Question 1 of 10

    Atopic Dermatitis

    Atopy2010[1]

    Atopic dermatitis (atopic eczema) is a relapsing, inflammatory, pruritic and eczematous skin disorder.

    Atopic Dermatitis is associated with the following process: auto-immune.

    Presentation

    The areas of skin most commonly affected are the skin folds like folds of arms, behind of knees, wrists, face and hands. In children, the extensor surfaces of limbs are commonly involved whereas in adults, usually the flexor surfaces get affected. The patients of atopic dermatitis present with the following clinical features [4] [5]:

    • Skin dryness (xerosis) and redness
    • Raised, eczematous vesicles over the skin
    • Itching (pruritus) that worsens at night, thereby disturbing the sleep pattern of the individual
    • Crusting and scaling of lesions with time
    • Cracking of lesions, making them potential sites for acquiring bacterial (most commonly, the skin colonizer Staphylococcus aureus) viral or fungal infections
    • Other forms of allergy

    Of the patients who develop atopic dermatitis before the age of 2 years, 50% are likely to develop other forms of allergic reactions later in life.

    Face, Head & Neck
  • more...
  • Skin
    Dry Skin
    • Moisturize often to treat and prevent dry skin .[webmd.com]
    • Those who suffered from eczema as a child may always have a tendency towards dry skin.[acaai.org]
    • Eczema is linked to dry skin.[aafa.org]
    • Treatments, however, are very effective in reducing the symptoms of itching and dry skin.[my.clevelandclinic.org]
    Excoriation
    • The lesions in childhood eczema are mainly eczematized, excoriated and may be lichenified.[drmhijazy.com]
    • It is manifested by lichenification, excoriation, and crusting, mainly on the flexural surfaces of the elbow and knee.[icd10data.com]
    • Lichenification, excoriation and erosion or crusting on the trunk may indicate secondary infection.[en.wikipedia.org]
    • Erythematous papules and patches Dry skin (xerosis) Excoriations Generally, spares the groin and axilla Consider other conditions that may mimic appearance : Psoriasis Ichthyoses Erythroderma Scabies Seborrheic dermatitis Contact dermatitis Photosensitivity[pedemmorsels.com]
    • Thickened, lichenified plaques with excoriation ( Figs. 2 to 4 ) are common.[clevelandclinicmeded.com]
    Koebner Phenomenon
    • One intriguing characteristic of psoriasis is the ‘Koebner phenomenon’, first reported by Heinrich Koebner in 1872.[hmg.oxfordjournals.org]
    Lichenification
    • All stages are characterized by xerosis, fissures, pruritus, and lichenification.[clevelandclinicmeded.com]
    • It is manifested by lichenification, excoriation, and crusting, mainly on the flexural surfaces of the elbow and knee.[icd10data.com]
    • Nummular dermatitis is not flexural, and lichenification is rare.[merckmanuals.com]
    • Primary physical findings include the following: Xerosis Lichenification Eczematous lesions The eczematous changes and its morphology are seen in different locations, depending on the age of the patient (ie, infant, child, or adult).[emedicine.medscape.com]
    • In addition, the normal markings of the skin are exaggerated in lichenification.[encyclopedia.com]
    Papule
    • In general, the eczema becomes drier and lichenified with excoriations, papules, and nodules. 5.1.3.[hindawi.com]
    • Erythematous papules and patches Dry skin (xerosis) Excoriations Generally, spares the groin and axilla Consider other conditions that may mimic appearance : Psoriasis Ichthyoses Erythroderma Scabies Seborrheic dermatitis Contact dermatitis Photosensitivity[pedemmorsels.com]
    • There are some papules on the extensor surface of the forearms.[pedclerk.bsd.uchicago.edu]
    • Papule — A solid, raised bump on the skin.[encyclopedia.com]
    • Acute lesions are papules and vesicles on a background of erythema.[aafp.org]
    Pruritus
    • […] or Atopic Dermatitis Birmingham Alabama A clinical trial seeking patients for a research study for the treatment of Pruritus or Atopic Dermatitis Hoover Alabama A clinical trial seeking patients for a research study for the treatment of Pruritus or Atopic[centerwatch.com]
    • The three most common presentations are urticaria (“hives”), urticaria with pruritus (itching), and pruritus alone.[thehorse.com]
    • Oral antihistamines can help decrease pruritus.[clevelandclinicmeded.com]
    • Chronic inflammatory skin disorder in individuals with a hereditary predisposition to a lowered threshold to pruritus; characterized by extreme itching, leading to scratching and rubbing that result in typical lesions of eczema.[icd10data.com]
    • Its most frequent symptom is pruritus.[aafp.org]
    Scaly Rash
    • They also may have circular, slightly raised, itchy, and scaly rashes in the bends of the elbows, behind the knees, or on the backs of the wrists and ankles.[kidshealth.org]
    • Eczema, also known as atopic dermatitis, is a chronic, non-contagious, inflammatory skin condition characterized by severe itching, redness, oozing, and scaly rashes.[acaai.org]
  • more...
  • Workup

