What is it?
Atopic dermatitis or atopic eczema is a chronic inflammatory skin disease which often starts in infancy. It affects two of ten children, therefore it is very common for the babies to have this disease. It is a non-fatal disease but very often it is associated with increased risk of food allergy, asthma, allergic rhinitis, other immune-mediated inflammatory diseases, and mental health disorders. It is, therefore, very important for the parents to carefully observe and understand baby’s skin condition and intensity of symptoms in order to avoid complications and other risks associated with atopic dermatitis.
Symptoms
Dry skin and rashes
The infants might show dry and rough skin and reddish patches called rashes on different parts of the skin especially on the face, knees and legs.
Itching and scratching
Dry patches on the skin could be itchy and if the babies are big enough to scratch by themselves then intense scratching can lead to inflammatory lesions. These lesions might stay for a long period continuously or they appear and disappear in a repeated manner. These lesions can be continuous and intense and can affect any part of a baby’s body. Lesions due to atopic eczema might also appear on their own during or after second month of baby’s life.
Flare-ups
Its very important to understand what a flare-up actually means if a baby is suffering from atopic dermatitis. A flare up is a sudden appearance of symptoms like rashes, hives, wheezing, swelling etc in response to an allergen. In the early years of life, baby’s immune system is developing and changing very rapidly and therefore flare ups are very frequent. Flare-ups are quite common during tooth eruptions in babies.
Causes and risk factors
The strongest risk factor is a positive family history for atopic diseases, particularly for atopic dermatitis which simply means if either of the parent have atopic dermatitis then there is greater possibility of children inheriting this disease from their parents. The main causal agent of the disease is the defects in the epidermal barrier of the affected person, therefore, skin care and repair is the most basic requirement for the treatment of atopic dermatitis.
Research has shown significant positive association between atopic dermatitis and usage of broad-spectrum antibiotics during pregnancy and infancy. Pregnant women should therefore avoid unnecessary intake of antibiotics during pregnancy.
Complications
Atopic dermatitis and food allergy
Allergic response to food allergens are very common in babies for first 2 years of life. Up to two-thirds of infants with moderate to severe atopic eczema show such allergic response, which could be in the form of itching, rashes, hives (raised itchy bumps), rapid swelling on the skin, respiratory symptoms like wheezing, breathing problem, gastrointestinal symptoms like abdominal cramps, nausea, vomiting, diarrhea etc. that may or may not be followed by eczema flares. Allergies to milk, egg, and wheat resolve during childhood but allergies to nuts and fish often persist. As children grow older, the allergic response pattern shifts towards inhalant allergens like pollens, dust, smoke etc, the exposure to which might also contribute to flares.
Secondary infections
Babies with atopic dermatitis are prone to secondary skin infections. It is therefore, important to vaccinate the baby against chicken pox at earliest (12 Months). Staphylococcus aureus is a bacterium that is frequently found on healthy skin and usually non-pathogenic (not causing disease). But in babies with atopic eczema it is reported to be leading cause of skin infections as it frequently provokes inflammation of preexisting lesions.
Disease Management
First step towards disease management is to identify that the baby has atopic dermatitis. If the baby has dry skin and rashes especially on the cheeks and the skin condition is not improving despite using emollients or improves temporarily and the symptoms return after sometime then it is better to consult a dermatologist or even better a pediatric dermatologist. The next stage is appearance of fluid-filled blisters which can ooze and form crusts making the skin appear thick and leathery and chances of secondary infection increase. Therefore, early diagnosis of disease is very crucial as one can avoid further skin damage and symptoms can be controlled with relatively lower doses of corticosteroids. Following information could be helpful for the parents to understand disease management.
Atopic dermatitis is incurable
Atopic dermatitis cannot be cured at present, therefore, treatment of disease revolves around improving symptoms and achieve long-term disease control with a multi-step approach. It is very important to NOT panic when the skin condition of the baby starts deteriorating. Panicking and trying various creams, emollients, oils, ayurvedic or homeopathic preparations etc might only make things worse. If you are not sure about your baby’s skin condition then it is better to consult a dermatologist about your baby’s skin condition rather than relying on your pediatrician’s advice. Also keep in mind that skin repair is a long and slow process, therefore, patience and strict adherence to the treatment plan is very important.
Internal structure of human skin
For disease management it is very important to understand the internal structure of human skin. Human skin is made up of two main structural layers called epidermis and the dermis. Epidermis is generally made up of five sub-layers as follows:
The topmost layer called the horny layer is responsible for barrier function of the skin. It prevents diffusion of water out of the skin and defends our skin against dehydration. It also protects the skin from harmful chemicals, irritants and infection due to invading surface microorganisms. It is this layer of skin which is mainly affected during atopic dermatitis. Let us take a closer look at this layer.
One can imagine the horny layer as a brick wall shown above in the diagram. The cells of horny layer could be considered as bricks and the layers of lipids between the cells as cement (binding material). These lipids play an important role in maintaining the barrier function of the horny layer. Healing the skin is the first step to improving the barrier layer and an essential component is replacing depleted lipids. It is for this reason that use of fatty creams and emollients forms an important part of the therapy.
Use of emollients
At present the prevention and treatment focuses on restoration of epidermal barrier function, which is best achieved through the use of emollients like oils, ointments, lotions, moisturizer etc. Emollients soften the skin by supplying external lipids and help in reducing water loss by forming a protective lipid layer. Additional ingredients such as urea (not to be used in infants), glycerine, and lactic acid can further increase water binding in the skin layers and reduce loss of moisture. Try to avoid emollients with fragrances and perfumes to avoid allergic reactions.
