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Accurate diagnosis is required to treat and manage children with atopic dermatitis appropriately. Many conditions resemble this disease, including seborrheic dermatitis, psoriasis, tinea, Langerhans cell histiocytosis, metabolic and immunologic diseases, biotin deficiencies, and acrodermatitis enteropathica. After correctly diagnosing atopic dermatitis in a child, the physician must explain to the parent or caregiver that although the child may appear to outgrow the disease, recurrence can occur in the teenage or adult years. Atopic dermatitis is, therefore, a condition that the physician can attempt to control rather than cure.
Atopic dermatitis is often triggered by changes in temperature and humidity. Children with atopic dermatitis do not respond to changes in temperature and humidity as rapidly as other children and will begin to feel the need to scratch. In fact, atopic dermatitis has been defined as “the itch that rashes.” Often children with atopic dermatitis do not have a visible eruption or inflammatory process, but they still scratch, beginning an itch-scratch cycle that provokes an eruption.
Parents should not overdress children with atopic dermatitis, because if the child begins to sweat and increase humidity, he or she will start to scratch. I recommend that in winter, parents dress children in all the clothing thought to be necessary, and then remove one item. Also, parents tend to overdress children for bedtime. Only one layer of blanket is necessary for a child with atopic dermatitis. At night, most of these children tend to kick off all bed clothing and remove blankets because they itch and begin to perspire, increasing humidity and resulting in the need to scratch.
I recommend that children with atopic dermatitis wear fabric that is at least 75% cotton. Parents should not dress children in wool because it is extremely rough. Under the microscope, wool resembles barbed wire. The material scratches the child and causes the child to itch. Synthetic fabrics are also uncomfortable for children with atopic dermatitis. Nylon, for example, can induce sweating.
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Also, it is important that the physician remembers to treat the whole child, not just the atopic dermatitis. Children on strict diets to control food allergies are at risk for nutrition deficiency. These children, therefore, must maintain proper nutrition with sufficient calcium and vitamin D.
Daily bathing for children in dry climates should last no more than 5 to 10 minutes. In addition, I recommend that after bathing the child, parents remove water with their hands rather than a towel. Parents should then apply an emollient such as Aquaphor or Eucerin cream (Beiersdorf, Inc.) or Cetaphil cream (Galderma Laboratories, L.P.). The most appropriate emollient vehicle depends on the time of the year. Parents should not use thick formulations in hot weather because children will become prone to prickly heat, aggravating the atopic dermatitis. Under these conditions, children begin to scratch and worsen the disease.
Parents of children with atopic dermatitis should not use too much water on the child’s face. Parents regularly wash the child’s face after eating but do not apply an emollient afterward. The child’s skin consequently becomes dry, aggravating the atopic dermatitis. I recommend using a cleansing lotion, rather than water, to clean and wipe the face and then applying an emollient. Emollients usually remain on the skin for up to 6 hours, and parents should apply emollients more often than once or twice a day.
When children eat, some food inevitably gets on the face. Citrus and slightly acidic foods aggravate atopic dermatitis. I recommend that parents apply petrolatum on the face as a barrier before feeding their children.
A patient who has severe atopic dermatitis on the cheeks and chin may require treatment with a steroid ointment (Figure 1). I recommend tapering steroid treatment and later replacing the ointment with a less potent steroid, eventually moving to a calcineurin inhibitor until the disease is under control. Finally, emollients should be used once the dermatitis is controlled.
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Children with secondary infection can be treated with topical or systemic antibiotics. Oral antibiotics should be administered for only 7 to 10 days, because organisms will develop resistance. When secondary infection presents with oozing (Figure 2), I recommend a compress of plain water to dry it slightly. Then, the ointment should be applied, followed by an emollient.
In my experience, most children with atopic dermatitis breath through the mouth and drool frequently. It is helpful to apply petrolatum around the mouth to protect that area. I also recommend that infants who drool significantly wear bibs with plastic backing, because all-fabric bibs routinely become saturated and dry out, and this wet/dry cycle aggravates the atopic dermatitis.
