Atopic dermatitis (Besnier's disease)

Willan, 1808

Neurodermatitis, endogenous eczema, atopic dermatitis, prurigo Besnier, neurodermatitis diffusa, neurodermatitis constitutionalis sive atopica, asthma eczema.

Chronic recurrent atopic disease with eczema and often severe itching.

• Prevalence: approx. 5-20% of all children worldwide , 1-3% of adults
• In adults, the prevalence decreases, however many people originally affected by A.D. still have hand and foot eczema. 
• More common in cities and western countries
• Men are slightly more frequently affected than women
• In about 70% there is a positive family history
• 1 parent with atopic dermatitis: 2-3 times ↑ risk of a child developing atopic dermatitis (approx. 50%)
• 2 parents with atopic dermatitis: 3-5 times ↑ risk of a child developing atopic dermatitis (approx. 75%)
• Monozygotic twins: 73% concordance
   

• Extrinsic atopic eczema
  • IgE-mediated
  • Approx. 60-70 % of all patients
  • Frequent sensitization to food or environmental allergens
• Intrinsic atopic eczema
  • Non IgE-mediated (not elevated)
  • No sensitization to food or environmental allergens
  • Approx. 30-40% of cases
  • Possibly own entity

• Genetic factors (familial atopy).
• ↑ IgE formation, pathologically more Th2 cells (compared to Th1).
• Diets for pregnant women do not reduce the risk to the newborn.
• Dysregulation of the cellular (Th2 ↑) and humoral (IL-4, IL-5, IL-10, IL-13, 16) immune system.
• Disruption of the skin barrier with dehydration of the skin.
• Disorders in filaggrin structure due to various mutations (FLG, SPINK5).
• Filaggrin can be broken down into the Natural Moisturizing Factor NMF when the stratum corneum is dry. This binds water and is therefore a moisture reserve. If filaggrin is missing, this reserve is also missing. 
• Long showers or baths with water that is too warm. We recommend reducing the bath or shower time to 1-2 minutes with lukewarm water.
• Very warm environments with low humidity.
• ↓ Regreasing. 
  • Pathological, microbial colonization: e.g: Staph. aureus, enterotoxins, Pityrosporum ovale
  • Infections: Sinusitis, dental infections etc.
  • Psychological and emotional stress.
• Type I sensitization (e.g. to house dust mite, animal epithelia, mould, pollen, etc.) is frequently observed in atopic patients. 
  • In about 30-80% of cases, there is a type I sensitization to certain foods.
     

• Erythematous, confluent, often itchy vesicles and papules. There are linear excoriations with severe pruritus. Secondary impetiginization and lichenification common.
• Further atopic manifestations: white dermographism, xerosis cutis or ichthyosis, fur cap-like hairline, Dennie-Morgan fold, Hertoghe's sign, earlobe rhaghade, perlèche, palmar hyperlinearity, cataracta neurodermitica, possibly diffuse alopecia, dermopathic lymphadenopathy.
   

• Medical history (family history, personal history, atopic diathesis?, other atopic diseases? Increased bacterial or viral infections? Food allergies).
• Clinic
• Laboratory: eosinophilia?, IgE value (IgE > 150 kU/l), adults: rx1, rx2; children: rx1, rx2, fx5
• Atopy score according to Diepgen 

Atopy score according to Diepgen et al. Source: Acta Derm Venereol 1989; Suppl 144: 50-54

0-  6 points: atopy unlikely

7-10 points: atopy possible

 >10 points: atopy likely

Other scoring systems:

• Always the Eczema Area and Severity Index (determine  ): The spread of the eczema is measured. Erythema, edema, excoriations and lichenification are rated with points between 0-4. Excel table with all scores available. EASI
• No longer recommended, as objective and subjective data are mixed: SCORAD ("Severity Scoring of Atopic Dermatitis") 
  1. Involvement of the BSA (body surface area).
  2. Determination of severity (1= mild, 2= moderate, 3= severe) of erythema, oedema/papularity, oozing/crusting, excoriation, lichenification, dryness
  3. VAS for itching and insomnia
  • SCORAD: A/5+7B/2+C. As subjective and objective criteria are mixed, the score is used less in studies than the EASI score.

• Infants: face, diaper area. The nose often remains free (clinical clue).
• Childhood and adults: More likely flexural eczema (elbow and knee bends)
   

Allergic rhinoconjunctivitis, asthma, food allergy, urticaria, eosinophilic esophagitis inquire in personal and family history.

Superficial perivascular and interstitial lymphohistiocytic/mastocytic dermatitis in the upper corium, spongiosis, spongiotic blistering, acanthosis, parakeratosis, low eosinophilia.

• Eczema molluscatum
• Impetiginization
• Eczema herpeticatum
• Erythroderma
   

• Early skin care does not reduce the risk of atopic eczema at the age of 1-3 years (Kelleher et al. 2021). It is still controversial whether they even increase the risk of food allergies. 
• Early introduction of peanut into the diet is now recommended for high-risk infants for peanut allergy. This is not yet clear for other foods. 
• Probiotics: Here, too, the data is limited. However, a slight improvement in the skin condition can be expected.
• Food supplements, vitamins, fish oil and other oils: Overall, the data is weak. Vitamin D could show a benefit. We at the USB do not recommend supplementation unless there is a deficiency.
• Chinese medicinal herbs: A total of 3 studies were conducted (all with a very low number of patients). 2 studies showed a benefit, while one study showed no difference between the placebo and the intervention group.
   

The symptoms often disappear after childhood, but persistence and relapses do occur. A chronic recurrent course is then to be expected.

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