Atopic eczema

Last Updated: 2021-11-19

Author(s): Anzengruber, Navarini

Willan, 1808

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
    • IgE-mediated
    • 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:
 
  Points
Itchiness when sweating 3
Wool intolerance 3
Xerosis of the skin 3
White dermographism 3
Hertoghe sign 3
Milk scab 2
Perlèche 2
Cheilitis 2
Enhanced hand line drawing 2
Pityriasis alba 1
Positive family history of atopy 1
Rhinitis 1
Conjunctivitis 1
Asthma 1
Dyshidrosis 1
Dennie Morgan wrinkle 1
Nickel sensitisation 1
Food intolerance 1
Facial erythema 1
Light hypersensitivity 1
Follicular hyperkeratosis 1
Score  

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")
    1. Involvement of 
    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. 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
  • Impetiginisation
  • Eczema herpeticatum
  • Erythroderma
  • 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.

General measures:

  • Elimination of exacerbation factors
  • Avoidance of toxic-irritative stress (↓ water contact). CAVE: choice of occupation

  • Breathable clothing made of cotton or silk. No polyester, wool or furs.

 

  • Topical therapy
    • Antiseptic showers: can reduce the risk of bacterial colonisation.
    • Remoisturization: at least once daily
    • Topical steroides (class III):
      • once daily for seven days, then reduce usage of topical steroids to a minimum. In patients with relapse it is possible to perform a proactive treatment (twice a week)
    • Calcineurin inhibitors
      • Approved from the age of 2 years, off-label-use before that. Second-line therapy
      • Theoretical malignancy induction risks have not been proven in long-term experience with these preparations, and they are used very frequently. Consensus: The benefit exceeds the risk
      • Do not use on the day of light therapy or with increased sun exposure

 

  • UV therapy
    • Narrowband UVB, UVA1 therapy, PUVA bath therapy
    • Balneophototherapy: combination of UV therapy and balneotherapy
    • No UV therapy should be given to children if they could take off their UV glasses in the cabin. Alternative therapy should be discussed in patients with skin type I
    • Climate therapy: stay at the North Sea or in the high mountains (Davos)

       

  • Systemic therapy (for moderate-to-severe AD)
    • Dupilumab: A human monoclonal antibody against the IL-4 receptor, inhibits IL-4 and IL-13, see the chapter on the drug.
    • JAK inhibitor baricitinib, upadacitinib (oral), see the chapter on the drug.
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