Atopic dermatitis often occurs under the ear, extending onto the face (Figure 3). In patients with seborrheic dermatitis or psoriasis, the top of the ear and the area behind the ear extending to the end of the earlobe becomes affected, but not the face. At times, the child may have a combination of seborrheic dermatitis and atopic dermatitis. Both are common diseases, especially in young children. Seborrheic dermatitis rarely occurs in children 4 to 6 years old. If it does occur at that age, the physician should examine the child for an immunodeficiency disease.
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Children who show evidence of lichenification will require more moisturization. Ointments are more useful than creams for these patients, because creams do not penetrate as well. Also creams can irritate some patients.
In typical lichenification, children have increased skin markings, increased thickening, and hyperpigmentation. Tar treatment may be helpful for some children with lichenification. I prefer to add liquor carbonis detergents (5% or 10%) to Aquaphor. This combination is messy, however, and parents should only apply the treatment at night.
Patients with atopic dermatitis with follicular papular eruption on the stomach area frequently have a secondary nickel contact dermatitis. Belt buckles and metal snaps on jeans or pants rub against the area and aggravate the skin. Parents can cover the backs of metal snaps with duct tape or muslin to prevent contact with skin.
For patients with a marked finding of Dennie’s pleats or Dennie-Morgan lines in addition to atopic dermatitis on the upper eyelids (Figure 4), I recommend treating with a calcineurin inhibitor, such as Protopic ointment (Astellas Pharma US, Inc.). Creams should not be used around the eyes because of possible burning and stinging. After 2 to 4 days of treating with a calcineurin inhibitor, petrolatum or emollients may be used.
Children with draining ear will often develop infectious eczematoid dermatitis, because pus in the ear secretes onto the skin. Many children with infectious eczematoid dermatitis have atopic dermatitis. Oral antibiotics are necessary to treat the secondary infection.
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Weinberg S, Prose NS, Kristal L. Color Atlas of Pediatric Dermatology. 3rd ed. New York, NY: McGraw-Hill; 1998. Reproduced with permission from The McGraw-Hill Companies. |
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For a patient with significant crusting, however, topical antibiotics are more effective than oral antibiotics. Oral antibiotics do not penetrate into the superficial area of the crust. Crusting, however, will subside with some soaking and treatment with topical and systemic antibiotics.
Children with eczema may have eczema herpeticum (Figure 5), which can appear vesicular, papular, or umbilicated. Eczema herpeticum must be treated immediately, because it can be extremely dangerous and even fatal because of systemic involvement, including neurologic involvement. Physicians should examine the patient carefully, however, because some children may have a Staphylococcus or Streptococcus infection, which is follicular and looks exactly like eczema herpeticum. Typical eczema herpeticum lesions used to be confused with eczema vaccinatum, but vaccination is no longer practiced in this population.
Treating a child with mollusca contagiosum, which presents with villiform lesions, is difficult because physicians cannot use the entire armamentarium normally available. I recommend a small amount of light liquid nitrogen to remove the mollusca. Other options include a topical immunomodulator. Cantharidin may sometimes cause spreading and leave scars. Candida antigen 1:1,000 is another option for removing mollusca.
For a single mollusca, I recommend using a small amount of novocaine or lidocaine and lightly curetting it off. Spray such as those formulated with ethyl chloride, however, are uncomfortable for children because of stinging.
Children may also present with mollusca lesions around the eyes. Pediatric ophthalmologists sometimes recommend scraping off the lesions under general anesthesia. I find this procedure unnecessary, however, because the lesions are self-limiting and normally disappear within two years.
Although treatment with therapies such as antibiotics or calcineurin inhibitors is necessary for some children, atopic dermatitis can often be prevented and controlled with appropriate clothing, proper cleansing, and moisturization with emollients.
Samuel Weinberg, MD, FAAP, FAAD, FACP, is clinical professor of dermatology at New York University School of Medicine in New York.
[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]
