Atopic dermatitis (AD), also known as atopic eczema, is a type of inflammation of the skin (dermatitis). It results in itchy, red, swollen, and cracked skin. Clear fluid may come from the affected areas, which often thicken over time. The condition typically starts in childhood with changing severity over the years. In children under one year of age much of the body may be affected. As children get older, the back of the knees and front of the elbows are the most common areas affected. In adults the hands and feet are the most commonly affected areas. Scratching worsens symptoms and affected people have an increased risk of skin infections. Many people with atopic dermatitis develop hay fever or asthma.
The cause is unknown but believed to involve genetics, immune system dysfunction, environmental exposures, and difficulties with the permeability of the skin. If one identical twin is affected, there is an 85% chance the other also has the condition. Those who live in cities and dry climates are more commonly affected. Exposure to certain chemicals or frequent hand washing makes symptoms worse. While emotional stress may make the symptoms worse it is not a cause. The disorder is not contagious. The diagnosis is typically based on the signs and symptoms. Other diseases that must be excluded before making a diagnosis include contact dermatitis, psoriasis, and seborrheic dermatitis.
Treatment involves avoiding things that make the condition worse, daily bathing with application of a moisturising cream afterwards, applying steroid creams when flares occur, and medications to help with itchiness. Things that commonly make it worse include wool clothing, soaps, perfumes, chlorine, dust, and cigarette smoke. Phototherapy may be useful in some people. Steroid pills or creams based on calcineurin inhibitors may occasionally be used if other measures are not effective. Antibiotics (either by mouth or topically) may be needed if a bacterial infection develops. Dietary changes are only needed if food allergies are suspected.
Atopic dermatitis affects about 20% of people at some point in their lives. It is more common in younger children. Males and females are equally affected. Many people outgrow the condition. Atopic dermatitis is sometimes called eczema, a term that also refers to a larger group of skin conditions. Other names include "infantile eczema", "flexural eczema", "prurigo Besnier", "allergic eczema", and "neurodermatitis".
Signs and symptoms
People with AD often have dry and scaly skin that spans the entire body, except perhaps the diaper area, and intensely itchy red, splotchy, raised lesions to form in the bends of the arms or legs, face, and neck.
AD commonly occurs on the eyelids where signs such as Dennie-Morgan infraorbital fold, infra-auricular fissure, periorbital pigmentation can be seen. Post-inflammatory hyperpigmentation on the neck gives the classic 'dirty neck' appearance. Lichenification, excoriation and erosion or crusting on the trunk may indicate secondary infection. Flexural distribution with ill-defined edges with or without hyperlinearily on the wrist, finger knuckles, ankle, feet and hand are also commonly seen.
Causes
The cause of AD is not known, although there is some evidence of genetic, environmental, and immunologic factors.
Genetics
Many people with AD have a family history of atopy. Atopy is an immediate-onset allergic reaction (type 1 hypersensitivity reaction) that manifests as asthma, food allergies, AD or hay fever.
About 30% of people with atopic dermatitis have mutations in the gene for the production of filaggrin (FLG), which increase the risk for early onset of atopic dermatitis and developing asthma. Filaggrin plays an important role in keeping the skin surface slightly acidic, hence giving it anti-microbial effects. It breaks down into trans-urocanic acid, which keeps the pH low.
Hygiene hypothesis
According to the hygiene hypothesis, when children are brought up exposed to allergens in the environment at a young age, their immune system is more likely to tolerate them, while children brought up in a modern "sanitary" environment are less likely to be exposed to those allergens at a young age, and, when they are finally exposed, develop allergies. There is some support for this hypothesis with respect to AD. Those exposed to dogs while growing up have a lower risk of atopic dermatitis. There is also support from epidemiological studies for a protective role for helminths against AD. Likewise children with poor hygiene are at a lower risk for developing AD, as are children who drink unpasteurised milk.
