Many factors or conditions can intensify the symptoms of atopic dermatitis, including dry skin, winter or cold weather, wool cloths, and other irritating skin conditions. These factors may further trigger the itch-scratch cycle, further stimulating the many times already overactive immune system in the skin. Repeated aggravation and activation of the itch-scratch cycle may cause further skin damage and barrier breakdown. These exacerbating elements can be broken down into two main categories: irritants and allergens. Emotional factors and some infections can also influence atopic dermatitis.
What are skin irritants in patients with atopic dermatitis?
Irritants are substances that directly affect the skin, and when used in high enough concentrations with long enough contact cause the skin to become red and itchy or to burn. Specific irritants affect people with atopic dermatitis to different degrees. Over time, many patients and their families learn to identify the irritants that are most troublesome to them. For example, wool or synthetic fibers may affect some patients. Rough or poorly fitting clothing can rub the skin, trigger inflammation, and prompt the beginning of the itch-scratch cycle. Soaps and detergents may have a drying effect and worsen itching, and some perfumes and cosmetics may irritate the skin. Exposure to certain elements (such as chlorine, mineral oil, or solvents) or irritants (such as dust or sand) may also aggravate the condition. Cigarette smoke may irritate the eyelids. Because irritants vary from one person to another, each person has to determine for himself or herself what substances or circumstances cause the disease to flare.
- Wool or synthetic fibers
- Soaps and detergents
- Some perfumes and cosmetics
- Substances such as chlorine, mineral oil, or solvents
- Dust or sand
- Dust mites
- Cigarette smoke
- Animal fur or dander
- Flowers and pollen
What are allergens?
Allergens are substances from foods, plants, or animals that provoke an overreaction of the immune system and cause inflammation (in this case, the skin). Inflammation can occur even when the person is exposed to small amounts of the allergen for a limited time. Some examples of allergens are pollen and dog or cat dander (tiny particles from the animal’s skin or hair). When people with atopic dermatitis come into contact with an irritant or allergen to which they are sensitive, inflammation-producing cells permeate the skin from elsewhere in the body. These cells release chemicals that cause itching and redness. As the person scratches and rubs the skin in response, further damage occurs.
Certain foods act as allergens and may trigger atopic dermatitis or exacerbate it (cause it to become worse). Food allergens clearly play a role in a number of cases of atopic dermatitis, primarily in infants and children. An allergic reaction to food can cause skin inflammation (generally hives), gastrointestinal symptoms (vomiting, diarrhea), upper respiratory tract symptoms (congestion, sneezing), and wheezing. The most common allergy-causing (allergenic) foods are eggs, peanuts, milk, fish, soy products, and wheat. Although the data remain inconclusive, some studies suggest that mothers of children with a family history of atopic diseases should avoid eating commonly allergenic foods themselves during late pregnancy and while they are breastfeeding the baby. Although not all researchers agree, most experts think that breastfeeding the infant for at least four months may have a protective effect for the child.
If a food allergy is suspected, it may be helpful to keep a careful diary of everything the patient eats, noting any reactions. Identifying the food allergen may be difficult and require supervision by an allergist if the patient is also being exposed to other allergens. One helpful way to explore the possibility of a food allergy is to eliminate the suspected food and then, if improvement is noticed, reintroduce it into the diet under carefully controlled conditions. A two week trial is usually sufficient for each food. If the food being tested causes no symptoms after two weeks, a different food can be tested in like manner afterward. Likewise, if the elimination of a food does not result in improvement after two weeks, other foods may be eliminated in turn.
Changing the diet of a person who has atopic dermatitis may not always relieve symptoms. A change may be helpful, however, when a patient’s medical history and specific symptoms strongly suggest a food allergy. It is up to the patient and his or her family and physician to judge whether the dietary restrictions outweigh the impact of the disease itself. Restricted diets often are emotionally and financially difficult for patients and their families to follow. Unless properly monitored, diets with many restrictions can also contribute to nutritional problems in children.
What are aeroallergens?
Some allergens are called aeroallergens because they are present in the air. They may also play a role in atopic dermatitis. Common aeroallergens are dust mites, pollens, molds, and dander from animal hair or skin. These aeroallergens, particularly the house dust mite, may worsen the symptoms of atopic dermatitis in some people. Although some researchers think that aeroallergens are an important contributing factor to atopic dermatitis, others believe that they are insignificant. Scientists also don’t understand the way in which aeroallergens affect the skin — whether the aeroallergen affects the person internally after being inhaled or whether the aeroallergen actually penetrates the patient’s skin.
