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Childhood atopic dermatitis: 1

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Linda Moffat, RGN, SCM, Cert Health Ed.

Sister, Dermatology and Medical Procedure Unit, Cumberland Infirmary, Carlisle, Cumbria

Atopic dermatitis (AD) is a common childhood condition affecting between 10 and 15% of children. Its prevalence has increased gradually over the past 30 years in developed countries and although the reason for this has not been fully investigated, there is speculation that urbanisation, air pollution, access to a wider variety of food, increase in domestic pets and higher maternal age may be contributory factors (Barneston and Rogers, 2002).
Atopic dermatitis (AD) is a common childhood condition affecting between 10 and 15% of children. Its prevalence has increased gradually over the past 30 years in developed countries and although the reason for this has not been fully investigated, there is speculation that urbanisation, air pollution, access to a wider variety of food, increase in domestic pets and higher maternal age may be contributory factors (Barneston and Rogers, 2002).


The terms dermatitis and eczema are used synonymously. The word eczema comes from the Greek word for 'boiling' and refers to the vesicles that are often seen in the early stages of acute AD. Atopy is derived from the Greek for 'without a place' and was designed to make the point that the associated atopic diseases of asthma, eczema and hay fever had no place in the medical classification then in existence. (Coca and Cooke, 1923).


AD normally appears in the first year of life but uncommonly before two months of age. It can vary from very mild to very severe. It will clear in about 60% of children by the age of 12 years and in 75% by the age of 16. Some of those who clear will flare again in adult life; prevalence in adults is put at between 2 and 10% (Verbov, 2000).


The aetiology of AD is multifactorial. There is a genetic predisposition for the child's immune system to overreact to environmental triggers and provoke an abnormal immune response manifesting in the skin. Common triggers, features and diagnostic criteria are discussed below.


Investigations
There are a number of key investigations used to determine a diagnosis of atopic dermatitis (see below). It should be noted that some of these might be distressing and impractical when dealing with babies and small children; they should therefore be carried out only when there is a clinical indication to do so. RAST or skin prick tests to inhalant allergens such as house dust mites are usually positive in atopic people but do not alter treatment, and they are unhelpful as random screening for dietary allergens, (although useful to confirm a suspect agent). Similarly, patch testing is usually unhelpful as contact allergy is rare in children.


The psychosocial impact of atopic dermatitis


Health-care professionals often underestimate the effects of AD on the child. AD can affect a child's physical, psychological and social development, depending on severity. Dry, itchy and uncomfortable skin combined with sleep disturbance results in irritability and poor concentration. When skin is inflamed it becomes painful, causing difficulty with movement and dexterity.


An older child may develop low self-esteem, lack confidence and have difficulty forming relationships with peers because of their appearance. Lewis-Jones and Finlay (1995) undertook a study to create and initially validate a simple questionnaire to measure quality of life in children with skin disease.


Further studies carried out by Lawson et al (1998) measure the family impact of AD. It demonstrates the following significant physical, psychological, emotional, social and financial problems:


- Psychological pressures on the parents: 71% described feelings of guilt, frustration, exhaustion, resentment and helplessness


- School: Six out of 10 children had problems at school. All experienced teasing and bullying


- Effects on child behaviour: 54% of parents reported changes in behaviour such as being naughty, irritable, bad-tempered, easily bored and hurtful to other family members during flare-ups of eczema


- Sleep disturbance: 63% of children had current sleep problems and most had had sleep disturbance at some time


- Financial aspects: special diets, extra laundry, bathing and clothes add to the cost of family life


- Practical support: 17% reported receiving inadequate support from the teaching and medical professions


Conclusion
Treating AD in pre-school children may be costing as much as £47 million a year in the UK (Dobson, 2001). AD is not necessarily a minor skin disorder; severe forms of the disease can have a major impact on a child's development and quality of life. A personal, social and financial strain may also be put on the family unit as a whole. Its effects are often underestimated and ignored by health-care professionals.


Much can be done in primary and secondary care to minimise the effects of AD on children and their families by improving the service we offer.


COMMON TRIGGERS


- Irritants: extremes of temperature - cold, very dry or hot environments; repeated use of soap and detergents; prolonged contact with wool and synthetic materials


- Allergens: repeated contact with chemicals, metals or topical skin preparations; microbes, particularly Staphylococcus aureus. Inhalant allergens such as house dust mites, pollens, animal hair and dander, moulds. Ingested allergens such as dairy products, colourings and preservatives


- Secondary infection: Staphylococcus aureus, Beta haemolytic streptococci and Herpes simplex


- Psychological and emotional stress


- Urbanisation and its associated problems of pollution, modern homes, affluence


- Climatic conditions: cold and wind, hot and dry atmospheres


- Physiological stress: exercise, illness.


