Atopic dermatitis is a chronic non–contagious inflammatory skin lesion that occurs with periods of exacerbations and remissions. It is manifested by dryness, increased skin irritation and severe itching. It causes physical and psychological discomfort, reduces the quality of life of the patient at home, family and at work, outwardly presents cosmetic disadvantages. Continuous combing of the skin leads to its secondary infection. Diagnosis is carried out by an allergist and dermatologist. Treatment is based on diet, general and local drug therapy, specific hyposensitization and physiotherapy.
L20 Atopic dermatitis
Atopic dermatitis is the most common dermatosis (skin disease) that develops in early childhood and retains some of its manifestations throughout life. Currently, the term “atopic dermatitis” refers to a hereditary, non-contagious, allergic skin disease of a chronic recurrent course. The disease is the subject of supervision by specialists in the field of outpatient dermatology and allergology.
Synonyms of atopic dermatitis, also found in the literature, are the concepts of “atopic” or “constitutional eczema”, “exudative-catarrhal diathesis”, “neurodermatitis”, etc. The concept of “atopy”, first proposed by American researchers A. Coca and R. Cooke in 1923, implies a hereditary tendency to allergic manifestations in response to a particular stimulus. In 1933, Wiese and Sulzberg introduced the term “atopic dermatitis” to denote hereditary allergic skin reactions, which is now generally accepted.
The hereditary nature of atopic dermatitis determines the widespread prevalence of the disease among related family members. The presence of atopic hypersensitivity in parents or close relatives (allergic rhinitis, dermatitis, bronchial asthma, etc.) determines the probability of atopic dermatitis in children in 50% of cases. Atopic dermatitis in the anamnesis of both parents increases the risk of transmission of the disease to the child by up to 80%. The vast majority of the initial manifestations of atopic dermatitis occur in the first five years of life (90%) of children, of which 60% occur during infancy.
As the child continues to grow and develop, the symptoms of the disease may not bother or weaken, however, most people live with the diagnosis of “atopic dermatitis” all their lives. Often atopic dermatitis is accompanied by the development of bronchial asthma or allergies.
The widespread spread of the disease throughout the world is associated with problems common to most people: unfavorable environmental and climatic factors, nutritional errors, neuropsychiatric overloads, an increase in infectious diseases and the number of allergic agents. A certain role in the development of atopic dermatitis is played by disorders in the immune system of children caused by shortening the terms of breastfeeding, early transfer to artificial feeding, maternal toxicosis during pregnancy, improper nutrition of a woman during pregnancy and lactation.
Atopic dermatitis symptoms
The initial signs are usually observed in the first six months of life. This may be triggered by the introduction of complementary foods or the transfer to artificial mixtures. By the age of 14-17, almost 70% of people have the disease on their own, and the remaining 30% go into adult form. The disease can last for many years, escalating in the autumn-spring period and subsiding in the summer.
According to the nature of the course, there are acute and chronic stages.
The acute stage is manifested by red spots (erythema), nodular rashes (papules), peeling and swelling of the skin, the formation of areas of erosion, wetness and crusts. The addition of a secondary infection leads to the development of pustular lesions.
The chronic stage of atopic dermatitis is characterized by thickening of the skin (lichenization), the severity of the skin pattern, cracks on the soles and palms, scratching, increased pigmentation of the eyelid skin. In the chronic stage, symptoms typical of atopic dermatitis develop:
- Morgan’s symptom – multiple deep wrinkles in children on the lower eyelids
- The symptom of a “fur hat” is the weakening and thinning of the hair on the back of the head
- The symptom of “polished nails” is shiny nails with worn edges due to constant skin scratching
- The symptom of “winter foot” is puffiness and hyperemia of the soles, cracks, peeling.
There are several phases in the development of atopic dermatitis: infancy (the first 1.5 years of life), childhood (from 1.5 years to puberty) and adult. Depending on the age dynamics, the features of clinical symptoms and localization of skin manifestations are noted, but the leading symptoms in all phases remain the strongest, constant or intermittent itching of the skin.
The infantile and infantile phases of atopic dermatitis are characterized by the appearance of bright pink erythema patches on the skin of the face, limbs, buttocks, against which bubbles (vesicles) and areas of wetness appear, followed by the formation of crusts and scales.
