first show up later in life. In most cases, there are periods of time when the disease is worse, called exacerbations or flares, which are followed by periods when the skin improves or clears up entirely, called remissions. Many children with atopic dermatitis enter into a permanent remission of the disease when they get older, although their skin often remains dry and easily irritated. Environmental factors can activate symptoms of atopic dermatitis at any time in the lives of individuals who have inherited the atopic disease trait.
How common?
Atopic dermatitis is very common. It affects males and females equally and accounts for 10 to 20 % of all referrals to dermatologists (doctors who specialize in the care and treatment of skin diseases). Atopic dermatitis occurs most often in infants and children and its onset decreases substantially with age. 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 often occurs after exposure of the skin to harsh conditions. People who live in urban areas and in climates with low humidity seem to be at an increased risk for developing atopic dermatitis.
About 10% of all 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 even after they reach adulthood. This means that more than 15 million people in the United States have symptoms of the disease.
The Causes
The cause of atopic dermatitis is not known, but the disease seems to result from a combination of genetic (hereditary) and environmental factors. Evidence suggests that the disease is associated with other so-called atopic disorders such as hay fever and asthma, which many people with atopic dermatitis also have. In addition, many children who outgrow the symptoms of atopic dermatitis go on to develop hay fever or asthma. Although one disorder does not cause another, they may be related, thereby giving researchers clues to understanding atopic dermatitis.
In the past, it was thought that atopic dermatitis was caused by an emotional disorder. We now know that emotional factors such as stress can exacerbate, but do not cause the condition.
The Other Predisposition Factors
In addition to irritants and allergens, other factors, such as emotional issues, temperature and climate, and skin infections can affect atopic dermatitis. Although the disease itself is not caused by emotional factors or personality, it can be exacerbated 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. Often, emotional stress seems to prompt a flare of the disease.
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 intensify the disease, as can overheated indoor areas and long or hot baths and showers. Alternately sweating and chilling can induce an attack in some people. Bacterial infections can also prompt or increase the severity of atopic dermatitis. If a patient experiences a sudden onset of illness, the doctor may check for a viral infection (such as herpes simplex) or fungal infection (such as ringworm or athlete's foot).
Is atopic dermatitis contagious?
No. Atopic dermatitis is definitely not contagious; it cannot be passed from one person to another. There is no cause for concern in being around someone with even an active case of atopic dermatitis.
The Symptoms
Symptoms vary from person to person. The most common symptoms are dry, itchy skin, cracks behind the ears, and rashes on the cheeks, arms, and legs. The itchy feeling is an important factor in atopic dermatitis, because scratching and rubbing in response to itching worsen the skin inflammation that is characteristic of this disease. People with atopic dermatitis seem to be more sensitive to itching and feel the need to scratch longer in response. They develop what is referred to as the "itch-scratch" cycle. The extreme itchiness of the skin causes the person to scratch, which in turn worsens the itch, and so on. Itching is particularly a problem during sleep, when conscious control of scratching decreases and the absence of other outside stimuli makes the itchiness more noticeable.
How atopic dermatitis affects the skin can be changed by patterns of scratching and resulting skin infections. Some people with the disease develop red, scaling skin where the immune system in the skin becomes very activated. Others develop thick and leathery skin as a result of constant scratching and rubbing. This condition is called lichenification. Still others develop papules, or small raised bumps, on their skin. When the papules are scratched, they may open (excoriations) and become crusty and infected. The box below lists common skin features of the disease. These conditions can also be found in people without atopic dermatitis or with other types of skin disorders.
