Atopic dermatitis in children
Atopic dermatitis is one of the most common dermatological disease in children (and adults) and is also a common reason for pediatrician visits, mostly in the first years of the child.
So, after reading this chapter I expect you to know a lot more on the subject, in order for you to get better treatment for your child.
Let’s start.
What is Atopic dermatitis and how common is it?
About 20% of children worldwide suffer from atopic dermatitis in different levels of severity. The disease is charichtaridzed by fluctuating exacerbations of chronic rash and itch.
In most cases the severity of the disease is mild. However, in 25% of cases children suffer from a moderate disease and in 5-10% of cases it is a serious disease.
The pathogensis of the atopic dermatitis is very complex and is influenced by genetic and environmental factors. Certain genetic predispostions cause changes in the skin’s normal structure and function. These in turn cause, loss of natural moisture mechanisms and reduced protection againts different environmental pollutants and allergens. These environmental factors activate inflammatory reaction of the immune system, which causes the chracteristic rash, itching and other structural changes of the skin.
Many families have “atopic tendencies” in a variety of forms, including atopic dermatitis, ,asthma, allergic rhinitis (“runny nose” due to allergy), allergic conjunctuvitis (seasonal red, itching eyes) etc. In general, if a family member suffers from one of these, there is a high probability for other family members to suffer from one of them as well (not necessarily the same).
Is there a correlation between atopic dermatitis and allergy?
Atopic dermatitis is not an allergic disease. However, it is importent to know that children who suffer from atopic dermatitis are more likely to have associated allergies to different foods, asthma and allergic rhinitis. However, becuse there is no circumstantial connection between these conditions, it is unnecessary to try and diagnose one of these allergies if there is no clear rash, edema or shortness of breath after exposure to certaind foods.
What is the common age for atopic dermatitis in children?
The disease can emerge at any age, however in most cases (about 60%) it appears during the first year. It can also appear later in life, even in adults.
How does the rash look like?
The rash consists of pink-red rough lesions with white scales. Scratch marks are often found in the area of the rash (its itchy…). The rash tends to appear in specific areas, mostly elbows and knees. In infants and children the rash is mainly distributed on the face and neck, elbows and knees. Usually there is no rash in the armpits and groin.
Additional characteristics include: dry skin, rough skin on the arms, highlighted skin folds in the lower eyelids, darker skin colorations around the eyes, lighter skin color around the mouth, light spots on the cheeks, highlightened lines of the palms of the hands and more.
How would the doctor diagnose atopic dermatitis?
Atopic dermatitis is a clinical diagnosis.The pediatrician or the dermatologist will question the parents or the older child about the rash, associated signs and symptoms, age of appearance of first symptoms and their course, relevant family history (mostly “atopic tendencies) and background illnesses. The doctor will then examine the skin lesions and will be able to make the most probable diagnosis. Blood tests or skin biopsy are generally not necessary for the diagnosis. They are helpful only in cases where the diagnosis is not certain.
What are the possible complication of atopic dermatitis in children?
Although sometimes it seems that most cases are mild with no more than some rash and itching, atopic dermatitis in infants and children is associated with many potential morbidities.
Disturbed sleep – atopic dermatitis is an itchy disease. In most children the itch worsens in the evening, after bathing or before sleep. In some cases there will be difficulties falling asleep or a distribution to proper sleep cycles. The disturbed sleep leads to daytime tiredness, decreased function during the day, aggressiveness and mood changes.
Eye complications – conjunctuvitis (red eyes), blepharitis (inflammation of the eyelids) and changes in the structure of the cornea.Therefore, in case of redness in the eyes or itch it’s important to consult an ophthalmologist.
Bacterial skin infections – up to 90% of children with atopic dermatitis carry a bacterium named Staphylococcus aureus on their skin. This bacterium may cause:
1. Secondary bacterial infection of atopic dermatitis lesions.
2. Exacerbation of atopic dermatitis inflammation with no active infection.
3. Skin infection in areas that are not affected with atopic dermatitis.
Manifestation of bacterial infection are yellow or white discharge, golden scabs or small lesions with white-headed purulent content. You can read about skin infections in children in this chapter.
