Atopic Dermatitis in a Child: A Review

Epidemiology

Atopic dermatitis (AD) is considered the third most prevalent skin disease worldwide affecting up to 2.79% of the population globally ¹. The global burden of disease caused by AD was the largest in high-income countries, female patients, and children between 1-5 years ². The prevalence of AD varies a great deal between countries. It was reported that the prevalence of adult AD was 4.9% of the population in the United States, 2.1% in Japan, and 20% of children in Sweden ^3,4. AD is a common, chronically recurring skin inflammation with a benign course. However, disability-adjusted life years (DALYs) showed a steep rise from 0.27% in 1990 to 0.36% in 2017 ⁵. The detrimental effects of AD encompass the academic, social, and occupational aspects of the individual’s life. Moreover, AD is associated with other atopic conditions such as allergy ⁶ and asthma ⁷ and is associated with other medical conditions including cardiovascular disorders ⁸, obesity ⁹, anxiety ¹⁰, and depression ¹¹. Therefore, AD can be regarded as a systemic illness with significant physical and psychological manifestations ¹².

 

Diagnosis

            Atopic dermatitis is a chronic skin disease characterized by skin pruritic inflammation that occurs mostly in children. The onset of AD is usually between 3-6 months of age with most of the patients (60%) developing skin eruption in the first year of life and about 90% developing the disease by the age of 5 ^13,14. However, adults are also affected. Relapse is a distinctive feature of the disease. Immunoglobulin E (IgE) is often elevated in the sera of the patients ^15,16. There is usually a positive family history of type 1 allergies, allergic rhinitis, and asthma ⁷. The diagnosis of AD depends on the clinical history of the patient, lesion morphology and distribution, and the presence of positive family history. Hanifin and Rajka ^17,18 and the United Kingdom (UK) Working Party diagnostic criteria have been validated to be used for epidemiological and population-based studies ^19,20. In 2003, the American Academy of Dermatology consensus conference suggested revised Hanifin and Rajka criteria to apply to all age groups ²¹. On occasion, skin biopsy, serum IgE, potassium hydroxide preparation, and patch testing can be carried out to rule out other skin pathologies or associated skin conditions ²².

Food allergy, bacterial and viral infection

            A food allergy may play a role in the onset of AD skin symptoms, which can exacerbate disease severity and affect treatment response ^23,24. However, skin testing, in vitro serum assays for allergen-specific IgE, and food restriction are not generally recommended because of the uncertainty of their validity ²⁵. Moreover, colonization with Staphylococcus aureus impacts more than 90% of patients with AD aggravating the clinical condition ²⁶. Therefore, severe cases of AD may need the addition of antibiotics even in the absence of obvious signs of infection ²⁷. In addition, viral infection was detected in patients with AD mainly herpes simplex virus (HSV-1 or -2) leading to eczema herpeticum and coxsackie A6 causing eczema coxsackium. Eczema herpeticum causes fever, lymphadenopathy, keratoconjunctivitis, and multi-organ damage leading to fatal outcomes ²⁸. On the other hand, eczema coxsackium may cause eruptions at the sites of AD lesions ²⁹. Moreover, attention should be paid to patients who received small box vaccination or were in contact with small box-vaccinated persons because those patients with AD may suffer from a potentially fatal condition, eczema vaccinatum ³⁰.

Management

            Managing AD in children is challenging, involving a diversity of medications, behavioral adjustments, and lifestyle modifications. Primary healthcare providers including pediatricians and general practitioners are on the frontline of diagnosing and treating AD in children, especially in rural areas where specialist dermatologists or pediatricians may be unavailable ^31,32. Therefore, the approach to the diagnosis and management of AD by healthcare providers should follow the updated guidelines of the American Academy of Dermatology (AAD) ^22,33 and the American Academy of Pediatrics ³⁴. Knowledge and awareness of the appropriate management of pediatric AD including topical corticosteroids (TCS), emollients, water baths, and antibiotic therapies should be ensured among the healthcare providers.

 

Patient and caregiver education

            On the other hand, extensive patient or caregiver education is of paramount importance ³⁵. Not only information about the clinical features and the natural history of AD should be given, but also clear instructions about the given medications and the possible benefits and side effects as well as the treatment plan according to the severity and associated morbidity. The caregiver should understand that AD treatment is individualized according to the underlying pathology and possible co-morbidities ¹⁴.

