Atopic dermatitis in children: symptoms (photo), treatment, drugs

What is atopic dermatitis?

Atopic dermatitis (synonyms: atopic eczema, neurodermatitis) is a typical disease that first occurs in childhood, characterized by increased skin sensitivity, which clinically leads to the appearance of itchy dermatitis and dry skin (xerosis).

It is a chronic multifactorial inflammatory disease caused by a combination of several different causes; the exact mechanisms underlying the symptoms with which he manifests himself are not yet fully elucidated, but they are believed to stem from dysfunctions at the level of the skin barrier and the immune response due to both genetic predisposition and trigger factors environment.

The goals of treating atopic dermatitis in a child are focused on treating symptoms, as there are currently no drugs that can definitively eliminate inflammation, the most recent recommendations in this regard determine many strategies that are useful for the treatment of this disease, including including:

• applying creams and emollients;
• oily detergents that have a softening effect;
• dietary interventions only based on proven allergy to specific foods;
• local anti-inflammatory therapy;
• phototherapy;
• any pre-oral antihistamines (prescribed by a doctor).

The prognosis is good as symptoms tend to improve with age in most casesalthough in childhood the disease can have a significant impact on daily life, both mental and physical.

Causes and risk factors

Atopic dermatitis in children does not have a single cause, on the contrary, it is considered a multifactorial syndrome due to:

• genetic predisposition;
• immunological factors;
• and not by immunological factors.

Concerning family predisposition, 90% of patients have a history of positive family history, that is, diseases characterized by a predisposition the immune system to hypersensitivity reactions to common antigens (that is, substances foreign to the body) present in the body.

• Food;
• home environment;
• external environment.

V non-immunological factors external stimuli such as:

• sweating;
• microbial infections;
• stressful situations at the physical and psychological level;

Immunological factorsFinally, allergens (as a rule, i.e. protein substances capable of causing allergic reactions) of the type:

• food (the presence of an allergen in food),
• inhalants (present in the air),
• on contact (allergens that come into direct contact with the skin).

Triggers (trigger factors)

Atopic dermatitis is a chronic disease characterized by remission phases alternating with exacerbation phases.

The evolution of the disease follows a seasonal rhythm:

• it gets worse:
  • in autumn / winter due to the irritating effects of cold climates,
  • spring due to greater exposure to seasonal inhalation allergens such as pollen;
• instead improves in summer.

Exacerbations can also occur as a result of:

• profuse sweating;
• physical activity;
• infectious diseases, especially of a viral nature;
• vaccination;
• being in a particularly dusty environment (dust mites, house dust mites (dermatophagoidosis), is one of the most common allergenic agents),
• emotional stress.

Deeper into the pathogenetic mechanism

Atopic dermatitis is a condition characterized by a decrease in the barrier function of the skin due to a decrease in the amount of epidermal (fat or lipid molecules) ceramides and a noticeable loss of transepidermal water.

Thus, the reduced barrier function of the skin facilitates the penetration of irritating or sensitizing molecules (allergens) capable of activate Langerhans cells, whose role is to capture and re-process antigens to present them to CD4 + T-lymphocytes. These lymphocytes, in turn, capture antigens and migrate to the lymph nodes, to their region of origin, where the immune response begins. In addition, Langerhans cells in an atopic subject possess type E immunoglobulin receptors (IgE), to which they bind specific IgE and allergens,

Atopy, or predisposition of the immune system to hypersensitivity reactions (mediated IgE) against common antigens, is a biological condition present in 35% of the population in the whole; atopic skin diseases (atopic dermatitis) and beyond skin diseases (asthma and allergic rhinitis) affect 20% of the general population. In particular, atopic dermatitis occurs in 10% of school-age children.

Symptoms of atopic dermatitis in children

The main symptom of atopic dermatitis is itching., and the clinical manifestations are the appearance of eczematous lesions, namely

• red (erythematous) spots;
• with a dry and scaly surface;
• sometimes exudative (fluid oozing from the wound).

In newborns (onset often occurs in the first year of life within the 4th month) and in the first two years of life, eczematous lesions are mainly localized on the face:

• cheeks (see. Photo);
• forehead;
• the chin.
• torso.

As a result of scratches that cause erosion and wounds, lesions can be subject to microbial superinfections, especially Staphylococcus aureus (impetiginization): in this case, the exudation is marked and can be next:

• serous (with leakage of transparent liquid material);
• purulent (with discharge of pus).

General conditions are satisfactory, and there is no temperature even with skin infections.

In childhood and adolescence, eczematous lesions, always itchy, affect very specific areas of the body:

• elbow folds (large folds);
• knees (popliteal folds);
• neck;
• the back of the hands.

If untreated, lesions fissure, crack, and may acquire lichenized (lichen) species with increased thickness, grayish color and rough surface skin (see. photo above).

In adulthood, the lesions have the same appearance and location as in the previous age, but are more prone to persistence and lichenification.

Clinical manifestations present at any age:

• dry skin (xerosis)
• and follicular keratosis or thickening of the skin on hair follicles.

The folds of the skin of the eyelids become more and more visible after re-localization of the rash in this area. Involvement of lips and perioral region with erythematous, dry and scaly lesions as in seborrheic dermatitisdefined as atopic cheilitis.

Atopic dermatitis is rarely so severe that it affects the entire surface of the skin, resulting in a situation called erythroderma.

