ATOPIC DERMATITISATOPIC DERMATITIS

Definition

Atopic dermatitis is a very common, often chronic (long-lasting) skin disease that affects a large percentage of the world's population. It is also called eczema, dermatitis, or atopy. Most commonly, it may be thought of as a type of skin allergy or sensitivity.

The atopic dermatitis triad includes asthma, allergies (hay fever), and eczema. There is a known hereditary component of the disease, and it is seen more in some families. The hallmarks of the disease include skin rashes and itching.

ATOPIC DERMATITISATOPIC DERMATITIS The skin of a patient with atopic dermatitis

reacts abnormally and easily to irritants, food, and environmental allergens and becomes red, flaky and very itchy. It also becomes vulnerable to surface infections caused by bacteria. The skin on the flexural surfaces of the joints (for example inner sides of elbows and knees) are the most commonly affected regions in people.

The word "dermatitis" means inflammation of the skin. "Atopic" refers to diseases that are hereditary, tend to run in families, and often occur together. In atopic dermatitis, the skin becomes extremely itchy and inflamed, causing redness, swelling, cracking, weeping, crusting, and scaling. Dry skin is a very common complaint and an underlying cause of some of the typical rash symptoms.

Although atopic dermatitis can occur in any age, most often it affects infants and young children. In some instances, it may persist into adulthood or actually first show up later in life. A large number of patients tend to have a long-term course with various ups and downs. 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 may remain somewhat dry and easily irritated.

Triggers

Multiple factors can trigger or worsen atopic dermatitis, including dry skin, seasonal allergies, exposure to harsh soaps and detergents, new skin products or creams, and cold weather. Environmental factors can activate symptoms of atopic dermatitis at any time in the lives of individuals who have inherited the atopic disease trait.

Scientists estimate that 65% of patients develop symptoms in the first year of life, and 90% 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% of these infants continue to have one or more symptoms of atopic dermatitis even after they reach adulthood.

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. Many patients also notice worsening of their itch in the early evening when they get home from work or school when there are less external stimuli to keep them occupied. When things at home sort of quiet down, the itching seems to become more noticeable.

Major and minor features of atopic dermatitis

Major features Itching Characteristic rash in locations

typical of the disease (arm folds and behind knees)

Chronic or repeatedly occurring symptoms

Personal or family history of atopic disorders (eczema, hay fever, asthma)

Some minor features Early age of onset Dry, rough skin High levels of immunoglobulin E (IgE), an

antibody, in the blood Ichthyosis Hyper linear palms Keratosis pilaris Hand or foot dermatitis Cheilitis (dry or irritated lips) Nipple eczema Susceptibility to skin infection Positive allergy skin tests

Conditions aggravating AD Many factors or conditions can intensify the

symptoms of atopic dermatitis, including dry skin, winter or cold weather, wool cloths, and other irritating skin conditions. These factors may further trigger the itch-scratch cycle, further stimulating the many times already overactive immune system in the skin. Repeated aggravation and activation of the itch-scratch cycle may cause further skin damage and barrier breakdown. These exacerbating elements can be broken down into two main categories: irritants and allergens. Emotional factors and some infections can also influence atopic dermatitis.

ManagementManagement Although there is no cure for atopic

eczema, and its cause is not well understood, it can be treated very effectively in the short term through a combination of prevention (learning what triggers the allergic reactions) and drug therapy.

ManagementManagement Most patients can be successfully

managed with proper skin care and lifestyle changes and do not require the more intensive treatments discussed. Much of the improvement comes from homework, including lubricating generously especially right after showers or baths.

ManagementManagement The doctor should have 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.

ManagementManagement A simple and basic regimen is key.

Staying with one recommended soap and one moisturizer is very important. Using multiple soaps, lotions, fragrances, and mixes of products may cause further issues and skin sensitivity.

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 three minutes of bathing.

ManagementManagement 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. Bath oils are not usually helpful.

ManagementManagement 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.

ManagementManagement 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 a 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.

Controlling atopic dermatitis Lubricate the skin frequently. Avoid harsh soaps and cleansers. 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.

Prevention Since there is no cure for atopic eczema,

treatment should mainly involve discovering the triggers of allergic reactions and learning to avoid them.

