Atopic dermatitis, also known as eczema, is the most common dermatological diagnosis. It is an inflammation of the skin that results in a red, itchy rash normally on the cheeks arms and legs. It is characterized by pruritic, erythematous, and scaly skin lesions often localized to the flexural surfaces of the body. It can present with asthma and allergic rhinitis as part of an allergic triad (Berke, Singh & Guralnick, 2012).
The incidence and prevalence of this skin disorders is that it affects nearly 33 million Americans every year, mostly children. Approximately 5-25 cases per 1000 cases per year affecting children more than any other age group especially under age 5 (Ferri, 2017). The highest incidence is among children (10% to 20%) and accounts for 4% of acute care pediatric visits. It effects 1-3% of the adult population. Onset is usually before age 5 and there is a major correlation of eczema and asthma and allergic rhinitis by age 13.
Berke et al., (2012) state a genetic defect in the filaggrin protein is thought to cause atopic dermatitis by disrupting the epidermis. This disruption, in turn, results in contact between immune cells in the dermis and antigens from the external environment leading to intense itching, scratching, and inflammation. Scratching can then lead to further disruption and inflammation of the epidermal skin barrier; this has been described as the itch scratch cycle.
Diagnostic criteria for eczema, per Ferri, includes the presence of three of four major features including pruritus, personal or family history of asthma, allergic rhinitis or atopic dermatitis, facial involvement in infants and children and flexural lichenification in adults which is the thickening of the skin in the flexural areas of the body such as knees, armpits, elbows and groin. The criteria also include three of the minor features which include elevated IgE, accentuation, recurrent conjunctivitis, ichthyosis (dry scaly, thick skin), nipple dermatitis, wool intolerance, cutaneous staph infection, food intolerance, hand dermatitis, facial pallor, cheilitis (chapped lips), white dermographism, and early onset after 2 months of age (2018). Common symptoms of eczema include itching, redness, dry scaly or crusty skin that might become thick and formation of bumps or small, fluid-filled blisters. Adults are most affected on their hands, children are more affected in the bends of their knees and elbows and infants more so on their face, scalp and neck. Eczema can present in three clinical phases. Acute presents with a vesicular, weeping, crusting eruption. Subacute presents with dry, scaly, erythematous papules and plaques. Chronic demonstrates lichenification from repeated scratching.
Treatment of eczema is based on the presenting symptoms and should be very individualized to the patient. The goal of treatment is the prevention of flare-ups; therefore, patients should be aware of triggers such as food allergens and dyes and detergents. Skin should be kept clean and moisturized with regular and liberal use of emollients. Use of over the counter medications such as hydrocortisone creams can be used to control itching, swelling and redness. Prescriptions such as topical corticosteroids can also be offered for short term use when the patient has acute flare ups. Second-line prescriptions such as topical calcineurin inhibitors can be used short-term or intermittent long-term in persons with moderate to severe atopic dermatitis, especially when there is concern that ongoing use of conventional topical corticosteroids will lead to atrophy or other complications. Phototherapy has also been shown to improve certain skin disorders through exposure to Ultraviolet B light (Cleveland Clinic, 2017).
According to Ferri (2017), 70% of all childhood cases of eczema resolve by adulthood but patients should follow up with their health care provider for ongoing treatment and evaluation. The National Eczema Association (2018), states that patients need to implement a daily bathing and lotion routine in order to cut down on the flare ups. Patients should also keep track of foods and environmental factors that may exacerbate symptoms. Patients and families need to be educated that there is no cure for eczema and that treatment is based around helping to alleviate symptoms and minimize flare ups (National Eczema Association, 2018).
References:
Barbarot, S. and Stalder, J.F. (2014). Therapeutic patient education in atopic eczema. British Journal of Dermatology, 170 (s1), 44-48. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/bjd.12932/abstract;jsessionid=4CA5E90274E1C83F3B95D835C11FF993.f01t01
Berke, R., Arshdeep, S. and Guralnick, M. (2012). Atopic dermatitis: An overview. American Family Physician, 86 (1), 35-42. Retieved from https://www.aafp.org/afp/2012/0701/p35.html
Cleveland Clinic. (2017). Eczema. Retrieved from: https://my.clevelandclinic.org/health/diseases/9998-eczema/management-and-treatment
Ferri, F.F. (2017). 2018 Ferri’s clinical advisor: 5 books in one. Philadelphia: Elsevier.
National Eczema Association. (2018). What is eczema?. Retrieved from https://nationaleczema.org/eczema/
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