Neurodermatitis is a skin disease of a neurogenic-allergic nature (neuroallergodermatosis), which has a chronic recurrent course. Neurodermatitis is characterized by wet skin rashes, attacks of severe itching, combing, followed by the formation of crusts, pigmentation and thickening of the skin on the affected areas. Disease is diagnosed on the basis of dermatological examination, determination of IgE level, skin allergy tests, skin biopsy. Treatment includes a hypoallergenic diet, a protective regime, taking antihistamines, sedatives, corticosteroids, external use of ointments, balneotherapy, physiotherapy, spa treatment.
L20 Atopic dermatitis
Neurodermatitis is a chronic dermatosis of a neuroallergic nature, occurring with frequent exacerbations. Currently, in clinical dermatology, the term “atopic dermatitis” is used to designate a group of diseases occurring with skin allergic manifestations. This concept united such separate nosological forms as neurodermatitis, prurigo (pruritus), eczema, exudative diathesis, diaper dermatitis, etc. However, until now, individual diagnoses are widely used in clinical allergology, dermatology, pediatrics, which dictates the need for detailed consideration of each of these forms. According to numerous studies, neurodermatitis is widespread in different age groups and occurs in 0.6–1.5% of adults. The incidence of neurodermatitis is higher among women (65%) and residents of megacities.
Despite many years of studying the problem of neurodermatitis, there are still many “white spots” in its etiology and pathogenesis.
- The neurogenic theory of the origin of assigns a leading role in the genesis of the disease to GNI disorders, which is accompanied by discoordination of nervous processes, pathological changes in their strength, balance and mobility. In patients with neurodermatitis, there is a direct correlation between the severity of skin manifestations and functional disorders of the nervous system. The neurogenic theory is also supported by the fact that stressful situations can provoke the manifestation of neurodermatitis or its exacerbation. Persons suffering from neurodermatitis have neurotic personality traits: anxiety, emotional lability, tension, depression, hypochondria, etc.
- The allergic theory of the genesis of neurodermatitis focuses on the hypersensitivity of the body to certain food, medicinal, chemical substances. Followers of this theory believe that neurodermatitis is a direct continuation of the exudative-catarrhal diathesis of childhood. The proximity of neurodermatitis to allergic diseases is indicated by a frequent combination of allergodermatosis with urticaria, pollinosis, bronchial asthma, allergic conjunctivitis.
- The hereditary theory considers the etiology and pathogenesis in line with the genetic predisposition to atopy. Thus, studies show that neurodermatitis develops in 56-81% of people whose parents (respectively, one or both) also suffered from this disease. Given the above, most likely, one should think about the neurogenic-allergic nature form and its predominant development in people with a hereditary predisposition.
Psychogenic factors, intoxication, endogenous and exogenous stimuli (exacerbation of chronic infections, food, inhalation, contact allergens, insolation, vaccination), endocrine disorders, pregnancy, lactation, etc. can serve as an impetus to the onset and progression of neurodermatitis. A significant role in the development of disease is assigned to gastrointestinal pathology (fermentopathy, gastroduodenitis, intestinal dysbiosis, constipation, biliary dyskenesia, chronic pancreatitis, etc. D.) and ENT organs (sinusitis, ethmoiditis, chronic tonsillitis and pharyngitis), creating conditions for auto-allergization and auto-intoxication.
The main pathogenetic changes in neurodermatitis relate to immune disorders, excessive production of vasoactive substances and disorders of vascular tone regulation. Thus, 80% of patients with neurodermatitis have a significant increase in the level of IgE and eosinophils in the blood. Increased release of inflammatory mediators, in particular histamine, determines persistent itching and skin sensitivity characteristic of neurodermatitis. The consequence of changes in the tone of the skin vessels is persistent white dermographism, a decrease in the temperature of unaffected skin areas. Violation of lipid metabolism, the function of sebaceous and sweat glands leads to dry skin. Pathomorphological skin changes in neurodermatitis are represented by acanthosis, intercellular edema (spongiosis), hyperkeratosis, and the presence of perivascular infiltrates in the dermis.
Depending on the prevalence of skin lesions , the following forms of neurodermatitis are distinguished:
- limited (Vidal’s lichen) – captures individual areas of the skin
- disseminated – combines several foci of limited neurodermatitis.
- diffuse – diffuse lesion of the skin.
A number of authors identify diffuse neurodermatitis with atopic dermatitis. According to the nature of skin changes in the affected foci, the following types of limited neurodermatitis are distinguished: psoriasis-like (with foci of peeling), white (with foci of depigmentation), decalating (with lesions of the scalp and the development of alopecia), warty or hypertrophic (with tumor-like skin changes), linear (with skin manifestations in the form of linear stripes), follicular (with the formation of pointed papules in the hairline area).