Diet: Originally controversial, the association of food allergy with atopic dermatitis has now been clearly demonstrated. Many common food allergens can trigger an allergic reaction: such as milk, nuts, cheese, tomatoes, wheat, yeast, soy, and corn. Many of these allergens are common ingredients in grocery store products (especially corn syrup, which is a sugar substitute).

Prevention

Specialty health food stores often carry products that do not contain common allergens. If a child avoids these allergens early on, the frequency of reactions to these later in life is decreased significantly. Breastfeeding is the best way to avoid these problems, but if that is unavailable, then hydrolyzed formulas are preferred to cow's milk.

Prevention

Environment and Lifestyle: Since dust is a very common allergen and irritant, adults with atopic eczema should likely avoid smoking, as well as the inhalation of dust in general. The dander from the fur of dogs and cats may also trigger an inflammatory response. It is a common misconception that simply removing an animal from a room will prevent an allergic reaction from occurring.

Prevention

A room must be completely free of animal dander in order to prevent an allergic reaction. Anger, stress, and lack of sleep are also factors that are known to aggravate eczema. Excessive heat (especially with humidity) and coldness are known to provoke outbreaks, as well as sudden and extreme temperature swings.

The Scratch Test: An allergy skin-patch or "scratch" test, given by an allergist, can often pinpoint the triggers of allergic reactions. Once the causes of the allergic reactions are discovered, the allergens should be eliminated from the diet, lifestyle, and/or environment. If the eczema is severe, it may take some time (days to weeks depending on the severity) for the body's immune system to begin to settle down after the irritants are withdrawn.

The primary treatment involves prevention, includes avoiding or minimizing contact with (or intake of) known allergens. Once that has been established, topical treatments can be used. Topical treatments focus on reducing both the dryness and inflammation of the skin.

To combat the severe dryness associated with eczema, a high-quality, dermatologist approved moisturizer should be used daily. Moisturizers should not have any ingredients that may further aggravate the condition. Moisturizers are especially effective if applied within 5–10 minutes after bathing. A doctor might also prescribe lotion containing sodium hyaluronate to improve skin dryness

Most commercial soaps wash away all the oils produced by the skin that normally serve to prevent drying. Using a soap substitute such as aqueous cream helps keep the skin moisturized. A non-soap cleanser can be purchased usually at a local drug store. Showers should be kept short and at a lukewarm/moderate temperature.

If moisturizers on their own don't help and the eczema is severe, a doctor may prescribe topical corticosteroid ointments, creams, or injections. Corticosteroids have traditionally been considered the most effective method of treating severe eczema.

Disadvantages of using steroid creams include stretch marks and thinning of the skin. Higher-potency steroid creams must not be used on the face or other areas where the skin is naturally thin; usually a lower-potency steroid is prescribed for sensitive areas. If the eczema is especially severe, a doctor may prescribe prednisone or administer a shot of cortisone or triamcinolone If complications include infections (often of Staphylococcus aureus), antibiotics may be employed.

A more novel form of treatment involves exposure to broad or narrow-band ultraviolet light. UV radiation exposure has been found to have a localized immunomodulatory effect on affected tissues, and may be used to decrease the severity and frequency of flares. The usage of UVA1 is more effective in treating acute flares, whereas narrow-band UVB is more effective in long-term management scenarios.However, UV radiation has also been implicated in various types of skin cancer,and thus UV treatment is not without risk.

Lifestyle and home remedies

To help reduce itching and soothe inflamed skin, try these self-care measures:

Try to identify and avoid triggers that worsen the inflammation. Rapid changes of temperature, sweating and stress can worsen the condition. Avoid direct contact with wool products, such as rugs, bedding and clothes, as well as harsh soaps and detergents.

Lifestyle and home remedies Apply an anti-itch cream or calamine lotion

to the affected area. A nonprescription hydrocortisone cream, containing at least 1 percent hydrocortisone, can temporarily relieve the itch. A nonprescription oral antihistamine, such as diphenhydramine (Benadryl, others), may be helpful if itching is severe.

Avoid scratching whenever possible. Cover the itchy area if you can't keep from scratching it. Trim nails and wear gloves at night.

Lifestyle and home remedies Apply cool, wet compresses. Covering the

affected area with bandages and dressings can help protect the skin and prevent scratching.