Skin Features of Atopic Dermatitis
- Lichenification: thick, leathery skin resulting from constant scratching and rubbing
- Papules: small raised bumps that may open when scratched, becoming crusty and infected
- Ichthyosis: dry, rectangular scales on the skin
- Keratosis pilaris: small, rough bumps, generally on the face, upper arms, and thighs
- Hyperlinear palms: increased number of skin creases on the palms
- Urticaria: hives (red, raised bumps), often after exposure to an allergen, at the beginning of flares, or after exercise or a hot bath
- Cheilitis: inflammation of the skin on and around the lips
- Atopic pleat (Dennie-Morgan fold): an extra fold of skin that develops under the eye
- Hyperpigmented eyelids: eyelids that have become darker in color from inflammation or hay fever
The doctor has three main goals in treating atopic dermatitis: healing the skin and keeping it healthy; preventing flares; and treating symptoms when they do occur. Much of caring for the skin involves developing skin care routines, identifying exacerbating factors, and avoiding circumstances that stimulate the skin's immune system and the itch-scratch cycle. It is important for the patient and family members to note any changes in skin condition in response to treatment, and to be persistent in identifying the most effective treatment strategy.
Skin Care
Healing the skin and keeping it healthy are of primary importance both in preventing further damage and enhancing the patient's quality of life. Developing and following a daily skin care routine is critical to preventing recurrent episodes of symptoms. Key factors are proper bathing and the application of lubricants, such as creams or ointments, within 3 minutes of bathing. People with atopic dermatitis should avoid hot or long (more than 10 to 15 minutes) baths and showers. A lukewarm bath helps to cleanse and moisturize the skin without drying it excessively. The doctor may recommend limited use of a mild bar soap or non-soap cleanser because soaps can be drying to the skin. Bath oils are not usually helpful.
Once the bath is finished, the patient should air-dry the skin, or pat it dry gently (avoiding rubbing or brisk drying), and apply a lubricant immediately. Lubrication restores the skin's moisture, increases the rate of healing, and establishes a barrier against further drying and irritation. Several kinds of lubricants can be used. Lotions generally are not the best choice because they have a high water or alcohol content and evaporate quickly. Creams and ointments work better at healing the skin. Tar preparations can be very helpful in healing very dry, lichenified areas. Whatever preparation is chosen, it should be as free of fragrances and chemicals as possible.
Another key to protecting and restoring the skin is taking steps to avoid repeated skin infections. Although it may not be possible to avoid infections altogether, the effects of an infection may be minimized if they are identified and treated early. Patients and their families should learn to recognize the signs of skin infections, including tiny pustules (pus-filled bumps) on the arms and legs, appearance of oozing areas, or crusty yellow blisters. If symptoms of a skin infection develop, the doctor should be consulted to begin treatment as soon as possible.
Treating Atopic Dermatitis in Infants and Children
- Give brief, lukewarm baths.
- Apply lubricant immediately following the bath.
- Keep child's fingernails filed short.
- Select soft cotton fabrics when choosing clothing.
- Consider using antihistamines to 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.
Medications and Phototherapy:
If a recurrence of atopic dermatitis occurs, several methods can be used to treat the symptoms. With proper treatment, most symptoms can be brought under control within 3 weeks. If symptoms fail to respond, this may be due to a flare that is stronger than the medication can handle, a treatment program that is not fully effective for a particular individual, or the presence of trigger factors that were not addressed in the initial treatment program. These factors can include a reaction to a medication, infection, or emotional stress. Continued symptoms may also occur because the patient is not following the treatment program instructions.
Corticosteroid creams and ointments are the most frequently used treatment. Sometimes, over-the-counter preparations are used, but in many cases, the doctor will prescribe a stronger corticosteroid cream or ointment. Occasionally, the base used in certain brands of corticosteroid creams and ointments is irritating for a particular patient and a different brand is required. 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.
Tacrolimus (Protopic) and pimecrolimus (Elidel) ointments are powerful topical medicated creams (drugs that are applied to the skin) that is used for the treatment of atopic dermatitis. These new drugs are referred to as "immune modulators." They were first used internally to help patients with kidney and liver transplants avoid rejecting the organs they received. They work by suppressing the immune system. When these drugs are used externally to treat the skin, however, they do not weaken or change the body's immune system. Also, unlike topical steroids (cortisone creams), these new medications don't cause thinning of the skin and breaking of superficial blood vessels (atrophy).
