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Atopic dermatitis:
Taming "the itch that rashes"

By Ronald C. Hansen, MD

It isn't just about skin: Atopic dermatitis affects a child's psyche. To keep the disease under control, prescribe sufficient topical corticosteroids and administer a generous dosage of reassurance.

For reasons that are unclear, atopic dermatitis, also known as eczema (I'll use the terms interchangeably here), is much more common than it used to be.¹ This condition now affects 10% to 20% of children younger than 14 years at some point in their childhood; from 5% to 10% of children in your practice probably have atopic dermatitis at any one time.² Although atopic dermatitis is not usually a major illness, managing it successfully is extremely important because intense itchiness makes the patient miserable and leads to disruptions in the family and a host of other psychosocial problems.

Topical corticosteroids are the gold standard for treating eczema; however, two new topical immunomodulators offer an attractive supplement or alternative in certain circumstances. Pediatricians need to know how best to use these agents—as well as how to take into account factors that may be contributing to disease. Most important, perhaps, is to provide emotional support to patients and their family and to counsel parents about how to care for their child's skin.

A straightforward diagnosis

Chronic itching is the key to diagnosing atopic dermatitis. Itching combined with lichenification—an increase in thickness of the skin lines—and dry skin make the diagnosis (Figure 1). No other condition meets these simple criteria. Most cases of eczema begin in the first year of life, and 85% appear by 5 years of age. The face often is affected, particularly in infants (Figure 2). In some children, the rash is all over the body (Figure 3). Eczema is chronic and characterized by intermittent flares. It usually clears up before adulthood but may reappear at any time.

But contributing factors make for management complexity

Appropriate drug treatment along with good general skin care is the key to managing atopic dermatitis. Because many factors contribute to the condition, however, the pediatrician needs to keep these variables in mind in creating a management plan.

Scratching. Eczema is not a rash that itches; rather, it's an itch that rashes. The child naturally wants to scratch that itch and, the more he scratches, the worse the eczema gets. Getting rid of the itch requires topical treatment (discussed in detail later) and lots of family work and patience. Antihistamines do not control the itching of eczema, but they have a role in management because they help the child sleep and break the itch-scratch cycle, if given at a sufficiently high dosage at bedtime. For diphenhydramine hydrochloride (Benadryl), for example, the usual necessary dose is 5 mg/kg; start at half that dose and build up. After two weeks of applying an appropriate topical corticosteroid or immunomodulator, an antihistamine generally isn't needed.

Psychological stress. Pediatricians often overlook the severe impact atopic dermatitis has on the child and his family. Chronic itching makes it difficult for the child to concentrate, leads to irritability, and disrupts family life. According to a study in Great Britain, more than 80% of children with severe atopic dermatitis exhibit psychosocial dysfunction.³ A survey in Australia of the families of 48 children with atopic dermatitis and an equal number of families of children with insulin-dependent diabetes mellitus found that significantly more stress was associated with taking care of a child with moderate or severe eczema than with caring for a child who has diabetes.⁴ Because of the constraints eczema puts on the child's life, relationships with peers also suffer.⁵ The child's self-image plummets, in part because he doesn't like the way he looks. And when the child can't sleep because of itchiness, he may go to the parents' bed for comfort, leaving all three of them tired, frustrated, and irritated.

Given these problems, the clinician should provide emotional support for the entire family of a child with eczema, along with education about the importance of proper skin care and complying with the drug regimen and any dietary restrictions. Educational resources include the Web sites for the National Eczema Society ( www.eczema.org ) and Talk Eczema ( www.eczema.com ), an online support service. The parent guide also should be helpful.

Temperature, humidity, sweating. Excessive humidity is associated with sweating, and sweating exacerbates eczema. Dry air also worsens the skin dryness that is part of the condition. This does not mean that the child with eczema should sit in a temperature-controlled environment instead of being outdoors playing with his friends. What it does mean is that, at the end of the soccer match, she should jump in the shower, get rid of all the sweat and grime, and then apply the prescribed medication, followed by a lubricant (more about this later).

