Atopic eczema

Atopic eczema (atopic dermatitis) is a chronic relapsing itchy skin disease. As a result of the skin's lipid barrier damage it comes up to increased loss of water, dehydratation and high dryness of the skin. This way skin becomes more sensitive to such factors as irritating agents and allergens, which continue to worsen the atopic eczema. It's a very frequent, episodic disease with swapping phases of exacerbation and remission, exceptionally the disease can be continuous.

Prevalence and prognosis
15–30 % of children and 2–10 % suffer from the atopic eczema. It occurs in men and in women with the same frequency. Almost 80 % of cases manifest in the first five years of life, high frequency of occurrence is already in the first year. Incidence of the atopic dermatitis is constantly rising. It has a relapsing progression with tendency to continuous improvement in the adulthood. Prognosis is worse in case if the disease develops in the young age and with occurence of astma bronchiale at the same time.

Etiology
It is a multifactorial disorder. Progression is affected by the genetic factors, skin barrier defect, immune response, effects of the environment and infectious agents. No particular genetic reason was detected so far. Atopic eczema can be worsen by the provoking factors - irritative agents, allergens, microbes and climate, hormonal and psychical factors.

Related factors

 * diet change;
 * emotional stress;
 * contact with pets;
 * contact with the irritating agents (irritants) – hot water, soaps, cigarette smoke, washing detergents with lots of enzymes, fresh juices (citrus, tomatoes, strawberries), clothes made of clothes made of synthetic fibres (polyester), wool and fur;
 * hormonal changes in women – in first and second trimester of pregnancy, peripartálního období (kolem porodu) a v menopauze; premenstruační exacerbace;
 * aeroallergens – animal fur, roztoči, plísně a pyly;
 * coldness and hotness;
 * microorganisms – bacteria, viruses, molds, yeast;
 * allergens – production of the IgE antibodies.

Inhalant and food allergens
There are forms with and without coincident allergic sensibilisation. Allergic sensibilisation in atopic eczema increases the risk of the development of the respiratory allergies. Contact with pets or house dust increases the risk of the atopic eczema. In most of the grown-up patients with atopic eczema the exacerbation of the disease is more often affected by inhalant then food allergens. However inhalant allergies are closely related to response to the food allergens, which have a cross-reaction to the pollen - in pathophysiology it means the cross-reactivity caused by the similar proteins contained both in food and in pollen grain. The most common food allergens in adults with the atopic eczema are peanuts, eggs, wheat flour, soya and milk. Risk products are possible to detect with the anamnesis, skin prick tests, serum specific IgE and atopic patch tests (non-IgE mediated hypersensitivity). Diagnosis is then confirmed by the remission after the elimination diet (elimination of the food product for 3-4 weeks) and the relapse in the exposure test. In patients with severe forms of the atopic eczema is sometimes recommended a strict diagnostic hypoallergic diet which includes cooked vegetables (except celery) and cooked fruits, then rice, potatoes, corn and meat (except fish). The task is to ensure that after the dieting the skin state will improve.

'In children with the atopic eczema is stated a prevalence of the food allergies in different stages in range 20–80 %. The most prevailing food allergens are eggs, cow milk, soya and wheat flour. In about 1/3 of children food allergy disappears after 1-2 years of the exclusion of the allergen, however it depends on the type of the allergen.

Earlier a „hypoallergenic diet„ used to be recommended for infants as the essential part of the atopic eczema's prevention and treatment. In toddlers with the atopic eczema it used to be recommended to reduce and even completely exclude the products which cause the allergic reaction most offen, for example cocoa, chocolate, almonds, fish, poppy seeds, nuts, citrus, kiwi, tomatoes, celery, parsley, moldy cheese. Eggs used to be recommended only as a part of backed products and side dishes, not as a separate dish.

According to the new recommendations any restrictive (elimination) diet has to be indicated considering the results of the complex immuno allergy investigation. Unjustified elimination of the products in children with mere sensibilisation has risks of malnutrition and deficiency of the antioxidants. Restrictive „low allergy“ diets without any stated allergy are not approved in evidence-based medicine. The same way the „low allergy“ diet is not indicated to mothers of breastfed babies. However the diagnostic elimination diets make an exception - diet is evaluated after 2-4 weeks, if it has no effect, then there is no sense to continue dieting, in case of favourable effect it has to be confirmed by the further re-exposition. Children with mild form of the atopic eczema don't require any diet restrictions. In allergy with clear diet it is not necessary to eliminate the non-related products (for example in the allergy to cow milk protein the amino acid formula is indicated so there's no reason to eliminate dishes with eggs, gluten an so on).

Clinical picture
In diagnosis are used clinical signs, symptoms and anamnesis data. There are no laboratory or biological markers or specific histopathological picture.

