Atopic dermatitis (also called eczema) is right up there with diaper rash as one of the most common skin conditions I see in clinic. This post will answer some of the most common questions parents have about atopic dermatitis (AD), as well as describe the types of treatment your child’s health care provider may recommend. As with all topics, please consult with your child’s physician if you have specific questions about your child.

What is atopic dermatitis?

Atopic dermatitis is one of the most common types of skin inflammation in kids. It has variable appearance and severity, but most commonly appears as patches (plaques) of red, dry, thick very itchy skin. Most kids with eczema start having symptoms during the first year of life. Very young children are most likely to have affected skin on face, neck, arms, and legs. Older children often have patches of itchy skin in the elbow creases, at the wrists, or behind the knees. Atopic dermatitis is a chronic or relapsing/remitting condition. This means that children have “flares” and often require daily treatment in order to keep symptoms at bay.

What causes atopic dermatitis?

The exact cause of atopic dermatitis is still poorly understood and may vary from child to child. It is part of what is known as the “atopic triad”, which also includes asthma and allergies. Children with one of these conditions are more likely to have one of the others, although not always. Like asthma and allergies, atopic dermatitis has become more common over the last few decades. The “hygiene hypothesis” has been proposed as a potential reason for this increase. Basically, certain children have genetic/familial tendency towards atopic dermatitis, and exposure to environmental triggers (or lack of exposure to others) leads to actual changes on the skin.

Just as the appearance of atopic dermatitis varies between children, so do the triggers. Some children have worsening of symptoms if they are exposed to irritant triggers. These include sweat, saliva (especially for infants), harsh clothing material (such as wool), tobacco smoke, soaps, perfumes, or detergents. For other children allergic triggers are more problematic. These include pollens, dust mites, and pets. About 10% of children with atopic dermatitis have a food allergy that may trigger their symptoms.

What are the types of treatment for atopic dermatitis?

The best treatment plans for atopic dermatitis include a multi-pronged approach.

• Prevention: This includes avoidance of a triggers that have caused flares for your child in the past. Some children, especially those with asthma or allergies, may benefit from mattress and pillow covers and other environmental accommodations. Although more study is needed, there is some evidence to suggest that exclusive breastfeeding during the first months of life decreases the incidence of atopic dermatitis in the first two years of life.
• Bathing: There is some controversy as to how often children with eczema should bathe. Some say that children should not bathe every day because of the evaporative moisture loss that occurs after kids get out the bath. Others say that daily baths are an effective means of hydration and help cleanse irritants from the skin. Find the bathing pattern that seems to work best for your child. Regardless of how often your child bathes, make it a relatively short bath in warm water, pat dry instead of rubbing with a towel, and apply a liberal amount of emollient (see below) soon after getting out of the bath. Only mild soaps (such as Dove) or soapless-cleansers (such as Cetaphil) that are free of fragrance or dyes should be used.
• Skin care: Excellent skin care is the mainstay of treatment. Skin care consists of:
  • Emollients: These are moisturizing products that are used at least twice daily to reduce dryness of the skin. They can be further divided into
    • Lotions: These are water-based, often sold in tubes or pumps, and in general do not work well for atopic dermatitis. Examples: Aveeno or Johnson & Johnson lotion
    • Creams: A thicker emollient that is often sold in tubs, creams work well for some children with atopic dermatitis. Examples: Cetaphil or Eucerin cream
    • Ointments: These emollients have a much higher oil/petrolatum content relative to other products and often work very well for kids with atopic dermatitis. The only downside for some families is that the skin is greasy after application. Examples: Aquaphor, Vasoline
    • There are hundreds of commercial products available for skin care in atopic dermatitis. Treatment of eczema can become quite expensive. Remember that high cost does not always mean better. Find a product that works well for your child and stick with it. Many products can be effective as long as they are applied consistently, frequently, and in sufficient quantity. Also, ask your child’s doctor whether they can prescribe emollients via prescription to offset the cost.
  • Treatment for flares: Flares of atopic dermatitis are characterized by cracked, red skin and intense itching. Two major classes of topical medicines are prescribed for flares- corticosteroid creams and topical calcineurin inhibitors. There are many medications in these classes and they should be used in consultation with your child’s physician. Steroid creams vary greatly in potency. It is important to ask your provider which area of the body each cream is intended for, how many times each day it should be used, and for how long you should continue to apply it.

Why is it important to treat atopic dermatitis?

Atopic dermatitis can cause children severe itching, sleeplessness, and skin disfigurement and scarring. In addition, skin provides a barrier against infection. If that barrier is broken-down, as often happens in atopic dermatitis, infection can occur. Skin infections at times are severe enough to require antibiotics or even cause hospitalization. Signs of skin infection include pustules/boils, severe redness of the skin, and painful skin lesions. Consult with your child’s doctor if you think they may have this type of infection. A daily skin care regimen is the best means of preventing infection.

Will this eventually go away?

In addition to the above complications, atopic dermatitis can cause significant stress for both child and family, and treatment can be time-consuming and expensive. Thus, the question of whether atopic dermatitis will eventually resolve is an important one, but it is difficult to answer. In general, about 50% of children will have resolution prior to or at puberty. For other children, the frequency and severity of flares will improve, but they will always have dry or sensitive skin.

Resources For Families

There are a number of on-line resources for atopic dermatitis that are worth a look.

• National Eczema Association: “Improving the health and quality of life for individuals with eczema through support, research, and education.”
• The National Eczema Association has partnered with the Dermatology Unit of Baylor Healthcare to create the Eczema App. This useful app allows patients/families to track flares, triggers, and keep notes on which treatments seemed to work best.

What other resources have you found helpful when caring for your child with atopic dermatitis?

*Disclosure: I have no financial relationship with any of the products mentioned in the post.

References:
Hurwitz Clinical Pediatric Dermatology. A Textbook of Skin Disorders of Childhood and Adolescence. 3rd edition.
Krakowski et al. “Management of Atopic Dermatitis in the Pediatric Population.” Pediatrics. 2008; 122; 812