Lawrence C. Parish, MD
Q: My son is up all night scratching. When he was an infant, our doctor told us that he had infantile eczema. Now he is 12 years old and he still has eczema.
A: Sound familiar? This boy has eczema, or better termed atopic dermatitis. This is a type of allergy, like hay fever or asthma, but unlike the other allergic disorders, there is nothing for the child to avoid. Most dermatologists will say that skin testing is not helpful because the allergen(s) cannot be found.
Atopic dermatitis appears as redness, scaling, and thickening of the skin, called lichenification. It is most common on the back of the neck, the back of the elbows, and behind the knees. There is no real primary lesion; that is, the child may itch but there is nothing to see until the area is scratched or rubbed. In addition to the scratch marks or the rubbed redness, the skin may begin to show crusting and water blisters (vesicles). Sometimes, there may even be pustules as part of secondary bacterial infection.
Atopic dermatitis can look different in appearance in different age groups. In infants and toddlers, the redness and scaling may be on the cheeks, arms, and legs, or even on the trunk. Infantile atopic dermatitis may be present for a short time. There is no way of knowing whether this is the only appearance of the atopic dermatitis or whether the child will have skin problems for many years. As the boy or girl grows older, the more traditional areas (neck, elbows, and knees) become involved.
There are characteristic signs of the atopic patient. For example: When the eyes are rubbed too much, they can develop lines called Dennie-Morgan lines, or a darkness called "raccoon face". Excessive rubbing of the lips leads to cracking and redness, called the "furrowed mouth syndrome." In older children or when the condition is not active, the skin might just be dry with mild scaling; i.e. sensitive skin.
Atopic dermatitis might be confused with several other skin conditions. For example, neurodermatitis looks the same, but is distinguished from atopic dermatitis by the fact that there is no allergic history in child or in his/her family. Seborrheic dermatitis appears on the scalp (dandruff), between the eyebrows, around the nose, and behind the ears. Contact dermatitis, like poison ivy, would not be symmetrical and might be short-lived. Ringworm (tinea corporis) has sharp borders with central clearing.
The most important part of treatment is avoiding more irritation of the skin. Excessive hot water can set off an itch-scratch cycle, while soap use should be limited to the critical areas. Unworstered wool oftentimes sets off more irritation. Wool can also be found elsewhere, in lotions and creams. Wool alcohol is another name for lanolin. That is why Cetaphil lotion or cream, which contain no irritants, makes a good lubricating agent.
Treatment today involves two types of drugs: corticosteroids and immunomodulators. Steroid lotion, cream, or ointment will reduce the itching and the redness. As an alternative, the new immunomodulators work very well in most children. Steroid pills or injectable steroids should be reserved for extreme situations and severe flair-ups.
Both types of drugs are safe when used appropriately. Do not be frightened of the term steroids ‚ these are corticosteroids, not the anabolic steroids used by athletes. When using steroid lotions or creams, do not apply them at the same time as lubricating lotions, as this will dilute the active ingredients and make the steroids less effective.
Colloidal baths are often helpful in the acute phase to reduce the itching. Oral antihistamines make the patient ignore the itching but they do not treat the underlying problem. Neither affects the course of the disease ‚ they just lessen its symptoms.
The symptoms of atopic dermatitis tend to come and go on its own. Some children will outgrow it while others will continue to be plagued by it for years to come. You should remember this is a controllable disease.
Lawrence Charles Parish, M.D., is a clinical professor of Dermatology and Cutaneous Biology and director of the Jefferson Center for International Dermatology, Jefferson Medical College, Philadelphia, PA. Please send your questions and comments to him care of Pediatrics for Parents, P.O. Box 63716, Philadelphia, PA 19147.
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