Infection. Localized bacterial infection is the most common complication of eczema (Figure 4). Although the skin is colonized by Staphylococcus aureus in about 90% of cases of eczema,⁶ infection may not be clinically apparent and may not be necessary to treat. Because S aureus could be perpetuating the eczema, however, I recommend empiric antibiotic treatment if excessive crusting (more than scratching would cause) suggests infection. For localized infection, use topical mupirocin. For more widespread involvement, a course of an oral antibiotic that covers S aureus, such as dicloxacillin sodium or cephalexin, is appropriate.

Allergic reactions. The relationship between food sensitivity and severe atopic dermatitis is controversial. In nearly 25 years of practice, I have seen only one child whose eczema markedly improved with avoidance of a dietary protein to which testing demonstrated he was allergic. Keep in mind, too, that a positive prick test for a food may not correlate with real-life food sensitivity. Results of the radioallergosorbent test (RAST) may not be helpful, either: A positive RAST for 10 foods may mean that the child simply is making antibodies to those 10 foods but none of them is causing the eczema. However, a negative RAST test should mean that that particular food is safe.

Nonetheless, if treatment is going poorly in severe atopic dermatitis, you may want to join forces with an allergist and a nutritionist and try an elimination diet to RAST-positive food. To ensure that the child does not end up malnourished, eliminate one food at a time—for a month or two. Then reintroduce the food to see if the child's condition becomes worse. This procedure must be followed rigorously, requiring parents to read labels on food products carefully and to be vigilant about avoiding the food in question.

External irritants. The child with atopic dermatitis should wear clothes made with 100% cotton if possible, or, at least, with an 80% cotton blend. Synthetics and wools have sharp fibers, which irritate the skin.

All-important guidelines for skin care

Keeping the skin moist is extremely important in managing eczema because the skin is so dry (Figure 5). I recommend that the child soak in lukewarm water for five to 15 minutes twice a day. Then she should be patted—not rubbed—dry. After that, a thin film of the prescribed steroid or immunomodulator ointment is applied, followed by a generous slathering all over the face and body with a heavy lubricant. Useful lubricants include petrolatum (inexpensive, safe, and easily spread), Aquaphor, Eucerin, Nivea, and Cetaphil. Lotions wipe on more easily than ointments and creams but contain less oil; hence, they are less lubricating. Caution parents not to use preparations with a fragrance, which can irritate the skin.

What about soap? In general, I believe parents should avoid it or minimize its use. All soaps are irritating to some degree. Dove (not Ivory, as many parents believe) is the least irritating soap, so I recommend using Dove—but only on parts of the body where the parent can see dirt or knows dirt is there. These places—primarily the face, hands, feet, and groin—need to be cleansed gently with a soft cotton cloth. Parents should avoid scrubbing the child's skin because doing so exacerbates itching.

Topical corticosteroids: Treatment mainstays

The goal of treatment of atopic dermatitis is to relieve the itching and to flatten the top of lesions. Mainstays of treatment are topical corticosteroids, which have been proved safe in children younger than 10 years.^7,8 Your objective is to use the lowest potency steroids that achieve the treatment goal. Generally, this means prescribing 1% or 2.5% hydrocortisone (one of the least potent steroids) for the face and 0.1% triamcinolone (a more potent steroid) for the body. Steroids should be applied twice a day, after soaking, as described earlier. Topical steroids never need to be applied more than twice a day.

Be sure to prescribe an adequate quantity of the topicals—something many pediatricians hesitate to do. Keep in mind that, because it takes 5 to 8 grams to cover the entire body of a 1-year-old child who weighs 10 kilograms, a 15 gram tube contains just two applications of steroid—enough for only one day. It takes 45 grams to cover once the total body of an adolescent; to treat the hands of an adolescent for two weeks would require 60 grams of corticosteroid.

