What is atopic dermatitis?

Atopic dermatitis is a very common, often chronic (long-lasting) skin disease that affects a large percentage of the world's population. It is also called eczema, dermatitis, or atopy. Most commonly, it may be thought of as a type of skin allergy or sensitivity. The atopic dermatitis triad includes asthma, allergies (hay fever), and eczema. There is a known hereditary component of the disease, and it is seen more in some families. The hallmarks of the disease include skin rashes and itching.

The word "dermatitis" means inflammation of the skin. "Atopic" refers to diseases that are hereditary, tend to run in families, and often occur together. In atopic dermatitis, the skin becomes extremely itchy and inflamed, causing redness, swelling, cracking, weeping, crusting, and scaling. Dry skin is a very common complaint and an underlying cause of some of the typical rash symptoms.

Although atopic dermatitis can occur in any age, most often it affects infants and young children. In some instances, it may persist into adulthood or actually first show up later in life. A large number of patients tend to have a long-term course with various ups and downs. In most cases, there are periods of time when the disease is worse, called exacerbations or flares, which are followed by periods when the skin improves or clears up entirely, called remissions. Many children with atopic dermatitis enter into a permanent remission of the disease when they get older, although their skin may remain somewhat dry and easily irritated.

Multiple factors can trigger or worsen atopic dermatitis, including dry skin, seasonal allergies, exposure to harsh soaps and detergents, new skin products or creams, and cold weather. Environmental factors can activate symptoms of atopic dermatitis at any time in the lives of individuals who have inherited the atopic disease trait.

What is the difference between atopic dermatitis and eczema?

Eczema is used as a general term for many types of skin inflammation (dermatitis) and allergic-type skin rashes. There are different types of eczema, like allergic, contact, irritant, and nummular eczema. Several other forms have very similar symptoms. The diverse types of eczema are listed and briefly described below. Atopic dermatitis is typically a more specific set of three associated conditions occurring in the same person including eczema, allergies, and asthma. Not every component has to be present at the same time, but usually these patients are prone to all of these three related conditions.

Types of eczema

• Contact eczema: a localized reaction that includes redness, itching, and burning where the skin has come into contact with an allergen (an allergy-causing substance) or with an irritant such as an irritating acid, a cleaning agent, or other chemical
• Allergic contact eczema: a red, itchy, weepy reaction where the skin has come into contact with a substance that the immune system recognizes as foreign, such as poison ivy or certain preservatives in creams and lotions like Neosporin or Bacitracin
• Seborrheic eczema (also called seborrheic dermatitis or seborrhea): is a very common form of mild skin inflammation of unknown cause that presents as yellowish, oily, scaly patches of skin on the scalp, face, ears, and occasionally other parts of the body. Often this is also called dandruff in adults or "cradle cap" in infants.
• Nummular eczema: coin-shaped (round), isolated patches of irritated skin -- most commonly on the arms, back, buttocks, and lower legs -- that may be crusted, scaling, and extremely itchy
• Neurodermatitis: a very particular type of dermatitis where the person frequently picks at their skin, causing rashes. The underling cause may be a sensitivity or irritation which sets off a cascade of repeated itching and scratching cycles. It may be seen as scratch marks and pick marks on the skin. Sometimes scaly patches of skin on the head, lower legs, wrists, or forearms caused by a localized itch (such as an insect bite) may become intensely irritated when scratched.
• Stasis dermatitis: a skin irritation on the lower legs, generally related to circulatory problems and congestion of the leg veins. It may have a darker pigmentation, light-brown, or purplish-red discoloration from the congestion and back up of the blood in the leg veins. It's sometimes seen more in legs with varicose veins.

Picture of stasis eczema on the leg

• Dyshidrotic eczema: irritation of the skin on the palms of hands (mostly) and less commonly soles of the feet characterized by clear, very deep-seated blisters that itch and burn. It's sometimes described as a "tapioca pudding"-like rash on the palms.

How common is atopic dermatitis?