In the adult phase, erythema foci are pale pink in color with a pronounced skin pattern and papular rashes. They are localized mainly in the elbow and popliteal folds, on the face and neck. The skin is dry, rough, with cracks and peeling areas.
With atopic dermatitis, focal, widespread or universal skin lesions occur. The areas of typical localization of rashes are the face (forehead, the area around the mouth, near the eyes), the skin of the neck, chest, back, flexor surfaces of the limbs, inguinal folds, buttocks. Plants, household dust, animal hair, mold, dry fish food can aggravate the course of atopic dermatitis. Often atopic dermatitis is complicated by viral, fungal or pyococcal infection, is the background for the development of bronchial asthma, pollinosis and other allergic diseases.
The main cause of complications in atopic dermatitis is permanent injury to the skin as a result of its combing. Violation of the integrity of the skin leads to a decrease in its protective properties and contributes to the attachment of microbial or fungal infection.
The most common complication of atopic dermatitis is bacterial infections of the skin – pyoderma. They are manifested by pustular rashes on the body, limbs, in the scalp, which, drying out, form crusts. At the same time, general well-being often suffers, body temperature rises.
The second most common complication of atopic dermatitis is viral infections of the skin. Their course is characterized by the formation of vesicles (vesicles) on the skin filled with a transparent liquid. The causative agent of viral infections of the skin is the herpes simplex virus. The most commonly affected are the face (skin around the lips, nose, ears, eyelids, cheeks), mucous membranes (conjunctiva of the eyes, mouth, throat, genitals).
Complications of atopic dermatitis are often fungal infections caused by yeast-like fungi. The affected areas in adults are more often skin folds, nails, hands, feet, scalp, in children – oral mucosa (thrush). Fungal and bacterial lesions are often observed together.
Atopic dermatitis treatment
Treatment of atopic dermatitis is carried out taking into account the age phase, the severity of the clinic, concomitant diseases and is aimed at:
- exclusion of the allergic factor
- desensitization (reduction of sensitivity to allergen) of the body
- itching relief
- detoxification (cleansing) of the body
- removal of inflammatory processes
- correction of the identified concomitant pathology
- prevention of relapses of atopic dermatitis
- the fight against complications (when an infection is attached)
For the treatment of atopic dermatitis, various methods and medications are used: diet therapy, PUVA therapy, acupuncture, plasmapheresis, specific hyposensitization, laser treatment, corticosteroids, allergoglobulin, cytostatics, sodium cromoglycate, etc.
Regulation of nutrition and diet can significantly improve the condition and prevent frequent and pronounced exacerbations of atopic dermatitis. During periods of exacerbations of atopic dermatitis, a hypoallergenic diet is prescribed. At the same time, fried fish, meat, vegetables, rich fish and meat broths, cocoa, chocolate, citrus fruits, black currant, strawberry, melon, honey, nuts, caviar, mushrooms are removed from the diet. Also, products containing dyes and preservatives are completely excluded: smoked meats, spices, canned food and other products. With atopic dermatitis, compliance with a hypochloride diet is indicated – limiting the amount of table salt consumed (however, not less than 3 g of NaCl per day).
Patients with atopic dermatitis have a violation of the synthesis of fatty acids, so diet therapy should include dietary supplements saturated with fatty acids: vegetable oils (olive, sunflower, soy, corn, etc.), linoleic and linolenic acids (vitamin F-99).
Drug therapy in the treatment of atopic dermatitis includes the use of tranquilizers, antiallergic, detoxification and anti-inflammatory drugs. The most important in the practice of treatment are drugs that have an antipruritic effect – antihistamines (antiallergic) drugs and tranquilizers. Antihistamines are used to relieve itching and relieve puffiness of the skin, as well as for other atopic conditions (bronchial asthma, pollinosis).
A significant disadvantage of first-generation antihistamines (mebhydroline, clemastine, chloropyramine, hifenadine) is the rapidly developing addiction of the body. Therefore, the change of these drugs should be carried out every week. The pronounced sedative effect, leading to a decrease in concentration and impaired coordination of movements, does not allow the use of first-generation drugs in the pharmacotherapy of people of some professions (drivers, students, etc.). Due to the atropine-like side effect, a number of diseases serve as contraindications to the use of these drugs: glaucoma, bronchial asthma, prostate adenoma.
