A new study of atopic disease in families has come to the conclusion that fathers’ genes play an equal part in the spread of eczema.

Doctors have known for many years that eczema - also known as atopic dermatitis - runs in families. In the past, it was thought that if a baby suffered from eczema, it was more likely to have come from the mother’s side.

The latest study overturns that theory - suggesting that fathers’ genes are equally responsible.

The results come from information provided by 8,500 families taking part in the Children of the 90s study based at the University of Bristol. The project has already reported a dramatic rise in eczema and asthma over the last 20 years.

Researchers asked parents to report on their history of atopic disease (asthma, hayfever and eczema) and compared it with their children’s record of eczema upto the age of 3½.

Among the parents - 47 per cent of mothers and 41 per cent of fathers reported some atopic disease themselves with hayfever the most common.

In families where there was no history of eczema in either parent - 28 per cent of children showed signs of eczema as infants.

Where either the mother or father had eczema - 40 per cent of their children had eczema. If both parents had eczema - it went up to 52 per cent in their children.

The report’s author Dr Nellie Wadonda-Kabondo says: “While doctors have tended to group the atopic diseases together - our findings support the idea that there are several different genes involved.

“The child’s risk of developing eczema was much higher if parents had a history of eczema, but if parents had hay fever or asthma the risk of the child developing eczema was substantial only if both parents had one or both of these diseases.

“It is important to establish the patterns of how children inherit eczema so that we can search for the genes that cause this disease.”

Wadonda-Kabondo N, Sterne J, Golding J, Kennedy CTC. Archer C, Dunnill MG, Association of parental eczema, hayfever and asthma with atopic dermatitis in infancy: birth cohort study. Archives of Disease in Childhood.

http://www.bris.ac.uk

Books

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Eczema: It's Time To Take Control
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Factors That Make Atopic Dermatitis Worse

Many factors or conditions can make symptoms of atopic dermatitis worse, further triggering the already overactive immune system, aggravating the itch-scratch cycle, and increasing damage to the skin. These factors can be broken down into two main categories: irritants and allergens. Emotional factors and some infections and illnesses can also influence atopic dermatitis.

Irritants are substances that directly affect the skin and, when present in high enough concentrations with long enough contact, cause the skin to become red and itchy or to burn. Specific irritants affect people with atopic dermatitis to different degrees. Over time, many patients and their family members learn to identify the irritants causing the most trouble. For example, frequent wetting and drying of the skin may affect the skin barrier function. Also, wool or synthetic fibers and rough or poorly fitting clothing can rub the skin, trigger inflammation, and cause the itch-scratch cycle to begin. Soaps and detergents may have a drying effect and worsen itching, and some perfumes and cosmetics may irritate the skin. Exposure to certain substances, such as solvents, dust, or sand, may also make the condition worse. Cigarette smoke may irritate the eyelids. Because the effects of irritants vary from one person to another, each person can best determine what substances or circumstances cause the disease to flare.

Allergens are substances from foods, plants, animals, or the air that inflame the skin because the immune system overreacts to the substance. Inflammation occurs even when the person is exposed to small amounts of the substance for a limited time. Although it is known that allergens in the air, such as dust mites, pollens, molds, and dander from animal hair or skin, may worsen the symptoms of atopic dermatitis in some people, scientists aren't certain whether inhaling these allergens or their actual penetration of the skin causes the problems. When people with atopic dermatitis come into contact with an irritant or allergen they are sensitive to, inflammation-producing cells become active. These cells release chemicals that cause itching and redness. As the person responds by scratching and rubbing the skin, further damage occurs.

Common Irritants

• Wool or synthetic fibers
• Soaps and detergents
• Some perfumes and cosmetics
• Substances such as chlorine, mineral oil, or solvents
• Dust or sand
• Cigarette smoke

A number of studies have shown that foods may trigger or worsen atopic dermatitis in some people, particularly infants and children. In general, the worse the atopic dermatitis and the younger the child, the more likely food allergy is present. An allergic reaction to food can cause skin inflammation (generally an itchy red rash), gastrointestinal symptoms (abdominal pain, vomiting, diarrhea), and/or upper respiratory tract symptoms (congestion, sneezing, and wheezing). The most common allergenic (allergy-causing) foods are eggs, milk, peanuts, wheat, soy, and fish. A recent analysis of a large number of studies on allergies and breastfeeding indicated that breastfeeding an infant for at least 4 months may protect the child from developing allergies. However, some studies suggest that mothers with a family history of atopic diseases should avoid eating common allergenic foods during late pregnancy and breastfeeding.

In addition to irritants and allergens, emotional factors, skin infections, and temperature and climate play a role in atopic dermatitis. Although the disease itself is not caused by emotional factors, it can be made worse by stress, anger, and frustration. Interpersonal problems or major life changes, such as divorce, job changes, or the death of a loved one, can also make the disease worse.

Bathing without proper moisturizing afterward is a common factor that triggers a flare of atopic dermatitis. The low humidity of winter or the dry year-round climate of some geographic areas can make the disease worse, as can overheated indoor areas and long or hot baths and showers. Alternately sweating and chilling can trigger a flare in some people. Bacterial infections can also trigger or increase the severity of atopic dermatitis. If a patient experiences a sudden flare of illness, the doctor may check for infection.

Natural Remedies for Eczema

1) Probiotics

Probiotics, or "good" bacteria, are live microbial organisms naturally found in the digestive tract. They are thought to suppress the growth of potentially harmful bacteria, influence immune function, and strengthen the digestive tract's protective barrier.

