Atopic eczema is a chronic inflammatory skin condition that affects thouthands of children worldwide. While many parents told their child will grow out of eczema before they start school, tincreasingly eczema is seen in school-aged children.
In older children and adolescents, the distribution of eczema commonly involves the flexor surfaces, neck, wrists, ankles and hands, with lichenification (thickening of the skin) and dryness. Itch is the main clinical feature of eczema. This can be severe and can cause profound sleep disturbance, irritability and generalised stress for the affected patient and their family. The effect of eczema on quality of life is significantly correlated with severity, and uncontrolled eczema also affects concentration, behaviour, self-esteem and confidence in the school-aged child.
Atopic dermatitis (AD) is another name that is used for the eczema rash. It is a pruritic, inflammatory skin disorder that frequently presents in childhood but is also common in adults. The pathogenesis of AD is due to a multitude of factors including skin barrier defects, dysregulation of innate immune responses, defects in adaptive immune response with development of strong type 2 immunity, and altered skin microbiome. Two of the major risk factors that predispose a person to developing AD include a positive family history of atopy and loss-of-function mutations in the filaggrin gene.
Eczema, as defined by the World Allergy Organization (WAO) revised nomenclature in 2003, affects 15% to 20% of school children and 2% to 5% of adults worldwide. About 50% of people with eczema demonstrate atopy, with specific immunoglobulin E responses to allergens.
Symptoms
Eczema or atopic dermatitis (AD) typically presents with:
Red scaly rash involving the face, scalp, trunk, and extensor surfaces of the extremities
Oozing and crusting of the irritated and scratched areas on the face, neck, extremities
Severe itch
Other symptoms such as irritability, crying, poor sleep
Inability to concentrate, poor academic performance
Although AD can have a more generalized distribution, it typically involves the flexural aspects of the extremities in later childhood and adulthood.
< 2 years
> 2 years
Infants: Even with generalized disease, the diaper area is usually spared.
Children, adolescents and adults: Flexural dermatitis (antecubital and popliteal fossae)
Adolescents and adults: Hand dermatitis, depending on skin irritant exposure
Infants and small children: Localized disease often confined to cheeks and extensor surfaces of limbs
Adults: Prurigo variant with very pruritic papules and nodules especially on the shoulder girdle and arms
Minimal variants of atopic dermatitis (all age groups): Cheilitis, perlèche, ear lobe fissures
What Causes Eczema?
Irritants
Irritants may contribute to localised patches of eczema. The more sensitive areas of skin that are more likely to be irritated include the face, flexures and groin. Irritants include physical irritants, such as carpets, harsh fabrics, seams and sand, and chemical irritants, such as soaps, detergents, antiseptics, chlorine, shampoos, urine, faeces and saliva. Even water can be a mild irritant for sensitive skin.
Patients in whom irritants are suspected of contributing to their eczema should be educated about the various different irritants. Their exposure to these irritants should be minimised; for example, apply a moisturiser all over before and after swimming to protect the skin from prolonged exposure to the pool water, or use a bland lip balm regularly to minimise lip licking.
Contact allergy
Allergic contact dermatitis should be suspected when there is a persistent and severe localised reaction, particularly if it is symmetrical. Common contact allergens include nickel in metals, rubber products and topical medicaments.
Patients with suspected allergic contact dermatitis as the trigger for their eczema should avoid the suspected allergen. For older children, refer the patient for patch testing if unable to identify the allergen. Referrals can be made to a dermatologist or allergist who offers patch testing.
Environmental allergy
About 50% of people suffering from eczema also become sensitised to environmental allergens, such as house dust mite. Allergies to environmental agents, such as house dust mite, grasses and animal danders can contribute to eczema, particularly with an ‘exposed’ area distribution. Hay fever and asthma may also be present. Allergies to these agents are common and a positive test does not necessarily indicate relevance.
Management of patients with suspected environmental allergies includes:
skin prick or specific immunoglobulin E (IgE) testing to delineate the allergens
minimisation of exposure to these allergens
use of oral antihistamines prior to anticipated exposure to the allergen.