Choice of emollient: It depends on baby’s individual needs—i.e, age, body area, acuteness of symptoms, climate and individual preferences. Depending on the skin condition, a baby might need fatty creams during winter and lotions or oils during summer. Different emollients have varied lipid content. Lotions for example have lower lipid content and higher water content and can be used to cool or dry strongly inflamed and oozing lesions. Creams contain intermediate lipid content and are best applied on large and subacute areas where the skin is patchy or leathery in appearance. Ointments are richer in lipids and are useful for treatment of dry and lichenified areas. Emollients should be used at least twice per day all over the body, including after bathing.
Bathing: For babies no need to use any soaps, bubble baths or shower gels, bathing the baby with water is enough. During early stages of life when the disease is in its progressive stage, its better to bathe the baby twice or just once a week. Sometimes doctors prescribe bath additives like almond oil preparations but it might or might not work for your baby. Antiseptic bath additives or soaps, or the addition of antimicrobial agents to topical therapies in non-infected atopic dermatitis might be helpful for babies with frequent superinfections but not really necessary.
Topical corticosteroids
Topical corticosteroids are still the first-line therapy to treat acute flares and are also used proactively along with topical calcineurin inhibitors to control the symptoms. As a general rule on areas with thinner skin like on face, genitals etc and in children, low-potency corticosteroids are used. It is recommended to apply corticosteroids twice a day on affected areas. It is better to apply emollients first and leave at least half an hour and then apply corticosteroids or calcineurin inhibitors, to avoid their dilution and diversion. After an acute flare has subsided or stabilized parents should continue the emollient treatment of the affected areas afterwards.
Types of topical steroids: Based on steroid potency the type of topical steroid may be high potency steroid (Groups I to III), medium potency steroids (Group IV and V) and low potency steroids (Group VI and VII). For babies, depending on the acuteness of symptoms and body part affected, medium to low potency topical steroids are used for treatment.
Side effects of corticosteroids: Prolonged use of topical corticosteroids may cause side effects like skin atrophy or thinning of skin. But it is also reported that routine, appropriate, long-term use of topical corticosteroids in children with dermatitis does not cause skin atrophy. Hence, depending on the intensity of symptoms the least potent steroid should be used for the shortest time, while still maintaining effectiveness.
Proactive secondary prevention
Proactive therapy procedure uses application of topical corticosteroids or topical calcineurin inhibitors to previously active sites or affected areas for two days per week (with a gap of 3 days) in order to reduce flares. This approach is useful when frequent outbreaks occur on the same sites on the body. Topical calcineurin inhibitors are non-steroidal antiinflammatory agents that are available as ointments (tacrolimus 0.03% and 0.1% for adults, 0.03% for children aged ≥2 years) and creams (pimecrolimus 1% for patients aged ≥2 years). The topical calcineurin inhibitors do not cause skin atrophy and could be applied on delicate skin areas such as the face and genitals.
Failure of treatment
Treatment failure is mainly due to poor adherence to topical therapy. Skin repair and rejuvenation is a gradual process and one needs patience and thorough understanding of how the treatment actually works. Treatment failure is mainly due to to irrational fears around potential adverse effects of corticosteroids, insufficient information, and inconvenient therapy procedure. After application of topical corticosteroids the skin appears to have repaired and parents might want to switch to some corticosteroids-free therapy, but please don’t be in a rush. Though the skin appears to be normal to the eyes, microscopically one can see that it is far from being healed. It is much better to understand and strictly follow the therapy procedure with topical corticosteroids and emollients and try to tailor it to your baby’s individual need. You can ask your doctor for a written action plan if needed. Now a days hospitals are also providing comprehensive and structured education and training programmes for the same, enroll for one if you have an opportunity to do so.
Please be informed that no research based evidence has been reported in favour of probiotics, dietary supplements, botanical extracts or homoeopathy for treatment of atopic dermatitis. Similarly, no evidence-based recommendation for the routine use of specialised clothing fabrics can be made, but, in individual cases, silk garments or clothing impregnated with silver might be beneficial. One might try to switch to other forms of therapies like homeopathy or botanical extracts etc after the baby is around 2 years old and baby’s skin condition has stabilized.
Prevention
Avoidance of trigger factors
Specific factors such as food, inhalant, or contact allergens and unspecific factors such as detergents, wool fabrics, extremes of temperature and humidity, infections, cutaneous microbial colonisation and psychological stress are widely assumed to provoke flares or cause worsening of the disease. If you know the individual trigger factors for your baby, it is best to avoid them temporarily. As for food allergies, if there is a strong suspicion that a certain type of food component like nuts, fish, orange juice, tomato juice, milk or other dairy products, eggs etc is triggering an allergic reaction or flare up, avoid that food for 4-6 weeks and then reintroduce the same in small quantity. If the baby still reacts negatively to the food item then avoid again for 3-4 weeks and reintroduce. Do not cut out any food items from baby’s meals unless your baby shows severe allergic response to it. Please note that if the allergic reaction is severe, take your doctor’s advise rather than experimenting on your own.
Emollient therapy after birth
Research has shown that full-body emollient therapy from birth can reduce the occurrence of atopic dermatitis in high-risk infants by 30–50%. The traditional practice of giving an oil massage to the baby before bathing is, therefore, a beneficial practice that should be continued and encouraged.
To sum it up, atopic dermatitis is an incurable chronic inflammatory skin disease. Treatment of atomic dermatitis is all about improving the symptoms in order to achieve long-term disease control. Topical corticosteroids therapy coupled with regular use of emollients is a standardized procedure which should be followed without any corticosteroids-phobia. After the acute phase of the disease is over the symptoms can be controlled simply by emollient therapy.
References
Weidinger S, Novak N: Atopic dermatitis (2016) Lancet, 387: 1109–22