Allergens
In a small percentage of cases, atopic dermatitis is caused by sensitization to foods. Also, exposure to allergens, either from food or the environment, can exacerbate existing atopic dermatitis. Exposure to dust mites, for example, is believed to contribute to one's risk of developing AD. A diet high in fruits seems to have a protective effect against AD, whereas the opposite seems true for fast foods. Atopic dermatitis sometimes appears to be associated with celiac disease and non-celiac gluten sensitivity, and the improvement with a gluten-free diet indicates that gluten is a causative agent in these cases.
Hard water
Atopic dermatitis in children may be linked to the level of calcium carbonate or "hardness" of household water, when used to drink. So far these findings have been supported in children from the United Kingdom, Spain, and Japan.
Pathophysiology
The pathophysiology may involve a mixture of type I and type IV-like hypersensitivity reactions.
Diagnosis
Atopic dermatitis is typically diagnosed clinically, meaning it is diagnosed based on signs and symptoms alone, without special testing. Several different forms of criteria developed for research have also been validated to aid in diagnosis. Of these, the UK Diagnostic Criteria, based on the work of Hanifin and Rajka, has been the most widely validated.
Treatments
There is no known cure for AD, although treatments may reduce the severity and frequency of flares.
Lifestyle
Applying moisturisers may prevent the skin from drying out and decrease the need for other medications. Affected persons often report that improvement of skin hydration parallels with improvement in AD symptoms.
Health professionals often recommend that persons with AD bathe regularly in lukewarm baths, especially in salt water, to moisten their skin. Avoiding woollen clothing is usually good for those with AD. Likewise silk, silver-coated clothing may help. Dilute bleach baths have also been reported effective at managing AD.
Diet
The role of vitamin D on atopic dermatitis is not clear, but there is some evidence that vitamin D supplementation may improve its symptoms.
Studies have investigated the role of long chain polyunsaturated fatty acids (LCPUFA) supplementation and LCPUFA status in the prevention and treatment of atopic diseases, but the results are controversial. It remains unclear if the nutritional intake of n-3 fatty acids has a clear preventive or therapeutic role, or if n-6 fatty acids consumption promotes atopic diseases.
Several probiotics seem to have a positive effect with a roughly 20% reduction in the rate of atopic dermatitis. The best evidence is for multiple strains of bacteria.
In people with celiac disease or non-celiac gluten sensitivity, a gluten free diet improves their symptoms and prevents the occurrence of new outbreaks.
Medication
Topical corticosteroids, such as hydrocortisone have proven themselves effective in managing AD. If topical corticosteroids and moisturisers fail, short-term treatment with topical calcineurin inhibitors like tacrolimus or pimecrolimus may be tried, although they are usually avoided as they can increase the risk of developing skin cancer or lymphoma. Alternatively systemic immunosuppressants may be tried such as ciclosporin, methotrexate, interferon gamma-1b, mycophenolate mofetil and azathioprine. Antidepressants and naltrexone may be used to control pruritus (itchiness). In 2016 crisaborole was approved as a topical treatment for mild-to-moderate eczema. In 2017, the biologic agent dupilumab was approved to treat moderate-to-severe eczema.
Light
A more novel form of treatment involves exposure to broad or narrow-band ultraviolet (UV) 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. In particular, 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.
Epidemiology
Since the beginning of the twentieth century, many mucosal inflammatory disorders have become more common; atopic eczema (AE) is a classic example of such a disease. It now affects 15â€"30% of children and 2â€"10% of adults in developed countries and in the United States has nearly tripled in the past thirty to forty years. Over 15 million American adults and children have atopic dermatitis.
Research
Evidence suggests that IL-4 is central in the pathogenesis of AD. Therefore, there is a rationale for targeting IL-4 with anti-IL-4 inhibitors. People with atopic dermatitis are more likely to have Staphylococcus aureus living on them. The role this plays in pathogenesis is yet to be determined.
References
External links
- NIH Handout on Health: Atopic Dermatitis
- DermAtlas 9