See the patient often. For mild to moderate atopic dermatitis, I usually see the patient in two weeks for the first follow-up visit, and then six to eight weeks later if the two-week visit went well. The eczema should improve markedly within two weeks if the topical steroids are working. If you don't see an improvement by this time, something is probably wrong with the program. Is the parent putting the lubricant on first and the steroid on top of it? Might triamcinolone not be strong enough? That is, do we need a short course of a more potent corticosteroid?

I turn to a systemic steroid only in extreme circumstances—for example, to avoid hospitalization, to prevent school absence, or to stabilize a family crisis. Using sufficient and appropriate topical corticosteroids avoids such a crisis.

New kids on the block: Topical immunomodulators

Tacrolimus and pimecrolimus—both topical immunomodulators—have been approved for treatment of atopic dermatitis within the last two years. These products are derived from macrolides, and their actions are similar to those of cyclosporine. Tacrolimus and pimecrolimus do not replace topical steroids as the mainstay of treatment. They should be used primarily when a medication more potent than hydrocortisone is required for the face and groin—areas where potent steroids should not be used. Topical immunomodulators also are useful for around the eye, where long-term use of steroids should be avoided. (Use hydrocortisone or any other steroid on the eyelid for no longer than a week or two.) Use of topical immunomodulators also avoids possible side effects associated with steroids, such as striae and skin thinning. Steroid side effects generally are uncommon, however, with the exception of an acne-type facial rash (perioral dermatitis).

The new immunomodulatory products also offer an alternative to long-term use of midpotency steroids for mild or moderate total body eczema. Short-term use of steroids is never a problem, but I prefer to avoid using them—particularly the more potent steroids—over a long period. Topical steroids are ranked in seven categories of potency, with group 1 containing the most potent topical steroids and group 7 the least potent. Class 1 steroids should not be used longer than two weeks, and even class 4 or 5 steroids are best used on small body surfaces for less than eight weeks if possible. These new agents are preferable over long periods.

Tacrolimus was formulated specifically for the treatment of atopic dermatitis and has been shown to be safe and effective.^9–11 It is approved for use in children 2 to 15 years old, in a concentration of 0.03%, and has been used for as long as 12 months. (A 0.1% preparation also is available, but only for adults.) I have used tacrolimus ointment in all places where steroids might be a concern—face, groin, eyelids. Although the agent is meant for moderate or severe eczema, my experience has been that it may not be as effective as higher potency steroids in severest cases but does work well for moderate eczema. Tacrolimus also has been useful in some cases when eczema does not respond to steroids.

Parents can apply lubrication after putting on tacrolimus, as they do with steroids. Caution them, however, not to wrap the skin with a bandage, dressing, or other type of occlusive wrap. The idea is to avoid possible absorption because the product has the same side effect profile as cyclosporine and is potentially nephrotoxic. In approximately 40% of patients, tacrolimus produces a stinging, burning, or itching sensation. Although this limits the agent's usefulness, these side effects decrease as the atopic dermatitis improves.¹² Tacrolimus also is expensive and is not included in the formulary of some health maintenance organizations.

Pimecrolimus is even newer than tacrolimus, has a similar mode of action, and is also applied twice a day after bathing. Pimecrolimus is unquestionably less irritating than tacrolimus is—and, therefore, better tolerated. In addition, it is not nephrotoxic and does not have the side effect profile of cyclosporine. Efficacy of tacrolimus and pimecrolimus is probably similar, but no head-to-head studies have been conducted. Indicated for mild or moderate eczema, pimecrolimus 1% cream has been shown safe and effective in children 2 to 17 years old.^13,14 In a recent report, pimecrolimus 1% also was determined to be safe and effective in children 3 to 23 months of age who have mild or moderate eczema, but Food and Drug Administration approval is still lacking for children under age 2.¹⁵ Although pime- crolimus is less expensive than tacrolimus, it is still costly, and may not be covered by the patient's insurer or may be subject to a high copayment.