Some treatments reduce specific symptoms of the disease. Antibiotics to treat skin infections may be applied directly to the skin in an ointment, but are usually more effective when taken by mouth in pill form. Certain antihistamines that cause drowsiness can reduce nighttime scratching and allow more restful sleep when taken at bedtime. This effect can be particularly helpful for patients whose nighttime scratching aggravates the disease. If viral or fungal infections are present, the doctor may also prescribe medications to treat those infections.
Phototherapy is treatment with light that uses ultraviolet A or B light waves, or a combination of both. This treatment can be an effective treatment for mild to moderate dermatitis in older children (over 12 years old) and adults. Photochemotherapy, a combination of ultraviolet light therapy and a drug called psoralen, can also be used in cases that are resistant to phototherapy 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 in treating the symptoms of atopic dermatitis, he or she will use the minimum exposure necessary and monitor the skin carefully.
When other treatments are not effective, the doctor may prescribe systemic corticosteroids; drugs that are taken by mouth or injected into muscle 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 are 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.
In adults, immunosuppressive drugs, such as cyclosporine, are also used to treat severe cases of atopic dermatitis that have failed to respond to any other forms of therapy. Immunosuppressive drugs restrain the overactive immune system by blocking the production of some immune cells and curbing the action of others. The side effects of 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 discontinued. 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 or immunosuppressive drugs should be referred to a dermatologist or an allergist specializing in the care of atopic dermatitis to help identify trigger factors and alternative therapies.
In rare cases, when no other treatments have been successful, the patient may have to be hospitalized. A 5 to 7 day hospital stay allows intensive skin care treatment and reduces the patient's exposure to irritants, allergens, and the stresses of day-to- day life. Under these conditions, the symptoms usually clear quickly if environmental factors play a role or if the patient is not able to carry out an adequate skin care program at home.
- Provide complete, accurate medical information about yourself or your child.
- 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 before making them.
Atopic Dermatitis and Quality of Life
Despite the symptoms caused by atopic dermatitis, it is possible for people with the disorder to maintain a high quality of life. The keys to an improved quality of life are education, awareness, and developing a partnership among the patient, family, and doctor. Good communication is essential for all involved. It is important that the doctor provides understandable information about the disease and its symptoms to the patient and family and demonstrate any treatment measures recommended to ensure that they will be properly carried out.
When a child has atopic dermatitis, the entire family situation may be affected. It is important that families have additional support to help them cope with the stress and frustration associated with the disease. The child may be fussy and difficult, and often is unable to keep from scratching and rubbing the skin. Distracting the child and providing as many activities that keep the hands busy is key, but requires much effort and work on the part of the parents or caregivers. Another issue families face is the social and emotional stress associated with disfigurement caused by atopic dermatitis. The child may face difficulty in school or other 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 other 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 due to emotional stress. 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. Structured activity that keeps their hands occupied may prevent further damage to the skin. Occupational counseling 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.
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.
- Atopic dermatitis is the most common and significant type of eczema.
- The skin sensitivity of this disease is inherited.
- The patient's skin is "super sensitive" to many irritants.
- Dry scaly patches develop in a characteristic distribution.
- Itching is intense and scratching hard to resist.
- Scratching can cause skin thickening and darkening and lead to bacterial infection.
- Extremely dry skin can break down and ooze or weep.
- If the itch can be controlled, the rash (which is aggravated by vigorous scratching) can be contained.
- ;Treatment of atopic dermatitis is centered around rehydrating the skin with moisturizers and cautious use of topical steroids to reduce inflammation and itching.
- Oral antihistamines are often necessary to break the "itch-scratch" cycle.
- Since secondary infections can aggravate the rash, topical or oral antibiotics may also be occasionally indicated.
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