Studies suggest that babies at high risk for allergic disorders such as eczema have different types and numbers of bacteria in their digestive tracts than other babies, and that probiotic supplements taken by pregnant women and children may reduce the occurrence eczema in children.

A large, long-term study examined whether the use of a probiotic supplement or a placebo could influence the incidence of eczema in infants. Researchers randomized 1223 pregnant women carrying high-risk babies to use a probiotic supplement or a placebo for 2 to 4 weeks before deliver.

Starting from birth, infants received the same probiotics as their mothers had plus galacto-oligosaccharides (called a "prebiotic" because it has been shown to help multiple strains of beneficial bacteria flourish) for 6 months. After 2 years, the probiotics were significantly more effective than placebo at preventing eczema.

In addition to the use of probiotics to prevent eczema, probiotics have also been explored as a treatment for infants and children who already have eczema. Some studies have found that probiotics alleviate symptoms of eczema only in infants and children who are sensitized to food allergens.

Researchers are testing different strains of bacteria to see if one particular strain is more effective for eczema. One of the most commonly used probiotic strains used in eczema studies is Lactobacillus GG. Other strains used include Lactobacillus fermentum VRI-033 PCC, Lactobacillus rhamnosus, Lactobacillus reuteri, and Bifidobacteria lactis. The prebiotic galacto-oligosaccharides has also been used.

Consult a qualified health professional before using probiotics. Children with immune deficiencies should not take probiotics unless under a practitioner's supervision. For more information about probiotics, read Acidophilus and Other Probiotics.

2) Topical Herbal Creams and Gels

Gels and creams made from herbal extracts of chamomile, licorice, and witch hazel have been explored to reduce symptoms of eczema. The following are results of some of the preliminary studies.

• A double-blind study compared a 1% and 2% licorice gel compared to a placebo gel for eczema. After two weeks, both the 1% and 2% licorice gels were more effective than the placebo gel, and the 2% gel was more effective at reducing redness, swelling, and itching than the 1% gel.
  
  
• A study compared chamomile cream to 0.5% hydrocortisone cream or placebo. After two weeks, the chamomile cream was more effective than the hydrocortisone cream, but was not significantly more effective than the placebo cream. This study was not double-blind, so it cannot be used as proof that chamomile cream is effective for eczema.
  
  
• In a German double-blind study, 72 people with moderately severe eczema used either a placebo cream containing witch hazel extract, 0.5% hydrocortisone cream, or the cream alone for 14 days. The hydrocortisone was more effective than witch hazel. Witch hazel was not significantly more effective than the placebo cream.

Consult a qualified practitioner before using any topical herbal applications. Some herbs, such as chamomile, are known to cause allergic contact dermatitis.

3) Gamma-linolenic Acid

Gamma-linolenic acids (GLA), such as evening primrose oil and borage oil, are a type of essential fatty acid. GLA has been shown to correct deficiencies in skin lipids that can trigger inflammation, which is why it is thought to help with eczema. However, recent, well-designed clinical studies with GLA have generally found that it does not help with eczema.

For example, one double-blind study examined the use of borage oil (500 mg a day) or placebo in 160 adults with moderate eczema. After 24 weeks, the overall effectiveness was not significantly better with borage oil compared with the placebo.

Atopic Dermatitis Pictures

Atopic dermatitis is quite often seen on the cheeks of infants. It consists of red (erythematous), scaling plaques that are diffusely scattered over the infant's body and face.

This person has inherited allergic skin inflammation (atopic dermatitis) on the arms. Red (erythematous), scaly plaques can be seen on the inside of the elbows (antecubital fossa). In adults, atopic dermatitis usually involves the body creases, or flexural areas (antecubital fossa and popliteal fossa).


These red (erythematous), scaly plaques on the legs are caused by an inherited allergic condition called atopic dermatitis. Many of these areas have been scratched until they are raw and infected, with the infection triggering and perpetuating the problem. In adults, atopic dermatitis frequently involves the body creases (inside elbows, behind knees).

Atopic Dermatitis (Atopic Eczema)

Atopic Dermatitis (or Atopic Eczema) is a chronic relapsing inflammatory skin disorder in infancy and childhood associated with increased serum IgE levels, allergen sensitisation and a family history of allergic diseases.

Symptoms for severe cases of atopic dermatitis are:

• persistent skin lesions;
• regular use of topical steroids;
• co-existent allergic morbidities (diarrhea, vomiting, rhinitis, wheeze);
• 
  
faltering growth.

Originally controversial, the association of food allergy with atopic dermatitis has now been clearly demonstrated, especially in severe disease of infancy.

The association between food allergy and atopic dermatitis has been demonstrated through various studies and clinical observations: 37% of children with atopic eczema have food allergy.

There is an increasing prevalence with increasing severity. Many children out-grow their allergies. Transient allergies include those to milk, eggs, soy and wheat, whereas allergies to peanut, tree nuts, fish and shellfish appear to be more persistent.

The management of infantile atopic dermatitis should therefore incorporate appropriate strategies to diagnose and manage underlying food allergies. Food elimination has been shown to resolve symptoms of atopic dermatitis.
In cases where appropriate dietary elimination must accompany measures taken to reduce inflammation in the skin, treatment goals are twofold the control of cutaneous symptoms and the promotion of optimal growth.

by AAA Editorial Board
Date of publication: 01/02/2006

Dust mite

The house dust mite may be an important year-round cause of atopic dermatitis (eczema) and asthma.

Dermatophagoides pteronyssinus, the house dust mite, can only be seen with a microscope but it is nevertheless a common and significant cause of allergy. It may make the nose run or cause sneezing and wheezing. In some patients it also contributes to exacerbations of atopic dermatitis.