ACUTE FEATURES


- Redness, heat and swelling of the skin


- Vesicles that may coalesce to form bullae


- Exudation and crusting


- Dryness and scaling


- Pruritus and excoriation.


CHRONIC FEATURES


- Less vesicular


- Less exudation


- More scaly, pigmented and thickened


- Lichenification with increased skin markings (secondary to repeated scratching or rubbing)


- Fissuring.


DIAGNOSTIC CRITERIA (McHenry et al, 1995)
AD must include


- An itchy skin condition (or reported scratching or rubbing in a young child)


Plus three or more of the following:


- History of itchiness in skin creases such as folds of the elbows, behind the knees, fronts of ankles or around the neck (or the cheeks in children under four years)


- History of asthma or hay fever (or a history of atopic disease in first-degree relative in children under four years)


- General dry skin in the past year


- Visible flexural eczema (or eczema affecting the cheeks or forehead and outer limbs in children under four years)


- Onset in the first two years of life (not always diagnostic in children under four years).


INVESTIGATIONS


- RAST (radioallergosorbent test) is a blood test that aims to identify specific IgE antibodies to particular allergens such as house dust mites, pollens or foods - that is inhaled or ingested allergens


- Skin prick testing is used to measure specific IgE antibodies attached to mast cells in the skin. A small amount of a suspected allergen is introduced into the skin by a needle prick. The reaction between the allergen and antibodies will manifest as a wheal on the skin around the needle prick site and represent a positive result


- Patch testing is carried out to confirm a contact allergy, for example to metal, rubber or topical drugs, and not to diagnose allergy to inhaled or ingested allergens. Small amounts of possible contact allergens are placed directly in contact with the skin and left for 48 hours. They are then removed and read at this time and again at 96 hours. A positive result would show varying degrees of local inflammation.


It is recognised that infection plays a major part in exacerbations of atopic eczema, in particular Staphylococcus aureus. Dry and excoriated skin provides a perfect host for its colonisation and the organism itself produces an allergic reaction within the skin.


- A skin swab culture is carried out to isolate specific organisms and their antibacterial sensitivity


- Virology swabs should be obtained if Herpes simplex is suspected. If there are strong clinical grounds to suspect its presence treatment should be initiated immediately and should not be delayed to await results, as it can be a serious complication of AD.


Studies carried out by Leyden et al (1974) found that over 90% of patients with AD had Staphylococcus aureus on the skin in contrast with 5% of non-AD patients, who tend to harbour the organism in the nose or perineum. Furthermore the density of Staphylococcus aureus on inflamed AD lesions is frequently 1000 times higher than in non-lesional skin. The mechanism for increased Staphylococcus aureus colonisation is unknown but it is thought that the disruption in the barrier function of the skin results in the loss of innate antibacterial activities which, when combined with a reduced immune response to infection, plays a key role (Leung, 2000).


Next month, Part 2 of this Factfile will examine current treatment options.


Useful address
National Eczema Society, Hill House, Highgate Hill, London N19 5NA Information line: 0870-241 3604 Website: www.eczema.org

Barneston, R., Rodgers, M. (2002)Childhood atopic eczema. British Medical Journal 324: 1376-1379.

Coca, A.E., Cooke, R.A. (1923)The classification of the phenomena of hypersensitiveness. Journal of Immunology 8: 163-182.

Dobson, R. (2001)Atopic dermatitis in children costs £47m each year (News item). British Medical Journal 322: 884.

Lawson, V., Lewis-Jones, M.S., Finlay, A.Y. et al. (1998)The family impact of childhood atopic dermatitis: the Dermatitis Family Impact Questionnaire. British Journal of Dermatology 138: 107-113.

Leung, D.Y.M. (2000)Rationale for antibiotic/steroid combination in the treatment of atopic dermatitis. Dermatology in Practice 8: 3 (suppl): S1-S7.

Lewis-Jones, M.S., Finlay, A.Y. (1995)The Children's Dermatology Life Quality Index (CDLQI): initial validation and practical use. British Journal of Dermatology 132: 942-949.

Leyden, J.J., Marples, R.R., Kligman. A.M. (1974)Staphylococcus aureus in the lesions of atopic dermatitis. British Journal of Dermatology 90: 525-530.

McHenry, P.M., Williams, H.C., Bingham, E.A. (1995)Management of atopic eczema. British Medical Journal 310: 843-847.

Verbov, J.L. (2000)Handbook of Paediatric Dermatology. London: Martin Dunitz.

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