Atopic Dermatitis in Children: Clinical Picture, Diagnosis and Treatment
Essentials
Atopic dermatitis is a chronic, itching, inflammatory skin disease characterized by exacerbations that are difficult to foresee.
In most children, atopic dermatitis is mild and has a favourable prognosis. The condition is managed in primary health care.
The diagnosis is based on patient history and clinical examination. Itching and the typical appearancea and location of the dermatitis are often sufficient for diagnosis. The disease starts in 70% of the cases by the age of 2 years and it is associated with chronic or constantly recurring inflammation of the skin in areas typical for different ages. The skin is dry and the eczema is erythematous, showing papules, itching, and there are often signs of scratching, crusts and lichenification. Laboratory tests or allergy investigations are not needed .
In infants less than one year of age with severe atopic dermatitis, the possibility of food allergy as an aggravating factor should be kept in mind and an assessment carried out in specialized care may be warranted. In other patient groups there is usually no need to search for food allergy.
There are no known effective prophylactic measures.
Clinical picture
Infants (below 1 year of age)
The eczema typically appears during the first 4-8 months of life.
The typical locations include cheeks (picture 1), legs, calves, ankles, wrists and folds of the joints.
Preschool-aged children
The eczema often occurs on the flexural surfaces of the elbows and knees and on the legs, thighs, face and anterior and/or posterior neck.
School-aged children
At school age, dermatitis is predominantly found in the folds of the joints and on the wrists, hands, ankles and feet. Special forms of dermatitis affect volar sides of the hands and plantar surfaces of the feet (juvenile palmar and plantar dermatoses; picture 2). Hand and feet symptoms are at their worst in wet and cold weather, typically in the spring and fall.
Foot ringworm is rare in children: avoid misdiagnosis.
Atopic dermatitis on the buttocks and the inner sides of the thighs usually begins 1-2 years before school age and usually ends in adolescence.
Differential diagnosis
Seborrhoeic eczema with associated increased sebum production
Occurs in infants
Scaling and eczema usually in the scalp and face during the first months of life
Mild topical glucocorticoids help; a mix containing 1-2% of sulphur and 1% of hydrocortisone in an emollient base is also used.
Scabies Scabies is an itchy papular dermatitis; look for burrows in the palms of the hands and soles of the feet. Often several family members have scabies at the same time.
Nummular eczema appears as round patches, often weeping and crusty, on the cheeks, buttocks or extremities (picture 3) usually at the age of 2-6 months.
Nappy dermatitis. Reddened eczema caused by urine and faeces can be distinguished from atopic eczema which usually does not appear in the napkin area.
In dermatitis herpetiformis, intensely itching papules occur on the elbows, knees and buttocks.
Determination of specific serum IgE antibodies or skin prick testing (picture 4) may be indicated when an infant less than one year of age has severe or moderate dermatitis and there is a suspicion that some foodstuffs may make it worse; in older children testing is rarely needed.
The tests are performed and interpreted by a specialist.
Patch testing for foods is not used in the diagnostics of food allergy in children.
The symptoms in most patients are well controlled with moderately greasy basic emollients and intermittent courses of treatment withmild glucocorticoid creams or ointments. The condition is managed in primary health care.
Guidance in the topical treatment (application of emollients, creams and ointments; use of compresses if needed) is an important part of the treatment.
Topical treatment
Glucocorticoid creams comprise the cornerstone of therapy. They are used in short 1-2 week courses, and mild agents (hydrocortisone) are preferred.
Emollients do not alleviate the inflammation of atopic dermatitis, but they do reduce the evaporation of moisture from the skin and may thus reduce the need for glucocorticoid creams Emollients and Moisturisers for Eczema.
Normal washing is allowed. In some children, water dehydrates the skin, and the frequency of washing should then be decreased. Soaps and wash liquids can be used when the skin is infected, but a water-based emollient is also suitable for washing. Sweating aggravates itching.
If no response is achieved with the glucocorticoid creams or if the eczema recurs or rapidly worsens during the treatment intervals, alternatives include topical pimecrolimus (Elidel® ) cream in children over 3 months of age or topical tacrolimus (Protopic® 0.03%) cream in children over 2 years of age. Both can be used as continuous treatment with intermittent administration.
Pimecrolimus cream is applied twice a day until symptoms resolve. Tacrolimus cream is applied initially twice a day for 3 weeks, then once daily until symptoms resolve. After symptom resolution the treatment is paused, and a new course of treatment is started as soon as symptoms reappear.
During treatment, exposure to sunlight should be minimized by avoiding excessive time spent in the sun, using sun creams and by wearing protective clothing.
Treatment can only be initiated by a physician with experience in the diagnosis and treatment of atopic dermatitis.
There have been doubts suggesting a possible association of pimecrolimus and tacrolimus with malignancies but this has not been confirmed.
In frequently recurring dermatitis, a glucocorticoid or calcineurin inhibitor may be used as maintenance therapy 2-3 times a week for preventing exacerbations of the dermatitis. In maintenance therapy, the topical ointment is applied on areas that typically become symptomatic even though there is no skin eruption at that time.
For children over 3 months of age, topical pimecrolimus (Elidel® ) cream twice daily until symptoms disappear (in courses of a few weeks, as necessary)
Emollients are used during the intervals that last for at least as long as the the hydrocortisone courses.
Selective ultraviolet phototherapy (SUP) can be used for moderate to severe eczema, but research evidence on the effect of phototherapy in children is scarce. Its use has reduced as the use of calcineurin inhibitors has increased in severe cases.
There is no evidence that antihistamines alleviate pruritus other than through their sedative effect.
Pro- and prebiotics as a group have not been shown to have an effect in the treatment of eczema Probiotics for Treating Eczema.
Lactobacillus rhamnosus GG preparations have been shown to relieve IgE mediated eczema, but the level of evidence is low.
There is no reliable evidence on the effectiveness of gammalinoleic acid, vitamins or trace elements.
References
Williams HC, Burney PG, Pembroke AC et al. Validation of the U.K. diagnostic criteria for atopic dermatitis in a population setting. U.K. Diagnostic Criteria for Atopic Dermatitis Working Party. Br J Dermatol 1996;135(1):12-7. [PubMed]
Williams HC, Burney PG, Pembroke AC et al. The U.K. Working Party's Diagnostic Criteria for Atopic Dermatitis. III. Independent hospital validation. Br J Dermatol 1994;131(3):406-16. [PubMed]
Eichenfield LF, Tom WL, Chamlin SL et al. Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol 2014;70(2):338-51. [PubMed]
Ring J, Alomar A, Bieber T et al. Guidelines for treatment of atopic eczema (atopic dermatitis) part I. J Eur Acad Dermatol Venereol 2012;26(8):1045-60. [PubMed]