A mother recently brought her 6-month old infant in for a terrible skin rash. A glance from the doorway was all it took to see that the child suffered from atopic dermatitis, but more impressive was the mother’s obvious frustration and fatigue from caring for this infant who cried all the time, slept little, and fussed all the more every time he ate. In addition to the obvious generalized rash that the child scratched incessantly during the examination, mom noted that even normal appearing skin would rash terribly if she allowed him to scratch there as well. Despite nail clipping, socks on the hands at night, and keeping him completely covered, the rash seemed to appear from out of nowhere.
Atopic dermatitis is often the very first manifestation of allergic disease in children, and may affect more than 10-20% of kids and 1-3% of adults. This skin condition has a significant effect on the quality of life for both the patient and their family. This form of eczema occurs in genetically disposed individuals in a complex interplay of genes, environment, and inflammatory cells – the perfect storm. Immune dysregulation, disruption of the skin barrier, moisture loss; all and more play a role.
The skin disease is characterized by chronic itching, scratching, and relapsing eczema lesions. In infants the disease commonly affects the face, neck, and outside surfaces of the body, while almost typically the lesions later localize to creases in the arms, behind the knees, skin folds of the neck and ears. Continuous scratching leads to skin thickening, scabs, and secondary infections. Aggravating factors may include temperature, humidity, irritants, infections, foods, inhalants, contact allergens, and stress. Additionally, food allergy may be present in 30-40% of children.
The diagnosis of atopic dermatitis rests on how the disease appears and unfolds. Judicious use of allergy skin tests or blood tests can identify potential allergic triggers, which are confirmed most commonly by eliminating the foods and looking for response.
Treatment for atopic dermatitis requires multiple steps and is often difficult to maintain, including trigger avoidance, restoration of skin barrier function, and reduction of skin inflammation. Trigger avoidance such as foods, skin irritants and allergens should be individualized based on the history and testing. Improving the barrier function of the skin is best accomplished by careful hydration and moisturizer application, such as soaking in a warm bath for at least 10 minutes followed immediately by application of an effective moisturizer cream or ointment. In areas with active skin sores, anti-inflammatory medicated creams reduce the intensity and scope of the lesions. Judicious use of topical corticosteroids are appropriate for the majority of patients, and the potency of the cream selected based on the severity of the sores, location of the lesions, and the patient’s age. Temporary flares may require short-term use of more potent creams, and pesky lesions that respond poorly may require additional non-corticosteroid creams to spare the long-term use of corticosteroid creams. Other treatments may include wet dressings, occlusion therapy, phototherapy, oral immune-suppressants, and antibiotics for lesions that become infected.
Fortunately for many children, symptoms of atopic dermatitis may wane through childhood, and one of the goals of treatment is to use medications carefully but sufficiently to prevent long term chronic skin changes and scarring. Families know first-hand what a tremendous impact this condition may have on patient and family quality of life, and there is an increased risk of psychological distress. Hopefully, with careful diagnosis and appropriate therapy, children and affected adults will avoid the debilitating effects of this disease.
If you think you or your child might be suffering from atopic dermatitis or any other skin allergy, give us a call at (801) 501-2100 to schedule an appointment with one of our doctors.