Atopic dermatitis

Dermatology Nursing, Dec, 2006 by Bill Wade, Michael Dubinski

History: A 45-year-old male presented to the clinic with a 2-week history of extensive, dry, scaly, pink eczematous plaques on the legs, thighs, forearms, arms, and dorsal aspects of the hands (see Figures 1-5). He has had previous attacks of eczema since the age of 18, and his brother has a history of eczema. The diagnosis was atopic dermatitis, aggravated by workplace exposure as a mechanic, to irritants such as varsol, coolants, and solvents.

[FIGURES 1-5 OMITTED]

Description: Atopic dermatitis is a chronic disease that affects the skin, leading to intense pruritus, lichenification, and other skin features such as papules and ichthyosis. Scratching leads to redness, swelling, cracking, "weeping" of clear fluid, and finally, crusting and scaling. In most cases, there are exacerbations of flares followed by periods of remission. Atopic dermatitis is the most common of the many types of eczema. It usually occurs in people who have an "atopic tendency," which is a predisposition to develop any or all of three closely linked conditions: atopic dermatitis, asthma, and hay fever.

Etiology: The cause of atopic dermatitis is not known, but the disease seems to result from a combination of genetic (hereditary) and environmental factors. Children are most likely to develop the disorder if one or both parents have had it or have allergic conditions such as asthma or hay fever. While some people outgrow skin symptoms, approximately 75% of children with atopic dermatitis develop hay fever or asthma. Atopic dermatitis is also associated with malfunction of the body's immune system. The immune system can become misguided and create an inflammation in the skin even in the absence of a major infection. This can be viewed as a form of autoimmunity, where a body reacts against its own tissues. Emotional factors such as stress can make the condition worse, but does not cause the disorder. Environmental factors such as extreme heat or humidity, medication, clothing (especially wool or silk), grease, oils, soaps and detergents, and environmental allergens can bring on symptoms of atopic dermatitis at any time in individuals who have inherited the atopic disease trait.

Location: Atopic dermatitis may cover many parts of the body, including in the elbows, knees, hands, and feet, lips, and palms. It may also affect the skin around the eyes, the eyelids and the eyebrows and lashes. The areas of highest predilection are flexural folds, front and sides of the neck, eyelids, forehead, face, wrists, and dorsa of feet and hands.

Hallmarks of the Disease: Patients with atopic dermatitis typically experience intense pruritus in characteristic locations typical of the disease. For infants and young children, this is usually present on the scalp, cheeks, chin, and other surfaces of the extremities. Older children and adults typically experience pruritus on the neck, wrists, ankles, and the antecubital and popliteal fossas. They also have chronic or recurring symptoms as well as a personal or family history of atopic disorders (eczema, hay fever, asthma). They may also have an extra fold of skin that develops under the eye, increased number of skin creases on the palms, and inflamed eyelids (Dennie-Morgan sign).

Treatment: Corticosteroid creams and ointments have been used for many years to treat atopic dermatitis and other autoimmune diseases affecting the skin. New medications known as immunomodulators have been developed that help control inflammation and reduce immune system reactions when applied to the skin. Examples of these medications are tacrolimus ointment (Protopic[R]) and pimecrolimus cream (Elidel[R]). They can be used in patients older than 2 years of age and have few side effects (burning or itching the first few days of application). They not only reduce flares, but also maintain skin texture and reduce the need for long-term use of corticosteroids. Emollients (such as Cetaphil[R], Prevex[R], Trixera[R], Lipikar[R], and Impruv[R]) are also a very important part of managing atopic dermatitis because they provide moisture to the skin and help minimize water loss.

Normal Course: The course is unpredictable, though exacerbations are common during childhood, adolescence, or adulthood, and may persist throughout life.

Patient Education and Nursing Measures: Healing the skin and keeping it healthy are important to prevent further damage and enhance quality of life. Developing and maintaining a daily skin care routine are critical to preventing flares. A lukewarm bath helps cleanse and moisturize the skin without drying it excessively. Emollients applied immediately after a soaking bath can also help retain skin moisture. Because soaps can be drying to the skin, a mild bar soap or nonsoap cleanser may be recommended. Bath oils are not usually helpful. Another key to protecting and restoring the skin is taking steps to avoid repeated skin infections. Emollients are also important to use as part of the daily skin care regimen and during remissions.