Atopic dermatitis and eczema

Specialties > Child health

Background knowledge 🧠

Definition

Atopic dermatitis (AD) is a chronic, relapsing inflammatory skin condition.
Commonly associated with other atopic diseases, such as asthma and allergic rhinitis.
Characterised by intense pruritus and eczematous lesions.
Primarily affects flexural areas in older children and adults.
In infants, the face and extensor surfaces are commonly involved.

Epidemiology

Affects 15-20% of children and 2-10% of adults in the UK.
Onset typically occurs before the age of 5 years.
Prevalence has increased in recent decades.
More common in urban areas and industrialised countries.
Often associated with a family history of atopic disease.

Aetiology and Pathophysiology

Complex interaction between genetic, immunological, and environmental factors.
Mutations in the filaggrin (FLG) gene can lead to skin barrier dysfunction.
Th2-skewed immune response contributes to inflammation.
Environmental triggers include allergens, irritants, and climate.
Emotional stress can exacerbate the condition.

Types

Infantile AD: Begins at 2-6 months, often on cheeks, scalp, and extensor surfaces.
Childhood AD: Affects flexural areas such as the elbows, knees, and neck.
Adult AD: Predominantly flexural but can affect hands and eyelids.
Discoid eczema: Circular, well-demarcated plaques, usually on limbs.
Eczema herpeticum: Severe form with viral infection (HSV), requiring urgent treatment.

Clinical Features 🌡️

Symptoms

Intense pruritus, often worse at night.
Dry, scaly skin.
Erythema (redness).
Lichenification (thickened skin) in chronic cases.
Exacerbations triggered by stress, allergens, and climate.

Signs

Erythematous, eczematous plaques, often excoriated.
Crusting and oozing in acute flares.
Lichenification in chronic stages, particularly in flexural areas.
Post-inflammatory hyperpigmentation or hypopigmentation.
Secondary infections (e.g., Staphylococcus aureus) common.

Investigations 🧪

Tests

Diagnosis is primarily clinical based on history and examination.
Skin swabs: To rule out secondary bacterial infection.
Patch testing: To identify contact allergens in suspected allergic contact dermatitis.
Serum IgE: Often elevated but not diagnostic.
Skin biopsy: Rarely needed, may help in atypical cases.

Management 🥼

Management

Emollients: Regular use to maintain skin hydration.
Topical corticosteroids: First-line treatment for flares.
Topical calcineurin inhibitors: Used in sensitive areas like the face.
Antihistamines: To reduce pruritus, especially at night.
Systemic treatments (e.g., ciclosporin, methotrexate): For severe, refractory cases.
Phototherapy: Narrowband UVB for moderate to severe cases.
Patient education: Importance of adherence to treatment and trigger avoidance.

Complications

Secondary bacterial infection: Commonly due to Staphylococcus aureus.
Eczema herpeticum: Disseminated HSV infection, a medical emergency.
Psychosocial impact: Depression and anxiety are common.
Sleep disturbance: Due to intense pruritus.
Post-inflammatory pigment changes: Hyperpigmentation or hypopigmentation.

Prognosis

Many children outgrow the condition by adolescence.
Chronic relapsing course in those who do not outgrow it.
Quality of life may be significantly impacted, particularly in severe cases.
With appropriate management, long-term control is possible.

Key Points

AD is a chronic, relapsing inflammatory skin condition with significant morbidity.
Management focuses on skin hydration, reducing inflammation, and avoiding triggers.
Complications include infection and psychosocial impact.
Multidisciplinary approach may be needed for severe cases.
Early intervention and patient education are crucial for long-term control.

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