Take a warm bath. Sprinkle the bath water with baking soda, uncooked oatmeal or colloidal oatmeal — a finely ground oatmeal that is made for the bathtub (Aveeno, others). Or, add 1/2 cup (118 milliliters) of bleach to a 40 gallon (151 liter) bathtub filled with warm water. The diluted bleach bath is thought to kill bacteria that grow on the skin.

Lifestyle and home remediesChoose mild soaps without dyes or perfumes. Be sure to rinse the soap completely off your body.

Moisturize your skin. Use an oil or cream to seal in moisture while your skin is still damp from a bath or shower. Pay special attention to your legs, arms, back and the sides of your body. If your skin is already dry, consider using a lubricating cream.

Wear cool, smooth-textured cotton clothing. Avoid clothing that's rough, tight, scratchy or made from wool. This will help you avoid irritation. Also, wear appropriate clothing in hot weather or during exercise to prevent excessive sweating.

Factors that worsen atopic dermatitis

Long, hot baths or showers

Dry skin

Stress

Sweating

Rapid changes in temperature

Low humidity

Solvents, cleaners, soaps or detergents

Wool or man-made fabrics or clothing

Dust or sand

Atopic Dermatitis At A Glance Atopic dermatitis is a type of eczema. The skin sensitivity of this disease may be

inherited and genetically determined. The patient's skin may be "super sensitive"

to many irritants. Dry scaly patches develop in a

characteristic distribution. Itching varies but may be intense and

scratching hard to resist. Scratching can cause skin thickening and

darkening and lead to further complications, including bacterial infection.

Atopic Dermatitis At A Glance Extremely dry skin can break down and ooze or

weep. If the itch can be controlled, the rash (which is

aggravated by vigorous scratching) may be more readily contained.

Treatment of atopic dermatitis is centered around rehydrating the skin with rich moisturizers like Vaseline 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.

Researchers have discovered a very effective and low-tech means of managing eczema.  It’s called household bleach.

The bleach study, published in the journal Pediatrics, found that giving diluted bleach baths to children with moderate or severe eczema (atopic dermatitis) reduced signs of infection and reduced the severity and extent of the eczema on their bodies.

Dr. Amy Paller and researchers treated 31 patients (6 months to 17 years old) who had eczema and a bacterial staph infection for 14 days with oral antibiotics. Half of the patients received bleach in their bath water (half a cup per full standard tub), while the other half received a look-alike placebo. All were instructed to bathe in the bleach twice a week, and soak for five to 10 minutes for three months.

The research team saw such rapid improvement in the kids taking the real bleach baths that they terminated the study early because they wanted the children getting the placebo to get the same relief. "The eczema kept getting better and better with the bleach baths and these baths prevented it from flaring again," Paller said. "We presume the bleach has antibacterial properties and decreased the number of bacteria on the skin, which is one of the drivers of flares."

Myths and Facts Myth: Keep Bathing to a Minimum

It is a common misconception that bathing dries the skin and should be kept to a bare minimum.

What dermatologists recommend: People with atopic dermatitis tend to have excessively dry skin. To hydrate the skin, take a short, daily bath(s) in warm — not hot — water. A mild, non-irritating soap should be used only when needed.

The facts: Daily bathing as recommended by a dermatologist helps to hydrate the skin, which can reduce flare-ups and relieve discomfort when moisturizers also are used as directed.

For severe atopic dermatitis, a dermatologist may recommend up to 3 short baths a day. Even patients who avoid water because getting wet can be painful tend to get relief after some initial discomfort.

Myth: Moisturizers Add Moisture to the SkinThe word “moisturizer” causes a great deal of confusion. People often think that a moisturizer adds moisture to the skin and can be applied any time.

What dermatologists recommend: Apply moisturizer within 3 minutes of bathing. This will trap moisture in the skin. Continue to apply moisturizer throughout the day to very dry areas.

The facts: A moisturizer cannot add moisture to the skin. Moisturizer seals in the water from the bath, preventing water from evaporating. This is why moisturizer is most effective when applied within 3 minutes of bathing.

To apply a moisturizer after bathing: Gently pat the skin partially dry. Apply medication directly on the lesions. Apply moisturizer on top of the medication and to the rest

of the skin. For best results, dermatologists recommend using a thick, oily moisturizer and applying it in the same way that you would apply icing to a cake.

