Atopic Dermatitis - Eczema Overview
Eczema affects all races, ages, and skin types, and refers to a group of non-contagious acute and chronic conditions that cause the skin to become red, itchy, and inflamed.
Atopic dermatitis (AD) is the most common type of eczema, affecting millions of children and adults. The word “dermatitis” means inflammation of the skin. “Atopic” refers to a group of diseases often traced to an inherited tendency toward allergic conditions. In atopic dermatitis, the skin becomes extremely itchy. Scratching leads to redness, swelling, cracking, “weeping” clear fluid, and finally, crusting and scaling. Most often, there are periods of time when the disease flares (or worsens), followed by periods of improvement or clearance. It is a chronic condition that can come and go for years or throughout life and can overlap with other types of eczema.
Atopic dermatitis occurs equally in males and females, affecting up to 30% of the United States population. Although atopic dermatitis may occur at any age, onset most often begins in infancy or childhood. Onset after age 30 is less common. With a disease burden that can encompass various debilitating and painful physical, mental, and emotional symptoms, eczema has the highest effect on disability-associated life years for patients with skin diseases worldwide.
Diagnosis is made by examining the patient’s skin. A patch test or other tests may be made to rule out other skin diseases or identify conditions that often accompany eczema. No lab test is needed to identify atopic dermatitis (eczema). The pattern, location, and appearance of a rash provides the doctor with important information about its causes. The doctor will also discuss when symptoms appeared, what parts of the body they affect, and whether a rash is persistent or comes and goes, such as if there is a seasonal variation or if the rash appears when using certain perfumes or after exposure to certain metals or fabrics. A review will be done of the medical history, including any underlying allergies. Knowing whether anyone else in the patient’s family has been diagnosed with eczema or dermatitis may help the doctor better understand the diagnosis.
Types and Symptoms
Atopic Dermatitis (AD)
Atopic dermatitis is the most common form of eczema. Atopic dermatitis typically begins in childhood, usually in the first six months of a baby’s life. Even though it is a common form of eczema, it’s also severe and long-lasting. When you or your child have atopic dermatitis, it may improve at times; but at other times, it may get worse. In some children, symptoms may taper off as they grow up, while other children will have atopic dermatitis flares into adulthood.
Atopic dermatitis exists with two other allergic conditions: asthma and hay fever (allergic rhinitis). People who have asthma and/or hay fever or who have family members who do, are more likely to develop AD. If the doctor is not been able to diagnose the condition during a physical exam or patch test, a skin biopsy may be performed and for analysis by a dermatopathologist.
Symptoms for Atopic Dermatitis
Itching is the hallmark of AD, with some data showing that more than 85% of people with the condition experience this distressing symptom every day. Sore or painful skin and poor sleep caused by itching are also common. People with AD can get rashes anywhere on the body that can ooze, weep fluid and bleed when scratched, making skin vulnerable to infection. Skin can become dry and discolored, and repeated scratching can cause thickening and hardening — a process called lichenification.
- the rash often forms in the creases of your elbows or knees
- skin in areas where the rash appears may turn lighter or darker, or get thicker
- small bumps may appear and leak fluid if you scratch them
- babies often get the rash on their scalp and cheeks
- your skin can get infected if you scratch it
Causes of Atopic Dermatitis
Though the causes of atopic dermatitis are not precisely known, the disease seems to result from a combination of inherited tendencies and environmental factors that include:
- dry skin
- an immune system problem
- triggers in the environment
Atopic dermatitis happens when your skin’s natural barrier against the elements is weakened. This means your skin is less able to protect you against irritants and allergens. Many factors or conditions can make symptoms of atopic dermatitis worse, further triggering the already overactive immune system, aggravating the itch-scratch cycle, and increasing damage to the skin. These factors typically fall into two main categories: irritants and allergens. Emotional factors and some infections and illnesses can also influence atopic dermatitis.
Research shows that some people with eczema, especially atopic dermatitis, have a mutation of the gene responsible for creating filaggrin. Filaggrin is a protein that helps our bodies maintain a healthy, protective barrier on the very top layer of the skin. Without enough filaggrin to build a strong skin barrier, moisture can escape and bacteria, viruses and more can enter. Therefore, many people with AD have very dry and infection-prone skin.
If you have red, irritated skin that is caused by a reaction to substances you touch, you may have contact dermatitis. It comes in two types:
- Allergic Contact Dermatitis is an immune system reaction to an irritant like latex or metal
- Irritant Contact Dermatitis starts when a chemical or other substance irritates your skin.
Symptoms for Contact Dermatitis
- your skin itches, turns red, burns, and stings
- itchy bumps called hives may pop up on your skin
- fluid-filled blisters can form that may ooze and crust over
- over time, the skin may thicken and feel scaly or leathery
Causes of Contact Dermatitis
Contact Dermatitis happens when you touch a substance that irritates your skin or causes an allergic reaction. The most common causes are:
- poison ivy and other poisonous plants
- skin care products, including makeup
- soaps and perfumes
- tobacco smoke
Dyshidrotic eczema causes small blisters to form on your hands and feet. It is more common in women than men.
Symptoms for Dyshidrotic Eczema
- fluid-filled blisters form on your fingers, toes, palms, and soles of your feet
- these blisters may itch or hurt
- the skin can scale, crack, and flake
Causes of Dyshidrotic Eczema
- damp hands and feet
- exposure to substances such as nickel, cobalt, or chromium salt
Eczema that only affects your hands is called hand eczema. You may get this type if you work in a job like hairdressing or cleaning, where you regularly use chemicals that irritate the skin.
