Last Updated: 2021-11-19
neurodermitis, endogenous eczema, atopic dermatitis, prurigo besnier, neurodermatitis diffusa, neurodermatitis constitutionalis sive atopica, asthmatic eczema.
Chronic recurrent inflammatory dermatitis, often with intense itching. It occurs typically in persons with atopic diathesis
- Prevalence: approx. 5-20% of all children worldwide, 1-3/100 of adults
- More common in cities and western countries
- Men are slightly more often affected than women
- Approximately 70% have a positive family history
- 1 parent with atopic dermatitis: 2-3-fold ↑ risk for a child to develop atopic dermatitis (approx. 50%)
- 2 parents with atopic dermatitis: 3-5-fold ↑ risk for a child to develop atopic dermatitis (approx. 75%)
- Monzygotic twins: 73% concordance
- Extrinsic atopic eczema
- About 60-70% of all patients
- Frequent sensitisation to food or environmental allergens
- Intrinsic atopic eczema
- Non IgE-mediated
- No sensitisation to food or environmental allergens
- About 30-40% of cases
- Possibly own entity, research ongoing
- Genetic factors (familial atopy).
- ↑ IgE formation, pathologically more Th2 cells (vs. Th1).
- Diets for pregnant women do not reduce the risk of the newborn to develop atopic dermatitis, nor does systematic skin care of newborns.
- Dysregulation of the cellular (Th2 ↑) and humoral (IL-4, IL-5, IL-10, IL-13, 16) immune system.
- Disturbance of the skin barrier with dehydration of the skin.
- Disturbances in the filaggrin structure due to various mutations (FLG, SPINK5).
- Long showers or bathing with water that is too warm. A reduction of the bathing or showering time to 1-2 minutes with lukewarm water is recommended.
- Very warm environments with low humidity.
- ↓ Remoistering
- Pathological, microbial colonisation: e.g.: Staph. aureus, enterotoxins, Pityrosporum ovale
- Infections: Sinusitis, dental infections etc.
- Psychological and emotional stress.
- Type I sensitization (e.g. against house dust mite, animal epithelia, mould, pollen etc.) are often observed in atopic patients.
- In approx. 30-80%, there is a type-I sensitisation to certain foods.
- Type IV sensitization is not usually increased (controversial studies).
- Erythematous, confluent, often pruritic erythema and papules. Not infrequently, there is secondary impetiginisation and lichenification.
- Other atopic manifestations: white dermographism, xerosis cutis or ichthyosis, furry cap-like hairline, Dennie-Morgan fold, Hertoghe's sign, ear lobe fissure, perlèche, palmar hyperlinearity, cataracta neurodermitica, possibly diffuse alopecia, dermopathic lymphadenopathy.
- History (family history, own history, atopic diathesis?, other diseases from the atopic group? Increased bacterial or viral infections? Food allergies).
- Clinical features
- Lab: Eosinophilia?, IgE level (IgE > 150 kU/l), adults: rx1, rx2; children: rx1, rx2, fx5
- Atopy score according to Diepgen:
|Itchiness when sweating||3|
|Xerosis of the skin||3|
|Enhanced hand line drawing||2|
|Positive family history of atopy||1|
|Dennie Morgan wrinkle||1|
0- 6 points: atopy unlikely
7-10 points: atopy possible
>10 points: atopy likely
Atopy score according to Diepgen et al. Source: Acta Derm Venereol 1989; Suppl 144: 50-54
More scoring systems:
- Always determine the Eczema area and severity index (EASI): It measures the spread of eczema. Erythema, oedema, excoriations and lichenification are scored between 0-4. Excel table with all scores available.
- SCORAD ("Severity Scoring of Atopic Dermatitis")
- Involvement of
- Determination of severity (1= mild, 2= moderate, 3= severe) of erythema, oedema/papularity, oozing/crusting, excoriation, lichenification, dryness
- VAS for itching and insomnia
- SCORAD: A/5+7B/2+C. Because subjective and objective criteria are mixed, the score is used less frequently in clinical studies than the EASI score.
- Infants: face, shoulders, nappy area. Typically, the nose is free.
- Childhood and adults: Typically, the eczema affects the bends of the elbows and knees
Superficial perivascular and interstitial lympho-histiocytic/mastocytic dermatitis in the upper corium, spongiosis, spongiotic blistering, acanthosis, parakeratosis, low eosinophilia.
- Spread of molluscum contagiosum: eczema molluscatum
- Eczema herpeticatum
- Early skin care does not reduce the risk of atopic eczema at 1-3 years of age (Kelleher et al. 2021). It is still controversial whether it even increases the risk of food allergies.
- Early introduction of peanut into the diet is now recommended in high-risk infants for peanut allergy. There is no clear strategy yet on how to introduce other foods that cause food allergy.
- Probiotics: Again, the data is limited. However, a decent improvement in skin findings is often observed and tolerability is high.
- Nutritional supplements, vitamins, fish oil and other oils: Overall, the data is weak. Vitamin D might show a benefit. We do not recommend supplementation, unless there is a deficiency condition.
- 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 intervention group.
The symptoms often disappear after childhood, but persistence and relapses do occur. A chronic, relapsing course is then to be expected.
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