The dust mite hides in the dust that can be found in even the cleanest bedroom – deep in carpets and curtains and in the seams of mattresses, where even the most house-proud individual can't find it. It thrives in poorly ventilated and humid homes.

Bedding

• The dust mite's favourite haunt is bedding, particularly mattresses. If sleeping in a bunk, an allergy-prone child is best on the top mattress.
• The dust mite may be found in high concentrations in bedding made from wool, cotton and artificial fibres. Wash and dry the sheets every week.
• Obtain special mite resistant covers for pillow, mattress and duvets.
• Wash the bedding in hot water (at least 54 Celcius) regularly or use a dust mite control laundry additive.

Measures to reduce the numbers of house dust mite.

• Use a vacuum cleaner that has a HEPA filter. Vacuum all carpets each week, especially in the bedrooms and under the beds. If you can, choose vinyl flooring rather than carpet as it tends to hoard less dust. Vacuum upholstery and curtains, and don't forget the mattress and blankets.
• Use a damp duster to do the cleaning as it is much better at collecting dust than a dry one.
• Wash curtains regularly. There is less dust when curtains are made of lightweight materials. They also need to be vacuumed often, and wash them regularly too (perhaps six-weekly).
• Hang clothes up in wardrobes, and that includes the dressing gowns! Make sure the wardrobe is well ventilated, or consider a chemical moisture remover such as anhydrous calcium chloride flakes.
• Dehumidifiers can reduce numbers of house dust mites, as they prefer a moist environment.
• Put soft toys in the freezer for a few hours.

Can Soaps & Detergents Cause A Rash?

Source: http://www.medicinenet.com

Can Soaps & Detergents Cause A Rash?

Medical Author: Alan Rockoff, MD
Medical Editor: Frederick Hecht, MD, F.A.A.P.

For years, patients have been coming to my office with eczema, complaining that they had changed their soaps and detergents but their rashes had not gone away.

The first thing I always tell them is: "Contrary to what you've heard, eczema is rarely, if ever, caused by soaps and detergents."

I say this because it fits with my experience. People get rashes when they haven't used anything different, and they don't become consistently better if they keep shifting products in a futile effort to locate the culprit in the laundry.

And now -- at last! -- there is published scientific evidence to back up my experience.

In the Journal of the American Academy of Dermatology, Donald V. Belsito from the University of Kansas and his colleagues in the North American Contact Dermatitis Group published an article entitled "Allergic contact dermatitis to detergents: A multicenter study to assess prevalence." Their conclusion reads, in part: "Laundry detergents appear to be a rare cause of ACD [allergic contact dermatitis]." They found that fewer than 1% of patients, in whose cases a laundry product was suspected, reacted to allergy testing with detergent. The authors added that the true prevalence of allergy may have been even less than this small number since several patients who did react may simply have had an irritation rather than a true allergy.

No single study, however carefully done, ever settles a complicated issue once and for all. Still, it's gratifying to see science confirm clinical experience. Many cases of eczema reflect heredity or sensitivity rather than allergy. These rashes come and go as they please. Despite their unexplained onset and fluctuations, treatment can control them with little effort or risk.

So, before you chuck all your expensive soap, detergent, fabric softener, shampoo, or makeup, put conventional wisdom on hold and check with a physician to see whether what you're doing is helpful or just a waste of time and money.

Reference: Belsito, D. Journal of the American Academy of Dermatology; ""Allergic contact dermatitis to detergents: A multicenter study to assess prevalence." February 2002

A Breakthrough Treatment for Eczema

Source: http://www.medicinenet.com

A Breakthrough Treatment for Eczema

Medical Author: Alan Rockoff, MD
Medical Editor: Leslie J. Schoenfield, MD, PhD

The word "breakthrough" is overused. If every hot item reporters gush about on the evening health news were the real thing, we would have "broken through" a long time ago. Instead, the word is often applied to soon-forgotten advances that aren't and cures that don't.

Every once in a while, however, something new comes along that represents a genuine breakthrough. In 2001, the FDA approved tacrolimus (brand-name: Protopic) for treating eczema, also known as atopic dermatitis. Protopic is the first effective nonsteroid treatment for this common, chronic, itchy condition. A related drug, pimecrolimus (brand-name: Elidel), is now on the market.

These new drugs are referred to as "immune modulators." They were first used internally to help patients with kidney and liver transplants avoid rejecting the organs they received. They work by suppressing the immune system. When these drugs are used externally to treat the skin, however, they do not weaken or change the body's immune system. Also, unlike topical steroids (cortisone creams), these new medications don't cause thinning of the skin and breaking of superficial blood vessels (atrophy).

The major side effect of these new topical medications is a sensation of burning of the skin. Some patients complain that their skin stings or burns for a period after they apply the cream. This feeling tends to lessen as the skin heals. At this point neither Protopic nor Elidil is approved for use in children under the age of 2. However, when further studies are complete, doctors will most likely be able to treat infants and very young children too.

The good news is that these immune modulators work. Many patients who respond poorly or not at all to topical steroids do very well when they use this new class of medication. This doesn't mean that steroid creams won't be used anymore. Properly prescribed, these old standbys are safe and effective for many situations, even for children, or in sensitive areas like the face or groin.

It is also important to remember that no drugs, including the new ones, cure eczema altogether. This condition represents an inherited sensitivity that tends to recur throughout life. Still, many patients with atopic dermatitis will now be able to achieve comfortable and better-looking skin by using tacrolimus, pimecrolimus, and the related medications that are sure to follow.

© 2007 MedicineNet, Inc. All rights reserved.

What is atopic dermatitis?