Atopic dermatitis is very common worldwide and increasing in prevalence. It affects males and females equally and accounts for 10%-20 % of all referrals to dermatologists (doctors who specialize in the care and treatment of skin diseases). Atopic dermatitis occurs most often in infants and children, and its onset decreases substantially with age. Scientists estimate that 65% of patients develop symptoms in the first year of life, and 90% develop symptoms before the age of 5. Onset after age 30 is less common and often occurs after exposure of the skin to harsh conditions. People who live in urban areas and in climates with low humidity seem to be at an increased risk for developing atopic dermatitis.

About 10% of all infants and young children experience symptoms of the disease. Roughly 60% of these infants continue to have one or more symptoms of atopic dermatitis even after they reach adulthood. This means that more than 15 million people in the United States have symptoms of the disease.

What causes atopic dermatitis?

The cause of atopic dermatitis is not known, but the disease seems to result from a combination of genetic (hereditary) and environmental factors. There seems to be a basic hypersensitivity and an increased tendency toward itching. Evidence suggests that the disease is associated with other so-called atopic disorders such as hay fever (seasonal allergies) and asthma, which many people with atopic dermatitis also have. In addition, many children who outgrow the symptoms of atopic dermatitis go on to develop hay fever or asthma. Although one disorder does not necessarily cause another, they may be related, thereby giving researchers clues to understanding atopic dermatitis.

While emotional factors and stress may in some cases exacerbate or initiate the condition, they do not seem to be a primary or underlying cause for the disorder. In the past, there was some thought that perhaps atopic dermatitis was entirely caused by an emotional disorder.

Is atopic dermatitis contagious?

No. Atopic dermatitis itself is definitely not contagious and it cannot be passed from one person to another through skin contact. There is generally no cause for concern in being around someone with even an active case of atopic dermatitis, unless they have active skin infections.

Some patients with atopic dermatitis get secondary infections of their skin with Staphylococcus "staph," other bacteria, herpes virus (cold sores), and less commonly yeasts and other fungal infections. These infections may be contagious through skin contact.

What are the symptoms of atopic dermatitis?

Although symptoms may vary from person to person, the most common symptoms are dry, itchy, red skin. Itch is the grand hallmark of the disease. Typical affected skin areas include the folds of the arms, the back of the knees, wrists, face, and hands. Less commonly there may be cracks behind the ears, and various other rashes on any part of the body.

The itchy feeling is an important factor in atopic dermatitis, because scratching and rubbing in response to itching worsen the skin inflammation that is characteristic of this disease. People with atopic dermatitis seem to be more sensitive to itching and feel the need to scratch longer in response. They develop what is referred to as the "itch-scratch" cycle. The extreme itchiness of the skin causes the person to scratch, which in turn worsens the itch, and so on. Itching is particularly a problem during sleep, when conscious control of scratching decreases and the absence of other outside stimuli makes the itchiness more noticeable. Many patients also notice worsening of their itch in the early evening when they get home from work or school when there are less external stimuli to keep them occupied. When things at home sort of quiet down, the itching seems to become more noticeable.

How atopic dermatitis affects the skin can be changed by patterns of scratching and resulting skin infections. Some people with the disease develop red, scaling skin where the immune system in the skin becomes very activated. Others develop thick and leathery skin as a result of constant scratching and rubbing. This condition is called lichenification. Still others develop papules, or small raised bumps, on their skin. When the papules are scratched, they may open (excoriations) and become crusty and infected. The box below lists common skin features of the disease. These conditions can also be found in people without atopic dermatitis or with other types of skin disorders.

Can atopic dermatitis affect the face?

Yes. Atopic dermatitis may affect the skin around the eyes, the eyelids, the eyebrows, and lashes. Scratching and rubbing the eye area can cause the skin to change in appearance. Some people with atopic dermatitis develop an extra fold of skin under their eyes, called an atopic pleat or Dennie-Morgan fold. Other people may have hyperpigmented eyelids, meaning that the skin on their eyelids darkens from the inflammation or hay fever (allergic shiners). Patchy eyebrows and eyelashes may also result from scratching or rubbing.

The face is very commonly affected in babies who may drool excessively and become irritated from skin contact with their flowing saliva.

Is the sufferer's skin type important?

Yes. Differences in the skin of people with atopic dermatitis may contribute to the symptoms of the disease. The epidermis, which is the outermost layer of skin, is divided into two parts: the inner part, which contains moist, living cells, and the outer part, which consists of dry, flattened, dead cells. Under normal conditions, the outer layer of skin acts as a barrier, keeping the rest of the skin from drying out and protecting other layers of skin from damage caused by irritants and infections. When this barrier is damaged or is naturally thin, irritants act more intensely on the skin.