Main criteria:
 * itching (pruritus)
 * typical manifestation in typical location – lichenification, roughen skin, erythema, vesicles, papules, peeling skin in predilection flexural locations: wrists, elbow and knee pits, face, neck, upper chest
 * chronic or chronic relapsing skin inflammation
 * positive personal or family anamnesis (including occurence of the hay fever and asthma)

Secondary criteria: Exacerbation (flare):
 * early occurence of the disease
 * increased level of the IgE in serum
 * positive skin tests
 * dermographismus albus
 * cheilitis
 * circles under the eyes
 * unbearableness of wool clothing
 * dry skin (xerosis)
 * increased dryness
 * itching
 * reddening
 * edema
 * general irritation.

Odlišnosti kůže postižené atopickou dermatitidou:
 * lower level of ceramides – affects the protective function of the skin and the immune response;
 * lower level of the natural hydrating factor – increases the transepidermal water loss;
 * microbial colonisation, mainly St. aureus – staphylococcus enterotoxins support the inflammation of skin; often without any clinical signs.

For the evaluation of the severeness and range of the atopic dermatitis there are different score systems, for example EASI, SCORAD.

Forms of the atopic dermatitis
The first manifestations occure in first 2.–6. months of life in form of dry, rough skin, reddening or strongly itching papular to focal sowings, most often in areas of face, forehead, hair, around the ears and neck. It can spread to the whole head, body and extremities, at first rather over extensors. A bit later it affects the flexor surfaces of the limbs and tends to generalize. Fluctuation and sudden flare-ups are typical. As the result a child has insomnia, uneasiness and cries. The most common trigger factors are the food allergens, exacerbation is often triggered by the teeth eruption, vaccination or infection. Between the 9th and 12th month it's getting worse.
 * Infant phase (1. to 2. year of life)

Atopic eczema can be idiopathic or continues from the infant phase. About 2 year of life lesions in elbow and popliteal pits start to dominate. Besides the neck, wrists and fingers can also be affected. The skin is coarse, rough, erythematous with first signs of lichenification. The typical look of the patient includes pale facial skin with darker and coarse eyelids. The external third of the eyebrows and sometimes the lashes are often missing. 75 % of children recover after this phase.
 * Child phase (2 to 12 years)

After the puberty the intensity of the atopic eczema goes down and the manifestations are more Po pubertě klesá intenzita atopického ekzému a projevy jsou discreet. In addition to the flexor surfaces ands, fingers, soles, cheeks, eye, lip and nipple areas also tend to be affected. Lichenification (skin roughening) dominates.
 * Adolescent and adult phase (above 12 years)

Complications

 * infections, mostly staphylococcus and herpes;
 * psychological problems – stress, feeling of the inferiority, low self-esteem, in case of severe itching - sleep disorders;
 * eye complications – irritations of the conjunctiva, rarely a aataract or retinal detachment.

Treatment
A goal of the treatment is the reduction of the severe symptoms and prevention of the further manifestations, control over the course of the disease and improvement of the quality of patient's life. The essence of the treatment is optimal skin care, regeneration of the skin barrier with emolencia and skin hydration. Besides it's also important to adjust the lifestyle (for example appropriate clothing and the right choice of the cosmetic and hygiene products), diet, home environment, acquaintance of the factors which trigger the itching and their restriction. The most important is a detailed patient's education.


 * Treatment of the mild forms (dry skin, occasional itching or reddening):
 * emoliencia and low potency local corticosteroids.


 * Treatment of the moderate forms (dry skin, reddening, frequent itching, occasional excoriation):
 * emoliencia, medium potency local corticosteroids and local calcineurin inhibitors.


 * Treatment of the severe forms (extensive areas of dry skin, constant itching and reddening, sometimes excoriation, weeping, cracked skin and changes of the pigmentation):
 * emoliencia, high potency local corticosteroids, local calcineurin inhibitors, wet compresses, phototherapy, also possibly a systemic therapy.

Emoliencia

 * standard in treatment and prevention of atopic dermatitis, in total skin care;
 * replacement of skin lipid's loss, soften and hydrate the skin, renew the skin barrier and water capacity in stratum corneum;
 * increase the anti-inflammatory effect of local corticosteroids and decrease their consumption;
 * ointments and creams, emollient substitutes of soaps, bath oils - for daily treatment, washing or bathing;
 * hydrophilic creams and emulsions – they contain more water and have higher cooling effect; the most appropriate are daily treatments, especially in warm climate conditions and in younger patients;
 * ointments and hydrophobic creams – grease better; they are more appropriate in more severe causes of skin dryness, in colder climate conditions, in older patients, primarily for legs and shoulders;
 * adjuvante emoliencia – contain further components, for example antiseptic and antipruritic;
 * some preparations contain hydrating substances, which are used as components of the natural hydration factor – for example urea, glycerol, dexpanthenol;
 * furthermore urea has a mild antipruritic effect, however it can cause the irritation in some patients, primarily in infants and small children, that's why it's recommended for children older than 3 years;
 * glycerol changes lipid's pozměňuje behaviour in stratum corneum and reduces the transepidermal water loss, protects the skin barrier;
 * dexpanthenol has mild anti-inflammatory effects, positively affects the reparation of the skin barrier and healing of the superficial affections;
 * lipophilic components renew the lipid lamelae and contribute to the skin hydrating by supporting the natural lipids in stratum corneum and by ensuring better barrier function – for example vaseline, ceramides, cholesterol, free fatty acids (linoleic acid).