Children can also be irritated by the feel of grass or animal fur. Use a blanket when sitting on grass and keep animals out of living areas and bedrooms if possible.
Food allergy
IgE-mediated food allergy affects about 20% of infants with eczema. With the prevalence of food allergy decreasing with age, the role of food allergy as a trigger of eczema will usually have been established by school age.6 It is exceptionally rare for a food that was once tolerated and did not cause problems to then start to trigger eczema. Look for a history of immediate flaring of eczema, urticaria or angioedema with ingestion of a new food. Food allergy not mediated by IgE is much more difficult to identify as reactions are delayed. Ask the patient or family to keep a food diary if suspected.
Management of patients with suspected IgE-mediated food allergies includes a history of eczema flaring with certain foods, specific IgE or skin-prick test to confirm suspected allergens, and avoidance of the allergen. Significant dietary manipulation should always be managed in conjunction with a dietitian or pediatric allergist.
Food intolerance
Food intolerance refers to any non-immunological reaction to food and may play a part in a small proportion of patients with eczema. The relevant foods that can contribute to eczema include tomatoes, strawberries, citrus fruits and artificial colours, flavours and preservatives. In our experience, food intolerance is a real entity for a small percentage of patients with eczema, even if the food is eaten without contact on the skin; however, the mechanism of this is unknown. Food intolerance should be suspected in children with stubborn perioral eczema.
There is no formal test and so critical trial and error is the only option for patients with a suspected food intolerance. Unlike allergic reactions, an intolerance does seem to depend on quantity and concentration and, therefore, ‘cutting down’ is often adequate rather than strict avoidance.
Infection
Infection is primarily a complication of eczema. However, once an infection is present, it tends to flare the eczema, creating a vicious cycle. Infection is most commonly due to bacteria (impetigo), but other infections and infestations can, at times, flare eczema. These include Herpes simplex virus (eczema herpeticum), molluscum, Malassezia yeast (seborrhoeic dermatitis) and scabies infestation.
When eczema is infected, weeping, yellow crusts and scabs are often present. There is often a sudden exacerbation of general eczema. The usual organism is Staphylococcus aureus. The role of Staphylococcus in clinically non-infected eczema is more controversial, but should be kept in mind as a factor for difficult‑to-clear eczema. With grouped, clear, fluid-filled vesicles, or painful, bloody, punched-out lesions, suspect secondary infection with H. simplex 1.
Management of patients in whom infection is suspected should include:
taking skin swabs for bacterial and/or viral testing and sensitivities
gently removing crust by soaking in the bath/shower
bleach baths for children with moderate-to-severe eczema
treatment of overt signs of infection with oral antibiotics (ie cephalexin)
treatment with intranasal bactroban for recurrent infections and positive (Staphylococcus) nasal swab results
Staphylococcus reduction measures (eg wash hands before applying creams and use a spatula/spoon to remove creams from tubs)
keeping fingernails short to minimise skin damage from scratching.
Eczema Around the Eyes
If there is eczema, the eyelids will almost always be involved.
Types of eyelid eczema
The types of the eyelid eczema depend on the overall disease. A discoid form of eczema is common in children, and can be confused with the ringworm.
Levels of Severity
AD can be categorized as acute (erythema, vesicles, bullae, weeping, crusting), subacute (scaly plaques, papules, erosions, and crusts), and chronic (lichenification, scaling, and hyperpigmentation or hypopigmentation) based on appearance.
There are grade criteria that are used by research dermatologists to assess severity of eczema for the research and intervention protocols.