The skin of a person with atopic dermatitis loses too much moisture from the epidermal layer. This allows the skin to become very dry, which reduces its protective abilities. In addition, the skin is very susceptible to recurring disorders, such as staphylococcal and streptococcal bacterial skin infections, warts, herpes simplex, and molluscum contagiosum (which is caused by a virus).

Skin features of atopic dermatitis Lichenification: thick, leathery skin resulting from constant scratching and rubbing Lichen simplex: refers to a thickened patch of raised skin that results from repeat rubbing and scratching of the same skin area Papules: small, raised bumps that may open when scratched, becoming crusty and infected Ichthyosis: dry, rectangular scales on the skin, commonly on the lower legs and shins Keratosis pilaris: small, rough bumps, generally on the face, upper arms, and thighs. These are also described as gooseflesh or chicken skin and may have a small coiled hair under each bump. Hyper linear palms: increased number of skin creases on the palms Urticaria: hives (red, raised bumps), often after exposure to an allergen, at the beginning of flares, or after exercise or a hot bath Cheilitis: inflammation of the skin on and around the lips Atopic pleat (Dennie-Morgan fold): an extra fold of skin that develops under the eye Dark circles under the eyes: may result from allergies and atopy Hyperpigmented eyelids: eyelids that have become darker in color from inflammation or hay fever Prurigo nodules also called "picker's warts" are not really warts at all. These are small thickened bumps of skin caused by repeated picking of the same skin site.

Picture of eczema on the leg

What are the stages of atopic dermatitis?

Atopic dermatitis affects each child differently, both in terms of onset and severity of symptoms. In infants, atopic dermatitis typically begins around 6 to 12 weeks of age. It may first appear around the cheeks and chin as a patchy facial rash, which can progress to red, scaling, oozing skin. The skin may become infected. Once the infant becomes more mobile and begins crawling, exposed areas such as the knees and elbows may also be affected. An infant with atopic dermatitis may be restless and irritable because of the itching and discomfort. Many infants improve by 18 months of age, although they remain at greater than normal risk for dry skin or hand eczema later in life.

In childhood, the rash tends to occur behind the knees and inside the elbows, on the sides of the neck, and on the wrists, ankles, and hands. Often, the rash begins with papules that become hard and scaly when scratched. The skin around the lips may be inflamed, and constant licking of the area may lead to small, painful cracks. Severe cases of atopic dermatitis may affect growth, and the child may be shorter than average.

The disease may go into remission (disease-free period). The length of a remission varies, and it may last months or even years. In some children, the disease gets better for a long time only to come back at the onset of puberty when hormones, stress, and the use of irritating skin-care products or cosmetics may cause the condition to flare.

Although a number of people who developed atopic dermatitis as children also experience symptoms as adults, it is less common (but possible) for the disease to show up first in adulthood. The pattern in adults is similar to that seen in children; that is, the disease may be widespread or limited. In some adults, only the hands or feet may be affected and become dry, itchy, red, and cracked. Sleep patterns and work performance may be affected, and long-term use of medications to treat the condition may cause complications. Adults with atopic dermatitis also have a predisposition toward irritant contact dermatitis, especially if they are in occupations involving frequent hand wetting, hand washing, or exposure to chemicals. Some people develop a rash around their nipples. These localized symptoms are difficult to treat, and people often do not tell their doctor because of modesty or embarrassment. Adults may also develop cataracts that are difficult to detect because they cause no symptoms. Therefore, the doctor may recommend regular eye exams.

How is atopic dermatitis diagnosed?

Atopic dermatitis is generally easily diagnosed based on a physical exam and visual inspection of the skin by a physician or dermatologist. Additionally, the history given by the patient and contributory family history help to support the diagnosis. A physician may ask about any history of similar rashes and other medical problems including hay fever (allergies) and asthma. While currently there may be no single specific laboratory test that says unequivocally "this is atopic dermatitis," a skin biopsy (a sample of a small piece of skin that is sent to the lab for examination under the microscope) may be helpful to establish the diagnosis in harder cases. Additionally, gentle skin swabs (long cotton tip applicator or Q-tip) samples may be sent to the lab to exclude infections of the skin which may mimic atopic dermatitis.