Atopic dermatitis is a chronic (long-lasting) disease that affects the skin. The word "dermatitis" means inflammation of the skin. "Atopic" refers to diseases that are hereditary, tend to run in families, and often occur together. These diseases include asthma, hay fever, and atopic dermatitis. In atopic dermatitis, the skin becomes extremely itchy and inflamed, causing redness, swelling, cracking, weeping, crusting, and scaling.

Atopic dermatitis most often affects infants and young children, but it can continue into adulthood or first show up later in life. In most cases, there are periods of time when the disease is worse, called exacerbations or flares, which are followed by periods when the skin improves or clears up entirely, called remissions. Many children with atopic dermatitis enter into a permanent remission of the disease when they get older, although their skin often remains dry and easily irritated. Environmental factors can activate symptoms of atopic dermatitis at any time in the lives of individuals who have inherited the atopic disease trait.

What is the difference between atopic dermatitis and eczema?

Eczema is a general term for many types of skin inflammation (dermatitis). Atopic dermatitis is the most common of the many types of eczema. Several other forms have very similar symptoms. The diverse types of eczema are listed and briefly described below.

Types of Eczema

• Atopic dermatitis: a chronic skin disease characterized by itchy, inflamed skin
• Contact eczema: a localized reaction that includes redness, itching, and burning where the skin has come into contact with an allergen (an allergy-causing substance) or with an irritant such as an acid, a cleaning agent, or other chemical
• Allergic contact eczema: a red, itchy, weepy reaction where the skin has come into contact with a substance that the immune system recognizes as foreign, such as poison ivy or certain preservatives in creams and lotions
• Seborrheic eczema: a form of skin inflammation of unknown cause that presents as yellowish, oily, scaly patches of skin on the scalp, face, and occasionally other parts of the body
• Nummular eczema: coin-shaped patches of irritated skin-most commonly on the arms, back, buttocks, and lower legs-that may be crusted, scaling, and extremely itchy
• Neurodermatitis: scaly patches of skin on the head, lower legs, wrists, or forearms caused by a localized itch (such as an insect bite) that becomes intensely irritated when scratched
• Stasis dermatitis: a skin irritation on the lower legs, generally related to circulatory problems
• Dyshidrotic eczema: irritation of the skin on the palms of hands and soles of the feet characterized by clear, deep blisters that itch and burn

How common is atopic dermatitis?

Atopic dermatitis is very common. It affects males and females equally and accounts for 10 to 20 % of all referrals to dermatologists (doctors who specialize in the care and treatment of skin diseases). Atopic dermatitis occurs most often in infants and children and its onset decreases substantially with age. Scientists estimate that 65 percent of patients develop symptoms in the first year of life, and 90 percent develop symptoms before the age of 5. Onset after age 30 is less common and often occurs after exposure of the skin to harsh conditions. People who live in urban areas and in climates with low humidity seem to be at an increased risk for developing atopic dermatitis.

About 10% of all infants and young children experience symptoms of the disease. Roughly 60 percent of these infants continue to have one or more symptoms of atopic dermatitis even after they reach adulthood. This means that more than 15 million people in the United States have symptoms of the disease.

What causes atopic dermatitis?

The cause of atopic dermatitis is not known, but the disease seems to result from a combination of genetic (hereditary) and environmental factors. Evidence suggests that the disease is associated with other so-called atopic disorders such as hay fever and asthma, which many people with atopic dermatitis also have. In addition, many children who outgrow the symptoms of atopic dermatitis go on to develop hay fever or asthma. Although one disorder does not cause another, they may be related, thereby giving researchers clues to understanding atopic dermatitis.

In the past, it was thought that atopic dermatitis was caused by an emotional disorder. We now know that emotional factors such as stress can exacerbate, but do not cause the condition.

Is atopic dermatitis contagious?


No. Atopic dermatitis is definitely not contagious; it cannot be passed from one person to another. There is no cause for concern in being around someone with even an active case of atopic dermatitis.

What are the symptoms of atopic dermatitis?

Symptoms vary from person to person. The most common symptoms are dry, itchy skin, cracks behind the ears, and rashes on the cheeks, arms, and legs. The itchy feeling is an important factor in atopic dermatitis, because scratching and rubbing in response to itching worsen the skin inflammation that is characteristic of this disease. People with atopic dermatitis seem to be more sensitive to itching and feel the need to scratch longer in response. They develop what is referred to as the "itch-scratch" cycle. The extreme itchiness of the skin causes the person to scratch, which in turn worsens the itch, and so on. Itching is particularly a problem during sleep, when conscious control of scratching decreases and the absence of other outside stimuli makes the itchiness more noticeable.

How atopic dermatitis affects the skin can be changed by patterns of scratching and resulting skin infections. Some people with the disease develop red, scaling skin where the immune system in the skin becomes very activated. Others develop thick and leathery skin as a result of constant scratching and rubbing. This condition is called lichenification. Still others develop papules, or small raised bumps, on their skin. When the papules are scratched, they may open (excoriations) and become crusty and infected. The box below lists common skin features of the disease. These conditions can also be found in people without atopic dermatitis or with other types of skin disorders.

Can atopic dermatitis affect the face?

Yes. Atopic dermatitis may affect the skin around the eyes, the eyelids, and the eyebrows and lashes. Scratching and rubbing the eye area can cause the skin to change in appearance. Some people with atopic dermatitis develop an extra fold of skin under their eyes, called an atopic pleat or Dennie-Morgan fold. Other people may have hyperpigmented eyelids, meaning that the skin on their eyelids darkens from the inflammation or hay fever (allergic shiners). Patchy eyebrows and eyelashes may also result from scratching or rubbing.

Is the sufferer's skin type important?