Six sites of the body are assessed for each of 6 features, each one scoring 0 to 3 for increasing severity:
Erythema
Exudation
Excoriation
Dryness
Cracking
Lichenification
Total score is calculated from:
Extent of affected areas: calculated as a percentage of total body area (from chart)
Intensity of a typical lesion (each scored 0 = none, 1 = mild, 2 = moderate, 3 = severe):
Erythema
Oedema/papulation
Oozing/crust
Excoriation
Lichenification
Dryness of unaffected areas
Subjective symptoms:
Pruritus (0–10 visual analogue scale)
Sleep loss (0–10 visual analogue scale)
Diagnosis
There is no definitive diagnostic “gold standard” for diagnosing eczema. But there are certain criteria that are used universally by doctors.
For example, UK working criteria is such:
An individual must have an itchy skin condition (or parental report of scratching or rubbing) in the last 12 months, plus three or more of the following:
a history of involvement of the skin creases (fronts of elbows, behind knees, fronts of ankles, around neck, or around eyes)
a personal history of asthma or hay fever (or history of atopic disease in a first-degree relative if a child is aged under 4 years
a history of a generally dry skin in the last year
onset under the age of 2 years (not used if a child is aged under 4 years) or visible flexural dermatitis (including dermatitis affecting cheeks or forehead and outer aspects of limbs in children under 4 years).
According to American Academy of Allergy and Americal Academy of Dermatology guidelines, the essential features of atopic dermatitis include pruritus and chronic or relapsing eczematous lesions that present with age-related typical morphology and distribution. A history of allergic diseases or immunoglobulin (Ig) E reactivity (ie, atopy) is considered essential to the diagnosis of atopic dermatitis.
Differential diagnosis
A firm diagnosis of atopic dermatitis requires the exclusion of other skin conditions that have a similar appearance:
keratoconus, which is a non-inflammatory, progressive corneal thinning disorder characterised by protrusion, irregular astigmatism and, in the final stage, scarring, which results in distorted and impaired vision. A number of studies have demonstrated a link between eye rubbing and keratoconus
uveitis
atopic cataract. Cataract in AD patients is usually bilateral, symmetrical and occurs in the posterior and anterior subcapsular regions.
retinal detachment. The most frequent surgery for retinal detachment in those eyes was scleral buckling (78.2%). Surgical management can be hindered by the fairly common presence of proliferative vitreoretinopathy (PVR). Flat retinal detachment is the most common type of RD observed in atopic dermatitis patients.
Atopic keratoconjunctivitis (AKC) is a chronic inflammatory allergic disease with clinical characteristics that include conjunctivitis, corneal ulceration, superficial punctuate keratitis, and corneal neovascularisation. Due to these characteristics, AKC is a condition that may potentially lead to blindness.
Ocular complications of atopic dermatitis in adults are blepharitis, keratoconjunctivitis, keratoconus, uveitis, subcapsular cataract and retinal detachment. Their frequency varies from 25% to 50%.
Severe ocular complications are rare in young children with mild atopic dermatitis.
Diseases associated with eczema
Atopic dermatitis comorbidities extend well beyond the march to allergic conditions (food allergy, asthma, allergic rhinitis, allergic conjunctivitis, and eosinophilic esophagitis), suggesting both cutaneous and systemic immune activation. In reviewing atopic dermatitis comorbidities, Councilors of the International Eczema Council found a strong pattern of immune activation in peripheral blood and the propensity to both skin and systemic infections. Associations with cardiovascular, neuropsychiatric, and malignant diseases were increasingly reported, but confirmation of their link with atopic dermatitis requires longitudinal studies.
Common diseases seen together with atopic dermatitis are:
Autoimmune diseases (thyroid autoimmunity in children)
Psychological and psychiatric disorders (sleep disturbance, abnormal interpersonal relations)
Treatment Options
As the skin is dependent on the condition of the gut and the quality of injested food, the first attention should be brought to the diet. A nutritionist can give you good recommendations on the quality food that does not contain harmful preservatives, antibiotics, growth factors and chemicals.