Local corticosteroids

 * účinné při situacích spojených se zánětem, imunologickou reakcí a hyperproliferací, mohou poskytnout symptomatickou úlevu od pálení a svědění;
 * rozlišují se 4 třídy účinnosti:
 * slabé: hydrokortizon-acetát, prednisolon,
 * středně silné: hydrokortizon-butyrát, dexamethason-acetát, triamcinolon-acetonid, alclomethason-dipropionát,
 * silné: betamethason-dipropionát, betamethason-valerát, fluocinolon-acetonid, momethason-furoát, methylprednisolon-acetonát, flutikason-propionát,
 * velmi silné: klobethasol-propionát;
 * aplikují se pouze na místa s aktivní atopickou dermatitidou nebo na místa aktivní v posledních 48 hodinách, obvykle 1–2× denně;
 * velmi silné lokální kortikosteroidy by se neměly aplikovat na obličej, podpaží, třísla nebo pod okluzi;
 * hydratace kůže, použití okluze a povaha vehikula ovlivňují vstřebávání a účinek lokálních kortikosteroidů;
 * nežádoucí účinky dlouhodobého podávání silných lokálních kortikosteroidů: atrofie kůže, strie, teleangiektázie;
 * systémové nežádoucí účinky mohou nastat při aplikaci lokálních kortikosteroidů na více než 30 % povrchu těla nebo při nadužívání silných lokálních kortikosteroidů.

Calcineurin inhibitors (topical immunomodulators)

 * decrease the range, magnitude and manifestations of the atopic dermatitis, reduce the itching;
 * are not convenient in treatment of the mild form of the atopic dermatitis, not even even in the first line of treatment of any form of atopic dermatitis;
 * moderate the inflammation and don't have such side effects as local corticosteroids, that's why they're possible to apply in areas with thin skin (eyelids, face, intertriginous areas);
 * one of the side effects is transient burning at the site of application, particularly in first days of usement;
 * are possible to apply in acute and chronic cases of the atopic dermatitis;
 * do not apply on skin with current bacterial or viral infection, don't use the occlusion, avoid the UV radiation after the application;
 * apply 2 weeks after vaccination to avoid its failure;
 * local pimecrolimus – is used in children older than 2 years as a second-choice drug in mild and moderate forms of eczema on the face and neck, where the treatment with the local corticosteroids is not effective enough and has a high risk of the side-effects, particularly the skin atrophy;
 * local tacrolimus (0,03% for children older than 2 years, 0,1% older than 16 years) – is used in children older than 2 years as a second-choice drug in mild and moderate forms of eczema on the face and neck, where the treatment with the local corticosteroids is not effective enough and has a high risk of the side-effects, particularly the skin atrophy.

Preparations containing tar

 * anti-itching and anti-inflammatory effects;
 * are applied in chronic lesions of the atopic dermatitis in monotherapy or in combination with local corticosteroids;
 * side effects: folliculitis, photosensitivity;
 * cons: bad smell, dark color of tar leaving stains on clothes.

Preparations containing ichthammol

 * supports the regeneration of the keratinocytes, anti-inflammatory effect;
 * k doléčení zánětu po ukončení terapie atopické dermatitidy; prevence rebound fenoménu;
 * minimální iritační, senzibilizační a fotosenzibilizační potenciál.

Further medications

 * local antibiotics and antiseptics – for secondary bacterial infection treatment;
 * peroral antihistamines – ineffective against itching;
 * systemic corticosteroids and immunosuppressive drugs treatment (prednisolone, azathioprine and cyclosporine A) – for the short-term application in severe atopic dermatitis, when other possible alternatives have failed.

Phototherapy

 * application primarily in chronic and subacute stage; narrowband ultraviolet radiation with wavelength 311 nm;
 * in acute forms is prefered UVA1.

Spa treatment

 * hydrogen sulfide mineral baths – antiseptic and anti-inflammatory effect.

Léčba červených, mokvajících okrsků kůže

 * compresses with soothing and drying effect: for example Jarisch solution, slightly pink potassium permanganate solution, decoction from the black tea.

Related articles

 * Allergic skin manifestations • Allergy
 * Lichenification
 * Immunopathological reaction type I