Atopic dermatitis: treatments, causes, what is it?

The atopic dermatitisalso called atopic eczema, is one of the most frequent diseases of the child which can appear from the first months of life. It also concerns adults. Atopic dermatitis is a “chronic inflammatory disease of the skin that turns red and itchy in individuals who are predisposed to these manifestations in the form of eczema which may be associated with other diseases: asthma, allergic rhinitis, etc.” defines Pr Julien Seneschal, Professor of Dermatology in the Adult and Child Dermatology Department at the Bordeaux University Hospital.

People with a close relative suffering from atopic eczema or associated diseases such as asthma, allergic rhinitis or food allergies) are at greater risk of developing atopic dermatitis. This is linked to a genetic predisposition (the genes being present at the level of the chromosomes). In addition, certain environmental factors such as a dry climate or living in cities are also risk factors for developing the disease.

infant and baby

Atopic dermatitis most often begins around the age of 3 months, but can also be observed from the first days of life. In infants,skin lesions mainly affect the face (cheeks) and the convex areas (elbow, knee)“says the dermatologist. It sometimes happens that almost all of the skin of the body of some babies is affected.

Photos of atopic dermatitis:

10% of children are affected by atopic dermatitis.

Child

As the child grows, atopic dermatitis usually localizes to the folds (elbows, wrists and back of the knees). The lesions also appear on hands, face and eyelids. As the child grows into an adolescent, it is not uncommon for symptoms to improve with less frequent flare-ups; or even disappear in some. “It is estimated that 10% of children are affected by atopic dermatitis“says Professor Julien Seneschal.

Teenager

In adolescence, it is possible to see reappearance of outbreaks of eczema due to the psychological state caused by this period of life.

Adult

Atopic dermatitis disappears most of the time before the age of 5, but “10% of children with atopic dermatitis will keep or reactivate atopic dermatitis in adulthood, indicates the dermatologist. 4.5% of the population adult has atopic dermatitis, with a majority of women (60% of cases).” In adulthood, lesions mainly affect the face and the creases of the elbows or knees.

Atopic dermatitis evolves in the form of flare-ups interspersed with phases of remission and calm. A flare-up of atopic dermatitis very often begins with the appearance of:

• of redness of the skin: erythema
• of the itching which can be significant and disrupt patients’ sleep and quality of life,
• a dry skin, called xerosis.
• Then, small elevations appear giving a feeling of roughness to the skin.
• They evolve in the form of vesicles, resembling small bubbles of liquid. These rupture and release a translucent liquid causing oozing.
• A scab formation takes place on the ruptured vesicles.

The causes are multiple. “Many factors can come into play to predispose someone to atopic dermatitis, including a genetic predisposition (having a parent or family member who has this disease or a related disease) at have skin that is more fragile and more permeable to allergens. This genetic predisposition is associated with elements of the immune system that will activate too much. Environmental factors will participate in the emergence of the disease (contact with allergens, winter climate which promotes drying of the skin, life in an urban environment…)“, informs Professor Julien Seneschal.

Infrared rays from the sun that heat the skin can aggravate eczema.

Exposure to ultraviolet radiation from the sun tends to improve atopic dermatitis, but only under certain conditions:

• a short exposure, before 12 p.m. or after 4 p.m.,
• in swimsuit,
• and if there is wind.

On the other hand, the infrared rays of the sun which heat the skin can aggravate eczema because of the production of sweat.

Tips for sun exposure: Children and adults with atopic dermatitis must follow a few instructions:

• Apply an emollient milk or cream.
• Wear breathable cotton or linen clothing to let the skin breathe.
• Take a shower after sun exposure.
• Protect yourself with an index 50 sunscreen, without perfume, without preservatives, without nanoparticles, especially if you have atopic-prone skin.

Asthma, urticaria or chronic rhinitis reinforce the need for an allergological assessment

“The diagnosis of atopic dermatitis is mainly clinical: it is based on a clinical aspect of lesions and consideration of family historysays Professor Julien Seneschal. Objective scores (evaluation by the doctor such as SCORAD, EASI or IGA scores for example) or subjective (questionnaires given to patients) can be used to assess the severity of the disease and the impact on daily life“

Complementary examinations are not necessary to make a diagnosis. The allergy assessment is done when there are arguments that the disease may be aggravated by an environmental factor. The presence of asthma, urticaria or chronic rhinitis reinforces the need for an allergological assessment.