Viral skin infections – Herpes simplex skin infection in children with atopic dermatitis can cause severe widespread disease (Eczema herpeticum). Herpetic lesions are chracterized by clusters of multiple small blisters that spread rapidly.
Therefore, in the event of the appearance of one these signs of secondary infection, a doctor should be consulted as soon as possible.
Principles in treating atopic dermatitis in children
Although there is no curative treatment for this disease, in many cases, it tends to wane during childhood. Therefore treatment modalities are aimed to relief and reduce symptoms until, hopefully, it will disappear by itself.
Atopic dermatitis treatment is directed against the three main components of the disease: dryness of the skin, itching and inflamation. Treating only one of these components or neglecting others, will hamper significant improvement.
Treating dry skin – changes in skin’s structure and function cause an increased loss of water through the skin. Therefore, it’s important to add moisture externally. The best way is by applying unscented rich moisturiser frequently, at least 3 times a day. You can find many moisturising products in the market, some marketed as specific products for atopic dermatitis. However, the is no preference to one moisturiser or another, and in most cases buying a moisturiser of expensive brands is unnecessary.The true story about mosturising is not the brand but applying it frequently.
It is important to understand that adding moisture doesn’t fix the skin and that a single application is not enough.
Preventing Itching – itchiness can cause restlessness, irritability and complications as mentioned earlier. In case of itchiness the recommendation is to use drugs from the antihistamine group and to cut the child’s nail in order to prevent self induced lacerations.
In addition, it is important to be aware of environmental factors that can aggravate itchy skin:
▪︎Sweat caused by environmental heat or wearing inappropriate warm clothes.
▪︎It is recommended to wear clothes made of 100% cotton.
▪︎Cosmetics – it is recommended to avoid soaps, scented products, fabric conditioners and bath foam.
▪︎It is recommended to avoid smoking in the environment of a child who suffers from atopic dermatitis.
Treating inflamation – inflameted skin is manifested with the appearance of reddness and itchiness.
Products containing steroids will be used first. This is a very effective treatment and its safety in children has been approved in many scientific studies. In general, we prefer to use the less potent steroids (weakest activity level) that leads to the disappearance of the rash in the shortest time. The type of steroid and duration of the treatment will be decided by the physician.
It is important to remember that steroid treatment helps to control symptoms but doesn’t cure the disease. Therefore, it is usually necessary to repeat this treatment when the rash reappears.
In cases where local steroid leads to a temporary or partial improvement, the dermatologist may recommend a non-steroid anti inflammatory drugs such as tacrolimus ointment, Pimecrolimus cream and more as a steroid sparing treatment. The recommendations for these specifiec treatments and use, will be given by a pediatric dermatologist.
In case of skin infection, the pediatrician or dermatologist will prescribe an antimicrobial treatment against the bacterium or herpes.
In cases of frequent infections the dermatologist will consider preventive measures such as use of antiseptic products and antibiotic ointment to be applied inside the nostrils for bacterial colonization eradication.
Can children heal from atopic dermatitis?
As previously noted, in most cases the disease wanes with age, but it is usually difficult to specifically predict the time frame. In any case, managing it correctly can reduce the child’s suffering and allow normal life.
Is there a connection between atopic dermatitis and other food sensitivities and if so, what is the recommendation for prevention?
Because infants with atopic dermatitis are at an increased risk of developing food allergies, it is recommended to introduce infant to potentially allergic foods along with other complemntary foods at about 6 months of age.
Read the important chapter dealing with starting tasting in the following link and with the guidance of your paediatrician, start presenting these infants with various antigenes from this young age.
In conclusion, a very common and important topic in pediatrics. Proper management can prevent unnecessary suffer from children. Food allergies are also very important and awareness for prevention will significantly reduce them.
In summary:
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