Dermatologist’s Guide to Atopic Dermatitis & Sensitive SkinNovember 10, 2017
Formerly known as Besnier prurigo, Eczema — also known as atopic dermatitis — is the most common form of dermatitis. It is categorised as a chronic, itchy skin condition. Eczema is less common in adults and more commonly affects 15–20% of children. It is almost impossible to predict whether the condition of one’s eczema will improve by itself or not in an individual.
Sensitive skin is a condition that persists life-long. In a meta-analysis of over 110,000 subjects, it was found that children who developed atopic dermatitis before the age of 2 had a much lower risk of persistent disease than those who developed eczema later in childhood or during adolescence. 20% of children with eczema still had persistent disease 8 years later. Fewer than 5% had persistent disease 20 years later.
Genetics in Atopic Dermatitis
Since ‘atopic tendency’ such as eczema, asthma and hay fever can be passed down through the family, knowing one’s own family history of asthma, eczema or hay fever is very useful in diagnosing atopic dermatitis in infants. The complex interaction between genetic and environmental factors causes and triggers atopic dermatitis. Defects in skin barrier function make the skin more susceptible to irritation by contact irritants such as soap, the weather, temperature and non-specific triggers.
The appearance of eczema varies from person to person. In acute eczema flares, inflamed, red, sometimes blistered and weepy patches are common. In between such eczema flares, the skin may appear normal or suffer from chronic eczema with dry, thickened and itchy areas. The appearance and feel of eczema varies from one’s ethnic origin, age, types of creams applies, the presence of infection or an additional skin condition. However, there are some general patterns to where the eczema is found on the body according to the age of the affected person.
Atopic Dermatitis Changes with Age
Although eczema can manifest itself in older people for the first time, the onset of eczema is usually seen before a child turns two. It is widely distributed amongst infants less than one-year-old. It is unusual for an infant to be affected with atopic dermatitis before the age of four months. However, they may suffer from infantile seborrhoeic dermatitis or other rashes prior to this.
As infant’s tend to scratch at their itchy skin with their sharp baby nails, the appearance of eczema in infants tend to be usually scaly, dry, and red. The signs of eczema are physically first apparent on cheeks of infants. Due to the moisture retention of nappies, the appearance of eczema in the napkin area is frequently spared. However, just like other babies, if wet or soiled nappies are left on too long, they can develop irritant napkin dermatitis. Although, eczema is often worst between the ages of two and four it usually improves after four and it may clear altogether by the time one enters into teenhood.
As toddlers tend to scratch vigorously at their itchy skins, the appearance of their atopic dermatitis may look very raw and uncomfortable. As they start to move around, the dermatitis tends to become more thickened and localised. Body parts and areas such as the extensor aspects of joints, specifically the elbows, wrists, knees and ankles and even genitals are most commonly affected in this age group. This changes as the child grow older. The pattern frequently shifts from extensor aspects of the joints to the flexor surfaces of the same joints, such as creases. This is when the affected skin often becomes lichenified; thickened and dry from constant rubbing and scratching.
However, the extensor pattern of eczema persists into later childhood in some children. Older school-age children tend to develop a flexural pattern of eczema which commonly affects the elbow and knee creases and other susceptible areas such as the scalp, eyelids, earlobes, and neck. It is possible for school-age children to develop recurrent acute itchy blisters on their palms, fingers and sometimes on the feet, medically known as pompholyx or vesicular hand/foot atopic dermatitis
Many children in this age group tend to develop a ‘nummular’ pattern of atopic dermatitis. This refers to the appearance of small coin-like areas of eczema scattered over the body. Commonly mistaken for a fungal infection such as a ringworm, the appearance of these round patches of eczema are usually red, dry and itchy. Most of the eczema tends to improve during school years and it may completely clear up by the time they reach their teenage years. However it is important to note that the barrier function of the skin is never entirely normal.
The presence of atopic dermatitis in adults are varied in many ways. Despite having a possibility to have a diffused pattern of eczema, eczema in adults is usually more dry and lichenified compared to eczema in children. Eczema is adults are commonly persistent, localised, and possibly confined to the eyelids, nipples, flexure, and hands or all of these areas. Hand dermatitis in adult atopic tends to appear thickened, dry but may also be blistered at the same time. Infections such as staphylococcal infections are both recurrent and a prominent possibility. Occupational irritant contact dermatitis can trigger eczema. This most often affects hands that are regularly exposed to water, detergents and /or solvents.
As eczema can be triggered by physical, environmental and cosmetic factors, particular occupations such as hairdressing, farming, domestic duties, domestic and industrial cleaning and caregiving tend to expose the skin to various irritants and, sometimes, allergens, aggravating eczema. As it is easier to choose a more suitable occupation from the outset than to change it later, tt is wise to bear this in mind when considering career options. Having atopic dermatitis does not exclude contact allergic dermatitis (confirmed by patch tests in children and adults).
- It could take many months to years to treat eczema and treatments plans often includes:
– Intermittent topical steroids
– Reduction of exposure to trigger factors
– Ceramide based moisturisers (such as the Multi-CERAM which helps restore healthy skin barrier function)
– In some cases, management may also include one of more of the following:
– Crisabarole ointment
– Topical calcineurin inhibitors, such as pimecrolimus cream or tacrolimus ointment
– Oral corticosteroids
– Longstanding and severe eczema may be treated with an immunosuppressive agent.
- Clinical trials of biologics such as Dupilumab are promising cures for eczema.
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