No reliable test is available that determines whether a specific aeroallergen is an exacerbating factor in any given individual. If the doctor suspects that an aeroallergen is contributing to a patient’s symptoms, the doctor may recommend ways to reduce exposure to the offending agents. For example, the presence of the house dust mite can be limited by encasing mattresses and pillows in special dust-proof covers, frequently washing bedding in hot water, and removing carpeting. However, there is no way to completely rid the environment of aeroallergens.
What other factors may play a role in atopic dermatitis?
In addition to irritants and allergens, other factors, such as emotional issues, temperature and climate, and skin infections can affect atopic dermatitis. Although the disease itself is not caused by emotional factors or personality, it can be exacerbated by stress, anger, and frustration. Interpersonal problems or major life changes, such as divorce, job changes, or the death of a loved one, can also make the disease worse. Often, emotional stress seems to prompt a flare of the disease.
Bathing with harsh soaps like Ivory or Irish Spring and without proper moisturizing afterward is a common factor that triggers a flare of atopic dermatitis. Typical recommendations include using a very gentle soap-free cleanser or milder soap like Dove, Cetaphil, or Aquanil. The “three-minute rule” of lubricating with a rich moisturizer such as Vaseline, Aquaphor, or Crisco Vegetable Shortening within three minutes of drying off after a bath or shower is particularly helpful for many patients.
The low humidity of winter or the dry year-round climate of some geographic areas can intensify the disease, as can overheated indoor areas and long or hot baths and showers. Alternately, sweating and chilling can induce an attack in some people. Bacterial infections can also prompt or increase the severity of atopic dermatitis. If a patient experiences a sudden onset of illness, the doctor may check for a viral infection (such as herpes simplex) or fungal infection (such as ringworm or athlete’s foot).
How is atopic dermatitis treated?
Treatment involves a partnership between the doctor and the patient and his or her family members. The doctor will suggest a treatment plan based on the patient’s age, symptoms, and general health. The patient and family members play a large role in the success of the treatment plan by carefully following the doctor’s instructions. Some of the primary components of treatment programs are described below. Most patients can be successfully managed with proper skin care and lifestyle changes and do not require the more intensive treatments discussed. Much of the improvement comes from homework, including lubricating generously especially right after showers or baths.
The doctor has three main goals in treating atopic dermatitis: healing the skin and keeping it healthy; preventing flares, and treating symptoms when they do occur. Much of caring for the skin involves developing skin-care routines, identifying exacerbating factors, and avoiding circumstances that stimulate the skin’s immune system and the itch-scratch cycle. It is important for the patient and family members to note any changes in skin condition in response to treatment and to be persistent in identifying the most effective treatment strategy.
Skin care: A simple and basic regimen is key. Staying with one recommended soap and one moisturizer is very important. Using multiple soaps, lotions, fragrances, and mixes of products may cause further issues and skin sensitivity.
Healing the skin and keeping it healthy are of primary importance both in preventing further damage and enhancing the patient’s quality of life. Developing and following a daily skin care routine is critical to preventing recurrent episodes of symptoms. Key factors are proper bathing and the application of lubricants, such as creams or ointments, within three minutes of bathing. People with atopic dermatitis should avoid hot or long (more than 10 to 15 minutes) baths and showers. A lukewarm bath helps to cleanse and moisturize the skin without drying it excessively. The doctor may recommend limited use of a mild bar soap or non-soap cleanser because soaps can be drying to the skin. Bath oils are not usually helpful.
Once the bath is finished, the patient should air-dry the skin or pat it dry gently (avoiding rubbing or brisk drying) and apply a lubricant immediately. Lubrication restores the skin’s moisture, increases the rate of healing, and establishes a barrier against further drying and irritation. Several kinds of lubricants can be used. Lotions generally are not the best choice because they have a high water or alcohol content and evaporate quickly. Creams and ointments work better at healing the skin. Tar preparations can be very helpful in healing very dry, lichenified areas. Whatever preparation is chosen, it should be as free of fragrances and chemicals as possible.
Another key to protecting and restoring the skin is taking steps to avoid repeated skin infections. Although it may not be possible to avoid infections altogether, the effects of an infection may be minimized if they are identified and treated early. Patients and their families should learn to recognize the signs of skin infections, including tiny pustules (pus-filled bumps) on the arms and legs, appearance of oozing areas, or crusty yellow blisters. If symptoms of a skin infection develop, the doctor should be consulted to begin treatment as soon as possible.
Treating atopic dermatitis in infants and children
- Give brief, lukewarm baths.
- Apply lubricant immediately following the bath.
- Keep a child’s fingernails filed short.