Applying moisturizer within 3 minutes of bathing and frequently throughout the day will help the skin to retain moisture from bathing. This, in turn, helps prevent dryness and cracking, which is especially important when the air is dry. With regular use, moisturizer can help to reduce discomfort and flare-ups as well as decrease the need for medication.

Myth: Identify and Avoid Allergens to Prevent Flare-upsDermatologists often hear their patients and caregivers say that if only a patient’s allergies could be identified, then the patient could avoid these and prevent atopic dermatitis flares.

What dermatologists recommend: No one thing — not even allergen (substance to which the patient is allergic) avoidance — can control atopic dermatitis. Successfully managing this complex condition requires a multi-faceted approach. Proper skin care, using medication as directed, and avoiding one’s personal triggers all play a role. A trigger is anything that irritates the skin. A trigger need not be an allergen.

The facts: Laundry detergents, soaps, smoke, skin care products that contain alcohol or fragrance, and rough-textured clothing such as wool are common triggers that cause atopic dermatitis to flare. Triggers vary from person to person though, so it is important to learn what irritates the skin and avoid contact with individual triggers.

Preventing Flare-Ups

Lifestyle modifications are the first line of defense in controlling eczema, regardless of whether the eczema is mild, moderate, or severe. Recommended by dermatologists, the following guidelines can help reduce the severity and frequency of flare-ups, which also may decrease the need for anti-inflammatory medicine. Continuing to follow these guidelines once the signs and symptoms clear can help prevent further outbreaks:

Preventing Flare-Ups 1. Moisturize, moisturize, moisturize.

Eczema is usually dry and itchy, so applying moisturizers as needed to keep the skin moist is part of an effective treatment plan. Frequent moisturizing locks in the skin’s own moisture to prevent dryness and cracking.

One of the best ways to lock in moisture is to apply moisturizer after bathing. When bathing, care must be taken to avoid irritating the skin. For tips on how to bathe and moisturize to help alleviate eczema,

Preventing Flare-Ups 2. Limit contact with anything that irritates the skin.

Soaps, bubble bath, perfumes, cosmetics, laundry detergents, household cleaners, too much time spent in water, finger paints, gasoline, turpentine, wool, a pet’s fur, juices from meats and fruits, plants, jewelry, and even lotions can irritate sensitive skin. Know what irritates your skin and limit contact with all that does. Avoiding personal-care products that contain alcohol and not washing hands too frequently also will help reduce irritation. 

3. Avoid sweating and overheating. The most common triggers of the scratch/itch cycle are sweating and overheating. It is essential to prevent these situations whenever possible.

Preventing Flare-Ups 4. Avoid sudden changes in temperature and

humidity. A sudden rise in temperature can cause overheating and sweating. A drop in humidity can dry skin and lead to a flare-up.

5. Grab a cold compress to curb the itch. Scratching makes the condition worse and may puncture skin allowing bacteria to enter and cause an infection. Gently applying a cold compress to the area that itches can reduce inflammation and lessen the desire to scratch.

6. Keep fingernails short. Short nails decrease the likelihood that scratching will puncture the skin. Keeping nails short and wearing cotton gloves at night may help prevent scratching that punctures the skin while asleep.

Preventing Flare-Ups 7. Dress in loose-fitting cotton clothes. Synthetic

fabrics, wool, and other materials that feel rough to the touch often irritate the skin and trigger a flare-up. Cotton and cotton-blend clothes usually make skin feel better.

8. Double rinse clothes, and wash new clothes before wearing. Laundry detergents can trigger flare-ups. Using a fragrance-free, neutral pH detergent and double rinsing clothes can help prevent flare-ups caused by laundry detergent. It also may be helpful to wash new clothes before they are worn as washing removes excess dyes and fabric finishers, which can irritate the skin. Tags should be removed, too, as these can rub the skin, causing irritation.

Preventing Flare-Ups

9. Reduce stress. Stress reduction plays a key role in preventing eczema flares. In today’s fast-paced world, reducing stress can be challenging; however, there are ways to effectively reduce stress.

10. Follow a prescribed treatment regimen. Moisturizing and using medications as directed by a dermatologist go a long way toward keeping flare-ups at bay.