The treatment of atopic dermatitis is based on “treatment of relapses and long-term maintenance treatment to prevent recurrencesinforms Professor Julien Seneschal. The treatment of atopic dermatitis, a chronic disease, requires close collaboration between patient and doctor..”

Medications

Flares of atopic dermatitis are treated with anti-inflammatories. “First-line treatments are topical topical corticosteroids. It may take large doses of topical corticosteroids at the start of treatment to calm the inflammation. Then we reduce the doses to arrive at average doses without side effects“, underlines our interlocutor. In general, the treatment goes from daily to weekly or bi-weekly.

Avoid the use of corticosteroids on the face!

“For adults with lesions on the face, it may be prescribed a calcineurin inhibitor (tacrolipus topical) because the use of corticosteroids on the face should be avoided. Antihistamines are rarely useful and effective because it is not a treatment that addresses the mechanism causing the scratching“, he informs.

“When dermocortocoid treatments are not enough to calm the inflammation or when flare-ups are too frequent, systemic treatments (subcutaneous or oral route) can be offered to patients: ciclosporin which has an MA for atopic dermatitis and methotrexate which does not have Marketing Authorization for atopic dermatitis but for which a number of studies have shown a benefit for patients as well as a new molecule available since the beginning of 2019, Dupilumab, a monoclonal antibody (biotherapy) by injection“, indicates the dermatologist. Namely that many molecules are in the process of development, according to Pr Seneschal.

Creams

The daily application (morning and evening) of neutral moisturizing creams without perfume or preservatives (emollients) is an integral part of the treatment. It is advisable to apply its emollient care on damp skin after showering. This facilitates the application and above all facilitates the retention in the epidermis of the water which may have penetrated during washing.

Maintenance treatment consists of in the application of emollients which aim to restore the skin barrier. “The emollient creates a protective film on the skin and protects it from the environment“explains the dermatologist. This treatment must be daily.

The use of essential oils is not recommended.

Essential oils

The use of essential oils is not recommended in a person with atopic dermatitis because of the risk of allergy.

The most frequent complications of atopic dermatitis concern superinfections of the skin: indeed, lesions caused by atopic dermatitis can be colonized by staphylococcus aureus or the herpes virus.

• If they are infected with Staphylococcus aureus, the lesions become pustular and the scabs yellowish. Antibiotic treatment should be prescribed promptly.
• If they are infected with the herpes virus, there may be onset of fever, rapid change in the appearance of lesions and deterioration in general condition. It is urgent to consult a doctor in order to carry out antiviral therapy.

Growth retardation can be observed in severe atopic dermatitis. Growth retardation recovers when treatment of the dermatitis improves the lesions. Atopic dermatitis can lead to sleep disturbances (night awakening, irritability, crying, etc.). On the other hand, ophthalmological complications of atopic dermatitis, such as keratoconjunctivitis and cataracts are rarely observed.

Primary prevention of atopic dermatitis is not possible today. “In view of the promising results of a first study with a small number of patients, which suggested that the use of emollients from birth in infants at risk could prevent the onset of atopic dermatitis, two recent international studies have not unfortunately not confirmed these first results“, informs Professor Julien Seneschal. On the other hand, emollients allow secondary prevention of flare-ups.

However, simple measures make it possible to avoid or not aggravate the inflammatory flare-ups of atopic dermatitis:

• do not heat the room above 19 degrees, ventilate in winter and summer
• respect anti-mite measures
• avoid smoking
• prefer cotton clothes because they are less irritating
• avoid wearing synthetic fabrics and wool
• wash your hair with mild dermatological shampoos
• use soap-free products
• cut the nails well to avoid lesions occurring during scratching
• rinse well after bathing in the sea because salt irritates the skin
• avoid swimming in the pool during outbreaks because chlorine is an irritant:; apart from flare-ups, rinse well in a shower after swimming and apply an emollient to the body.

Thanks to Pr Julien Seneschal, Professor of Dermatology in the Adult and Child Dermatology Department at the Bordeaux University Hospital.