Atopic dermatitis in ChildSee also in: Cellulitis DDx,External and Internal Eye
Alerts and Notices
SynopsisAtopic dermatitis (eczema) is a chronic, relapsing, pruritic condition. It is commonly recognized by a constellation of the following principle characteristics: (1) pruritus (itch); (2) facial and extensor involvement during infancy that changes to flexural involvement in late childhood; (3) a chronic relapsing course; and (4) a personal or family history of atopy (atopic dermatitis, food allergies, 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.
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. Children of African descent may present with an infantile distribution of lesions even later in childhood. Follicular patterns (ie, follicular eczema) are more common in darker skin phototypes. A lichen planus-like appearance has also been reported in persons with darker skin phototypes, due to lichenification and the difficulties in perceiving erythema in darker skin.
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
Intense pruritus is a hallmark of atopic dermatitis. Scratching leads to lichenification (skin thickening). Impaired barrier function increases 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 dermatitis is increasing in the developed world. In the United States, about 10% of children may be affected by atopic dermatitis, but the majority of these cases are mild. Mild cases may improve in adulthood, although some may retain stigmata of dry or sensitive skin.
L20.9 – Atopic dermatitis, unspecified
24079001 – Atopic dermatitis
Differential Diagnosis & Pitfalls
- Pityriasis rosea
- Lichen simplex chronicus is composed of isolated hyperpigmented, leathery plaques, frequently seen on the posterior neck, genitals, and extensor forearms and lower legs. Xerosis and atopy may be exacerbating factors in this condition.
- Nummular dermatitis (nummular eczema)
- The impaired cutaneous barrier in patients with atopic dermatitis makes them more prone to both irritant and allergic contact dermatitis.
- Molluscum contagiosum infections may flare atopic dermatitis in patients prone to eczema and present as numerous flesh to pink-colored dome-shaped papules, often on flank or flexural creases. Molluscum can trigger an eczematous dermatitis in children who have no history of atopic dermatitis. Allergic contact dermatitis is also frequently encountered in atopic patients.
- Scabies is also intensely pruritic, classically accentuated at night. Typical sites of involvement include the interdigital web spaces, axillae, wrists, belt area, buttocks, and feet. The pathognomic sign is the burrow.
- Scaly plaques in tinea corporis are typically annular or arcuate. Tinea incognito may be mistaken for atopic dermatitis due to absence of scale and inflammation. Fungal elements can be demonstrated using a potassium hydroxide (KOH) preparation.
- Classic lesions in psoriasis are well-defined erythematous plaques involving the scalp and extensor elbows and knees with overlying silvery scale. In young children not yet potty-trained, groin psoriasis may present as well-demarcated pink plaques.
- Seborrheic dermatitis tends to involve the scalp and groin in infants and has greasy scale as opposed to dry scale seen in atopic dermatitis. In teenagers, facial seborrheic dermatitis may present as yellow-white scale overlying the eyebrows and glabella or medial cheeks.
- An atopic-like eczematous dermatitis may be observed in patients with Wiskott-Aldrich syndrome, selective IgA deficiency, Letterer-Siwe disease, hyper-IgE syndrome, and Netherton syndrome, as these conditions may display similar eruptions.
Patient Information for Atopic dermatitis in Child
- Atopic dermatitis (eczema) 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.
- Eczema is a condition primarily affecting people who have allergies.
- 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 in the affected areas (superimposed infection) because scratching creates breaks in the skin that can allow bacteria to get in.
- There is no cure for eczema, and it is not contagious.
Who’s At RiskInfants and children are most frequently affected by eczema, but this condition may continue into adulthood.
Signs & SymptomsEczema is usually itchy.
The most common locations for eczema are the face, neck, front of the elbows, behind the knees, and the arms and legs.
Thickened, scaly papules (small, raised bumps) and plaques (areas of raised skin that are larger than a thumbnail and feel rough and flaky) are seen in the skin of these areas. The condition may be:
- Mild – few, scattered areas that are easily treated with self-care measures.
- Moderate – more extensive areas that are more difficult to control with self-care measures and may require prescription therapy.
- Severe – widespread (diffuse) affected areas that are difficult to treat even with prescription therapy.
Children with eczema may have prominent affected areas on the arms and legs, particularly in front of the elbows and behind the knees.
There may also be extensive accentuation of the hair follicles and shiny skin without obvious thickened, raised areas.
Infected areas can develop thick crusts.
Self-Care GuidelinesMaintaining adequate moisture in the skin is very important.
Self-care measures include the following:
- Moisturizing skin-care routines are essential.
- Hypoallergenic moisturizing soaps, such as unscented Dove Sensitive Skin Beauty Bar, Vanicream Cleansing Bar, and Nature by Canus, are recommended.
- Thick moisturizers such as petroleum jelly (Vaseline), Aquaphor Healing Ointment, Eucerin Original Healing Cream, CeraVe Healing Ointment, or CeraVe Moisturizing Cream should be applied to damp skin daily after bathing.
- Treat areas of skin color change and itching 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 CareSee your child's medical professional for evaluation if you see no improvement with self-care measures or the eczema gets worse. Also see them 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 areas of limited (localized) eczema. Use lower-strength steroids on the face and medium-to-high-strength steroids on the body (trunk) and arms or legs (extremities). Be careful when using topical steroids in skin folds and on covered (occluded) skin areas to avoid the risk of thinning (atrophy) of the skin.
- Medications that allow you to reduce steroid exposure (called steroid-sparing agents), such as topical ruxolitinib (Jakafi) cream, tacrolimus (Prograf) ointment, or pimecrolimus (Elidel) cream, may be used for treating sensitive areas such as the face. Ruxolitinib cream is approved for use in children 12 years and older. Tacrolimus and pimecrolimus are not approved for use with children younger than 2 years. They have a warning that their use may have a small risk of causing cancer.
- Oral antihistamines may be prescribed to reduce itching.
- A short course of oral steroids may be prescribed for worsening (flared) eczema.
- Light therapy may be recommended for treatment of widespread, resistant eczema, as may newer medications such as dupilumab (Dupixent) or Janus kinase (JAK) inhibitors for severe cases.
- In patients who have multiple areas of broken skin or a history of bacterial skin infections, dilute bleach baths may be recommended.
- If an infection is suspected, topical or oral antibiotics may be prescribed.
Atopic dermatitis in ChildSee also in: Cellulitis DDx,External and Internal Eye