Stress Reduction Techniques Reducing stress makes controlling eczema much easier. In fact,

studies show that keeping calm and having a positive outlook may be the best ways to keep eczema under control. However, in today’s fast-paced world, managing stress can be a challenge even for children. Here are some time-tested techniques that can help effectively manage the stress of everyday life:

Maintain your treatment regimen. When life becomes especially hectic, it is important to comply with your treatment regimen to help avoid a flare-up. 

Don’t skimp on sleep. Adequate sleep reduces stress and gives skin time to rejuvenate.  

Pace yourself.  

Think calm. Take a minute or two to think calming thoughts when under stress.  

Stress Reduction Techniques Free your mind with a relaxation technique. Deep breathing,

progressive relaxation, visualization, yoga, meditation, or listening to a relaxation CD can help.  

Write away your worries. Research shows that taking 15 minutes each day to write down your concerns is an effective stress management technique. Ripping up the paper after you finish writing also helps relieve stress.  

Participate in a hobby. Doing something you enjoy can enhance your mental, emotional, and physical well-being.  

Get a pet. Pets reduce stress for many.  

Make time for yourself everyday. Create a list of things you enjoy. Maybe a walk, catching a favorite TV show, or curling up with a book are on your list. Find time everyday to do something you enjoy.  

Join a support group. Some find comfort and a feeling of well being when they talk with others who have eczema.

Around the Home Indoor allergens and irritants can trigger the signs and symptoms

of atopic dermatitis, a type of eczema that occurs when there is a genetic predisposition to atopic conditions, such as asthma and hay fever. Taking some precautions around the home can help prevent flare-ups:

1. Control Dust Mites. Some studies suggest that reducing dust mites can reduce symptoms; other studies show no effect. For the most part, only children have shown improvement when dust mites were controlled. This is what can be done to control dust mites in a child’s room:

Eliminate carpeting, rugs and blinds. Limit upholstered furniture. The only upholstered item in the

bedroom should be the bed. Cover box spring and mattress in plastic zippered covers and wipe

off covers weekly. Keep furnishings to a minimum. Only items made of wood, rubber,

metal, or plastic should be used. That goes for toys, too.

Around the Home Use a pillow and mattress pad made of

Dacron®. Clean the room thoroughly each week.

This should include wiping the floor, furniture, tops of doors, window frames, and sills with a damp cloth or oil mop.

Wash all bed clothes and curtains at least once a week in water that is 130° F or hotter.

Air the room thoroughly after cleaning. Keep all animals with fur or feathers out.

Around the Home 2. Keep home’s humidity level between 45% and 55%. Dehumidifiers

and humidifiers can keep humidity levels between 45% and 55%. Use a hygrometer, a device that measures humidity, to monitor the amount of moisture in the air. Hygrometers are available in places where thermometers are sold, such as a local hardware store.

3. Avoid contact with pets that have fur or feathers. When fur and feathers come into contact with skin, they can cause a flare-up. Pet dander is another common trigger. Be sure to keep pets with fur or feathers out of the bedroom.

4. Avoid contact with harsh dish-washing products and household cleaners.  Look for natural alternatives to bleaches and other cleaners that contain harsh chemicals.  If you must use such cleansers, wear protective gloves.  Wearing cotton gloves under rubber gloves can help prevent a flare-up if you have an allergy to latex.

5. Cover up in the yard. If plants or other things in the yard trigger a flare-up, wearing gloves and long pants and sleeves may help prevent a flare-up.

Homeopathic treatment Duration of treatment:

The total length of treatment varies form case to case, depending of the following factors:

Duration of Atopic Dermatitis

Areas affected

Extent of spread

Previous medication (Extensive use of oral or local cortisone)

One may expect a definite change in about three to five months, depending on the extent. The total length of medication may be anything between six months to two years or longer.

Mother’s History during pregnancy The baby’s constitution Activity status Thermal status of the baby Sleep position of the baby Fears of the baby- approaching

people, downward motion

Common remedies coming up

Belladonna Calc carb Stramonium Sulphur Chamomilla Rheum Calc Phos Tub Cup met

Common constitutional symptoms of babies

Desire to be carried Biting Spitting Pulling hair Restlessness Violent Fear of dark Clinging Aversion to be touched or looked at