Yes. Differences in the skin of people with atopic dermatitis may contribute to the symptoms of the disease. The epidermis, which is the outermost layer of skin, is divided into two parts: the inner part, which contains moist, living cells; and the outer part, which consists of dry, flattened, dead cells. Under normal conditions, the outer layer of skin acts as a barrier, keeping the rest of the skin from drying out and protecting other layers of skin from damage caused by irritants and infections. When this barrier is damaged or is naturally thin, irritants act more intensely on the skin.

The skin of a person with atopic dermatitis loses too much moisture from the epidermal layer. This allows the skin to become very dry, which reduces its protective abilities. In addition, the skin is very susceptible to recurring disorders, such as staphylococcal and streptococcal bacterial skin infections, warts, herpes simplex, and molluscum contagiosum (which is caused by a virus).

Skin Features of Atopic Dermatitis

• Lichenification: thick, leathery skin resulting from constant scratching and rubbing
• Papules: small raised bumps that may open when scratched, becoming crusty and infected
• Ichthyosis: dry, rectangular scales on the skin
• Keratosis pilaris: small, rough bumps, generally on the face, upper arms, and thighs
• Hyperlinear palms: increased number of skin creases on the palms
• Urticaria: hives (red, raised bumps), often after exposure to an allergen, at the beginning of flares, or after exercise or a hot bath
• Cheilitis: inflammation of the skin on and around the lips
• Atopic pleat (Dennie-Morgan fold): an extra fold of skin that develops under the eye
• Hyperpigmented eyelids: eyelids that have become darker in color from inflammation or hay fever

What are the stages of atopic dermatitis?

Atopic dermatitis affects each child differently, both in terms of onset and severity of symptoms. In infants, atopic dermatitis typically begins around 6 to 12 weeks of age. It may first appear around the cheeks and chin as a patchy facial rash, which can progress to red, scaling, oozing skin. The skin may become infected. Once the infant becomes more mobile and begins crawling, exposed areas such as the knees and elbows may also be affected. An infant with atopic dermatitis may be restless and irritable because of the itching and discomfort. Many infants improve by 18 months of age, although they remain at greater than normal risk for dry skin or hand eczema later in life.

In childhood, the rash tends to occur behind the knees and inside the elbows, on the sides of the neck, and on the wrists, ankles, and hands. Often, the rash begins with papules that become hard and scaly when scratched. The skin around the lips may be inflamed, and constant licking of the area may lead to small, painful cracks. Severe cases of atopic dermatitis may affect growth, and the child may be shorter than average.

The disease may go into remission. The length of a remission varies, and it may last months or even years. In some children, the disease gets better for a long time only to come back at the onset of puberty when hormones, stress, and the use of irritating skin care products or cosmetics may cause the condition to flare.

Although a number of people who developed atopic dermatitis as children also experience symptoms as adults, it is unusual (but possible) for the disease to show up first in adulthood. The pattern in adults is similar to that seen in children; that is, the disease may be widespread or limited. In some adults, only the hands or feet may be affected and become dry, itchy, red, and cracked. Sleep patterns and work performance may be affected, and long-term use of medications to treat the condition may cause complications. Adults with atopic dermatitis also have a predisposition toward irritant contact dermatitis, especially if they are in occupations involving frequent hand wetting, hand washing, or exposure to chemicals. Some people develop a rash around their nipples. These localized symptoms are difficult to treat, and people often do not tell their doctor because of modesty or embarrassment. Adults may also develop cataracts that are difficult to detect because they cause no symptoms. Therefore, the doctor may recommend regular eye exams.

How is atopic dermatitis diagnosed?

Currently, there is no single test that says unequivocally "this is atopic dermatitis" and there is no single symptom or feature that can be used to identify the disease. Each patient experiences a unique combination of symptoms, and the symptoms and severity of the disease may vary over time. The doctor bases the diagnosis on the individual's symptoms and may need to see the patient several times to make an accurate diagnosis. It is important for the doctor to rule out other diseases and conditions that might cause skin irritation. In some cases, the family doctor or pediatrician may refer the patient to a dermatologist or allergist (allergy specialist) for further evaluation.

A valuable diagnostic tool is a thorough medical history, which provides important clues as to the possible causes of the patient's ailment. The doctor may ask about all of the following: a family history of allergic disease; whether the patient also has diseases such as hay fever or asthma; exposure to irritants; sleep disturbances; any foods that seem to be related to skin flares; previous treatments for skin-related symptoms; use of steroids; and the effects of symptoms on schoolwork, career, or social life. Sometimes, it is necessary to do a biopsy of the skin or patch testing to determine if the skin's immune system overreacts to certain chemicals or preservatives in skin creams. A preliminary diagnosis of atopic dermatitis can be made if the patient has three or more characteristics from each of two categories: major features and minor features. Some of these characteristics are listed in the box below.

Skin scratch/prick tests (which involve scratching or pricking the skin with a needle that contains a small amount of a suspected allergen) and blood tests for airborne allergens generally are not as useful in diagnosing atopic dermatitis as a medical history and careful observation of symptoms. However, they may occasionally help the doctor rule out or confirm a specific allergen that might be considered important in the diagnosis. Negative results on skin tests are reliable and may help rule out the possibility that certain substances are causing skin inflammation in the patient. However, positive skin scratch/prick test results are difficult to interpret in people with atopic dermatitis and are often inaccurate. In some cases, where the type of dermatitis is unclear, blood tests to check the level of eosinophils (a type of white blood cell) or IgE (an antibody whose levels are often high in atopic dermatitis) are helpful.

