Symptoms
Atopic dermatitis, or neurodermatitis, is a noncontagious, chronic inflammatory skin disease that causes episodes of red, rough, dry or weeping, crusted and scaly skin. Eczema can occur all over the body and is typically accompanied by severe itching. Patients have dry skin. In infants, the disease begins on the scalp and cheeks. Depending on age, different areas of the body are affected, such as the face, scalp, trunk, buttocks, or extremities (elbows and knees). Other possible symptoms include brittle hair, a white skin reaction after scratching (white dermographism), pallor around the mouth, dark skin around the eyes, loss of lateral eyebrows, a congenital double lower eyelid crease (Dennie-Morgan crease), and skin inflammation of the nipples. Atopic dermatitis is the most common chronic skin disease in children. It often begins in infancy; between 10 to 20% of children in industrialized countries are affected. It is usually mild or moderate and often resolves with age. First onset in adulthood is rare.
Causes
The exact causes are not fully understood. There are a number of known factors that play a role in its development and progression. These include genetic factors (atopy, heredity), impaired skin barrier, inflammatory and immunologic factors, and allergies. Other factors and triggers include:
- Irritants: chemicals, detergents, environmental pollutants, smoke, pesticides, heavy metals, preservatives, soaps.
- Allergens: dust mites, pollen, fungi, animal epithelia.
- Textiles: wool, synthetic materials
- Food: eggs, milk, wheat, soy, peanuts, additives.
- Emotional stress
- Wet and cold weather
- Infectious diseases, pathogens: staphylococci,
- Medication, water hardness, sweat, hormones, washing habits.
The triggers differ individually and must be determined for each person individually.
Complications
The condition can cause great distress to the affected child and family. It can lead to psychosocial complications such as low self-esteem, depression, frustration, behavioral problems, and isolation. Children are teased, feel ashamed, and do not like to participate in social or sports activities (e.g., swimming). The itching also triggers irritability, difficulty concentrating, and sleep disturbances. A common problem is bacterial, viral or fungal superinfections of the pre-damaged skin, for example with (see also under impetigo). Scratching and rubbing can lead to skin damage, peeling, scarring, worsening of symptoms and superinfections. In addition, a vicious cycle occurs when scratching worsens the itching. An additional problem is nocturnal scratching during sleep (up to 20% of sleep time). Neurodermatitis sufferers often have asthma, hay fever, allergic conjunctivitis and hives at the same time. Asthma, hay fever and neurodermatitis are called the atopic triad. Asthma usually occurs in the later course of the disease. Proper treatment of atopic dermatitis can have a positive effect on later asthma complications. Finally, the medications used can cause adverse effects. Glucocorticoids lead to skin atrophy and antihistamines to fatigue if used improperly. Topical calcineurin inhibitors are suspected of causing malignancies such as skin cancer in rare cases.
Diagnosis
Differential diagnoses are numerous. Many skin diseases, such as other eczema, infectious diseases, scabies, lice, or psoriasis, can be confused with atopic dermatitis. The diagnosis should be referred to medical treatment.
Non-drug treatment
Inflicting pain is well effective against itching and results in a pleasantly experienced relief:
- Mechanical stimuli such as scratching, rubbing, slapping. However, scratching in particular leads to aggravation and secondary infections.
- Cold: cold water, ice, cold hot pack, cold stones or similar.
Cooling also helps against itching:
- Cool environment.
- Wear light, loose-fitting clothing. The clothes should not chafe.
- Take a lukewarm or cool shower.
- Avoid alcohol and strongly spiced foods.
- Rub cooling hydrolotions and gels (can be stored in the refrigerator).
- At night in bed, the symptoms worsen, so provide a cool climate there as well. A cool shower before bedtime can have a positive effect.
Other measures:
- Identify and avoid individual triggers and allergens.
- Avoid dehydration of the skin, daily basic care.
- Mild soaps should be used for washing. Bathed should be only briefly, in warm water, because the bath hydrates the skin, but at the same time dries it out. Immediately after drying, skin care products should be applied.
- Avoid synthetic textiles and wool. Cotton is usually well tolerated. Wear antimicrobial clothes. Remove clothing labels.
- Avoid stress, relaxation techniques.
- Cut nails short, wear light gloves at night (nocturnal itching!).
- Cosmetic products to cover the affected areas of the skin.
- Sun and UV radiation can lead to improvement in some cases.