    No specific diagnostic tests are available for atopic dermatitis. Patient’s history and examination are helpful in reaching a diagnosis. Serum testing for IgE antibodies can be used to detect ongoing allergic reactions in the body.

    It is essential to differentiate atopic dermatitis from other closely related diseases like seborrhic dermatitis on the basis of signs and symptoms and close examination of the manifestations.

    Laboratory

    Serum
  • more...
  • Treatment

    Conservative treatment of atopic dermatitis includes the following [6]:

    • Anti-inflammatory agents such as topical and systemic corticosteroids are administered. Topical steroids are preferred because they have less systemic side effects. Systemic corticodteroids are used in severe disease.
    • Immunosuppressant drugs may also be given to the patients suffering from atopic dermatitis [7].
    • Topical emollients can also be used and usually have a good outcome [8] [9].
    • Antibiotics are given to prevent secondary bacterial infections in these patients (particularly when immunosuppressive drugs are used).
    • Antihistamines can be used to prevent the allergic mediators from exaggerating this disease.

    Surgical measures for atopic dermatitis include the following:

    • Phototherapy with UVA (ultraviolet light with a frequency of 320 to 400 nanometers) or UVB (ultraviolet light with a frequency of 290 to 300 nanometers) is an effective mode of treatment in children as well as in adults [10]. Sometimes both types of ultraviolet light are used.
    • Photochemotherapy consists of phototherapy combined with chemotherapy and is given in patients with more severe disease.

