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).
Incidence and Prevalence
Per Ferri (2018), the incidence is between 5 and 25 cases/1000 persons. The highest incidence is among children (10% to 20%) and accounts for 4% of acute care pediatric visits. It affects 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.
Pathophysiology
Berke et al., (2012) state a genetic defect in the filaggrin protein are 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.
Physical Assessment and Examination
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.
Evidence-Based Treatment Plan
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. The 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 a 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).
Patient Education
Patient education influences patient satisfaction by improving knowledge related to their disease process, increasing compliance, manages expectations and improves everyday quality of life. Therapeutic patient education is a four-step process including educational diagnosis, educational objectives, acquisition of skills and assessment. Patients should be taught about the cause of eczema, triggers, treatments and expected outcomes. Through education, patients can manage eczema, reduce flare-ups and minimize complications, while improving their outlook on the disease.
Follow Up and Evaluation
Cleveland Clinic (2017) states that nearly half of children with eczema will outgrow the condition or experience great improvement by the time they reach puberty. Others will continue to have some form of the disease. For adults with eczema, the disease can be generally well-managed with good skincare and treatment, although flare-ups of symptoms can occur throughout life.
References
Barbarot, S. and Stalder, J.F. (2014). Therapeutic patient education in atopic eczema. British Journal of Dermatology, 170 (s1), 44-48. 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. 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). Ferri’s Clinical Advisor 2018: 5 Books in 1 (Ferri’s Medical Solutions)