Diagnostics

The diagnosis of atopic dermatitis is clinical and is based on the presence of:

• mandatory criterion, i.e. itchy dermatitis (inflammation of the skin with itching) that is associated with at least 3 of the following criteria (for positive personal history means present or past presence of the indicated symptom):
  • a positive personal history of dermatitis at the level of flexion folds (large, popliteal or cervical folds);
  • a personal history of asthma or allergic rhinitis (or a history of atopic disease in relatives of children under 4 years of age);
  • a positive personal history of generalized xerosis of the skin in the year preceding the visit;
  • the presence of eczematous lesions at the level of large folds or cheeks, chin or forehead at the current physical examination in children under 4 years of age;
  • onset of skin symptoms before the age of 2 years (the criterion is applicable for children under the age of 4 years).

The most significant blood tests are serum total IgE (which is usually high) and specific IgE, which target the most common respiratory and food allergens.

In addition to serum, allergens can be examined “inside the cell” with a “prick test”, which consists of puncturing the skin with a small needle dipped in a solution of the allergen. The test is positive if a swollen and itchy lesion is found at the puncture site after 15-30 minutes.

Treatment (products and care)

Local therapy is the first choice, especially in mild / moderate forms. The procedure consists primarily in the use of emollient creams, rich in lipid components, to counteract dryness and restore the skin's barrier function, which are applied to the entire surface of the skin, not just to the affected areas.

Cortisone creams are used instead in acute phases only on eczematous lesions, in combination with topical antibiotics when they present microbial superinfections. In the event that a long therapy time is envisaged or in the case of frequent relapses, the local cortisone can be replaced tacrolimus ointment, an effective immunosuppressant and without the side effects that cortisone ointments can cause.

Systemic therapy, on the other hand, is limited to particularly common or severe disease.

• Oral antibiotics (from the class of macrolides) are indicated in the presence of widespread signs of microbial superinfection.
• Narrowband phototherapy UVA or UVB consists of exposure to ultraviolet radiation of a specific wavelength inside special booths for use in a hospital or special environment.
• Cyclosporin A therapy, an immunosuppressant, which should be taken by mouth in doses of 3 to 5 mg per kg of body, is particularly effective to control the disease, regression of itching after about a week and remission of skin lesions within 2-3 weeks. Treatment should be continued for 3-6 months.

Which cream is best?

The bottom line is that there is no better cream or ointment.

However, some general considerations can be made for more effective treatment of atopic skin.

The main means for the treatment of atopic dermatitis is a semi-solid preparation (cream, ointment) of the emulsion type, which can apply directly to the skin to moisturize and reduce water loss, protecting it by forming a protective films.

There are numerous drugs in pharmacies (Advantan, Flucinar, Fluorocort) suitable for atopic skin because they do not contain allergens such as fragrances and are used for the following purposes:

• control and prevent dry skin condition,
• have a moderate anti-inflammatory effect,

for use not only in acute phases, but also in remission to prevent relapse. In fact, the patient suffering from atopic eczema should be instructed and encouraged to constantly use emollient creams, ointments since while reducing the barrier function of the skin, the daily use of lipids and emollient creams plays a fundamental protective and preventive role.

Daily use of emollients is usually necessary, even during stages of disease regression; as a rule, this requires:

• use a sufficient amount of the product for use in acute phases, not only on eczematous lesions, but also on dry skin that is not yet eczematous;
• do not rub into the skin and hair, but rather lightly, gently lubricate;
• apply an emollient immediately after bathing / showering, before the skin is completely dry (to retain some of the residual moisture);
• do not share creams with other people (to reduce the risk of infection).

Diet

According to some sources, consumption of certain foods, such as eggs and cow's milk, can cause signs of atopic dermatitis, but it is advised to avoid major dietary changes without special medical advice to avoid the risk of dangerous deficiencies (for example, young children risk a lack of calcium, calories and proteins from the lack of these products).

Prophylaxis

According to some authors, prolonged breastfeeding for as long as possible and a diet during pregnancy without potentially allergenic substances, such as milk and eggs, can prevent the onset of atopic dermatitis in children at risk (that is, with genetic predisposition). However, later studies refuted this theory, showing, on the contrary, that early weaning (at 4-5 months of a child's life) helps prevent the onset of atopic dermatitis.

Prevention, on the other hand, conceived as an attempt to reduce the incidence of acute phases, is primarily to avoid the greatest possible impact of trigger factors that are as numerous as subjective (that is, vary from one subject to to another); for example, in patients with dust hypersensitivity who test positive allergy tests on dust mites, it is necessary not only to avoid dusty environments, but also to remove carpets, blankets, pillows and all objects in which dust can easily accumulate from the house.

Prevention of exacerbations of dermatitis also occurs with the constant use of emollient creams, even in the remission phase of the disease.

Prognosis and complications

The prognosis is good, most children with atopic dermatitis tend to spontaneous healing or significant improvement in symptoms, despite the fact that the disease itself remains in mature age. At least 20% of patients remain ill even after puberty.

Complications are predominantly infectious.

• Among bacterial infections, one can distinguish infections that are caused by Staphylococcus aureus, a bacterium that almost regularly colonizes the skin and nasal mucosa of a patient with atopic dermatitis and causes complications (impetigination), especially when scratched, causes the formation of wounds and abrasions. This infection gives the eczematous lesions an exudative and sometimes purulent appearance.
• In subjects with atopic dermatitis, infections with herpes viruses (eg, herpes simplex 1 and 2) may be exposed to frequent exacerbations both on the skin and at the level of mucous membranes, or they may become generalized (varicose herpes).
• Smallpox virus infections (molluscum contagiosum) and human papillomavirus, HPV (warts, condylomas), apparently, occur in children with atopic eczema a little more often than without the disease.
• Finally, fungal infections of the skin, especially Trichophyton rubrum (Trichophyton red), a fungus transmitted by contact between people, have a longer evolution and a greater tendency to relapse in an atopic subject than in non-atopic.