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    Eczema (Atopic Dermatitis)

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    eczema atopic dermatitis

    This itchy, irritating, skin rash is something that walks through the doors of my family practice office multiple times weekly.  It affects infants all the way up to adults of all races.  Often, they won’t be the only one in the family who has or has had a rash similar to this.

    Today we will talk about the topic of atopic dermatitis, otherwise known as eczema or atopic eczema.  This condition causes erythematous, itchy, and scaly lesions that are commonly on the flexural surfaces of the body.  It often will present in patients with allergies and asthma known as the atopic triad.

    Who Does Eczema Affect?

    Eczema typically presents before two years of age, affecting over 11 percent of the United States population in this age group, and even as high as 19 percent of this age group in some states.  A United States survey noted that 17.8 million people are living with eczema and even more that are undiagnosed!

    Catching this diagnosis early on can avoid long-term skin changes such as scarring, post inflammatory changes, and secondary infections with Staphylococcus, Streptococcus, and herpes viruses.

    Atopic Dermatitis Etiology

    The cause of eczema is believed to be due to a genetic defect in the filaggrin protein which leads to interruption of the epidermis.1  This diversion in the skin results in contact between immune cells in the dermis and the environment.1  This interaction leads to pruritus, scratching, and further destruction of the epidermis and inflammation.1

    Patient Presentation

    Eczema typically presents in one of three different stages:

    1) acute
    2) subacute
    3) chronic

    Acute eczema often presents with weeping, crusting, and vesicular eruptions. 

    eczema atopic dermatitis
    Am Fam Physician. 2012 Jul 1;86(1):35-42.

    Subacute eczema presents as scaly, dry, erythematous plaques and papules, and chronic eczema with lichenification and darkening of the skin pigment due to repetitive scratching of the skin.

    eczema atopic dermatitis
    Am Fam Physician. 2012 Jul 1;86(1):35-42.

    An elusive presentation of eczema occurring in children is pityriasis alba, which is seen as hypopigmentation with nonprecise demarcated plaques and fine scales.

    eczema atopic dermatitis
    https://ozarkderm.com/media/k2/galleries/295/pityriasis-alba_15170421984eef90d28e7ea.jpg

    Regarding where eczema can show up, anywhere is the correct answer, but some areas are more common than others.  This includes the flexural surfaces of the body, on the eyelids, face, forehead, neck, wrists, feet and hands.1 

    As you can see from above, with so many ways that eczema can present the differential diagnosis can be quite broad and extensive.

    Diagnosing Eczema

    The diagnosis of eczema is made based on the history and physical examination.  The most validated criteria for diagnosis is the U.K. Working Party’s Diagnostic Criteria.  These criteria have a 95 and 97 percent sensitivity and specificity.1

    The criteria includes itchy skin with at least three of the following: a history of flexural involvement, history of asthma or allergies, onset before two years of age, history of generalized dry skin, or visible flexural dermatitis.1

    Treating Eczema (Atopic Dermatitis)

    Once the diagnosis is made, how do we treat this?  There are many different therapies for this condition that will be covered below.

    Skin emollients such as Aquaphor, Neosporin Eczema Essentials, Cetaphil, Eucerin, petroleum jelly, and many more are often used initially for eczema and the associated skin dryness.  Patients should liberally apply an emollient to the entire body whether they are having a flare up or not.  It has been seen that with routine use of topical emollients that the need for topical steroids is reduced as are irritative symptoms.

    In addition, there are newer barrier-repair moisturizers that are available that add ceramide lipids to the skin along with rehydration.1  These being Cerave and Restoraderm.  To avoid excessive skin itchiness, patients should also shower with warm water instead of hot, and use an emollient body wash while bathing.

    Another first-line therapy is topical steroids during flare-ups of eczema.  As we know, there are a vast amount of different topical steroids that span across a plethora of potencies.  A general rule is to tailor the strength based on the severity of the eczema flare up.

    In cases where there is lichenification from chronic eczema, a higher potency steroid for a longer duration is often needed.  Often with use of topical steroids, there is a risk of skin atrophy.  To avoid this, you will usually want to use mild potency topical steroids, but even lower potency on areas on the face, axilla, groin, neck, flexor surfaces, and other skin folds.