Since itching tends to be the main common symptom of the disease for many patients, it is not possible to say all itching is atopic dermatitis. Itching may be seen in many other medical conditions that have nothing to do with eczema. Each patient experiences a unique combination of symptoms, and the symptoms and severity of the disease may vary over time. The doctor bases the diagnosis on the individual's symptoms and may need to see the patient several times to make an accurate diagnosis. It is important for the doctor to rule out other diseases and conditions that might cause skin irritation. In some cases, the family doctor or pediatrician may refer the patient to a dermatologist or allergist (allergy specialist) for further evaluation.

A valuable diagnostic tool is a thorough medical history, which provides important clues as to the possible causes of the patient's ailment. The doctor may ask about all of the following: a family history of allergic disease, whether the patient also has diseases such as hay fever or asthma, exposure to irritants, sleep disturbances, any foods that seem to be related to skin flares, previous treatments for skin-related symptoms, use of steroids, and the effects of symptoms on schoolwork, career, or social life. Sometimes, it is necessary to do a biopsy of the skin or patch testing to determine if the skin's immune system overreacts to certain chemicals or preservatives in skin creams. A preliminary diagnosis of atopic dermatitis can be made if the patient has three or more characteristics from each of two categories: major features and minor features. Some of these characteristics are listed in the box below.

Skin scratch/prick tests (which involve scratching or pricking the skin with a needle that contains a small amount of a suspected allergen) and blood tests for airborne allergens generally are not as useful in diagnosing atopic dermatitis as a medical history and careful observation of symptoms. However, they may occasionally help the doctor rule out or confirm a specific allergen that might be considered important in the diagnosis. Negative results on skin tests are reliable and may help rule out the possibility that certain substances are causing skin inflammation in the patient. However, positive skin scratch/prick test results are difficult to interpret in people with atopic dermatitis and are often inaccurate. In some cases, where the type of dermatitis is unclear, blood tests to check the level of eosinophils (a type of white blood cell) or IgE (an antibody whose levels are often high in atopic dermatitis) are helpful.

Major and minor features of atopic dermatitis

Major features

• Itching
• Characteristic rash in locations typical of the disease (arm folds and behind knees)
• Chronic or repeatedly occurring symptoms
• Personal or family history of atopic disorders (eczema, hay fever, asthma)

Some minor features

• Early age of onset
• Dry, rough skin
• High levels of immunoglobulin E (IgE), an antibody, in the blood
• Ichthyosis
• Hyper linear palms
• Keratosis pilaris
• Hand or foot dermatitis
• Cheilitis (dry or irritated lips)
• Nipple eczema
• Susceptibility to skin infection
• Positive allergy skin tests

What factors can aggravate atopic dermatitis?

Many factors or conditions can intensify the symptoms of atopic dermatitis, including dry skin, winter or cold weather, wool cloths, and other irritating skin conditions. These factors may further trigger the itch-scratch cycle, further stimulating the many times already overactive immune system in the skin. Repeated aggravation and activation of the itch-scratch cycle may cause further skin damage and barrier breakdown. These exacerbating elements can be broken down into two main categories: irritants and allergens. Emotional factors and some infections can also influence atopic dermatitis.

What are skin irritants in patients with atopic dermatitis?

Irritants are substances that directly affect the skin, and when used in high enough concentrations with long enough contact cause the skin to become red and itchy or to burn. Specific irritants affect people with atopic dermatitis to different degrees. Over time, many patients and their families learn to identify the irritants that are most troublesome to them. For example, wool or synthetic fibers may affect some patients. Rough or poorly fitting clothing can rub the skin, trigger inflammation, and prompt the beginning of the itch-scratch cycle. Soaps and detergents may have a drying effect and worsen itching, and some perfumes and cosmetics may irritate the skin. Exposure to certain elements (such as chlorine, mineral oil, or solvents) or irritants (such as dust or sand) may also aggravate the condition. Cigarette smoke may irritate the eyelids. Because irritants vary from one person to another, each person has to determine for himself or herself what substances or circumstances cause the disease to flare.