    Prognosis

    Complications

    Allergic Rhinitis
    • One third of patients develop allergic rhinitis.[emedicine.medscape.com]
    • Clinical Information A chronic inflammatory genetically determined disease of the skin marked by increased ability to form reagin (ige), with increased susceptibility to allergic rhinitis and asthma, and hereditary disposition to a lowered threshold for[icd10data.com]
    • Atopic dermatitis usually begins in the first few years of life and is often the initial indication that a child may later develop asthma and/or allergic rhinitis (hay fever).[aaaai.org]
    • Susceptibility to atopic dermatitis is genetic and those who develop atopic dermatitis commonly have a higher incidence of other atopic diseases, such as asthma, allergic rhinitis and conjunctivitis.[brickellbio.com]
    • Children who have atopic dermatitis may be more prone to develop other allergic conditions such as allergy-induced asthma and allergic rhinitis .[iuhealth.org]
    Chronic Dermatitis
    • Atopy is a special type of allergic hypersensitivity that is associated with asthma , inhalant allergies ( hay fever ), and a chronic dermatitis.[medicinenet.com]
    • Morioka T et al (2009) IL-4/IL-13 antagonist DNA vaccination successfully suppresses Th2 type chronic dermatitis.[link.springer.com]
    Contact Dermatitis
    • Consultation with the Specialist: Contact Dermatitis .[pedclerk.bsd.uchicago.edu]
    • Atopic dermatitis can resemble other types of dermatitis (seborrheic dermatitis, allergic contact dermatitis, irritant contact dermatitis) and dermatophytosis.[clevelandclinicmeded.com]
    Eczema
    • Other names include "infantile eczema", "flexural eczema", "prurigo Besnier", "allergic eczema", and "neurodermatitis".[en.wikipedia.org]
    • Eczema herpeticum is suggested by: [ 4 ] Areas of rapidly worsening, painful eczema.[patient.info]
    • Parents with eczema are more likely to have children with eczema.[stanfordchildrens.org]
    Eczema Vaccinatum
    • In the current climate of threats of bioterrorism, vaccination may once again become necessary, and physicians should be aware of eczema vaccinatum in this setting.[emedicine.medscape.com]
    • . - Eczema vaccinatum: due to vaccinia virus is another serious viral secondary infection to the atopic patient.[drmhijazy.com]
    • They are predisposed to develop fungal foot disease and cutaneous staphylococcal infections, and they can disseminate herpes simplex lip infections ( eczema herpeticum ) and smallpox vaccination (eczema vaccinatum) to large areas of skin.[medicinenet.com]
    Eosinophilia
    • Uehara M, Izukura R, Sawai T (1990) Blood eosinophilia in atopic dermatitis.[link.springer.com]
    • In acute AD lesions, T-helper 2 (TH2) cells are present in larger numbers than normal and have increased expression of specific cytokines that, in turn, stimulate B cells to produce IgE, resulting in peripheral eosinophilia.[pedclerk.bsd.uchicago.edu]
    • The following is a constellation of symptoms and features commonly seen in AD: Pruritus Early age of onset Chronic and relapsing course IgE reactivity Peripheral eosinophilia Staphylococcus aureus superinfection Personal history of asthma or hay fever[emedicine.medscape.com]
    • Familial eosinophilia Familial eosinophilia (FE) is an autosomal dominant disorder characterized by peripheral hypereosinophilia of unidentifiable cause with or without other organ involvement ( 121 ).[hmg.oxfordjournals.org]
    Impetigo
    • An oral antibiotic with S. aureus coverage and good skin penetration, such as ampicillin–clavulanic acid, cephalexin, or azithromycin, is necessary for extensive excoriations and impetigo.[clevelandclinicmeded.com]
    • Antistaphylococcal antibiotics , both topical (eg, mupirocin , fusidic acid [applied for 2 wk]) and oral (eg, dicloxacillin , cephalexin , erythromycin [all 250 mg qid for 1 to 2 wk]), are used to treat bacterial skin superinfections such as impetigo[merckmanuals.com]
    • Complications Infection S. aureus infection may present with typical impetigo or as worsening of the eczema with increased redness, oozing and crusting.[patient.info]
    • Cell-mediated dysfunction As patients with E are prone to develop a variety of infectious diseases of fungal, viral or bacterial origin like candidosis, E herpeticum (Kaposi s varicelliform eruption), or staphylococcal impetigo, defective cellular immunity[worldallergy.org]
    • Table 3 Differential diagnosis of AD Other skin conditions • Contact dermatitis • Seborrheic dermatitis • Psoriasis Infections • Scabies • Impetigo Metabolic and nutritional deficiencies • Phenylketonuria • Zinc deficiency Immunodeficiency syndromes with[aacijournal.biomedcentral.com]
    Keratosis Pilaris
    • Keratosis pilaris, or spiny hair follicles, commonly affect the posterior aspects of the upper arms and the anterior thighs.[clevelandclinicmeded.com]
    • pilaris/pityriasis alba/hyperlinear palms/ichthyosis Ocular/periorbital changes Other regional findings (eg, perioral changes/periauricular lesions) Perifollicular accentuation/lichenification/prurigo Exclusionary conditions (conditions that should be[emedicine.medscape.com]
    • pilaris Pityriasis alba Hyperlinear palms Ichthyosis Facial pallor Infraorbital folds Nipple dermatitis Perifollicular accentuation Lichenification Prurigo lesions Delayed blanch response Certain regional changes (eg, perioral changes, periauricular[merckmanuals.com]
    • pilaris : small, rough bumps, generally on the face, upper arms, and thighs.[medicinenet.com]
    Lichen Simplex Chronicus
    • Lichen simplex chronicus .[patient.info]
    • Nummular eczema : coin-shaped (round), isolated patches of irritated skin -- most commonly on the arms and lower legs -- that may be crusted, scaling, and extremely itchy Lichen simplex chronicus (localized neurodermatitis) : a dermatitis localized to[medicinenet.com]
    Pityriasis Alba
    • Pityriasis alba, characterized by hypopigmented, scaly patches on the face, is commonly seen.[clevelandclinicmeded.com]
    • alba/hyperlinear palms/ichthyosis Ocular/periorbital changes Other regional findings (eg, perioral changes/periauricular lesions) Perifollicular accentuation/lichenification/prurigo Exclusionary conditions (conditions that should be excluded) are as[emedicine.medscape.com]
    • alba Hyperlinear palms Ichthyosis Facial pallor Infraorbital folds Nipple dermatitis Perifollicular accentuation Lichenification Prurigo lesions Delayed blanch response Certain regional changes (eg, perioral changes, periauricular changes) *Derived from[merckmanuals.com]
    • Special Manifestations Some patients may present with several other common, benign skin conditions, for example, pityriasis alba , which is a condition characterised by dry, pale patches on the face and upper arms, and keratosis pilaris , which manifests[hindawi.com]
    • Facial and extensor surfaces in infants and young children Flexure lichenification in older children and adults Minor features Eyes Cataracts (anterior subcapsular) Keratoconus Infraorbital folds affected Facial pallor Palmar hyperlinearity Xerosis Pityriasis[aafp.org]
    Urticaria
    • The three most common presentations are urticaria (“hives”), urticaria with pruritus (itching), and pruritus alone.[thehorse.com]
    • Urticaria and acute anaphylactic reactions to food occur with increased frequency in patients with AD.[emedicine.medscape.com]
    • Another skin symptom that may develop is urticaria.[patient.co.uk]
    • Usually there is a familial history of eczema, asthma, urticaria or hay fever.[drmhijazy.com]
    • 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[niams.nih.gov]
  • more...
  • Etiology

