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Atopic Eczema

Synonyms atopic dermatitis, endogenous eczema

Inflammatory skin disease characterised by erythema, pruritis, vesiculation, scaly desquamation and a predilection for the skin creases.

Epidemiology Affects 15-20% of U.K schoolchildren, and 2-3% of adults. 65% present before age 1, prevalence has increased over last 20-30 years^1,2

Causes ^1,2

• Genetic component
• Allergic component (T lymphocytes, Interleukins 4 and 5, mast cells, eosinophils and IgE)
• Environmental allergens (e.g. animal dander, house dust mite, pollen, outdoor pollution, climate, diet, prenatal or early life factors)

Exacerbating factors ⁴

• Local infection
• Irritants (e.g. soap, woolen or rough clothing)
• Allergens
• Stress

Diagnosis ^1,2,3,4 Likely if;

• Itch leading to scratching or rubbing
• Involvement of the skin creases (e.g. folds of elbows, behind knees, ankle anterior, and neck including cheeks in children)
• Personal or family history of atopy
• Chronic or relapsing
• Generalised dry skin
• Onset under age 2

Associated Diseases ^1,2,3

• Asthma
• Allergic Rhinitis
• Food allergies
• Keratoconus
• Anterior subcapsular cataracts
• Conjunctivitis

Non-Pharmacological Management

• General ^3,4
  • Avoidance of irritants
  • Explanation
  • Counselling and psychological support
• House Dust mite ^1,2,3
  • Extreme reduction in house dust mite allergen may reduce severity.
  • Bedding covers appear to be the most effective intervention
• Dietary manipulation ^1,2,3,4
  • Insufficient evidence to recommend
  • Dairy-free diets may lead to Calcium, protein, and calorie deficiency in children
  • Reserve for highly motivated patients with eczema unresponsive to treatments
• Bandages and dressings ^2,3,4
  • Used with emollient and/ or corticosteroid underneath
  • Moist bandaging with warm water often applied to limbs or trunk
  • Usually inpatient treatment or with motivated families

Drugs Management ^1,2,3,4

• Emollients ^1,2,3,4
  • Use as a soap and moisturiser
  • Multiple applications to prevent dryness
  • Bath additives
• Topical steroids ^1,2,3,4
  • Mainstay of treatment
  • Strength dependent on site and severity affected
  • Aim to reduce strength on face and if disease quiescent
  • May cause skin thinning in long term treatment, but little definitive evidence¹
• Antimicrobial Treatment ^1,4
  • Combinations of topical steroids and antimicrobials unlikely to be effective¹
  • Oral antibiotics useful if clinically infected
• Antihistamines ²
  • Widely used but histamine is not main immune mediator
  • Older more sedative treatments more likely to be effective (e.g. hydralazine, chlorpheniramine and trimeprazine)
• Topical Immunosupressants ^6,7
  • Tacrolimus and Pimecrolimus are potent topical immunosupressants
  • Both effective compared to placebo
  • Tacrolimus as effective as potent topical steroids
  • May reduce risk of skin thinning
  • Long-term effects on immunosupression not clear
  • Second line agent at moment
• Oral Steroids ²
  • Use with caution
  • Flare common on dose reduction
• Oral Cyclosporin ²
  • Severe disease
  • Monitor renal function and blood pressure
  • Short courses usually 8 to 12 weeks
• Oral Azathioprine ²
  • Severe chronic disease
  • May be used for long-term management, with blood monitoring

Complications Immune resistance reduced, hence:^2,3,4

• Viruses (warts, molluscum contagiosum)
• Herpes simplex virus (presents as blisters or pustules of uniform size, may be extensive and aggressive and requires immediate dermatology referral.)
• Bacteria (may manifest as weeping, oozing, crusting or development of pustules)

Prognosis 60-70% of children are clear by early teens, although relapses common¹

Prevention Prolonged breast feeding for at least the first five months may reduce eczema risk in children. Manipulation of mothers’ diet during lactation may protect against eczema development although insufficient evidence to recommend routinely^1,5

References Used

1. Charman C. Clinical evidence: atopic eczema. BMJ. 1999 Jun 12;318(7198):1600-4. Review. [Full Text]
2. Friedmann PS. Allergy and the skin. II--Contact and atopic eczema. BMJ. 1998 Apr 18;316(7139):1226-9. Review. [Full Text]
3. Barnetson RS, Rogers M. Childhood atopic eczema. BMJ. 2002 Jun 8; 324(7350):1376-9. Review. [Full Text]
4. Atopic eczema in children - Referral Practice; NICE guidelines Atopic eczema
5. Kramer MS. Maternal antigen avoidance during lactation for preventing atopic eczema in infants. Cochrane Database Syst Rev. 2000;(2):CD000131. Review.
6. Ruzicka T, Assmann T, Homey B; Tacrolimus: the drug for the turn of the millennium?;Arch Dermatol 1999 May;135(5):574-80.[abstract]
7. Williams H. New treatments for atopic dermatitis. BMJ. 2002 Jun 29; 324(7353):1533-4. [Full Text]

Internet and Further Reading

• British National Formulary

Acknowledgements EMIS is grateful to medify.com for facilitating draft authoring of this article. The final copy has passed peer review of the independent Mentor GP authoring team. ©EMIS 2003.

Last issued 02 Nov 2005