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San Diego Eczema (and Atopic Dermatitis)

Atopic dermatitis is a very common condition, occurring in 10-20% of people worldwide. Most individuals develop the condition during infancy, with 90% of cases occurring by age 5. Atopic dermatitis, also known as “the itch that rashes,” is almost always accompanied by severe itching, along with redness, scaling and weeping. In infancy, the rash tends to develop on the scalp and cheeks. In childhood, the condition has a predilection for the arms (elbows, wrists) and lower extremities (the knees, ankles). In adults, atopic dermatitis can occur over widespread areas, but can have a tendency to affect the hands (chronic hand dermatitis), flexural arms and legs, and eyelids.

Major criteria for diagnosing atopic dermatitis:

  • Pruritus (itching)
  • The typical appearance and distribution
  • Thickening of the skin in the flexural arms and legs in adults
  • Face and extensor extremity involvement in infants and children
  • Chronic or chronically recurring dermatitis
  • Personal or family history of asthma, allergic rhinitis (hay fever), atopic dermatitis

Although atopic dermatitis also can be a lifelong condition and can re-occur later in life, its severity tends to diminish after childhood.

Other associations of atopic dermatitis include:

  • Dry skin, particularly in the winter months.
  • Ichthyosis (hereditary scaly skin condition)
  • Fissuring of palms, soles, fingers.
  • Keratosis pilaris (horny bumps in association with hair follicles, on the arms, thighs and sometimes face)
  • Increased creases of the palms
  • Keratoconus (development of a cone-shaped cornea)
  • Pityriasis alba (white scaly patches on the face and arms)

Approach to the management of atopic dermatitis:

  • Skincare: Harsh soaps generally should not be used because they dry the skin. Cleansers (which usually do not lather) and mild soaps (e.g. Dove) can be used to cleanse the skin. Frequent use of moisturizers is recommended. Creams are preferred over lotions because they are more hydrating. Ointments provide an excellent barrier to water loss through the skin, but some may find the texture objectionable. Hypo-allergenic skincare products are recommended over those with lots of fragrances, colors and preservatives.
  • Topical Corticosteroids These are the mainstay of treatment for acute flares of atopic dermatitis. They help to decrease inflammation and itching, but should not be used for longer than 2 weeks, continuously to decrease the risks of side effects. Mid to high potency corticosteroids should not be used on the face or groin. Long-term use of topical corticosteroids can result in stretch marks, atrophy (thinning of the skin), pigmentary changes, and the appearance of blood vessels.
  • Antibiotics: Atopic dermatitis frequently becomes infected with gram-positive bacteria (staphylococcus and streptococcus). When this occurs, short courses of antibiotics are required. Antibiotics not only treat the, but also have anti-inflammatory effects that benefit the atopic patient.
  • Antihistamines: Patients commonly unconsciously scratch their skin when they are asleep. Mildly sedating antihistamines are useful to help control the itching that occurs at night. The sedating effect may actually be more beneficial than the anti-itch effect of antihistamines in the atopic dermatitis patient.
  • Systemic Corticosteroids: Systemic corticosteroids generally are not recommended for atopic dermatitis, the reason being that the disease often relapses after the corticosteroids are withdrawn.
  • Topical calcineurin inhibitors: These newer non-corticosteroid medications which include tacrolimus and pimecrolimus are very useful for controlling mild to moderate atopic dermatitis. They are approved for use in individuals older than 2 years and especially useful on the face, neck and groin, areas that can be problematic with corticosteroids. Side effects of the calcineurin inhibitors are mild and include a burning and stinging sensation when applied to fissured, broken skin.
  • Phototherapy: Treatment with ultraviolet wavelengths of light can decrease the inflammation and itching associated with atopic dermatitis. This therapy is appropriate for individuals with widespread disease.
  • Immunosuppressive therapy: For severe or refractory atopic dermatitis, we may need to resort to the administration of immunosuppressive agents such as cyclosporine. Though such medications tend to be very effective for acute flares of the disease, due to side effects, they are not recommended for long-term use.
  • Allergy shots: These may be especially useful if the atopic dermatitis patient also has allergies to certain environmental triggers.

Atopic dermatitis is not curable, but with the appropriate skin care and medication regimen, under the care of your dermatologist, the disease can be adequately controlled.