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Philip A. Brunell, MD: Please discuss the diagnosis of atopic dermatitis. How does a physician differentiate between seborrhea and atopic dermatitis in infants?
Bernard A. Cohen, MD: Atopic dermatitis and seborrheic dermatitis can occur concurrently in infants, but distinguishing between the two entities is relatively easy. Infants with seborrheic dermatitis present with dermatitis in unexposed areas such as the diaper area, neck crease, armpit creases, the scalp, and sometimes the flexors of the arms and legs. These unexposed areas tend to remain moist. Infants with atopic dermatitis manifest skin lesions in areas where they can reach, rub, and scratch, such as the neck, head, and parts of the extremities. Also, atopic dermatitis is itchy.
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Anthony J. Mancini, MD: Diaper or umbilical involvement in a neonate or infant usually suggests seborrhea or psoriasis. The scalp is one area of the body where it may be difficult to distinguish between seborrheic and atopic dermatitis, however. Fortunately, the treatment is generally the same in young patients, and with time, the exact diagnosis usually becomes clear.
Samuel Weinberg, MD, FAAP, FAAD, FACP: Children with seborrheic dermatitis on the scalp rarely scratch. Often, parents will try to pick off the scale, causing secondary infection, which in turn may induce children to scratch. Seborrheic dermatitis frequently involves the axilla, and sometimes children will present with sharply demarcated, orbicular or round lesions on the body. On the whole, children with seborrheic dermatitis are comfortable and not fussy, and they eat and sleep well.
Brunell: As a nondermatologist, I recommend using the nail of the little pinky finger to scrape the child’s eyebrows. If there is flaking, the child likely has seborrheic dermatitis.
Brunell: How do physicians differentiate between nummular or orbicular dermatitis and tinea corporus?
Weinberg: Tinea corporus is not nummular dermatitis or orbicular eczema. It is a disease in itself caused by various microsporon or trichophytin organisms, which can cause specific, round lesions. Some patients with tinea corporus present with bull’s-eye shaped lesions. Treatment with antifungal drugs may cause eczematization. The reaction does not necessarily indicate an allergic reaction to the drug, however, and treatment should continue.
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Cohen: Some patients with nummular dermatitis present with primary, small papular lesions on the extensor surfaces, and others present with acute eczematous lesions, also on the extremities. I treat patients with nummular dermatitis as a subset of patients with atopic dermatitis. Tinea corporus should be distinguished from atopic dermatitis.
Weinberg: In my opinion, nummular or orbicular dermatitis is separate from atopic dermatitis, because patients with nummular dermatitis do not normally have all of the other manifestations that often occur in patients with atopic dermatitis. Both groups of patients develop the same round, weepy, edematous, vesicular eruption observed in orbicular eczema, but patients with nummular dermatitis do not have allergic rhinitis, and they have normal IgE levels. Also, patients with nummular or orbicular dermatitis itch more than patients with atopic dermatitis.
Brunell: Do you recommend bleach baths for patients with atopic dermatitis?
Mancini: Bleach baths are recommended for patients with recurrent, frequent bacterial Staphylococcal skin infections, which may include secondarily-infected eczema or recurrent folliculitis or furunculosis. The recipe is one-quarter to one-half cup of bleach to a full bathtub of water, which is similar to swimming pool water and generally does not sting or smell. Patients should soak twice weekly for 5 to 10 minutes.
Weinberg: Bleach baths benefit patients with significantly inflammatory atopic dermatitis and secondary infection. I would not recommend bleach baths for patients with mild atopic dermatitis.
Brunell: Is Staphylococcus aureus an inciting agent in atopic dermatitis? Could bleach baths be used to prevent atopic dermatitis?
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Cohen: There is no question that atopic dermatitis will not improve in a patient with an infection unless that infection is managed.
Brunell: From an infectious disease standpoint, I look at these infectious complications as a manifestation of a breakdown of the skin barrier. I think the best preventative measure is to maintain the skin through the proper use of emollients and steroids.
Although resistant S. aureus is emerging, most community-acquired methicillin-resistant Staphylococcus aureus (MRSA) seems to respond to local therapy. Systemic therapy does not seem to be as critical as getting local infection under control.
Are antibiotic ointments effective on weeping lesions?
Mancini: A combined approach may be necessary for weeping, infected areas. Systemic antibiotics in combination with wet compresses and topical therapies are indicated. The goal is to improve the barrier function. It is now well established that patients with atopic dermatitis may have defective innate antibacterial skin proteins, defensins and cathelicidins, which make these patients more susceptible to bacterial infection.
Brunell: What is the best way to prevent atopic dermatitis?
Mancini: There is no way to completely prevent the disease, which occurs in genetically predisposed individuals, but the best way to prevent flares is with good dry skin care and emolliation. With flares, I recommend treating the disease early and aggressively (the “full court press” approach).
Weinberg: Parents should keep children as stress-free as possible, using proper methods of cleansing, hydration, and emolliation. If this regimen does not improve atopic dermatitis in an older child, the child may need a referral to an allergist.
Brunell: At what point do you make a referral to an allergist?
Cohen: When I have exhausted all possibilities and there is nothing else I can possibly do, I will refer a patient to an allergist.
Mancini: I make a referral to an allergist when the patient has recalcitrant and/or severe atopic dermatitis that has not responded to a solid therapeutic plan. I also refer patients to an allergist when there is a consistent temporal association between flares and ingestion of certain foods.
Weinberg: It is important to distinguish between an allergic reaction to food and an irritant contact reaction, because they look similar and both reactions itch, become red and inflamed, and occasionally ooze. I recommend that parents apply petrolatum as a barrier to prevent an irritant contact reaction.
Cohen: Parents should also apply emollients on the child’s face before and after every meal.
Brunell: Are you concerned that other allergens may trigger atopic dermatitis?
Weinberg: I think it is rare for house dust or mites to aggravate atopic dermatitis. A child with atopic dermatitis and who is also prone to poison ivy, however, will aggravate the atopic dermatitis when scratching the poison ivy. The poison ivy will resolve in approximately three weeks, but the atopic dermatitis will persist.
Mancini: Physicians must understand that the atopic diathesis is a cascade of events. For example, pet dander triggers hay fever. Patients with hay fever will scratch their eyes, sneeze, and rub their nose, which triggers the itch sensation, and hence, the itch-scratch cycle, of atopic dermatitis. Many allergens that exacerbate other atopic diseases, however, may not have been shown scientifically to be direct triggers of atopic dermatitis.
Brunell: Do flares of eczema occur at the same time of exacerbations of hay fever?
Cohen: I think factors causing stress in life, such as hay fever and food allergies, contribute indirectly. Although I use sedating antihistamines to help children with atopic dermatitis sleep at night, there is no evidence-based literature that shows that antihistamines are of any value in treating atopic dermatitis.
Brunell: In summary, I think the cornerstone of therapy for patients with atopic dermatitis is to maintain integrity of the skin by moisturizing, lubricating, controlling inflammation, using steroids if necessary, and treating infection when it occurs.
I would like to thank Infectious Diseases in Children for organizing this symposium and Beiersdorf, Inc., the makers of Eucerin and Aquaphor, for its sponsorship. I would also like to thank the panel members for their participation in this discussion and monograph project.
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[Introduction]
[The epidemiology of atopic dermatitis in children: Incidence, causes and control]
[The treatment of atopic dermatitis in children: A review of therapeutic options]
[Clinical insight: Case management for children with atopic dermatitis]
[Panel Discussion]