How does the efficacy of tacrolimus and pimecrolimus compare with that of steroids? No studies have directly compared these agents, but anecdotal evidence suggests that both of these products are about equal to a midpotency steroid, such as triamcinolone acetonide (group 4 steroid) or hydrocortisone valerate (group 5).

Final thoughts

Topical steroids are still the atopic child's best friend, but many pediatricians are steroid phobic. Too often, they prescribe agents that are too weak, use the steroids for too short a time, or prescribe too small a quantity. Sometimes, of course, it is parents who object to steroids. No amount of explanation and reassurance can convince them that these products do not carry the dangers of the anabolic steroids that are sometimes abused by athletes and that should not be confused with corticosteroids.

For these fearful or hesitant families, the new topical immunomodulators offer an alternative. These agents also are attractive for long-term intermittent treatment and for the face, eyelids, and groin. Offering education about general skin care and providing emotional support for the psychosocial difficulties that eczema fosters are important components of management; so is recognition of factors that may be exacerbating a child's condition.

REFERENCES

1. Rothe MJ, Grant-Keis JM: Atopic dermatitis: An update. J Am Acad Dermatol 1996;35:1

2. Kemp AS: Atopic eczema: Its social and financial costs. Journal of Paediatric Child Health 1999;35:229

3. Lawson V, Lewis-Jones MS, Finlay AY, et al: The family impact of childhood atopic dermatitis: The Dermatitis Family Impact Questionnaire. Br J Dermatol 1998;138:107

4. Su JC, Kemp AS, Varigos GA, et al: Atopic eczema: Its impact on the family and financial cost. Arch Dis Child 1997;76:159

5. Howlett S: Emotional dysfunction, child-family relationship and childhood atopic dermatitis. Br J Dermatol 1999;140:381

6. Eichenfield LF, Friedlander SF: Coping with chronic dermatitis. Contemporary Pediatrics 1998;15(10):53

7. Krafchik BR: The use of topical steroids in children. Seminars in Dermatology 1995;14:70

8. Queille C, Pommerade R, Saurat J-H: Efficacy versus systemic effects of six topical steroids in the treatment of atopic dermatitis of childhood. Pediatr Dermatol 1984; 1:246

9. Kang S, Lucky AW, Pariser D, et al: Long-term safety and efficacy of tacrolimus ointment for the treatment of atopic dermatitis in children. J Am Acad Dermatol 2001;44(1 suppl): S58

10. Paller A, Eichenfield LF, Leung DY, et al: A 12-week study of tacrolimus ointment for the treatment of atopic dermatitis in pediatric patients. J Am Acad Dermatol 2001;44(suppl):S47

11. Boguniewicz M, Fiedler VC, Raimer S, et al: A randomized, vehicle-controlled trial of tacrolimus ointment for treatment of atopic dermatitis in children. Pediatric Tacrolimus Study Group. J Allergy Clin Immunol 1998; 102(4 pt 1): 637

12. Russell JJ: Topical tacrolimus: A new therapy for atopic dermatitis. Am Fam Physician 2002;66: 1899

13. Eichenfield LF, Lucky AW, Boguniewica M, et al: Safety and efficacy of pimecrolimus (ASM 981) cream 1% in the treatment of mild and moderate atopic dermatitis in children and adolescents. J Am Acad Dermatol 2002; 46:495

14. Wahn U, Bos JD, Goodfield M, et al: Efficacy and safety of pimecrolimus cream in the long-term management of atopic dermatitis in children. Pediatrics 2002;110 (1 pt 1):e2

15. Ho VC, Gupta A, Kaufmann R, et al: Safety and efficacy of nonsteroid pimecrolimus cream 1% in the treatment of atopic dermatitis in infants. J Pediatr 2003;142:155

DR. HANSEN is chief, pediatric dermatology, Phoenix Children's Hospital, and professor, pediatrics and dermatology, University of Arizona College of Medicine, Arizona Health Sciences Center, Tucson. This article is based on his presentation at the 2002 Skytop Conference on Practical Office Pediatrics, sponsored by Children's Medical Center of Atlantic Health System, New Jersey. DR. HANSEN is a member of the advisory board of Novartis, manufacturer of Elidel (pimecrolimus), a treatment for atopic dermatitis.

GUIDE FOR PARENTS

How to cope with your child's eczema

Now you know why your child is so itchy! The pediatrician has told you he (or she) has eczema, which is also called atopic dermatitis. No one can explain exactly what causes this common condition, but scientists who study it believe it is related to allergies, such as hay fever, and the immune (infection-fighting) system.

As your child grows older, flare-ups of eczema probably will become less frequent and eventually disappear entirely. In the meantime, your pediatrician knows how to control that itch and your child's rashy skin, but you need to follow the recommended treatment plan faithfully.

Doing that calls for your effort, patience, and time—but it's worth it. The itching probably makes your child (and you and the rest of the family) miserable. The discomfort may be affecting your child's ability to concentrate or sleep or keep friendships, because of self-consciousness about the appearance of his skin. These sorts of problems should improve, along with the skin condition, shortly after you begin treatment.

Here's what you can expect your pediatrician to suggest about the most important elements of controlling eczema:

Taking care of the skin

• Keeping the skin moist is one key to controlling eczema. Your child should soak in lukewarm water several times a day. (Many pediatricians think two soaks a day are ideal.) Use a mild soap (Dove is best) only on the hands and feet and any other parts of the body where you see dirt. In the places where you do use soap, rub your child's skin gently with a soft cloth; never scrub the skin. Keep the child in the water for at least five minutes, and for no longer than 15. When she gets out of the water, pat— do not rub—her dry. Then apply a thin film of the medication—a cream or ointment—that the pediatrician has prescribed (more about this later) all over her face and body, or as otherwise directed by the pediatrician. After applying the medication, put an ample supply of a lubricant or moisturizer (ointment, cream, or lotion) on top. (The pediatrician will recommend some lubricants.) Remember: The MEDICATION goes on FIRST and the MOISTURIZER goes on SECOND. Never put any preparation with a fragrance in the bath water or on the child's skin because such preparations can be irritating.

Controlling the itching (and scratching)

• To control the itch and skin inflammation and to keep your child from scratching, which aggravates eczema, the pediatrician will likely prescribe a corticosteroid. Put this medication on the child's skin twice a day after soaking, as described on the previous page. (These medications, which are called topical steroids, are different from the type of steroids athletes use and, sometimes, abuse.) Topical steroids have been used for many years to treat eczema and have been proved safe. They also are effective in controlling eczema, but only if you use enough. So be sure to follow the doctor's directions. If the physician prescribes a different, newer type of medication for your child's eczema, instead of a corticosteroid, carefully follow the instructions for applying it.

Eliminating what may be aggravating the eczema

• Sweating, excessive humidity, or dryness can make eczema worse. This does not mean that your child should stay indoors and be a couch potato, but it does mean that after exercising—whatever the weather—he should wash off the grime, as described on the previous page (or in a quick shower). Immediately afterward, apply a lubricant (preceded by the medication if it is time for one of the twice-daily applications).

Your child should avoid wearing clothes made of synthetic fabric or wool. Loose clothes made of 100% cotton, or at least an 80% cotton blend, are best. Although it is unlikely that your child's eczema is caused by an allergy to any food, let the pediatrician know if you have noticed that a particular food—or a detergent or anything else—is associated with flare-ups of the condition.

At first, it may seem difficult to follow the treatment plan that your pediatrician recommends. But once you begin to see results (usually within two weeks) it will be a lot easier and extremely gratifying. Be sure to discuss any family or behavioral problems with the pediatrician—they may be contributing to your child's eczema.

This guide may be photocopied and distributed without permission to give to your patients and their parents. Reproduction for any other purpose requires express permission of the publisher.