    Various genetic and environmental factors are thought to give rise to atopic dermatitis like the following:

    • Individual history of allergic reactions like food allergy, hay fever, asthma, allergic rhinitis, urticaria etc.
    • Autoimmune reactions involving formation of IgE antibodies.
    • Mutations in the filaggrin gene, encoding a transmembrane protein that regulates the water retention mechanisms in the stratum corneum of skin and is essential for maintaining the barrier function of skin.
    • Allergens like dust, chemicals, viruses and other contaminants in the environment.
    • Other skin infections.

    Factors like pets, woolen clothing or exposure to pollens are the predisposing factors for the development of this disease.

    Epidemiology

    In developed countries, the disease is found in 15-30% children and in 2-10% of the adult population. Atopic dermatitis has been linked to living in ‘excessively sanitary’ conditions.

    A slight prevalence of disease in females as compared to the males has been reported. All races are equally affected. No specific geographic distribution, other than in pollen dense areas, has been found.

    Sex distribution
    Age distribution

    Pathophysiology

    Two different theories have been proposed regarding the pathogenesis of atopic dermatitis [2] [3].

    • The structural and functional abilities of the epidermis are lost as a result of mutations in the filaggrin gene. The barrier function of epidermis is, thereby, impaired and the first line of defense against external agents is lost. Water is lost from the skin, making it dry and itchy.
    • The second theory is centered on the concept of autoimmune reaction occurring in the body. The immune cells like macrophages, Langerhans cells, helper T cells (in the initial stages, Th2 and later, Th1 is involved) inflammatory cytokines, interleukins (IL4, IL5 and tumor necrosis factor) and several other immune mediators are activated as a result of exposure to environmental allergens and give rise to signs and symptoms of inflammation; flare, redness and erythema. All these immune mediators give rise to pruritus. This theory is more widely accepted as compared to the first one.