    In addition to potency, the duration of use is relevant as well.  When using moderate potency topical steroids, the period of use should be for two weeks or less.  After the acute flare has resolved, patients should return to their regular skin emollient regimen.

    eczema atopic dermatitis
    Am Fam Physician. 2009 Jan 15;79(2):135-140.
    eczema atopic dermatitis
    Am Fam Physician. 2009 Jan 15;79(2):135-140.
    eczema atopic dermatitis
    Am Fam Physician. 2009 Jan 15;79(2):135-140.

    Topical Calcineurin inhibitors are immunomodulators that are considered a second line treatment for eczema.  These include pimecrolimus and tacrolimus.  These are typically only used short-term or for intermittent long-term therapy in patients with moderate to severe disease.1

    Often, they are introduced when there is concern of adverse effects associated with prolonged topical steroid use, such as skin atrophy.  The topical Calcineurin inhibitors have not been found to cause skin weakening. Therefore, they are a worthy option to use on areas with thinner skin such as the face, neck, axilla, and skin folds.1 

    When comparing pimecrolimus versus tacrolimus, studies have shown that tacrolimus is slightly more effective in the treatment of severe eczema.1  Pimecrolimus has been shown to be weaker than moderate topical steroids, whereas tacrolimus has been seen to be at least as effective as moderate to high potency steroids.1

    Unfortunately, with what sounds to be good with the topical Calcineurin inhibitors, the United States FDA issued a black box warning for these medications due to their report of a possible link to lymphoma and skin malignancies.1  There was debate as to whether these drugs caused systemic immunosuppression as well.  However, the ADA did not find evidence of these medications causing immunosuppression or leading to malignancies if long-term use is avoided.1

    A newer therapy for eczema is Eucrisa (Crisaborole) which is a PDE4 inhibitor.  This medication leads to increased levels of cyclic AMP which is believed to help suppress proinflammatory cytokines.3  It is approved for anyone over two years of age and is indicated for twice daily usage.  The most common adverse effect seen with this medication is burning or stinging at the site of application.3

    For those patients who have eczema that is refractory to topical therapies, ultraviolet phototherapy and systemic immunomodulatory therapy (cyclosporine or interferon gamma-1b) can be used by a dermatologist.1 

    Rarely, short-term oral or intramuscular steroids can be used for severe eczema flare-ups.

    Other homeopathic remedies, hypnotherapy, or massage therapy efficacy has not been established.  Chinese herbal mixtures have shown some effectiveness in four small trials, but more extensive studies have not been completed.  Fish oil, minerals, vitamins, probiotics, and vitamin E have not been shown to be efficacious treatment options for eczema.

    Resources

    1. American Family Physician. Atopic Dermatitis: An Overview. Accessed: January 5, 2018.
    2. American Family Physician. Treatment Options for Atopic Dermatitis. Accessed: January 5, 2018.
    3. The Medical Letter. Crisaborole (Eucrisa) for Atopic Dermatitis. Accessed: January 5, 2018.
    4. American Family Physician. Choosing Topical Corticosteroids. Accessed: January 5, 2018.
    5. Ferri’s Clinical Advisor, 2017. Atopic Dermatitis.

    This article, blog, or podcast should not be used in any legal capacity whatsoever, including but not limited to establishing standard of care in a legal sense or as a basis of expert witness testimony.  No guarantee is given regarding the accuracy of any statements or opinions made on the podcast or blog.

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    Clay Walker
    Clay Walker is a board-certified physician assistant practicing in family medicine and urgent care in rural southern Illinois. He is a graduate of Southern Illinois University School of Medicine Physician Assistant Program - class of 2016. Prior to going to PA school, Clay worked as a histology technician in southern Illinois.  From an early age, he has been interested in medicine. Clay was diagnosed as a type 1 diabetic in the first grade. He began learning about his condition and teaching others about T1DM; since then, he began to have a passion to learn medicine and make a difference in the lives of others. In his free time, Clay enjoys watching sports and going to sporting events, specifically the Chicago Cubs and Philadelphia Eagles.