- Hypoallergenic infant milk
- Moist compresses at night
- It is also important to educate parents or patients. AHA offers, for example, appropriate courses http://www.ahaswiss.ch
Drug treatment
Skin care products:
- Skin-conditioning, hydrating, and hypoallergenic ointments, creams, and lotions are essential for the treatment of atopic dermatitis. They keep parched skin moist and supple and reduce the need for glucocorticoids. They should be applied regularly and at least twice daily or more often, even when a rash is not present. It is especially important to apply them shortly after bathing or showering. They are usually free of active ingredients and fragrances, but may contain urea or lactic acid, which promote hydration.
Topical glucocorticoids:
- In addition to skin care products, topical glucocorticoids, which are anti-inflammatory, immunosuppressive, anti-allergic and indirectly relieve itching, are among the first-line agents. They are applied to the rashes. Local and systemic adverse effects can be avoided by following the instructions for use; attention must be paid to the possible side effects. Attention must be paid to the strength of the glucocorticoid, the age of the patient, the site of application, the characteristics of the skin lesion, and the duration of application. Preparations with the weakly effective hydrocortisone are available without prescription in pharmacies, other glucocorticoids are available exclusively on medical prescription.
Topical calcineurin inhibitors:
- Tacrolimus and pimecrolimus are approved for external treatment from 2 years of age. They have an anti-inflammatory effect and are used as 2nd-line agents when the desired effect is not achieved with skin care products and glucocorticoids. They are well effective and do not cause skin atrophy. However, they should only be used in the short term or for interval treatment, since in rare cases the development of malignant diseases such as skin cancer and lymphoma has been reported during therapy. However, a connection could not be proven with certainty. The most common adverse effects include local skin irritation and a burning sensation. Alcohol should not be consumed during treatment, as intolerance reactions may occur. In addition, good sun protection should be provided.
Monoclonal antibodies:
- Dupilumab is an agent from the group of monoclonal antibodies with anti-inflammatory and selective immunosuppressive properties. It is used as a second-line agent for the treatment of moderate to severe atopic dermatitis. The effects are based on binding to the alpha subunit of the interleukin-4 receptor and the interleukin-13 receptor. This abolishes the biological effects of the cytokines interleukin-4 and interleukin-13. The drug is administered as a subcutaneous injection every two weeks. The most common potential adverse effects include injection site reactions, conjunctivitis, eyelid margin inflammation, and oral herpes.
Other drug treatment options
Systemic therapeutics:
- Immunosuppressants such as ciclosporin, azathioprine, methotrexate, and mycophenolate mofetil, oral glucocorticoids, and interferons are used in refractory patients and in severe cases. They are effective when administered internally, but their use is limited by the sometimes severe adverse effects.
Fatty acids:
- Commonly used evening primrose oil, the fatty oil from the seeds of the evening primrose. It contains unsaturated fatty acids such as linoleic acid and linolenic acid and can be taken in the form of capsules, some of which are approved from one year. For children, the capsules can be opened and the oil mixed with milk or added to food. A treatment trial should be carried out for a longer period of time during at least 1-2 months. Fish oil is also used.
Antihistamines:
- Whether the anti-allergic antihistamines applied to the skin or administered internally relieve itching is controversial. They can have a positive effect if allergies are present at the same time. Administered as a gel, they have a cooling effect. First-generation antihistamines such as dimetindenmaleate or hydroxizine are drowsiness-inducing when administered internally and are therefore helpful against sleep disorders. They should be administered in the evening. Possible adverse effects must be taken into account. In children under one year of age, apneic episodes may occur during sleep, and in infants they may cause agitation.
Mast cell stabilizers:
- Ketotifen is approved in many countries for this indication and can be used for pruritus from 3 years of age. It is not a competitive antihistamine but inhibits the release of inflammatory mediators such as histamine and leukotrienes. Other anti-allergic and anti-asthmatic drugs such as the leukotriene antagonists are also used for allergies and asthma.
Essential oils and their components:
- Menthol, thymol and camphor are locally applied as a cream or lotion cooling, analgesic and antipruritic. Unfortunately, the duration of action is short. In infants and young children, they are contraindicated because they can lead to respiratory arrest.
Extremolyte:
- Ectoin (Sanadermil EctoinAcute) is a natural active ingredient with cell-protective, anti-inflammatory and nourishing properties that can be used both for prevention and treatment of eczema.
Antidepressants:
- Tricyclic antidepressants such as doxepin and amitriptyline are antidepressant, analgesic and antipruritic.
Anti-infectives:
- Antibiotics (e.g., fusidic acid), antifungals (e.g., topical ketoconazole), and antivirals (e.g., nucleoside analogues) are used topically or orally to treat superinfections. Local antiseptics such as triclosan are also used.
Vitamin B12 ointment:
- Small studies have shown the effectiveness of vitamin B12 (cyanocobalamin) applied locally as an ointment. See under vitamin B12 ointment
Alternative Medicine:
