This condition frequently generates questions in parents regarding the necessary care for their children’s skin.
Atopic dermatitis is long-lasting (chronic) and often flares up periodically. Lawrence F. Eichenfield, MD, chief of pediatric and adolescent dermatology at Radys Childrens Hospital, San Diego. Photo: Shutterstock and Radys Childrens Hospital, San Diego.
The most common question asked of Dr. Lawrence F. Eichenfield, chief of dermatology Pediatric and Adolescent Clinic at Rady’s Children’s Hospital, San Diego, is: Will my child outgrow eczema with age?
The answer “is quite complicated,” he said during the annual seminar of dermatology from Las Vegas. “We used to say, ‘yeah, her child will probably outgrow the disease,’ but now we have good data showing that there are variable courses.”
The atopic dermatitis it is long-lasting (chronic) and usually exacerbates periodically. In addition, it can manifest together with asthma or allergic rhinitis, which is known as the atopic triad.
“There have been several studies looking at the natural course of AD,” Eichenfield said. “A cohort study from Thailand showed that 50% of childhood AD patients lost their AD diagnosis by age 5 years, while there was an increase in allergic rhinoconjunctivitis and asthma, similar to what has been seen in atopic march studies,” he said.
A separate group of researchers analyzed records from The Health Improvement Network to determine the prevalence of AD among more than 8 million patients seen in primary care between 1994 and 2013. They found that the cumulative lifetime prevalence of atopic eczema was 9 .9%, and the highest rates of active disease were among kids and older adults.
In this regard, Eichenfield indicated that “in general, it has a high prevalence in the first years of life, decreases and can increase once more when people are 60 years and older. In this data set it is not known if that is really AD or eczema xerotic”.
Eichenfield tells parents that “there is a very good chance (depending on the severity of the disease) that 60% to 70% of kids get over the eczema or most of it,” she said. “If you ask me when, I won’t tell you. The important thing is to treat it to minimize its impact. We want minimal rash, minimal itching, and minimal sleep disturbance. Sometimes I say, that might improve the chance of eczema getting better over time.”
The following are four other common questions parents and patients ask:
Can we find out the allergies that cause eczema?
“This is probably one of the most perplexing questions I get asked,” he said. “It’s a trick question. My answer is that allergies are intertwined with Alzheimer’s disease. The search for the secret allergy that causes atopic dermatitis it is rarely successful.” Sensitization is much more common with Alzheimer’s disease, he added, which means specific IgE tests, either blood tests or skin tests. “The more severe your eczema, the more likely you are to have a true food allergy,” he said.
“About 15% of patients with milder eczema will have at least one food allergy, but when it comes to more moderate to severe cases, regarding 40% will have a true food allergy,” added the doctor.
However, food reactions may not cause eczema. Food reactions can cause urticaria, angioedema, eczematous dermatitis, allergic contact dermatitis, contact urticaria, and respiratory disturbances.
NIH guidelines suggest that kids children under 5 years of age with moderate to severe AD be considered for evaluation for food allergy to milk, egg, peanut, wheat, and soy, if at least one of the following conditions is met: the child has persistent AD despite optimized management and topical therapy, and/or the child has a reliable history of an immediate reaction following ingestion of a specific food.
How should I bathe and hydrate?
There are no standard guidelines for the frequency, type or duration of bathing in AD patients, he said, although in more severe illness, frequent bathing may be helpful along with standard topical anti-inflammatory medications, Eichenfield said.
“I do explain that we don’t want to use harsh soaps; we want to be gentle in our washing. I generally recommend bathing every day or every other day. It’s important to dry the skin pat and then apply a moisturizer. Applying a moisturizer 2-3 minutes following bathing is important and limited and significant use of cleansers can be helpful,” she added.
Do I have to use topical?
“I try to explain that there is a dysfunction of the barrier of the skin that stimulates the inflammatory environment, and that inflammation in the skin o blood in AD negatively affects the barrier function of the skinEichenfield said. “I explain that if the swelling doesn’t improve with good skin, moisturizers and avoiding triggers, we need anti-inflammatory medications. Then we looked at what the options are, the significant variation in concentrations of topical corticosteroids and topical non-steroids.”
Is it time for stronger systemic medicine?
Any conversation on this topic must support the concept that AD is multifactorial. “We have the rash of eczema,” he said. “We have the itching. We have an impact on sleep disturbance. We have the comorbidities. We have other physical changes. When we recognize that if patients have a disease significant enough that they don’t get better with topicals and it’s having a negative impact on their lives, we can move our discussion to systemic therapy.
Systemic therapy counseling includes shared decision making regarding the choice of biologics versus oral JAK inhibitors versus traditional systemic agent or phototherapy. Factors to consider in decision making include patient age, gender, severity, comorbidities, prior therapy, risk aversion, duration, access to medication, and desired efficacy.
“Evolving therapies may change the conversation, the questions and the outcomes, but the overall desired outcome is long-term disease control, minimal eczematous rash, minimal itching and minimal sleep disturbance,” he said.
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