Common irritants

• Wool or synthetic fibers
• Soaps and detergents
• Some perfumes and cosmetics
• Substances such as chlorine, mineral oil, or solvents
• Dust or sand
• Dust mites
• Cigarette smoke
• Animal fur or dander
• Flowers and pollen

What are allergens?

Allergens are substances from foods, plants, or animals that provoke an overreaction of the immune system and cause inflammation (in this case, the skin). Inflammation can occur even when the person is exposed to small amounts of the allergen for a limited time. Some examples of allergens are pollen and dog or cat dander (tiny particles from the animal's skin or hair). When people with atopic dermatitis come into contact with an irritant or allergen to which they are sensitive, inflammation-producing cells permeate the skin from elsewhere in the body. These cells release chemicals that cause itching and redness. As the person scratches and rubs the skin in response, further damage occurs.

Certain foods act as allergens and may trigger atopic dermatitis or exacerbate it (cause it to become worse). Food allergens clearly play a role in a number of cases of atopic dermatitis, primarily in infants and children. An allergic reaction to food can cause skin inflammation (generally hives), gastrointestinal symptoms (vomiting, diarrhea), upper respiratory tract symptoms (congestion, sneezing), and wheezing. The most common allergy-causing (allergenic) foods are eggs, peanuts, milk, fish, soy products, and wheat. Although the data remain inconclusive, some studies suggest that mothers of children with a family history of atopic diseases should avoid eating commonly allergenic foods themselves during late pregnancy and while they are breastfeeding the baby. Although not all researchers agree, most experts think that breastfeeding the infant for at least four months may have a protective effect for the child.

If a food allergy is suspected, it may be helpful to keep a careful diary of everything the patient eats, noting any reactions. Identifying the food allergen may be difficult and require supervision by an allergist if the patient is also being exposed to other allergens. One helpful way to explore the possibility of a food allergy is to eliminate the suspected food and then, if improvement is noticed, reintroduce it into the diet under carefully controlled conditions. A two week trial is usually sufficient for each food. If the food being tested causes no symptoms after two weeks, a different food can be tested in like manner afterward. Likewise, if the elimination of a food does not result in improvement after two weeks, other foods may be eliminated in turn.

Changing the diet of a person who has atopic dermatitis may not always relieve symptoms. A change may be helpful, however, when a patient's medical history and specific symptoms strongly suggest a food allergy. It is up to the patient and his or her family and physician to judge whether the dietary restrictions outweigh the impact of the disease itself. Restricted diets often are emotionally and financially difficult for patients and their families to follow. Unless properly monitored, diets with many restrictions can also contribute to nutritional problems in children.

What are aeroallergens?

Some allergens are called aeroallergens because they are present in the air. They may also play a role in atopic dermatitis. Common aeroallergens are dust mites, pollens, molds, and dander from animal hair or skin. These aeroallergens, particularly the house dust mite, may worsen the symptoms of atopic dermatitis in some people. Although some researchers think that aeroallergens are an important contributing factor to atopic dermatitis, others believe that they are insignificant. Scientists also don't understand the way in which aeroallergens affect the skin -- whether the aeroallergen affects the person internally after being inhaled or whether the aeroallergen actually penetrates the patient's skin.

No reliable test is available that determines whether a specific aeroallergen is an exacerbating factor in any given individual. If the doctor suspects that an aeroallergen is contributing to a patient's symptoms, the doctor may recommend ways to reduce exposure to the offending agents. For example, the presence of the house dust mite can be limited by encasing mattresses and pillows in special dust-proof covers, frequently washing bedding in hot water, and removing carpeting. However, there is no way to completely rid the environment of aeroallergens.

What other factors may play a role in atopic dermatitis?

In addition to irritants and allergens, other factors, such as emotional issues, temperature and climate, and skin infections can affect atopic dermatitis. Although the disease itself is not caused by emotional factors or personality, it can be exacerbated by stress, anger, and frustration. Interpersonal problems or major life changes, such as divorce, job changes, or the death of a loved one, can also make the disease worse. Often, emotional stress seems to prompt a flare of the disease.

