Atopic dermatitis in children

As you will see below, atopic dermatitis, or, skin asthma, is a chronic inflammatory condition and one of the most common skin conditions in children (and adults).

Usually, the condition develops during the first years of life and tends to improve or even resolve as the child grows, but there are cases when adult patients have to cope with it as well.

Since this is one of the most common skin conditions in children, it is also a common reason for visiting the pediatrician, especially in the first few years of life.

The purpose of this important topic, just like the rest of the content on this website, is to provide you, the parents, with the knowledge and tools to help you give your children better care.

Dr Shiran Reiss Hos, a fantastic pediatric dermatologist listed on the Dr Efi’s portal of recommended physician, has helped write this important and basic post.

What is atopic dermatitis and how common is it in children?

Atopic dermatitis is a common inflammatory skin condition, that has a chronic-recurrent course. The condition manifests in significant dryness of the skin and recurrent exacerbations of a rash accompanied by a strong and uncontrollable urge to itch.
About 20% of children in the world suffer from this condition, in different degrees of severity. In most of the cases, the condition is mild, in about 25% of the times it is intermediate in severity and in about 5-10%, it is severe.

What is the mechanism of development of disease?

The causes of this condition have been found to depend on genetic and environmental factors combined.
Certain genetic changes cause a loss of water from the skin, damage to the structure of the normal skin and activation of the immune system within the skin. In addition, there are environmental factors such as bacteria and allergens that are able to penetrate the skin and activate the immune system in the skin, which in turn causes the development of a rash, pruritis and further structural changes in the skin.
Additional environmental factors that could cause rash are cold and dry weather (which causes dryness of the skin), extreme heat, prolonged baths, use of soaps, irritants such as wool and tight, synthetic clothing, perfumes and cosmetics, dust, sand, grass and different types of flowers.

Is atopic dermatitis an allergic disease?

Many of the patients and their families suffer from additional atopic conditions such as asthma, allergic rhinitis, seasonal eye inflammation and food sensitivities. When one member of the family has one of these conditions, the rest of the members of the family have a higher chance of having one of these conditions as well (not necessarily the same one). Despite patients with atopic dermatitis having an increased risk of developing food allergies, exposure to different foods does not cause an exacerbation of skin symptoms and therefore we do not recommend avoiding exposure to certain foods in these children unless a specific recommendation has been given by an allergist.

What is the common age at which atopic dermatitis presents?

This condition can develop at any age but most of the time (60%) it presents in the first year of life. Of-course, it can also present at a later age and even in adults.

What does the rash in atopic dermatitis look like?

The rash is comprised of pink-red lesions covered with white scale. See the image attached. Sometimes, one can also find secretions, crust, thickened skin and signs of excoriation. The sites at which the rash develops vary with age. In babies, we tend to see signs on the face, the stomach and the back, the knee area, and the elbow area. In children, it tends to appear at the elbow depressions, the knees, and the neck area. In adults, it can present anywhere on the body, sometimes it is similar to the presentation in children and sometimes it is only seen on the palms of the hands or on the face.
Additional characteristics are general dryness of the skin, pronounced folds in the lower eyelids, darkening of the skin around the eyes, pallor of the skin around the mouth, lighter patches of colour around the cheeks, roughness of the arms, pronunciation of the skin lines in the palms of the hands and more.

How does a doctor diagnose atopic dermatitis in a child?

The diagnosis of atopic dermatitis is a clinical one. That means, the pediatrician or dermatologist will question the parents or the child about the rash and accompanying symptoms, the age at presentation, the course of the illness, the family history and the medical history. Of course, the physician will also examine the rash itself and the skin and by doing so is able to make the most likely diagnosis based on the findings.
Blood tests or skin biopsies are not necessary. They can be an aiding tool in cases where the diagnosis is not clear cut.

What are the complications of atopic dermatitis in children?

Despite atopic dermatitis seeming like a mild condition at times, where the child only suffers from minor pruritis, atopic dermatitis can still be accompanied by morbidity and many potential complications:

It can have an effect on the quality of life and quality of sleep – atopic dermatitis is a very itchy condition. For most children, the pruritis worsens in the evening, following a bath or before bedtime. In certain situations, it can cause difficulty in sleeping and may affect the child’s sleep cycle. The sleep disorder then causes a reduction in daytime functioning, aggression and altered mood. There are patients who experience depression, anxiety, behavioural disorders and learning disorders as a result of the condition, because the pruritis causes irritability and has a great effect on their ability to concentrate and therefore on their general daytime functioning. The effect on the child’s sleep affects the rest of the family’s sleep, and so the condition can really have an effect on the entire family.
Since the manifestations of the rash on the skin are such that most people are able to see them, sometimes these patients experience social embarrassment, especially children, to the extent that they prefer not attending school and avoid taking part in extracurricular activities.

Eye complications – eye infections, changes in the structure of the cornea, inflammation of the eyelids. Therefore, if any redness or itchiness appears around the eyes, it is important to see an ophthalmologist.

Bacterial skin infections – up to 90% of children with atopic dermatitis are carriers of the bacteria Staphylococcus aureus. This bacterium can cause the following:
1. Secondary infections in lesions caused by atopic dermatitis.
2. Exacerbation of the condition without any active infections. It is important to really understand this point, simply being a carrier of the bacteria can cause an exacerbation of the atopic skin.
3. Skin infections in areas of skin that are not involved with the condition.