 

Treatment

Topical emollients and water baths

            Atopic dermatitis is thought to relate to abnormalities in the gene encoding filaggrin and the subsequent effect on the pro-inflammatory cascade. Therefore, the most important variable in treatment is controlling trans-epidermal water loss ³⁶. This can be accomplished with the generous use of topical emollients to dry skin, especially when applied after a shower or bath for 5-10 min in lukewarm plain water. However, there is a dearth of conclusive evidence for optimal bathing duration and ingredients to be used ³⁷. An occlusive ointment should be applied immediately after the water bath, soak-and-seal ³⁸. In addition, all patients with AD should utilize emollients, and thicker moisturizing treatments like ointments and creams should be applied frequently. Bathing, showering, and washing are important for skin cleaning to remove the adhering sebum, sweat, and pathogens colonization (Staphylococcus aureus) ³⁹. Moisturizing agents are significant in preventing skin dryness. Regular use of moisturizers is considered the cornerstone in the treatment of  AD. Moisturizers contain admixtures of ceramides, urea, lactate, and salicylic acid that hydrate and repair the stratum corneum, thus mitigating skin dryness, itching, flares, and infections ^40,41. Ceramides constitute 50% of stratum corneum lipids. Therefore, ceramides are considered a potential therapeutic modality for AD ⁴². Several other moisturizers have been searched with potentially promising results ⁴³.

 

There is no evidence from the literature that soap and detergents are effective in AD. Therefore, the use of soap should be limited to a minimum in severe cases, during hot seasons when the skin is more liable to dryness, and in sensitive patients ³⁹. However, AD patients with a positive culture for S. aureus showed improvement in disease severity after using an antibacterial soap containing 1.5 percent triclocarban ⁴⁴.

 

Topical corticosteroids

            The prescription of TCS is common among pediatricians with AD and primary care providers ^45,46 for cases with AD. The utilization of TCS in the management of AD was approved by the Food and Drug Administration (FDA) for inflammatory and pruritic skin conditions in 1955 ^47,48. The mechanism of action of TCS is not clearly understood, however, TCS has a potential effect on the local immune system and the function of the skin barrier ⁴⁹. It has been reported that TCS mitigates pruritis, inflammation, and S. aureus colonization in children ⁵⁰. Based on recent guidelines, low-to-mid potency TCS is the first line for the management of AD for a short period, less than 4 weeks ⁵¹. However, several factors determine the choice of the TCS potency including case severity, the extent of skin lesion, and the site of the flare ⁵². A recent systematic review found no harm in the long use of TCS in patients with AD when TCS is used intermittently “as required” or as “weekend therapy” to treat and prevent flares ⁵³. However, moderate-to-severe AD cases may need long-term daily TCS therapy. A few studies reported that TCS can be safely used by pediatricians for children with AD younger than 2 years ^54,55. Patient desire, pharmaceutical availability, cost, and a balanced assessment of benefits and hazards all play a role in determining the maintenance therapy regimen and product selection. Factors such as preference, availability of drugs, cost, and a thorough assessment of benefits vs side effects should be taken into account when deciding on a regimen and product for maintenance therapy. Step-wise withdrawal of TCS should be applied when mid-to-high potency of TCS is used. Moreover, treatment plans involving TCS should be discussed with the patients or the caregiver of the child for better compliance and to eliminate the fear of corticosteroid use ^14,49.

 

Certain adverse effects should be considered when TCS is used for children. Atrophy-related side effect of TCS was reported including striae and purpura, hypopigmentation, focal hypertrichosis, telangiectasia, and perioral dermatitis ^56,57. Long-term TCS use was reported to be associated with subclinical barrier disruption leading to rebound flares when the drug is discontinued abruptly ⁵⁸.

 

 

Antibiotics

Antibiotics are used as adjunctive therapy in patients with AD who have S aureus colonization. The use of antibiotics should be guided by anti-microbial sensitivity tests to ensure efficacy against resistant bacteria. Bleach baths have been reported to be beneficial in the treatment of patients with AD from the age of 6 months to 17 years of age and associated with hyper-IgE syndromes ^59,60. Moreover, numerous compounds, many of which were not even labeled as antibiotics, exhibited antibiotic capabilities. Several ingredient combinations have been identified that may be useful in positively influencing the proliferation of the health microbiome over disease-associated strains. For example, the combination of colophonium and citral (known in the market as lemon myrtle oil and pine tar) ⁶¹. Skin microbiome shows protective potentials against skin pathogens. Therefore, dysbiosis of the skin microbiome can cause or trigger skin pathologies. A recent research study confirmed that the reintroduction of coagulase-negative Staphylococcus strains to human skin afflicted with AD led to a reduction of S. aureus colonization ⁶². The protective effect of the coagulase-negative Staphylococcus strains (e.g., Staphylococcus epidermidis) is mediated by the restoration of antimicrobial peptides that are essential immune defense molecules ^63,64.

Conclusion

Atopic dermatitis is a cumbersome skin disease affecting children and young adults. Several triggering factors initiates the disease and modulate severity. The treatment of AD is complex and multifaceted. Therefore, primary care providers should have adequate knowledge and awareness to diagnose, identify risk factors, and treat AD before referral to a specialist. Several medications have been proposed as potentially effective in the management of AD including moisturizing agents, baths, TCS, and antibiotics. The choice of treatment regimen depends on the age, severity, distribution, site of infections, and drug tolerability. Consequently, further research is needed to set a protocol for the appropriate treatment of AD.

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