    Prevention

    The preventive measures against atopic dermatitis include:

    • Observing skin hygiene.
    • Paying special attention to hygiene and sanitary measures in infants and children as they are more likely to acquire to the disease.
    • Avoiding excessive use of skin care products right after taking showers or baths.
    • Avoiding harsh soaps and skin wash products.
    • Frequently washing the bed linens, towels, clothing, utensils etc. to prevent the exposure to dust particles that are commonly found on these items.
    • Keeping the skin adequately hydrated, yet avoiding excessive exposure to moisture.
    • Avoiding scratching the vesicles. The doctor should properly advise the patients in this regard.
    • Avoiding environmental, industrial and occupational allergies.
    • Stress and anxiety have proved to be predisposing factors for atopic dermatitis. Therefore, stress should be avoided.

    Summary

    A commonly occurring inflammatory skin disorder, atopic dermatitis, also known commonly as eczema, is a form of allergic reaction to allergens found in the environment. It is frequently described as a cutaneous manifestation of systemic allergic reactions (atopy) [1].

    Atopic dermatitis is more common in children and is characterized by excessively dry, red and itchy skin. Various environmental and genetic factors have been implicated in the development of this disease. Although the condition persists over the years, it is not contagious and can be cured with medication.

    Patient Information

    Atopic dermatitis is a skin disease that affects children the most. Factors causing this disease mainly involve dust particles and other allergic substances present in the environment. It involves excessive dryness, redness and itching over the skin. Atopic dermatitis gives rise to an urge to scratch which should be avoided as much as possible because the eruptions can peel off, exposing the vulnerable ski underneath. This might become a cause of acquiring infections.

    The condition is not contagious and is not transmitted from one person to another. These eruptions can be cured with proper care and treatment.

    Self-assessment

    Ask Question


    5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.

    References

    1. Conde-Taboada A, Gonzalez-Barcala FJ, Toribio J. [Review and update of current understanding of childhood atopic dermatitis]. Actas dermo-sifiliograficas. Nov 2008;99(9):690-700.
    2. Takigawa M, Sakamoto T, Nakayama F, Tamamori T. The pathophysiology of atopic dermatitis. Acta dermato-venereologica. Supplementum. 1992;176:58-61.
    3. Kang K, Stevens SR. Pathophysiology of atopic dermatitis. Clinics in dermatology. Mar-Apr 2003;21(2):116-121.
    4. Guillet G. [Atopic dermatitis:epidemiologic, clinical features, the role of allergy (review)]. Allergie et immunologie. Dec 2000;32(10):393-396.
    5. Oakes RC, Cox AD, Burgdorf WH. Atopic dermatitis. A review of diagnosis, pathogenesis, and management. Clinical pediatrics. Jul 1983;22(7):467-475.
    6. Correale CE, Walker C, Murphy L, Craig TJ. Atopic dermatitis: a review of diagnosis and treatment. American family physician. Sep 15 1999;60(4):1191-1198, 1209-1110.
    7. Naeyaert JM, Lachapelle JM, Degreef H, de la Brassinne M, Heenen M, Lambert J. Cyclosporin in atopic dermatitis: review of the literature and outline of a Belgian consensus. Dermatology. 1999;198(2):145-152.
    8. Yun Y, Kim K, Choi I, Ko SG. Topical herbal application in the management of atopic dermatitis: a review of animal studies. Mediators of inflammation. 2014;2014:752103.
    9. Simpson EL. Atopic dermatitis: a review of topical treatment options. Current medical research and opinion. Mar 2010;26(3):633-640.
    10. Meduri NB, Vandergriff T, Rasmussen H, Jacobe H. Phototherapy in the management of atopic dermatitis: a systematic review. Photodermatology, photoimmunology & photomedicine. Aug 2007;23(4):106-112.