- Select soft cotton fabrics when choosing clothing.
- Consider using antihistamines to reduce scratching at night.
- Keep the child cool; avoid situations where overheating occurs.
- Learn to recognize skin infections and seek treatment promptly.
- Attempt to distract the child with activities to keep him or her from scratching.
Medications and phototherapy: If a recurrence of atopic dermatitis occurs, several methods can be used to treat the symptoms. With proper treatment, most symptoms can be brought under control within three weeks. If symptoms fail to respond, this may be due to a flare that is stronger than the medication can handle, a treatment program that is not fully effective for a particular individual, or the presence of trigger factors that were not addressed in the initial treatment program. These factors can include a reaction to a medication, infection, or emotional stress. Continued symptoms may also occur because the patient is not following the treatment-program instructions.
Corticosteroid creams and ointments are the most frequently used treatment. Sometimes, over-the-counter preparations are used, but in many cases, the doctor will prescribe a stronger corticosteroid cream or ointment. Occasionally, the base used in certain brands of corticosteroid creams and ointments is irritating for a particular patient and a different brand is required. Side effects of repeated or long-term use of topical corticosteroids can include thinning of the skin, infections, growth suppression (in children), and stretch marks on the skin.
Tacrolimus (Protopic) and pimecrolimus (Elidel) ointments are powerful topical medicated creams (drugs that are applied to the skin) that are used for the treatment of atopic dermatitis. These new drugs are referred to as “immune modulators.” They were first and are still commonly used internally (oral form) to help patients with kidney and liver transplants avoid rejecting the organs they received. They work by suppressing the immune system. When these drugs are used in limited and small quantities on intact skin to externally to treat the skin, they are not thought to significantly weaken or change the body’s immune system. Also, unlike topical steroids (cortisone creams), these new medications don’t cause thinning of the skin and breaking of superficial blood vessels (atrophy). However, over the recent few years, there has been concern and a positional change by the Food and Drug Administration (FDA). A special warning has been placed on these two immune modulator drugs with potential caution regarding cancers and other immune-system suppression issues. While dermatologists and other physicians have continued to safely prescribe many of these drugs for children and adults, it is important to discuss these possible concerns and precautions with your physician when beginning a treatment regimen.
A newer class of drugs for improving barrier function in both pediatrics and adults includes Atopiclair and MimyX. These creams may be used in combination with topical steroids and other emollients to help repair the overall dryness and broken skin function.
Additional available treatments may help to reduce specific symptoms of the disease. Antibiotics to treat skin infections may be applied directly to the skin in an ointment but are usually more effective when taken by mouth in pill form. Certain antihistamines that cause drowsiness can reduce nighttime scratching and allow more restful sleep when taken at bedtime. This effect can be particularly helpful for patients whose nighttime scratching aggravates the disease. If viral or fungal infections are present, the doctor may also prescribe medications to treat those infections.
Phototherapy is treatment with light that uses ultraviolet A or B light waves or a combination of both. This treatment can be an effective treatment for mild to moderate dermatitis in older children (over 12 years old) and adults. Photochemotherapy, a combination of ultraviolet light therapy and a drug called psoralen, can also be used in cases that are resistant to phototherapy alone. Possible long-term side effects of this treatment include premature skin aging and skin cancer. If the doctor thinks that phototherapy may be useful in treating the symptoms of atopic dermatitis, he or she will use the minimum exposure necessary and monitor the skin carefully.
When other treatments are not effective, the doctor may prescribe systemic corticosteroids, drugs that are taken by mouth or injected into muscle instead of being applied directly to the skin. An example of a commonly prescribed corticosteroid is prednisone. Typically, these medications are used only in resistant cases and are only given for short periods of time. The side effects of systemic corticosteroids can include skin damage, thinned or weakened bones, high blood pressure, high blood sugar, infections, and cataracts. It can be dangerous to suddenly stop taking corticosteroids, so it is very important that the doctor and patient work together in changing the corticosteroid dose.
Previous clinical trials using drugs like self-injectable interferon treatments demonstrated mixed results and have not become mainstream treatments. The most common side effects with interferon involve mild injection-site reactions and possible fever or flu-like symptoms. These drugs maybe used in severe or challenging situations that don’t respond to more traditional treatments.
