Atopic dermatitis (eczema) is a chronic inflammatory skin disorder common in patients and families who have allergic diseases. It affects 10-20% of children and 1-3 % of adults. It usually occurs before the age of 5 years old in most patients although it can develop in adulthood in up to 20% of patients. Atopic dermatitis can also be the beginning of the “allergic march” in many patients who later develop asthma, allergic rhinitis, or both.
Atopic dermatitis is diagnosed clinically by the typical presentation of skin lesions. The rash is itchy and red with eczematous areas that are relapsing in nature. Children usually have the rash on their face, neck, wrists, hands, ankles, and feet. Older children and adults have lichenification (rough, scaly skin) and hyperpigmentation in the flexural folds (elbows, knees) of the extremities. For some patients, allergy testing may help identify potential triggers (environmental or food allergies) that, if avoided, could reduce the rash.
Numerous triggers can worsen atopic dermatitis. These include temperature, humidity, irritants, infections (bacterial and viral), food, inhalant and contact allergens and emotional stress. These should be addressed in each patient to maximize treatment of their atopic dermatitis.
Treatment of atopic dermatitis includes restoring a healthy skin barrier and controlling inflammation. Daily hydration (soaking in lukewarm water for 10-20 minutes daily) and judicial use of skin moisturizers (i.e. lotions, creams, balms, etc.) is the first step to improving the skin barrier. Applying moisturizers several times per day is vital. For severe disease, topical steroids can reduce skin inflammation, but care must be taken to limit their use in order to minimize side effects such as thinning of skin, loss of pigmentation, and stretch-mark formation. In addition, steroid-sparing disease modifying ointments are FDA approved for patients >2 years old and can be used daily to control the skin rash. These include tacrolimus (Protopic), pimecrolimus (Elidel), and crisaborole (Eucrisa).
In 2017, the first biologic medicine was approved by the FDA for atopic dermatitis. Dupilumab (Dupixent) is approved for patients 12 years and older for moderate to severe atopic dermatitis, is given every 2 weeks by subcutaneous injection at home, and has shown vast improvement in patients’ symptoms.
Other complementary treatments include antihistamines to help control itching, bleach baths to decrease bacterial skin colonization, supplementation of Vitamin D in deficient patients, and immunotherapy (allergy shots).
Medications that modify the immune system such as cyclosporine, mycophenolate mofetil, azathioprine, methotrexate, interferon gamma, and systemic corticosteroids have been used in severe cases resistant to other treatments but have significant side effects to consider. Phototherapy has been useful in some severe atopic dermatitis patients. Additionally, hospitalization may be needed for intensified treatments (i.e. wet to dry wraps) or addressing other aspects of the disease such as sleep disturbance, psychosocial issues, separation from environmental allergen exposure, and improving adherence to treatment regimen.
Atopic dermatitis is a chronic disease, but with a multi-tiered approach directed by an allergy specialist at Allergy Partners, patients can successfully manage this disease and dramatically reduce its negative impact on their lives.
By Dr. Tracie Overbeck
Allergy Partners of Central Kentucky