Major and Minor Features of Atopic Dermatitis

Major Features

• Intense itching
• Characteristic rash in locations typical of the disease
• Chronic or repeatedly occurring symptoms
• Personal or family history of atopic disorders (eczema, hay fever, asthma)

Some Minor Features

• Early age of onset
• Dry, rough skin
• High levels of immunoglobulin E (IgE), an antibody, in the blood
• Ichthyosis
• Hyperlinear palms
• Keratosis pilaris
• Hand or foot dermatitis
• Cheilitis
• Nipple eczema
• Susceptibility to skin infection
• Positive allergy skin tests

What factors can aggravate atopic dermatitis?

Many factors or conditions can intensify the symptoms of atopic dermatitis, which can trigger the following cycle: further stimulating the already overactive immune system in the skin; aggravating the itch-scratch cycle; and increasing damage to the skin. These exacerbating elements can be broken down into two main categories; irritants and allergens. Emotional factors and some infections can also influence atopic dermatitis.

What are skin irritants in patients with atopic dermatitis?

Irritants are substances that directly affect the skin, and when used in high enough concentrations with long enough contact, cause the skin to become red and itchy or to burn. Specific irritants affect people with atopic dermatitis to different degrees. Over time, many patients and their families learn to identify the irritants that are most troublesome to them. For example, wool or synthetic fibers may affect some patients. Rough or poorly fitting clothing can rub the skin, trigger inflammation, and prompt the beginning of the itch- scratch cycle. Soaps and detergents may have a drying effect and worsen itching, and some perfumes and cosmetics may irritate the skin. Exposure to certain elements, such as chlorine, mineral oil, or solvents, or to irritants, such as dust or sand, may also aggravate the condition. Cigarette smoke may irritate the eyelids. Because irritants vary from one person to another, each person has to determine for himself or herself what substances or circumstances cause the disease to flare.

Common Irritants

• Wool or synthetic fibers
• Soaps and detergents
• Some perfumes and cosmetics
• Substances such as chlorine, mineral oil, or solvents
• Dust or sand
• Cigarette smoke

What are allergens?

Allergens are substances from foods, plants, or animals that provoke an overreaction of the immune system and cause inflammation (in this case, the skin). Inflammation can occur even when the person is exposed to small amounts of the allergen for a limited time. Some examples of allergens are pollen and dog or cat dander (tiny particles from the animal's skin or hair). When people with atopic dermatitis come into contact with an irritant or allergen to which they are sensitive, inflammation- producing cells permeate the skin from elsewhere in the body. These cells release chemicals that cause itching and redness. As the person scratches and rubs the skin in response, further damage occurs.

Certain foods act as allergens and may trigger atopic dermatitis or exacerbate it (cause it to become worse). Food allergens clearly play a role in a number of cases of atopic dermatitis, primarily in infants and children. An allergic reaction to food can cause skin inflammation (generally hives), gastrointestinal symptoms (vomiting, diarrhea), upper respiratory tract symptoms (congestion, sneezing), and wheezing. The most common allergy-causing (allergenic) foods are eggs, peanuts, milk, fish, soy products, and wheat. Although the data remain inconclusive, some studies suggest that mothers of children with a family history of atopic diseases should avoid eating commonly allergenic foods themselves during late pregnancy and (if breast feeding) while they are breast feeding the baby. Although not all researchers agree, most experts think that breast feeding the infant for at least 4 months may have a protective effect for the child.

If a food allergy is suspected, it may be helpful to keep a careful diary of everything the patient eats, noting any reactions. Identifying the food allergen may be difficult if the patient is also being exposed to other allergens, and may require supervision by an allergist. One helpful way to explore the possibility of a food allergy is to eliminate the suspected food and then, if improvement is noticed, reintroduce it into the diet under carefully controlled conditions. A two week trial is usually sufficient for each food. If the food being tested causes no symptoms after two weeks, a different food can be tested in like manner afterwards. Likewise, if the elimination of a food does not result in improvement after 2 weeks, other foods may be eliminated in turn.

Changing the diet of a person who has atopic dermatitis may not always relieve symptoms. A change may be helpful, however, when a patient's medical history and specific symptoms strongly suggest a food allergy. It is up to the patient and his or her family and physician to judge whether the dietary restrictions outweigh the impact of the disease itself. Restricted diets often are emotionally and financially difficult for patients and their families to follow. Unless properly monitored, diets with many restrictions can also contribute to nutritional problems in children.

What are aeroallergens?

Some allergens are called aeroallergens because they are present in the air. They may also play a role in atopic dermatitis. Common aeroallergens are dust mites, pollens, molds, and dander from animal hair or skin. These aeroallergens, particularly the house dust mite, may worsen the symptoms of atopic dermatitis in some people. Although some researchers think that aeroallergens are an important contributing factor to atopic dermatitis, others believe that they are insignificant. Scientists also don't understand the way in which aeroallergens affect the skin; whether the aeroallergen affects the person internally after being inhaled, or whether the aeroallergen actually penetrates the patient's skin.

No reliable test is available that determines whether a specific aeroallergen is an exacerbating factor in any given individual. If the doctor suspects that an aeroallergen is contributing to a patient's symptoms, the doctor may recommend ways to reduce exposure to the offending agents. For example, the presence of the house dust mite can be limited by encasing mattresses and pillows in special dust-proof covers, frequently washing bedding in hot water, and removing carpeting. However, there is no way to completely rid the environment of aeroallergens.

What other factors may play a role in atopic dermatitis?

In addition to irritants and allergens, other factors, such as emotional issues, temperature and climate, and skin infections can affect atopic dermatitis. Although the disease itself is not caused by emotional factors or personality, it can be exacerbated by stress, anger, and frustration. Interpersonal problems or major life changes, such as divorce, job changes, or the death of a loved one, can also make the disease worse. Often, emotional stress seems to prompt a flare of the disease.