Bathing with harsh soaps like Ivory or Irish Spring and without proper moisturizing afterward is a common factor that triggers a flare of atopic dermatitis. Typical recommendations include using a very gentle soap-free cleanser or milder soap like Dove, Cetaphil, or Aquanil. The "three-minute rule" of lubricating with a rich moisturizer such as Vaseline, Aquaphor, or Crisco Vegetable Shortening within three minutes of drying off after a bath or shower is particularly helpful for many patients.

The low humidity of winter or the dry year-round climate of some geographic areas can intensify the disease, as can overheated indoor areas and long or hot baths and showers. Alternately, sweating and chilling can induce an attack in some people. Bacterial infections can also prompt or increase the severity of atopic dermatitis. If a patient experiences a sudden onset of illness, the doctor may check for a viral infection (such as herpes simplex) or fungal infection (such as ringworm or athlete's foot).

How is atopic dermatitis treated?

Treatment involves a partnership between the doctor and the patient and his or her family members. The doctor will suggest a treatment plan based on the patient's age, symptoms, and general health. The patient and family members play a large role in the success of the treatment plan by carefully following the doctor's instructions. Some of the primary components of treatment programs are described below. Most patients can be successfully managed with proper skin care and lifestyle changes and do not require the more intensive treatments discussed. Much of the improvement comes from homework, including lubricating generously especially right after showers or baths.

The doctor has three main goals in treating atopic dermatitis: healing the skin and keeping it healthy; preventing flares, and treating symptoms when they do occur. Much of caring for the skin involves developing skin-care routines, identifying exacerbating factors, and avoiding circumstances that stimulate the skin's immune system and the itch-scratch cycle. It is important for the patient and family members to note any changes in skin condition in response to treatment and to be persistent in identifying the most effective treatment strategy.

Skin care: A simple and basic regimen is key. Staying with one recommended soap and one moisturizer is very important. Using multiple soaps, lotions, fragrances, and mixes of products may cause further issues and skin sensitivity.

Healing the skin and keeping it healthy are of primary importance both in preventing further damage and enhancing the patient's quality of life. Developing and following a daily skin care routine is critical to preventing recurrent episodes of symptoms. Key factors are proper bathing and the application of lubricants, such as creams or ointments, within three minutes of bathing. People with atopic dermatitis should avoid hot or long (more than 10 to 15 minutes) baths and showers. A lukewarm bath helps to cleanse and moisturize the skin without drying it excessively. The doctor may recommend limited use of a mild bar soap or non-soap cleanser because soaps can be drying to the skin. Bath oils are not usually helpful.

Once the bath is finished, the patient should air-dry the skin or pat it dry gently (avoiding rubbing or brisk drying) and apply a lubricant immediately. Lubrication restores the skin's moisture, increases the rate of healing, and establishes a barrier against further drying and irritation. Several kinds of lubricants can be used. Lotions generally are not the best choice because they have a high water or alcohol content and evaporate quickly. Creams and ointments work better at healing the skin. Tar preparations can be very helpful in healing very dry, lichenified areas. Whatever preparation is chosen, it should be as free of fragrances and chemicals as possible.

Another key to protecting and restoring the skin is taking steps to avoid repeated skin infections. Although it may not be possible to avoid infections altogether, the effects of an infection may be minimized if they are identified and treated early. Patients and their families should learn to recognize the signs of skin infections, including tiny pustules (pus-filled bumps) on the arms and legs, appearance of oozing areas, or crusty yellow blisters. If symptoms of a skin infection develop, the doctor should be consulted to begin treatment as soon as possible.

Treating atopic dermatitis in infants and children

• Give brief, lukewarm baths.
• Apply lubricant immediately following the bath.
• Keep a child's fingernails filed short.
• Select soft cotton fabrics when choosing clothing.
• Consider using antihistamines to reduce scratching at night.
• Keep the child cool; avoid situations where overheating occurs.
• Learn to recognize skin infections and seek treatment promptly.
• Attempt to distract the child with activities to keep him or her from scratching.

Medications and phototherapy: If a recurrence of atopic dermatitis occurs, several methods can be used to treat the symptoms. With proper treatment, most symptoms can be brought under control within three weeks. If symptoms fail to respond, this may be due to a flare that is stronger than the medication can handle, a treatment program that is not fully effective for a particular individual, or the presence of trigger factors that were not addressed in the initial treatment program. These factors can include a reaction to a medication, infection, or emotional stress. Continued symptoms may also occur because the patient is not following the treatment-program instructions.