In a limited variant, skin lesions are usually represented by local itchy plaques no larger than the palm of the hand in the area of the back or side surface of the neck, inguinal-femoral folds, scrotum, labia, interstitial fold. The altered skin areas are lichenification zones surrounded by disseminated papules on the periphery. In the late period of neurodermatitis, hyperpigmentation forms along the edges of the foci, against which, in places of combing, secondary leukoderma can form – areas of discolored skin.
The formation of diffuse neurodermatitis is usually preceded by the presence of exudative diathesis in infancy, then childhood eczema, and finally atopic dermatitis proper (diffuse neurodermatitis). Typical localization of the lesion: face (forehead, cheeks, red lip border), neck, elbow and knee bends, chest, inner thighs. The skin in the affected areas is dry, hyperemic, lichenized with excoriation, crusts, foci of exudation; the boundaries of the altered skin are indistinct. When the red border of the lips is involved, atopic cheilitis develops.
The leading symptom of neurodermatitis is a painful itching of the skin, which increases at night. Intense itching gives the patient emotional and physical experiences, leads to insomnia, irritability, neurotic personality changes, depression. Skin scratching is often accompanied by the formation of long-term non-healing wounds, the addition of secondary infection. Complications may include folliculitis, impetigo, furunculosis, staphyloderma, hydradenitis, lymphadenitis, lymphangitis, fungal infection, viral lesions (contagious mollusc, simple and plantar warts, Kaposi’s herpetiform eczema), etc.
Among other skin symptoms with diffuse form, there are dark circles under the eyes, longitudinal suborbital folds (Denny-Morgan lines) under the lower eyelids, deep palmar and plantar folds, follicular keratosis. Patients are characterized by weakness and fatigue, weight loss, arterial hypotension, hypoglycemia; sometimes they have cataracts, keratoconus, eczema of the nipples, ichthyosis. For diffuse neurodermatitis, exacerbations in the autumn-winter period and remissions during the warm season are typical.
The diagnosis of neurodermatitis can be made by a dermatologist or an allergist-immunologist already on the basis of clinical signs, since there are no specific laboratory and instrumental markers of this disease. The criteria for the diagnosis of neurodermatitis are: dermatitis with typical localization, dry skin, intense itching and scratching of the skin, recurrent chronic course. Of great diagnostic importance is the presence of concomitant allergic diseases (allergic rhinitis, bronchial asthma, etc.), hereditary burden of atopic diseases, the connection of exacerbations with additional allergization of the body, etc.
Blood tests for neurodermatitis show eosinophilia, an increase in the level of general and allergen-specific IgE. During skin allergy tests (scarification, application), a positive reaction to certain allergens is detected. During a skin biopsy, a morphological pattern characteristic of neurodermatitis is revealed. Differential diagnosis of neurodermatitis should be carried out with dermatitis (seborrheic, contact), dermatophytia, pink lichen, scabies, psoriasis, dyshydrotic eczema, etc.
The modern strategy of therapy includes the following directions: elimination of causally significant factors (infectious, allergenic, psychogenic) leading to exacerbation of allergodermatosis; external local (anti-inflammatory, moisturizing) treatment; systemic treatment.
- Diet therapy. A patient suffering from neurodermatitis is shown a hypoallergenic diet; compliance with a protective regime, including full sleep, lack of stress, etc.; wearing underwear and clothing made of natural materials; rehabilitation of chronic foci of infection of the ENT organs and the dental-maxillary system.
- Local therapy is carried out using corticosteroid ointments, tar ointments, naphthalan ointment, therapeutic cosmetics for skin care. Cryomassage, physiotherapy (phonophoresis with corticosteroids, diadinamotherapy, magnetotherapy, inductothermy, galvanization, darsonvalization, electroson), reflexotherapy (electropuncture, laseropuncture), pricking of foci of limited neurodermatitis with betamethasone, hydrocortisone can give a good effect.
- Systemic pharmacotherapy of neurodermatitis is carried out in various directions. The leading role in the treatment is given to antihistamines, sedatives and immunomodulatory agents, systemic corticosteroids, vitamins. Patients with severe forms of diffuse neurodermatitis may be shown immunosuppressive therapy, PUVA therapy and selective phototherapy, blood UV, hyperbaric oxygenation, plasmapheresis.
Patients with neurodermatitis are recommended spa treatment in a dry marine climate, radon and hydrogen sulfide baths, thalassotherapy.
Prognosis and prevention
Limited neurodermatitis has a lighter course than the diffuse form. Constant itching and cosmetic defects cause patients to fixate on their condition, leading to secondary mental layers, worsen the quality of life, limit performance. Nevertheless, with age (by about 25-30 years), many patients, even with diffuse neurodermatitis, may experience a regression of symptoms to focal manifestations or even spontaneous self-healing.
Prevention should begin from early childhood and include breastfeeding, rational introduction of complementary foods, compliance with dietary recommendations for the nutrition of children, therapy of concomitant diseases, exclusion of traumatic factors.