Symptoms for Hand Eczema
- your hands get red, itchy, and dry
- they may form cracks or blisters
- Hand eczemas triggered by exposure to chemicals. People who work in jobs that expose them to irritants are more likely to get this form, such as cleaning, hairdressing, healthcare and laundry or dry cleaning
Neurodermatitis is similar to atopic dermatitis. It causes thick, scaly patches to pop up on your skin.
Symptoms for Neurodermatitis
- thick, scaly patches form on your arms, legs, back of your neck, scalp, bottoms of your feet, backs of your hands, or genitals
- these patches can be very itchy, especially when you are relaxed or asleep
- if you scratch the patches, they can bleed and get infected
Causes of Neurodermatitis
Neurodermatitis usually starts in people who have other types of eczema or psoriasis. Doctors do not know exactly what causes it, although stress can be a trigger.
This type of eczema causes round, coin-shaped spots to form on your skin. The word “nummular” means coin in Latin. Nummular eczema looks very different from other types of eczema, and it can itch a lot.
Symptoms for Nummular Eczema
- round, coin-shaped spots form on your skin
- the spots may itch or become scaly
Causes of Nummular Eczema
Nummular eczema can be triggered by a reaction to an insect bite, or by an allergic reaction to metals or chemicals. Dry skin can also cause it. You are more likely to get this form if you have another type of eczema, such as atopic dermatitis.
Stasis dermatitis happens when fluid leaks out of weakened veins into your skin. This fluid causes swelling, redness, itching, and pain.
Symptoms for Stasis Dermatitis
- the lower part of your legs may swell up, especially during the day when you’ve been walking
- your legs may ache or feel heavy
- you will likely also have varicose veins, which are thick, ropey damaged veins in your legs
- the skin over those varicose veins will be dry and itchy
- you may develop open sores on your lower legs and on the tops of your feet
Causes of Stasis Dermatitis
Stasis dermatitis happens in people who have blood flow problems in their lower legs. If the valves that normally push blood up through your legs toward your heart malfunction, blood can pool in your legs. Your legs can swell up and varicose veins can form.
Treatment Choices for Eczema
Eczema often comes and goes. When it appears, you might need to try different medicines and other treatments to get rid of the rash.
Non Medication and Therapy Treatments
- avoiding known triggers
- maintaining a regular bathing and moisturizing routine to protect and strengthen the skin
- getting high-quality sleep
- eating a healthy diet
- managing stress
Medication and Therapy Treatments
- Narrowband UV-B Treatment
- Non-Steroidal Topicals
- Topical Corticosteroids
- These drugs are products produced from or containing parts from a living organism.
- This means the drug will have recombinant proteins, tissues, genes, allergens, cells, blood, blood components, or any combination of these parts.
- Biologics for skin treatments are provided via injection or intravenous infusion.
Narrowband UV-B Treatment
- Light therapy exposes the skin to ultraviolet light to heal the rash. Narrowband UV-B has been proven to be more effective in patients with moderate to severe atopic dermatitis than other treatment modalities.
- Most patients reduce itching (pruritus) by 81% in four weeks.
- There are no side effects and no worsening of the atopic dermatitis occurring at 1-month follow-up.
- Narrowband UV-B has produced greater improvement when compared with a topical corticosteroid ointment at 6-month follow-up using global assessment scores.
- Targeted Narrowband UV-B requires a lower cumulative dose for the clearance of atopic dermatitis to achieve comparable clinical results with other photo-therapies.
- Proven to be a safe and effective treatment for chronic cases of moderate to severe atopic dermatitis and with 80% of children showing good to excellent results.
- Topical calcineurin inhibitors (TCIs) are nonsteroidal medications that work by stopping certain cells of the immune system from “switching on,” preventing eczema symptoms such as redness and itch and inflammation.
- Two TCIs are available for use in eczema, tacrolimus ointment (Protopic® and generic options) and pimecrolimus cream (Elidel and generic options).
- One of the most commonly prescribed medications for all types of eczema is topical corticosteroids, or steroids, which can reduce inflammation and itching so that the skin can begin to heal.
- Steroids are naturally occurring substances that our bodies make in order to regulate growth and immune function.
- Corticosteroids have been used for more than 60 years in topical medications to treat many kinds of inflammatory skin conditions including eczema.
- Topical steroids are used for eczema in adults and children.
- Topical steroids are classified by their strength (or potency), which ranges from “super potent” (Class 1), to “least potent” (Class 7).
- There are a number of different topical steroid types as well as different concentrations, and dosage forms (ointment, cream, lotion, spray).
Treatment for Atopic Dermatitis
Guidelines of Care for The Management of Atopic Dermatitis (23 pgs.) 2014
Journal of the American Academy of Dermatology (JAAD)
Understanding the Challenges of Atopic Dermatitis
There are many challenges associated with eczema that include: anxiety, depression, attention-deficit hyperactivity disorder (ADHD), asthma, hay fever, and other serious conditions in children and/or adults.
Children and adolescents with Atopic Dermatitis (AD), the most common form of eczema, are two to six times more likely to have depression, anxiety or conduct disorder than children without Atopic Dermatitis.
In Atopic Dermatitis patients, the negative impact on mental health ranks greater than that for patients with heart disease, diabetes, and high blood pressure. Overall, in the U.S., it is estimated that nearly 5.9 million workdays annually are lost due to eczema. The annual economic burden of eczema, including direct medical costs, indirect costs from lost productivity, and quality of life impacts, is conservatively estimated at $5.3 billion.
Resources for Atopic Dermatitis
The National Eczema Association
National Eczema Society
American Academy of Dermatology Eczema Resource Center
American Academy of Allergy, Asthma & Immunology