Corticosteroid creams and ointments are the most frequently used treatment. Sometimes, over-the-counter preparations are used, but in many cases, the doctor will prescribe a stronger corticosteroid cream or ointment. Occasionally, the base used in certain brands of corticosteroid creams and ointments is irritating for a particular patient and a different brand is required. Side effects of repeated or long-term use of topical corticosteroids can include thinning of the skin, infections, growth suppression (in children), and stretch marks on the skin.

Tacrolimus (Protopic) and pimecrolimus (Elidel) ointments are powerful topical medicated creams (drugs that are applied to the skin) that are used for the treatment of atopic dermatitis. These new drugs are referred to as "immune modulators." They were first and are still commonly used internally (oral form) to help patients with kidney and liver transplants avoid rejecting the organs they received. They work by suppressing the immune system. When these drugs are used in limited and small quantities on intact skin to externally to treat the skin, they are not thought to significantly weaken or change the body's immune system. Also, unlike topical steroids (cortisone creams), these new medications don't cause thinning of the skin and breaking of superficial blood vessels (atrophy). However, over the recent few years, there has been concern and a positional change by the Food and Drug Administration (FDA). A special warning has been placed on these two immune modulator drugs with potential caution regarding cancers and other immune-system suppression issues. While dermatologists and other physicians have continued to safely prescribe many of these drugs for children and adults, it is important to discuss these possible concerns and precautions with your physician when beginning a treatment regimen.

A newer class of drugs for improving barrier function in both pediatrics and adults includes Atopiclair and MimyX. These creams may be used in combination with topical steroids and other emollients to help repair the overall dryness and broken skin function.

Additional available treatments may help to reduce specific symptoms of the disease. Antibiotics to treat skin infections may be applied directly to the skin in an ointment but are usually more effective when taken by mouth in pill form. Certain antihistamines that cause drowsiness can reduce nighttime scratching and allow more restful sleep when taken at bedtime. This effect can be particularly helpful for patients whose nighttime scratching aggravates the disease. If viral or fungal infections are present, the doctor may also prescribe medications to treat those infections.

Phototherapy is treatment with light that uses ultraviolet A or B light waves or a combination of both. This treatment can be an effective treatment for mild to moderate dermatitis in older children (over 12 years old) and adults. Photochemotherapy, a combination of ultraviolet light therapy and a drug called psoralen, can also be used in cases that are resistant to phototherapy alone. Possible long-term side effects of this treatment include premature skin aging and skin cancer. If the doctor thinks that phototherapy may be useful in treating the symptoms of atopic dermatitis, he or she will use the minimum exposure necessary and monitor the skin carefully.

When other treatments are not effective, the doctor may prescribe systemic corticosteroids, drugs that are taken by mouth or injected into muscle instead of being applied directly to the skin. An example of a commonly prescribed corticosteroid is prednisone. Typically, these medications are used only in resistant cases and are only given for short periods of time. The side effects of systemic corticosteroids can include skin damage, thinned or weakened bones, high blood pressure, high blood sugar, infections, and cataracts. It can be dangerous to suddenly stop taking corticosteroids, so it is very important that the doctor and patient work together in changing the corticosteroid dose.

Previous clinical trials using drugs like self-injectable interferon treatments demonstrated mixed results and have not become mainstream treatments. The most common side effects with interferon involve mild injection-site reactions and possible fever or flu-like symptoms. These drugs maybe used in severe or challenging situations that don't respond to more traditional treatments.

In adults, immunosuppressive drugs, such as cyclosporine, are also used to treat severe cases of atopic dermatitis that have failed to respond to any other forms of therapy. Immunosuppressive drugs restrain the overactive immune system by blocking the production of some immune cells and curbing the action of others. The side effects of cyclosporine can include high blood pressure, nausea, vomiting, kidney problems, headaches, tingling or numbness, and a possible increased risk of cancer and infections. There is also a risk of relapse after the drug is discontinued. Because of their toxic side effects, systemic corticosteroids and immunosuppressive drugs are used only in severe cases and then for as short a period of time as possible. Patients requiring systemic corticosteroids or immunosuppressive drugs should be referred to a dermatologist or an allergist specializing in the care of atopic dermatitis to help identify trigger factors and alternative therapies.

