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Atopic dermatitis

Last updated: March 18, 2021

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Atopic dermatitis (AD) is an inflammatory skin disease that typically manifests for the first time in early childhood. Although it often improves during adolescence, it may also become a chronic condition that extends into adulthood. Atopic dermatitis is often associated with other atopic diseases, such as asthma or allergic rhinitis. Although the underlying etiology is not completely understood, genetic components, as well as exogenous and endogenous triggers, are believed to play a role. The main symptoms of atopic dermatitis are severe pruritus and dry skin. Initial management of atopic dermatitis involves avoiding flare triggers and moisturizing the skin. Topical steroids and calcineurin inhibitors may be added if symptoms persist. In refractory and severe cases, phototherapy or systemic therapy with immunomodulating medications may be used. The most common complication of atopic dermatitis is the development of secondary infections; psychosocial complications may also arise.

  • Prevalence: Approx. 8–12% of children and 6–9% of adults are affected. [1][2][3]
  • Age [2][3]
    • Onset of symptoms usually occurs at 3–6 months of age.
    • Disease often improves with age.

Epidemiological data refers to the US, unless otherwise specified.

The etiology of atopic dermatitis is not completely understood. However, genetic factors (polygenic inheritance), as well as exogenous and endogenous triggers, may play a role.

The symptoms of atopic dermatitis are variable and often change in the course of a lifetime. Pruritus and dry skin are usually the main symptoms.

Diagnostic criteria [5]

Atopic dermatitis is a clinical diagnosis. Other conditions with a similar appearance should be excluded, e.g., seborrheic dermatitis, psoriasis, other eczematous diseases, or skin infections.

Severity assessment [5][13][14]

  • AD is often stratified by severity for practical purposes (e.g., “mild”, “moderate”, “severe”).
  • There is no accepted gold standard classification system for clinical practice.
  • A multifactorial assessment for individual patients is recommended, including the following:
    • Estimated body surface area involved
    • Clinical features of lesions: e.g., crusting, oozing, redness, swelling
    • Located of lesions in areas of greater sensitivity, visibility, or functional importance: e.g., palms, soles, face, neck, genitals, joints
    • Functional and psychosocial impact of symptoms: e.g., degree of pruritus, sleep disturbance
  • Consider supplementing this assessment with the focused use of scoring systems. [13]

Other investigations [2]

The differential diagnoses listed here are not exhaustive.

Approach

Management approach for atopic dermatitis [15][17][18][19]
Therapeutic goal Intervention
Primary prevention [20]

Maintenance therapy and secondary prevention

(flare reduction)

Very mild AD
  • Nonpharmacological therapy, e.g., emollients, can be administered as monotherapy.
Mild-to-moderate AD

Moderate-to-severe AD

(with significant functional impairment)

Treatment of acute flare
Adjunctive care

Nonpharmacological therapy [15][17][18]

  • Avoid triggers of flares
    • Patient-specific allergens and sensitivities (e.g., certain foods, animals, dust mites, excessive heat)
    • Mechanical and chemical irritants (e.g., wool clothing, solvents)
  • Maintain skin hydration
    • Emollients
    • Regular bathing is recommended. [18]
      • Consider bathing up to once daily for short periods of time (e.g., 5–10 minutes).
      • Hypoallergenic cleansers can be used, but with limited frequency.
      • Apply emollients shortly after bathing.
    • For severe or refractory cases: consider wet wrap therapy
      • A moistened bandage is applied with emollients or topical corticosteroids to the affected area.
      • A dry outer bandage is applied around the inner moist bandage.
  • Stress management: to help cope with the impact of AD on daily life (e.g., supportive psychotherapy) [17]

Topical pharmacotherapy [15][18]

Topical antihistamines are not recommended for the treatment of AD due to a lack of benefit and potential for local side effects. [18]

The potency of the topical corticosteroid used should be guided by patient factors (e.g., affected areas of the body, age) and disease severity.

Systemic therapy [15][19]

These advanced therapies should be administered in consultation with a specialist.

The optimal dosing, duration, and monitoring of systemic immunomodulatory therapy are unclear. Treatment should be tailored to the patient and made in consultation with a specialist. [19]Systemic steroids should only be used sparingly in AD due to side effects of corticosteroid therapy and the risk of rebound flares after discontinuation. [19]

We list the most important complications. The selection is not exhaustive.

The symptoms of atopic dermatitis usually improve with age and often resolve completely after puberty. [2]

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