    • A survey of skin disorders seen in pédiatrie general and dermatology clinics - WW Tunnessen - Pediatric dermatology, 2008 - Wiley Online Library
    • Cytokine milieu of atopic dermatitis skin subverts the innate immune response to vaccinia virus - MD Howell, RL Gallo, M Boguniewicz, JF Jones - Immunity, 2006 - Elsevier
    • (cutaneous lymphocyte-associated antigen-positive) CD8+ T cells respond to superantigen and contribute to eosinophilia and IgE production in atopic dermatitis - M Akdis, HU Simon, L Weigl, O Kreyden - The Journal of , 1999 - Am Assoc Immnol
    • Evaluation of minor clinical features of atopic dermatitis - AJ Kanwar, S Dhar, S Kaur - Pediatric dermatology, 1991 - Wiley Online Library
    • The CD4< sup>+ T cell profile from T< sub> H2-dominant type to T< sub> H1-dominant type after varicella-zoster virus infection in atopic dermatitis - T Fujimura, R Yamanashi, M Masuzawa, Y Fujita - Journal of allergy and , 1997 - Elsevier
    • Aetiology of canine otitis externa: a retrospective study of 100 cases - MN Saridomichelakis, R Farmaki - Veterinary , 2007 - Wiley Online Library
    • Atopic dermatitis symptoms decreased in children following massage therapy - L Schachner, T Field, M Hernandez‐Reif - Pediatric , 1998 - Wiley Online Library
    • Chronic nonhereditary blistering disease in children - SF Bean, RE Jordon - Archives of dermatology, 1974 - Am Med Assoc
    • An approach to the treatment of anogenital pruritus - GE Weichert - Dermatologic Therapy, 2004 - Wiley Online Library
    • An approach to clinical dermatologic diagnosis based on morphologic reaction patterns - CA Gropper - Clinical Cornerstone, 2001 - Elsevier
    • In experimentally induced hyperplastic skin of Balb/C mice by monoclonal anti-DNP IgE antibody: possible implications for skin lesion formation in atopic dermatitis - I Katayama, R Tanei, H Yokozeki - Archives of Allergy , 1990 - content.karger.com
    • Clinical dermatology - TP Habif - 2009 - books.google.com
    • A short-term trial of tacrolimus ointment for atopic dermatitis - T Ruzicka, T Bieber, E Schöpf, A Rubins - England Journal of , 1997 - Mass Medical Soc
    • A major susceptibility locus for atopic dermatitis maps to chromosome 3q21 - YA Lee, U Wahn, R Kehrt, L Tarani, L Businco - Nature , 2000 - nature.com
    • Evidence for a disease-promoting effect of Staphylococcus aureus–derived exotoxins in atopic dermatitis - R Bunikowski, MEA Mielke, H Skarabis, M Worm - Journal of allergy and , 2000 - Elsevier
    • A prospective study of the clinical manifestations of atopic disease in infancy - PP ASPEREN, AS KEMP, CM MELLIS - Acta Paediatrica, 1984 - Wiley Online Library
    • Atopic dermatitis, asthma, allergic rhinitis, and hand and contact dermatitis in adolescents. The Odense Adolescence Cohort Study on Atopic Diseases and Dermatitis - CG Mortz, JM Lauritsen - British Journal of , 2001 - Wiley Online Library
    • Coexistence of atopic dermatitis and lichen nitidus in three patients - GG Lestringant, P Piletta, R Feldmann, I Galadari - , 1996 - content.karger.com
    • Scanning microscopic observation of glycocalyx production by Staphylococcus aureus in skin lesions of bullous impetigo, atopic dermatitis and pemphigus foliaceus - H Akiyama, T Hamada, WK Huh - British Journal of , 2003 - Wiley Online Library
    • A short-term trial of tacrolimus ointment for atopic dermatitis - T Ruzicka, T Bieber, E Schöpf, A Rubins - England Journal of , 1997 - Mass Medical Soc

    Media References

    1. Atopy2010, CC BY-SA 3.0

    Languages

    Self-assessment