There is no evidence for a benefit of dietary restrictions without confirmed food allergies. Moreover, in children they carry the risks of severe malnutrition. Non-immunologic reactions to food such as reactions to food additives or sugar play a big role in atopic dermatitis, but these cannot be diagnosed by the skin test. Allergy skin test should be used to identify true food allergies. Then, allergist will provide you with the recommendations on avoidance or desensitization to food proteins. Many food allergies of the child will go away on its own later, but for the time being, some of the food should be excluded or substituted with other nutritious groups.
As environmental allergies play a big role in the development of the eczema, an allergy desensitization with sublingual drops or allergy shots will significantly reduce or stop the symptoms.
Emollients are generally considered to be effective for treating the symptoms of eczema. However, the few small short-term RCTs that have been done so far do not confirm this. Sufficiently powered long-term RCTs are needed to clarify the role of emollients in the treatment of eczema. Twice-daily moisturization is recommended by international guidelines as the bedrock of the management of atopic dermatitis (AD). Moisturizers should be selected based on proven clinical effectiveness in improving the skin barrier and improving the symptoms of AD.
The calcineurin inhibitors pimecrolimus and tacrolimus improve clearance of lesions compared with placebo and may have a role in people in whom corticosteroids are contraindicated. They also seem suitable for topical use in body areas where the skin is particularly thin, such as the face.
Corticosteroids improve clearance of lesions and decrease relapse rates compared with placebo in adults and children with eczema, although we don’t know which is the most effective corticosteroid or the most effective dosing regimen. Corticosteroids should be used very briefly and only in desperate situations when none of the other measures work. You should remember, that steroids can thin up the skin and produce significant discolorations, especially on the darker skin.
Topical corticosteroids seem to have few adverse effects when used intermittently, but if they are of potent or very potent strength, they may cause burning, skin thinning, and telangiectasia, especially in children.
Complications
Infections are the most common complication of atopic dermatitis and can be quite severe.
Skin quality can suffer significantly leaving “velvet” thin depigmented spots where eczema usually strikes.
Prognosis
Remission occurs by the age of 15 years in 60% to 70% of cases, although a large number of people re-present with hand eczema later on in life. While no treatments are currently known to alter the natural history of eczema, several interventions can help to control symptoms and prevent flares.
Prevention Methods
Although eczema has become increasingly common over past decades, the causes are not well understood and are probably a combination of genetic and environmental factors.
Eczema risk is increased in first degree relatives, and the discovery of the filaggrin gene strongly suggests that an impaired skin barrier is fundamentally involved in eczema development. However, genetics alone cannot explain the raise in the prevalence of eczema over past decades and also cannot explain why eczema often clears spontaneously. Migrant studies have found that children acquire the background population risk of their new home country.
There is also some evidence to suggest that eczema is associated with factors linked to a “Western” lifestyle, as the disease tends to be more common in industrialised countries and urban centres of developing nations. Broad-spectrum antibiotics during pregnancy and in early life seem to increase eczema risk, and it has been speculated that this may be because of alterations in the infant’s gut microflora.
So, the prevention of eczema is to avoid factors that cause it for you or/and your children:
Reduce the use of chemicals in the food and environment
Do not use antibacterial soaps and harsh cleaning solutions
Eat healthy organic food
Take probiotics or eat fermented foods
Go outside more
Use less sunblock based on organic components
There are other reasonable methods described in the literature that help treat or prevent eczema:
Breastfeeding
Microbial and lifestyle exposures
Vitamin D and UV light
Water filters and hardness reducers
Immunotherapy
Emollients are always discussed in a care for a dry skin in babies and children and should be used following the 15-20 min bath that rehydrates the skin. In a large multicenter trial a statistically significant protective effect was found with the use of daily emollient on the cumulative incidence of atopic dermatitis with a relative risk reduction of 50%.There were no emollient-related adverse events and no differences in adverse events between groups.
Eczema and immunizations
Both infections and immunizations can cause exacerbations of atopic dermatitis. Nonetheless, according to the Standing Committee on Vaccination Recommendations (STIKO), both children and adults with atopic dermatitis should be immunized following the formal recommendations. In case of acute exacerbations, vaccinations should be avoided until the skin stabilizes.
