Atopic Dermatitis

Atopic dermatitis, also called “eczema”, is a skin disorder that usually appears in babies or very young children.  It is a chronic skin condition, meaning there is no cure; however, there are excellent regimens to minimize symptoms.  Eczema causes the skin to itch, turn red, and flake.

Parents with eczema are more likely to have children with eczema, but not all children will have a family history of atopic dermatitis. Different triggers can make eczema worse, including heat or cold weather. Of children who have eczema, most will show signs of eczema in the first year of life and 85 percent will show signs of eczema within the first five years. Atopic dermatitis is not contagious.

Eczema occurs in approximately 10 to 20 percent of all infants. Of these children, nearly half will improve between ages five to 15. Roughly 60 percent of children may have some form of eczema throughout their lifetime.

What are the symptoms of eczema?

The distribution of eczema may change with age. In infants and young children, eczema is usually located on the face, outside of the elbows, and on the knees. In older children and adults, eczema tends to be on the hands and feet, the folds of the arms (antecubital fossae), and on the backs of the knees (popliteal fossae). The following are the most common symptoms of eczema. However, each child may experience symptoms differently. Symptoms may include:

• Dry, red, scaly skin
• Skin-colored rough texture or tiny skin-colored “bumps”
• A thickening of the skin (with chronic eczema)

Atopic dermatitis is characterized by intermittent flares when the skin is much worse.  Some children only have a few episodes of flare-ups, while other children will have atopic dermatitis throughout adulthood.  Children with atopic dermatitis are more prone to skin infections, including bacterial and viral infections. 

The symptoms of eczema may resemble other skin conditions. Always consult your child's doctor for a diagnosis.

How is eczema diagnosed?

Atopic dermatitis is very common.  The diagnosis can usually be made based on a physician’s physical examination alone.   There are no “blood tests” to diagnose atopic dermatitis.  A skin biopsy may be helpful, but is not usually necessary and is not always diagnostic.  A personal or family history of atopic dermatitis, allergies or asthma increases the likelihood of the diagnosis of atopic dermatitis

Treatment for eczema

Specific treatment for eczema will be determined by your child's doctor based on:

• Your child's age, overall health, and medical history
• Extent of the disorder
• Your child's tolerance for specific medications, procedures, or therapies
• Expectations for the course of the reaction

There is no cure for eczema. The goals of treatment are to reduce itching and inflammation of the skin, moisturize the skin, and prevent infection.

Management of eczema symptoms

The following are suggestions for the management of eczema:

• Use of moisturizers (fragrance free creams or ointments) at least twice a day is one of the most important aspects of management.   Ask your child's doctor to recommend a brand.
• Avoid harsh, drying soaps and use gentle, fragrance-free soaps.   Ask your child's doctor to recommend a brand.
• Bathe your child daily using lukewarm water. 
•  Make sure your child's fingernails are short, as scratching may contribute to an infection.
• Antihistamines. These medications help to decrease the amount of itching and help your child sleep. Some examples include diphenhydramine (Benadryl) and hydroxyzine (Atarax).  Some children may require daily use.  Consult your child's doctor for more information.
• Topical steroids. These medications decrease the inflammation in the skin, thus decreasing the itching and redness. Topical steroids are the mainstay of treatment for atopic dermatitis and can be used safely without side effects if you follow your physician’s directions.  Steroids, if overused, are potentially damaging to the skin. Follow the advice of your child's doctor.
• Topical immunomodulator (TIMs or TCIs). Topical immunomodulators are a newer class of drugs for the treatment of eczema. These drugs are applied directly to the skin to alter the immune response.  Although there is an FDA black box warning regarding the potential for cancer, this was based off on studies in animals that have not been replicated in humans.  These medications are very safe if used as directed by your physician. 
• Oral antibiotics. These medications may be used to treat an active infection in the skin or help decrease the inflammation associated with atopic dermatitis. A bacterial culture may help determine the type of bacteria growing on the skin and direct treatment. Follow the instructions for dosing and administration carefully and consult with your child's doctor as needed.
• Oral steroids.  This medication may be used to treat a very bad atopic dermatitis flare.  When used for short courses (2-3 weeks), there is very little potential for serious side effects.  The use of oral steroids for longer periods of time is avoided as much as possible, as the risk of side effects increases with time. 
• Oral immunosuppressive agents (cyclosporine, azathioprine, mycophenolate mofetil).   Some children with severe atopic dermatitis may not respond to topical steroids and short courses of oral antibiotics or oral steroids alone.  In these children, your physician may consider medications to “quiet” the immune system.  While all medications have the potential for side effects, these medications can be used safely under the guidance of your physician with close monitoring. Consult with your child's doctor as needed.
• Phototherapy (light therapy).   Some children with severe atopic dermatitis may not respond to topical steroids and short courses of oral antibiotics or oral steroids alone.  Phototherapy can be an effective method to improve atopic dermatitis but usually requires the family to bring the child to clinic 2-3 times a week for at least 3 months.  It is safest to have this treatment under medical supervision, but light therapy is not offered at all dermatology clinics. Home light therapy devices are available, but may not be covered by insurance. Narrow band UVB (ultraviolet B) light units are the most effective.