In adults, immunosuppressive drugs, such as cyclosporine, are also used to treat severe cases of atopic dermatitis that have failed to respond to any other forms of therapy. Immunosuppressive drugs restrain the overactive immune system by blocking the production of some immune cells and curbing the action of others. The side effects of cyclosporine can include high blood pressure, nausea, vomiting, kidney problems, headaches, tingling or numbness, and a possible increased risk of cancer and infections. There is also a risk of relapse after the drug is discontinued. Because of their toxic side effects, systemic corticosteroids and immunosuppressive drugs are used only in severe cases and then for as short a period of time as possible. Patients requiring systemic corticosteroids or immunosuppressive drugs should be referred to a dermatologist or an allergist specializing in the care of atopic dermatitis to help identify trigger factors and alternative therapies.
In extremely rare cases, when no other treatments have been successful, the patient may have to be hospitalized. A five- to seven-day hospital stay allows intensive skin-care treatment and reduces the patient’s exposure to irritants, allergens, and the stresses of day-to-day life. Under these conditions, the symptoms usually clear quickly if environmental factors play a role or if the patient is not able to carry out an adequate skin-care program at home.
Tips for working with your doctor
- Provide complete, accurate medical information about yourself or your child.
- Make a list of your questions and concerns in advance.
- Be honest and share your point of view with the doctor.
- Ask for clarification or further explanation if you need it.
- Talk to other members of the health-care team, such as nurses, therapists, or pharmacists.
- Don’t hesitate to discuss sensitive subjects with your doctor.
- Discuss changes to any medical treatment or medications with your doctor before making them.
Atopic dermatitis and quality of life
Despite the symptoms caused by atopic dermatitis, it is possible for people with the disorder to maintain a high quality of life. The keys to an improved quality of life are education, awareness, and developing a partnership among the patient, family, and doctor. Good communication is essential for all involved. It is important that the doctor provides understandable information about the disease and its symptoms to the patient and family and demonstrate any treatment measures recommended to ensure that they will be properly carried out.
When a child has atopic dermatitis, the entire family situation may be affected. It is important that families have additional support to help them cope with the stress and frustration associated with the disease. The child may be fussy and difficult and often is unable to keep from scratching and rubbing the skin. Distracting the child and providing as many activities that keep the hands busy is key but requires much effort and work on the part of the parents or caregivers. Another issue families face is the social and emotional stress associated with disfigurement caused by atopic dermatitis. The child may face difficulty in school or other social relationships and may need additional support and encouragement from family members.
Adults with atopic dermatitis can enhance their quality of life by caring regularly for their skin and being mindful of other effects of the disease and how to treat them. Adults should develop a skin-care regimen as part of their daily routine, which can be adapted as circumstances and skin conditions change. Stress management and relaxation techniques may help decrease the likelihood of flares due to emotional stress. Developing a network of support that includes family, friends, health professionals, and support groups or organizations can be beneficial. Chronic anxiety and depression may be relieved by short-term psychological therapy.
Recognizing the situations when scratching is most likely to occur may also help. For example, many patients find that they scratch more when they are idle. Structured activity that keeps their hands occupied may prevent further damage to the skin. Occupational counseling also may be helpful to identify or change career goals if a job involves contact with irritants or involves frequent hand washing, such as kitchen work or auto mechanics.
Controlling atopic dermatitis
- Lubricate the skin frequently.
- Avoid harsh soaps and cleansers.
- Prevent scratching or rubbing whenever possible.
- Protect skin from excessive moisture, irritants, and rough clothing.
- Maintain a cool, stable temperature and consistent humidity levels.
- Limit exposure to dust, cigarette smoke, pollens, and animal dander.
- Recognize and limit emotional stress.
What is the hope for long-term management of atopic dermatitis?
Although symptoms of atopic dermatitis can be very difficult and uncomfortable, the disease can be successfully managed. People with atopic dermatitis, as well as their families, can lead healthy, normal lives. Long-term management may include treatment with an allergist to control internal allergies and a dermatologist to monitor the skin-care component.
- Atopic dermatitis is a type of eczema.
- The skin sensitivity of this disease may be inherited and genetically determined.
- The patient’s skin may be “super sensitive” to many irritants.
- Dry scaly patches develop in a characteristic distribution.
- Itching varies but may be intense and scratching hard to resist.
- Scratching can cause skin thickening and darkening and lead to further complications, including bacterial infection.
- Extremely dry skin can break down and ooze or weep.
- If the itch can be controlled, the rash (which is aggravated by vigorous scratching) may be more readily contained.
- Treatment of atopic dermatitis is centered around rehydrating the skin with rich moisturizers like Vaseline and cautious use of topical steroids to reduce inflammation and itching.
- Oral antihistamines are often necessary to break the “itch-scratch” cycle.
- Since secondary infections can aggravate the rash, topical or oral antibiotics may also be occasionally indicated.