Bathing without proper moisturizing afterward is a common factor that triggers a flare of atopic dermatitis. The low humidity of winter or the dry year-round climate of some geographic areas can intensify the disease, as can overheated indoor areas and long or hot baths and showers. Alternately sweating and chilling can induce an attack in some people. Bacterial infections can also prompt or increase the severity of atopic dermatitis. If a patient experiences a sudden onset of illness, the doctor may check for a viral infection (such as herpes simplex) or fungal infection (such as ringworm or athlete's foot).

How is atopic dermatitis treated?

Treatment involves a partnership between the doctor and the patient and his or her family members. The doctor will suggest a treatment plan based on the patient's age, symptoms, and general health. The patient and family members play a large role in the success of the treatment plan by carefully following the doctor's instructions. Some of the primary components of treatment programs are described below. Most patients can be successfully managed with proper skin care and lifestyle changes and do not require the more intensive treatments discussed.

The doctor has three main goals in treating atopic dermatitis: healing the skin and keeping it healthy; preventing flares; and treating symptoms when they do occur. Much of caring for the skin involves developing skin care routines, identifying exacerbating factors, and avoiding circumstances that stimulate the skin's immune system and the itch-scratch cycle. It is important for the patient and family members to note any changes in skin condition in response to treatment, and to be persistent in identifying the most effective treatment strategy.

Skin Care: Healing the skin and keeping it healthy are of primary importance both in preventing further damage and enhancing the patient's quality of life. Developing and following a daily skin care routine is critical to preventing recurrent episodes of symptoms. Key factors are proper bathing and the application of lubricants, such as creams or ointments, within 3 minutes of bathing. People with atopic dermatitis should avoid hot or long (more than 10 to 15 minutes) baths and showers. A lukewarm bath helps to cleanse and moisturize the skin without drying it excessively. The doctor may recommend limited use of a mild bar soap or non-soap cleanser because soaps can be drying to the skin. Bath oils are not usually helpful.

Once the bath is finished, the patient should air-dry the skin, or pat it dry gently (avoiding rubbing or brisk drying), and apply a lubricant immediately. Lubrication restores the skin's moisture, increases the rate of healing, and establishes a barrier against further drying and irritation. Several kinds of lubricants can be used. Lotions generally are not the best choice because they have a high water or alcohol content and evaporate quickly. Creams and ointments work better at healing the skin. Tar preparations can be very helpful in healing very dry, lichenified areas. Whatever preparation is chosen, it should be as free of fragrances and chemicals as possible.

Another key to protecting and restoring the skin is taking steps to avoid repeated skin infections. Although it may not be possible to avoid infections altogether, the effects of an infection may be minimized if they are identified and treated early. Patients and their families should learn to recognize the signs of skin infections, including tiny pustules (pus-filled bumps) on the arms and legs, appearance of oozing areas, or crusty yellow blisters. If symptoms of a skin infection develop, the doctor should be consulted to begin treatment as soon as possible.

Treating Atopic Dermatitis in Infants and Children

• Give brief, lukewarm baths.
• Apply lubricant immediately following the bath.
• Keep child's fingernails filed short.
• Select soft cotton fabrics when choosing clothing.
• Consider using antihistamines to reduce scratching at night.
• Keep the child cool; avoid situations where overheating occurs.
• Learn to recognize skin infections and seek treatment promptly.
• Attempt to distract the child with activities to keep him or her from scratching.

Medications and Phototherapy: If a recurrence of atopic dermatitis occurs, several methods can be used to treat the symptoms. With proper treatment, most symptoms can be brought under control within 3 weeks. If symptoms fail to respond, this may be due to a flare that is stronger than the medication can handle, a treatment program that is not fully effective for a particular individual, or the presence of trigger factors that were not addressed in the initial treatment program. These factors can include a reaction to a medication, infection, or emotional stress. Continued symptoms may also occur because the patient is not following the treatment program instructions.

Corticosteroid creams and ointments are the most frequently used treatment. Sometimes, over-the-counter preparations are used, but in many cases, the doctor will prescribe a stronger corticosteroid cream or ointment. Occasionally, the base used in certain brands of corticosteroid creams and ointments is irritating for a particular patient and a different brand is required. Side effects of repeated or long-term use of topical corticosteroids can include thinning of the skin, infections, growth suppression (in children), and stretch marks on the skin.

Tacrolimus (Protopic) and pimecrolimus (Elidel) ointments are powerful topical medicated creams (drugs that are applied to the skin) that is used for the treatment of atopic dermatitis. These new drugs are referred to as "immune modulators." They were first used internally to help patients with kidney and liver transplants avoid rejecting the organs they received. They work by suppressing the immune system. When these drugs are used externally to treat the skin, however, they do not weaken or change the body's immune system. Also, unlike topical steroids (cortisone creams), these new medications don't cause thinning of the skin and breaking of superficial blood vessels (atrophy).

Some treatments reduce specific symptoms of the disease. Antibiotics to treat skin infections may be applied directly to the skin in an ointment, but are usually more effective when taken by mouth in pill form. Certain antihistamines that cause drowsiness can reduce nighttime scratching and allow more restful sleep when taken at bedtime. This effect can be particularly helpful for patients whose nighttime scratching aggravates the disease. If viral or fungal infections are present, the doctor may also prescribe medications to treat those infections.