The infections can present with secretions that are yellowish white, golden crusts and small lesions with pustular heads. You can read more about skin infections in children here or in the chapter dedicated to impetigo.

Viral skin infections – viral warts or different types of warty lesions such as Moluscum (more in this link) or the papilloma virus are common in children with atopic dermatitis. In addition, a skin infection caused by herpes virus can cause a severe and widespread disease in children with atopic dermatitis (eczema herpeticum). The disease itself presents with small vesicular (blistering) lesions that spread very quickly.

Therefore, if you see one of the above signs that are likely secondary skin infections, you must see a physician for an assessment as soon as possible.

How is atopic dermatitis in children treated?

Despite there still not being a fully curative therapy, that would cause this condition to disappear, in many of the cases the condition tends to fade in the first few years of childhood. Therefore, the current therapies are directed at relief and reduction of symptoms, until it starts fading on its own.
Treatment of atopic dermatitis is directed at three many components of the disease – dryness of the skin, pruritis and inflammation. Treating only one of the components, or disregarding treatment of one of the components will fail to lead to significant improvement.

Treatment of dryness of the skin / moisturizing products – dryness of the skin is one of the primary characteristics and therefore regular usage of moisturizing products is recommended as a basic and routine treatment regardless of severity of the disease and should be applied together with medication, when given. Regular usage of moisturizing products plays an important role at preventing and reducing frequency of exacerbations, preventing the sensation of dry skin, improving the response to therapeutic treatments and even reducing the use of topical steroids (find out more below).
It is important to use moisturizing products on a regular and daily basis, at least twice a day, such as applying creams and other products that insert moisture into the skin and by doing so soften it and reduce itchiness and inflammation.

Bathing and cleaning – having a bath once a day is recommended. Avoiding baths that are very warm and long is important. Ensuring the use of soft soap and avoiding the scrubbing of the skin are recommended. In addition, is important to use therapeutic soap/bathing oil that are designated for atopic skin.

Avoiding external irritants – avoiding irritants that exacerbate the disease, such as extreme weather, extreme heat/overheating the house, fragranced soaps and other products, wearing certain types of cloths, touching plants, and more. Since the pruritis can cause irritability, restlessness, and the complications mentioned above, one can use antihistaminic medications such as Dimethindene maleate drops (mainly because of their sedative effects) and make sure to cut the child’s nails because they tend to hurt themselves when scratching.

Local therapies – in areas of skin that are very inflamed and itching, creams or ointments that contain steroids should be used for limited periods of time. Steroids have an anti-inflammatory effect and with their help, we will be able to see a significant improvement. The decision on the type of steroids and the length of treatment will be determined by your physician. It is important to keep in mind that the direct use of moisturizing products on inflamed skin can cause a burning sensation, so if there is evidence of an active rash, make sure to first apply the anti-inflammatory product and only after the rash has improved return to moisturizing. Sometimes, there is a need for regular application of anti-inflammatory medications that aren’t steroids.

As mentioned above, skin infections can worsen the course of the disease and as a result, in these situations we use antibiotic treatment to help prevent development of infection and to reduce the severity of the inflammation.

What can be done when topical therapies are insufficient and are there any new therapies for this condition?

In cases where there is no improvement following the use of topical products on the skin, we are able to offer several different types of therapies.
The first one is phototherapy. This is a type of treatment that uses artificial light waves and it is done in phototherapy units in different medical centers. This therapy suppresses inflammation and reduces itching sensation. In certain situations, anti-inflammatory drugs are administered, such as “methotrexate” which can be given by mouth or through an injection. Fortunately, there are many novelties in the field of atopic dermatitis. In the past few years, several new and advanced therapies that can be used in children have been introduced, and they provide care for patients with intermediate to severe degrees of the illness. These are medications that inhibit certain inflammatory processes in the disease and thanks to these medications, patients who are coping with this illness experience a significant reduction in itchiness, a decrease in size of the rash and an improvement in the child and entire family’s daily life!

What is the degree of severity of the condition? How can we tell what the best treatment is for us?

The degree of severity of the condition will be determined by the dermatologist after they have questioned the parent or patient about the course of the illness, severity of itchiness, response to topical treatment, effect of the condition on the quality of life and activities of daily living and following a physical examination. A condition that is mild to intermediate in severity typically responds well to topical medications containing steroids (creams/ointments). In more severe cases, when application of these products does not lead to sufficient improvement, we advance to the systemic therapies mentioned above. For example: phototherapy or other therapies that can be given by mouth or through injections. If your child has atopic dermatitis, see your dermatologist to find out whether the new therapies available are suitable for your child.

Can one heal from atopic dermatitis?

In most of the cases, the condition tends to fade with age, but it is usually difficult to estimate how long it will last. Either way, proper management of the condition can reduce the suffering that the children experience.

Is there an association between atopic dermatitis and other sensitivities to food, and if so, what should be avoided?

Babies with atopic dermatitis are at higher risk of developing certain food sensitivities or allergies. As such, introduction of allergens as early as 4 months should be considered in these babies. Find out more about introduction of solids in the following link, and with the help of your pediatrician, start introducing different allergens to these babies at a young age. Early introduction can reduce the prevalence of food sensitivities in these children.

In summary, this is a very common topic in pediatrics and when managed correctly, can help reduce redundant suffering experienced by these babies and children. Consult with your pediatrician for primary guidelines and treatment and if your child has persistent atopic dermatitis, see a pediatric dermatologist for further care.