Significantly safer in the treatment of atopic dermatitis in people with concomitant pathology is the use of second-generation antihistamines (loratadine, ebastine, astemizole, fexofenadine, cetirizine). Addiction does not develop to them, there is no atropine-like side effect. The most effective and safe antihistamine currently used in the treatment of atopic dermatitis is loratadine. It is well tolerated by patients and is most often used in dermatological practice for the treatment of atopy.
To alleviate the condition of patients with severe itching attacks, drugs that affect the autonomic and central nervous system (sleeping pills, sedatives, tranquilizers) are prescribed. The use of corticosteroid drugs (metiprednisolone or triamcinolone) is indicated for limited and widespread skin lesions, as well as for severe, unbearable itching that cannot be removed by other medications. Corticosteroids are prescribed for several days to relieve an acute attack and are canceled with a gradual decrease in the dose.
In severe atopic dermatitis and severe intoxication, intravenous infusion of infusion solutions is used: dextran, salts, saline, etc. In some cases, it may be advisable to carry out hemosorption or plasmapheresis – methods of extracorporeal blood purification. With the development of purulent complications of atopic dermatitis, the use of broad-spectrum antibiotics in age-related dosages is justified: erythromycin, doxycycline, metacycline for 7 days. When a herpetic infection is attached, antiviral drugs are prescribed – acyclovir or famciclovir.
With the recurrent nature of complications (bacterial, viral, fungal infections), immunomodulators are prescribed: solusulfon, thymus preparations, sodium nucleinate, levamizole, inosine pranobex, etc. under the control of blood immunoglobulins.
The choice of the method of external therapy depends on the nature of the inflammatory process, its prevalence, the age of the patient and the presence of complications. In acute manifestations of atopic dermatitis with wetness of the surface and crusts, disinfecting, drying and anti-inflammatory lotions (tea infusion, chamomile, Burov liquid) are prescribed. When relieving an acute inflammatory process, pastes and ointments with antipruritic and anti-inflammatory components (ichthyol 2-5%, tar 1-2%, naphthalan oil 2-10%, sulfur, etc.) are used. Corticosteroid ointments and creams remain the leading drugs for the external therapy of atopic dermatitis. They have antihistamine, anti-inflammatory, antipruritic and decongestant effects.
Light treatment of atopic dermatitis is an auxiliary method and is used for the persistent nature of the disease. UFO procedures are carried out 3-4 times a week, practically do not cause adverse reactions (except erythema).
There are two types of prevention of atopic dermatitis: primary, aimed at preventing its occurrence, and secondary – anti-relapse prevention. The implementation of measures for the primary prevention of atopic dermatitis should begin during the period of intrauterine development of the child, long before his birth. A special role in this period is played by toxicosis of a pregnant woman, taking medications, occupational and food allergens.
Particular attention should be paid to the prevention of atopic dermatitis in the first year of a child’s life. During this period, it is important to avoid excessive medication, artificial feeding, so as not to create a favorable background for hypersensitivity of the body to various allergic agents. Dieting during this period is no less important for a nursing woman.
Secondary prevention aims to prevent exacerbations of atopic dermatitis, and, if it occurs, to facilitate their course. Secondary prevention of atopic dermatitis includes correction of identified chronic diseases, exclusion of the effects of disease-provoking factors (biological, chemical, physical, mental), compliance with hypoallergenic and elimination diets, etc. Preventive intake of desensitizing drugs (ketotifen, sodium cromoglycate) during periods of probable exacerbations (autumn, spring) avoids relapses.
Special attention should be paid to the issues of daily skin care and the correct choice of underwear and clothing. With a daily shower, you should not wash with hot water with a washcloth. It is advisable to use gentle hypoallergenic soaps (Dial, Dove, baby soap) and a warm shower, and then gently blot the skin with a soft towel, without rubbing or injuring it. The skin should be constantly moisturized, nourished and protected from adverse factors (sun, wind, frost). Skin care products should be neutral and free of fragrances and dyes. In underwear and clothing, preference should be given to soft natural fabrics that do not cause itching and irritation, and also use bedding with hypoallergenic fillers.
Children suffer from the most severe manifestations of atopic dermatitis, with age the frequency of exacerbations, their duration and severity become less pronounced. Almost half of the patients recover at the age of 13-14 years. Clinical recovery is a condition in which the symptoms of atopic dermatitis are absent for 3-7 years.