Atopic dermatitis - External and Internal EyeSee also in: Overview,Cellulitis DDx
Alerts and Notices
SynopsisAtopic dermatitis (eczema) is a chronic, relapsing, pruritic condition that is often associated with allergic rhinitis and/or asthma. Infants and children are most often affected, with 85% of cases appearing in the first year of life and 95% of cases appearing by 5 years. Uncommonly, the condition may persist into, or even arise in, adulthood. Less than 1% of adults are affected by atopic dermatitis. With increased understanding of immunosenescence, atopic dermatitis is increasingly being recognized in the older adult population.
In infants, the disease involves primarily the face, scalp, and torso. In children and adults, the disease usually involves chiefly the flexural aspects of extremities, but it may be more generalized.
Atopic dermatitis may be categorized as follows:
- Acute – erythema, vesicles, bullae, weeping, crusting
- Subacute – scaly plaques, papules, round erosions, crusts
- Chronic eczema – lichenification, scaling, hyper- and hypopigmentation
The cause of atopic dermatitis is unknown. Genetic and environmental predisposing factors exist. Multiple loci have been associated with atopic dermatitis. A family history of atopic dermatitis is common.
Intense pruritus (itching) is a hallmark of atopic dermatitis. Scratching leads to lichenification (skin thickening from chronic trauma). Eyelid skin may be involved with scaly or lichenified plaques. Impaired barrier function leads to increased transepidermal water loss and the risk of bacterial and viral cutaneous infections. Patients with atopic dermatitis are prone to impetiginization with Staphylococcus aureus. Secondary infections with herpes simplex virus (eczema herpeticum), molluscum contagiosum, Coxsackie virus, or vaccinia virus (eczema vaccinatum) can occur.
Patients with atopic dermatitis have difficulties in retaining skin moisture and suffer from xerosis (dry skin). Environmental triggers, such as heat, humidity, detergents / soaps, abrasive clothing, chemicals, smoke, and even stress, tend to aggravate the condition. Latex allergy and nickel allergy occur more often in persons with atopic dermatitis. Additionally, patients with atopic dermatitis have been found to be more likely to have positive patch test results to products commonly found in topical treatments, including cocamidopropyl betaine, wool alcohol / lanolin, and tixocortol pivalate. Allergy to eggs, cow's milk, or peanuts is common. There may be a relationship between atopic dermatitis and the development of aspirin-related respiratory disease.
Atopic keratoconjunctivitis is characterized by ocular pruritus, burning, and tearing. It is usually associated with concomitant dermatitis and asthma and affects 20%-40% of those with dermatitis, being seen somewhat more often in males.
Posterior subcapsular cataracts are typically asymptomatic and can be seen in adult patients with severe atopy. They rarely occur in children. Factors driving the development of cataracts in atopic dermatitis may be the disease itself or corticosteroid therapy. Keratoconus is reported in about 1% of patients with atopic dermatitis and appears to develop independently of cataract formation.
L20.9 – Atopic dermatitis, unspecified
24079001 – Atopic dermatitis
Differential Diagnosis & Pitfalls
- Seborrheic dermatitis
- Allergic contact dermatitis – The eyelids are a common site for allergic contact dermatitis. Patients with atopic dermatitis are at higher risk for developing contact dermatitis secondary to chronically compromised barrier function. Consider this diagnosis in recalcitrant cases.
- Irritant contact dermatitis
- Dermatomyositis – heliotrope
- Tinea faciei
Patient Information for Atopic dermatitis - External and Internal Eye
OverviewEczema (atopic dermatitis) is a disorder associated with dry skin that begins with intense itching that is aggravated by scratching. The condition runs in families and often occurs along with asthma and hay fever. Heat, humidity, detergents / soaps, abrasive clothing (eg, very scratchy wools), chemicals, smoke, and stress may trigger eczema. Scratching increases the chances of developing an infection because it produces breaks in the skin. There is no cure for eczema, and it is not contagious.
Who’s At RiskInfants and children are most frequently affected, but eczema may persist into adulthood in some individuals.
Signs & SymptomsEczema is usually itchy. The most common locations for eczema include the face, neck, in front of the elbows, and behind the knees. Adults with eczema may notice the most irritation on the arms and legs, but any part of the skin may be affected.
- Thickened, scaly papules (small, raised bumps) and plaques (areas of raised skin that is larger than a thumbnail and feels rough and flaky) are seen in these areas, and the condition can be:
- Mild – a few scattered areas of involvement that are easily treated with self-care measures.
- Moderate – more extensive involvement that is more difficult to control with self-care measures and may require prescription therapy.
- Severe – widespread involvement that is difficult to treat even with prescription therapy.
- In lighter skin colors, affected areas may appear pink or red; in darker skin colors, the redness may be subtle, or affected areas may appear purplish or darker brown.
- Some adults may have chronic hand involvement.
- There may also be accentuation of the hair follicles and shininess without obvious thickened, raised areas.
- Areas of eczema that become infected (known as a superimposed infection) can develop thick crusts.
Self-Care GuidelinesMaintaining healthy skin is very important for those with eczema.
- Moisturizing skin-care routines are essential.
- Avoid long, hot showers. Hot water can dry the skin.
- Hypoallergenic moisturizing soaps, such as unscented Dove, Vanicream bar soap, and Nature by Canus, are recommended.
- Thick moisturizers such as petroleum jelly, Aquaphor ointment, Eucerin cream, CeraVe healing ointment, or CeraVe moisturizing cream should be applied to damp skin daily after bathing.
- Treat red, itchy areas with over-the-counter hydrocortisone (eg, Cortaid) cream or ointment 0.5%-1% twice daily. Avoid using steroid cream on the eyelid area for more than a few days.
- Attempt to minimize exposure to heat, humidity, detergents / soaps, abrasive clothing, chemicals, smoke, and stress.
- Fragrance-free laundry detergent may be beneficial.
- Keep the home from getting too dry by using a humidifier, especially in the bedroom.
When to Seek Medical CareSeek medical care if there is a lack of response to self-care measures or if the condition worsens (flares).
Also see a medical professional if you see areas of pus or large numbers of crusty areas (scabs), as this might be caused by infection with bacteria.
TreatmentsTopical or oral (systemic) medications can include:
- Topical steroid creams or ointments to treat active areas of limited (localized) eczema. Low-strength steroids may be used on the face, and medium-to-high-strength steroids may be used on the body (trunk) and arms or legs (extremities). Care should be taken when using topical steroids in skin folds because of the risk of thinning (atrophy) of the skin.
- Tacrolimus (Prograf) ointment or ruxolitinib (Jakafi) cream may be prescribed in place of topical steroids.
- Pimecrolimus (Elidel) cream may be prescribed for milder eczema or for certain areas of involvement, such as the face.
- Oral antihistamines may be prescribed to decrease itching.
- A short course of oral steroids may be prescribed for flared eczema.
- Light therapy may be recommended for treatment of widespread, resistant eczema, as may immunosuppressive medications, such as methotrexate.
- Newer medications such as dupilumab (Dupixent) or Janus kinase (JAK) inhibitors may be prescribed for severe cases.
- In patients who have multiple areas of broken skin or a history of bacterial skin infections, diluted bleach baths may be recommended.
- If an infection is suspected, topical or oral antibiotics may be prescribed.
Atopic dermatitis - External and Internal EyeSee also in: Overview,Cellulitis DDx