Atopic dermatitis, dealing with the black beast

The arrival of autumn brings with it not only the fall of leaves and hair. This is well known to our patients with inflammatory dermatitis such as seborrheic dermatitis, psoriasis and atopic dermatitis. In this post I am going to focus on atopic dermatitis, specifically in infancy, because of its high prevalence and because it is a headache for children and parents.

Atopic dermatitis (AD) is a chronic inflammatory skin disease that occurs in outbreaks. Although the cause is unknown, it is known that genetic, immunological and environmental factors are involved, and it is possibly the latter that have determined the increase in prevalence in recent years (up to 20% of the general population in developed countries!). These have included environmental pollution, decreased breastfeeding time, maternal smoking, high antibiotic use and excessive hygiene. It is also known that in AD there is an alteration of the stratum corneum, which is the outermost layer of the epidermis, in contact with air and environmental allergens. The lipid composition in this layer is altered, with a lower ceramide content resulting in dry skin and altered barrier function, making it more permeable to allergens.

Popliteal hollow eczema
Clinically, these children will develop outbreaks of erythematous and scaly lesions, very pruritic, especially in the flexural areas. Other minor signs that can be seen in children with AD are hypopigmented macules on the face (pityriasis alba) and perifollicular papules especially on the arms and thighs (follicular keratosis); although they are more frequent in children with AD they can also be seen in children without AD.

In general these children are more frequently allergic to certain foods and environmental allergens, but the course of atopic dermatitis is independent of the symptoms derived from these such as asthma and rhinoconjunctivitis.

So far so good, but what can I do if my child has AD?

1.- If you have eczema, treat it.
When eczema appears, drug treatment under medical supervision is necessary. The first-line treatments for localized eczema are topical corticosteroids. Despite the bad reputation they enjoy, much to my regret, they are very safe treatments when applied under the guidance and supervision of a dermatologist, as well as fast and effective. The corticoid should be applied every day on the eczema until the eczema resolves (but no more than 3 weeks on the same area of skin…), and then apply it for a few more days before discontinuing it; this is because some inflammation may remain in the skin, which we call subclinical (it is not visible, but it is there), and if we discontinue the application as soon as we see improvement of the eczema it is very likely that it will reappear.

Other treatments would be tacrolimus and pimecrolimus. Their limitation is that when applied to eczema they may cause a transient burning sensation, and their action is slower than that of corticosteroids. However, unlike corticosteroids, they do not cause skin atrophy, so they can be given for longer periods of time, and also in areas of thin skin. Tacrolimus has been shown to be effective in the maintenance treatment of AD.

Oral antihistamines improve the itching sensation, but do not modify the course of the disease. They can be given as a complement to the previous ones to improve this unpleasant symptom until the previous ones take effect.

In case of severe, extensive and recurrent DA, oral treatments or phototherapy will be necessary. Children with AD usually improve in summer and this improvement is often more dramatic when they go on vacation to the beach… UV radiation from the sun (both UVA and UVB) improves atopic dermatitis. In addition, ambient humidity also improves DA. Since vacations cannot be prescribed, some medical centers have phototherapy machines that reproduce solar radiation in a controlled manner. Phototherapy is a very safe alternative for our children from a certain age, and we can count on their cooperation.

2.- If you do not have eczema, apply general maintenance measures.

  • Moisturizes your skin every day. Due to the ceramide deficiency in the stratum corneum, hydration is essential. But be careful, because moisturizers applied on eczema often sting. We therefore recommend moisturizing only the apparently healthy areas where eczema has not developed, and if eczema is present, apply one of the local treatments previously mentioned.
  • If possible, do not bathe the children every day or, do not always use soap (or use SINDET soaps, without detergent, or oil soaps), keep the baths short, and do not use very hot water. All these factors lead to water loss, which aggravates the skin dryness that occurs in AD.
  • If your child is not allergic to dust mites, he or she may benefit in winter from a humidifier in your home. Heating dries out the environment and atopic dermatitis can worsen in dry environments.
  • Use reliable hygiene and moisturizing products. We cannot forget that cosmetic products contain a series of substances to preserve their properties. In AD the skin barrier is altered, so that the passage of these substances can cause the patient to become sensitized to some of these compounds. Thus, atopic eczema would be aggravated by the presence of contact eczema.

Keratosis pilaris

3.- Be patient
AD is not a throat infection. By this I mean that we would like to be able to give patients a 7-day treatment and solve their problem, but it is not possible. The treatments we prescribe are to control the outbreak, but we cannot predict the next outbreak or whether it will happen again. What is clear is that the predisposition for dermatitis to return is there, and that is why the general maintenance guidelines can help you to keep these outbreaks more spaced out over time.

I leave you a link to the Association of relatives and patients of atopic dermatitis.

Lots of encouragement to all!