Phototherapy is treatment with light that uses ultraviolet A or B light waves, or a combination of both. This treatment can be an effective treatment for mild to moderate dermatitis in older children (over 12 years old) and adults. Photochemotherapy, a combination of ultraviolet light therapy and a drug called psoralen, can also be used in cases that are resistant to phototherapy alone. Possible long-term side effects of this treatment include premature skin aging and skin cancer. If the doctor thinks that phototherapy may be useful in treating the symptoms of atopic dermatitis, he or she will use the minimum exposure necessary and monitor the skin carefully.

When other treatments are not effective, the doctor may prescribe systemic corticosteroids; drugs that are taken by mouth or injected into muscle instead of being applied directly to the skin. An example of a commonly prescribed corticosteroid is prednisone. Typically, these medications are used only in resistant cases and are only given for short periods of time. The side effects of systemic corticosteroids can include skin damage, thinned or weakened bones, high blood pressure, high blood sugar, infections, and cataracts. It can be dangerous to suddenly stop taking corticosteroids, so it is very important that the doctor and patient work together in changing the corticosteroid dose.

In adults, immunosuppressive drugs, such as cyclosporine, are also used to treat severe cases of atopic dermatitis that have failed to respond to any other forms of therapy. Immunosuppressive drugs restrain the overactive immune system by blocking the production of some immune cells and curbing the action of others. The side effects of cyclosporine can include high blood pressure, nausea, vomiting, kidney problems, headaches, tingling or numbness, and a possible increased risk of cancer and infections. There is also a risk of relapse after the drug is discontinued. Because of their toxic side effects, systemic corticosteroids and immunosuppressive drugs are used only in severe cases and then for as short a period of time as possible. Patients requiring systemic corticosteroids or immunosuppressive drugs should be referred to a dermatologist or an allergist specializing in the care of atopic dermatitis to help identify trigger factors and alternative therapies.

In rare cases, when no other treatments have been successful, the patient may have to be hospitalized. A 5 to 7 day hospital stay allows intensive skin care treatment and reduces the patient's exposure to irritants, allergens, and the stresses of day-to- day life. Under these conditions, the symptoms usually clear quickly if environmental factors play a role or if the patient is not able to carry out an adequate skin care program at home.

Tips for Working With Your Doctor

• Provide complete, accurate medical information about yourself or your child.
• Make a list of your questions and concerns in advance.
• Be honest and share your point of view with the doctor.
• Ask for clarification or further explanation if you need it.
• Talk to other members of the health care team, such as nurses, therapists, or pharmacists.
• Don't hesitate to discuss sensitive subjects with your doctor.
• Discuss changes to any medical treatment or medications with your doctor before making them.

Atopic Dermatitis and Quality of Life

Despite the symptoms caused by atopic dermatitis, it is possible for people with the disorder to maintain a high quality of life. The keys to an improved quality of life are education, awareness, and developing a partnership among the patient, family, and doctor. Good communication is essential for all involved. It is important that the doctor provides understandable information about the disease and its symptoms to the patient and family and demonstrate any treatment measures recommended to ensure that they will be properly carried out.

When a child has atopic dermatitis, the entire family situation may be affected. It is important that families have additional support to help them cope with the stress and frustration associated with the disease. The child may be fussy and difficult, and often is unable to keep from scratching and rubbing the skin. Distracting the child and providing as many activities that keep the hands busy is key, but requires much effort and work on the part of the parents or caregivers. Another issue families face is the social and emotional stress associated with disfigurement caused by atopic dermatitis. The child may face difficulty in school or other social relationships and may need additional support and encouragement from family members.

Adults with atopic dermatitis can enhance their quality of life by caring regularly for their skin and being mindful of other effects of the disease and how to treat them. Adults should develop a skin care regimen as part of their daily routine, which can be adapted as circumstances and skin conditions change. Stress management and relaxation techniques may help decrease the likelihood of flares due to emotional stress. Developing a network of support that includes family, friends, health professionals, and support groups or organizations can be beneficial. Chronic anxiety and depression may be relieved by short-term psychological therapy.

Recognizing the situations when scratching is most likely to occur may also help. For example, many patients find that they scratch more when they are idle. Structured activity that keeps their hands occupied may prevent further damage to the skin. Occupational counseling also may be helpful to identify or change career goals if a job involves contact with irritants or involves frequent hand washing, such as kitchen work or auto mechanics.

Controlling Atopic Dermatitis

• Prevent scratching or rubbing whenever possible.
• Protect skin from excessive moisture, irritants, and rough clothing.
• Maintain a cool, stable temperature and consistent humidity levels.
• Limit exposure to dust, cigarette smoke, pollens, and animal dander.
• Recognize and limit emotional stress.

What is the hope for long term management of atopic dermatitis?

Although symptoms of atopic dermatitis can be very difficult and uncomfortable, the disease can be successfully managed. People with atopic dermatitis, as well as their families, can lead healthy, normal lives.

Atopic Dermatitis At A Glance

• Atopic dermatitis is the most common and significant type of eczema.
• The skin sensitivity of this disease is inherited.
• The patient's skin is "super sensitive" to many irritants.
• Dry scaly patches develop in a characteristic distribution.
• Itching is intense and scratching hard to resist.
• Scratching can cause skin thickening and darkening and lead to bacterial infection.
• Extremely dry skin can break down and ooze or weep.
• If the itch can be controlled, the rash (which is aggravated by vigorous scratching) can be contained.
• Treatment of atopic dermatitis is centered around rehydrating the skin with moisturizers and cautious use of topical steroids to reduce inflammation and itching.
• Oral antihistamines are often necessary to break the "itch-scratch" cycle.
• Since secondary infections can aggravate the rash, topical or oral antibiotics may also be occasionally indicated.