In extremely rare cases, when no other treatments have been successful, the patient may have to be hospitalized. A five- to seven-day hospital stay allows intensive skin-care treatment and reduces the patient's exposure to irritants, allergens, and the stresses of day-to-day life. Under these conditions, the symptoms usually clear quickly if environmental factors play a role or if the patient is not able to carry out an adequate skin-care program at home.

Tips for working with your doctor

• Provide complete, accurate medical information about yourself or your child.
• Make a list of your questions and concerns in advance.
• Be honest and share your point of view with the doctor.
• Ask for clarification or further explanation if you need it.
• Talk to other members of the health-care team, such as nurses, therapists, or pharmacists.
• Don't hesitate to discuss sensitive subjects with your doctor.
• Discuss changes to any medical treatment or medications with your doctor before making them.

Atopic dermatitis and quality of life

Despite the symptoms caused by atopic dermatitis, it is possible for people with the disorder to maintain a high quality of life. The keys to an improved quality of life are education, awareness, and developing a partnership among the patient, family, and doctor. Good communication is essential for all involved. It is important that the doctor provides understandable information about the disease and its symptoms to the patient and family and demonstrate any treatment measures recommended to ensure that they will be properly carried out.

When a child has atopic dermatitis, the entire family situation may be affected. It is important that families have additional support to help them cope with the stress and frustration associated with the disease. The child may be fussy and difficult and often is unable to keep from scratching and rubbing the skin. Distracting the child and providing as many activities that keep the hands busy is key but requires much effort and work on the part of the parents or caregivers. Another issue families face is the social and emotional stress associated with disfigurement caused by atopic dermatitis. The child may face difficulty in school or other social relationships and may need additional support and encouragement from family members.

Adults with atopic dermatitis can enhance their quality of life by caring regularly for their skin and being mindful of other effects of the disease and how to treat them. Adults should develop a skin-care regimen as part of their daily routine, which can be adapted as circumstances and skin conditions change. Stress management and relaxation techniques may help decrease the likelihood of flares due to emotional stress. Developing a network of support that includes family, friends, health professionals, and support groups or organizations can be beneficial. Chronic anxiety and depression may be relieved by short-term psychological therapy.

Recognizing the situations when scratching is most likely to occur may also help. For example, many patients find that they scratch more when they are idle. Structured activity that keeps their hands occupied may prevent further damage to the skin. Occupational counseling also may be helpful to identify or change career goals if a job involves contact with irritants or involves frequent hand washing, such as kitchen work or auto mechanics.

Controlling atopic dermatitis

• Lubricate the skin frequently.
• Avoid harsh soaps and cleansers.
• Prevent scratching or rubbing whenever possible.
• Protect skin from excessive moisture, irritants, and rough clothing.
• Maintain a cool, stable temperature and consistent humidity levels.
• Limit exposure to dust, cigarette smoke, pollens, and animal dander.
• Recognize and limit emotional stress.

What is the hope for long-term management of atopic dermatitis?

Although symptoms of atopic dermatitis can be very difficult and uncomfortable, the disease can be successfully managed. People with atopic dermatitis, as well as their families, can lead healthy, normal lives. Long-term management may include treatment with an allergist to control internal allergies and a dermatologist to monitor the skin-care component.

Atopic Dermatitis At A Glance

• Atopic dermatitis is a type of eczema.
• The skin sensitivity of this disease may be inherited and genetically determined.
• The patient's skin may be "super sensitive" to many irritants.
• Dry scaly patches develop in a characteristic distribution.
• Itching varies but may be intense and scratching hard to resist.
• Scratching can cause skin thickening and darkening and lead to further complications, including bacterial infection.
• Extremely dry skin can break down and ooze or weep.
• If the itch can be controlled, the rash (which is aggravated by vigorous scratching) may be more readily contained.
• Treatment of atopic dermatitis is centered around rehydrating the skin with rich moisturizers like Vaseline and cautious use of topical steroids to reduce inflammation and itching.
• Oral antihistamines are often necessary to break the "itch-scratch" cycle.
• Since secondary infections can aggravate the rash, topical or oral antibiotics may also be occasionally indicated.

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