John R. Tkach, M.D.
300 North Willson, Suite 203B
Bozeman, MT 59715
(406) 587-5442

Atopic Dermatitis (Atopic eczema)

Patient Information Sheet

Atopic dermatitis is an itchy rash that occurs in people who have allergies or allergies run in the family.

Dermatitis is a somewhat vague term. It refers to any rash that produces redness, scaliness, and itching. There are thousands of causes. Eczema means about the same thing now, but originally it referred to an oozing weeping dermatitis. Atopic dermatitis is a specific kind of dermatitis. Atopic refers to having allergies such as asthma, hayfever, and hives. Originally, it meant "out of place." How did that get changed into "allergic?" Go figure.

But, get this. The rash of atopic dermatitis occurs in people with allergies, but the rash is not an allergy. Confusing, huh? We do not understand what causes it, but it is very common. It occurs in 10% to 20% of people. That's ten times more common than psoriasis. A parent with atopic dermatitis may have as high as a 50% probability of passing it on to each baby. From this point on, everything I tell you about atopic dermatitis is mysterious, debatable, confusing, and elusive except that it is itchy and pesky.

Atopic dermatitis usually begins in childhood (60% in the first year of life, especially the 2nd month), but good news, there is a 70% chance it will improve by the age of about 15. Sometimes it begins in the adult years. Atopic dermatitis is an absolute 4-F condition for the military.

Major Features of Atopic Dermatitis

  1. Itching- every year since 1972, I have become more and more impressed with the importance of itching in atopic dermatitis.
  2. Distribution- although it can occur anywhere, the most common places are infront of the elbows and behind the knees. In small children, it may start on the face and neck.
  3. Chronic Problem- It tends to linger and recur off and on for years.
  4. Inherited- usually there is some personal or family history of atopic dermatitis or allergies.

Other Features: dry skin and ichthyosis, increased IgE antibodies, increased eosinophiles in the blood, increased skin infections (bacterial and viral-herpes, warts, and fungal), and keratosis pilaris. In some studies, 90% of people with atopic dermatitis, the skin lesions harbored Staph. aureus, often resistant to antibiotics. 10% of people with atopic dermatitis eventually get posterior subcapsular cataracts of the eyes. During the visit, don't be surprised if I look carefully at your lower eyelids for little lines called atopic pleats or Dennie's lines. They are present at birth, don't need treatment, and alert the doctor to watch for the development of allergies.

Dyshidrotic eczema is a variant of atopic dermatitis that shows up as itchy little water blisters on the fingers and toes, palms and soles. It can be especially pesky.

A life threatening situation may rarely arise if severe widespread atopic dermatitis gets secondarily infected with herpes simples virus (Kaopsi's varicelliform eruption). It is not likely to happen to you, but must be taken seriously.

Factors Influencing The Appearance Of The Rash Of Atopic Dermatitis

  1. Itchiness
  2. Irritants: Wool, Strong chemicals, Strong soaps and detergents
  3. Dryness: Winter, Soap, Too many baths
  4. Change of Season: hardest factor to understand, but dramatic when it occurs.
  5. Sweating: may dissolve irritating laundry agents from the clothes and into the skin.
  6. Infection: look for "honey crust" looks like dried honey.
  7. Anxiety and stress: the rash is not due to stress, but stress and anxiety make it worse.
  8. Itching
Itchiness
People with atopic dermatitis have itchy skin and things that do not make most people itchy will make the atopic itchy.
Irritants
Anything that irritates the skin may make the rash flare up. Wool is especially irritating. Under the microscope, wool looks like a barbed wire fence. You should avoid wool. Strong chemicals such as cleaning agents, ammonia, oven cleaner and household cleaners will irritate the skin and set off atopic dermatitis so avoid them or, at least, try not to get them on your skin. Strong rubber gloves are often helpful to prevent these chemicals from coming into contact with the hands. However, be careful. If there is a small hole or crack in the glove, the irritating chemicals can leak into the glove. Occlusion by the glove can drive the irritating chemicals into the skin and make the rash even worse than if you did not use gloves.
Avoid strong detergents. Detergents tend to stick in the fibers of the clothes. They make the rash worse. This is especially true in socks and underwear that soak up detergent like a sponge and then sweat dissolves the irritating chemicals out of the clothing and then carries it to the skin. Look for detergents that have the word "FREE." They may be less irritating. They are not really "free." You have to pay for them. Use less detergent, 1/3 to 1/2 as much and double rinse the laundry. Newer machines have that setting.
Dryness
Dr. Tkach says, "Dry skin is itchy skin." Once the skin is itchy, and you scratch it for a long time, it may initiate a vicious itch-scratch cycle. Dryness is a problem in the winter when the air is dry. Skin moisture is related to the humidity of the air, not how much water you drink. Dry air means dry skin. A humidifier in the house may help. Humidity should be set to 40% and no higher or it may damage the paint. Bathing too frequently will make the skin too dry. This is especially true when using soaps that wash away natural skin oils.
Cut down bathing to once or twice a week and make them shorter and not as hot. If particular parts of the body such as the underarms become dirty, you can wash just those particular areas. It is not necessary to wash the whole body just because one small area is dirty. I mean I don't want you to neglect your hygiene, but we Americans over wash and over deoderize. Who knows what an American really smells like?
Dry skin care should include less frequent and less hot baths and using a special soap for dry skin such as Dove, Basis, Aveenobar, etc. special dry skin lotions and bath oils are also helpful. When you bathe, soak in the water for about 5 minutes. This will completely hydrate your skin. When you get out of the bath, do NOT dry your skin by rubbing it with a towel. Instead, use a towel to pat the skin in such a way as to leave little beads of water on the skin. Step out of the tub and quickly rub the lotion or bath oil on the skin. Do not put the oil in a bath tub full of water before getting in. Get in, soak, then add oil. Better yet, apply the oil after getting out of the tub. Oil makes the tub slippery. Be careful you don't fall.
Change of Season
This is hard to understand. Why does change of season make atopic dermatitis worse? I don't know, but I have seen it many times. It does not seem to be a matter of the particular season although winter is often worse. It seems to be the change of season, especially, sudden extreme changes. In springtime in Montana, it can be snowing in the morning, hot in the afternoon, and cold again at night. It is like going back and forth from winter to summer and back to winter in one day. It is not so much a matter of whether it is hot or cold. It's the change that causes trouble. An air conditioner at home will sometimes buffer the changes and help. A humidifier at home may be helpful.
Sweating
Some people notice increases in areas of sweating especially the palms and soles, sweating on the back, and behind the knees and back of the legs that are against car seats on hot days. A ventilation cushion in the car may help. Sandals on the feet in the summer may help. Air conditioning in the car and home may help.
Infection
Once the rash develops, it breaks down the defensive outer barrier of the skin. Bacteria take advantage of that opportunity to invade the skin and the rash gets worse It becomes more red and swollen and more itchy. Infection is recognized by two signs. One is pus, and the other is honey crust. Honey crust looks like dried honey on the skin, slightly yellow or golden in color. Infection must be treated with antibiotic pills. If mild enough, a topical antibiotic Bactroban can be used, but no other topical over the counter antibiotics really works at this point. When infection occurs, you should see a doctor to get antibiotic pills. Smallpox vaccination is a live virus that can go wild in atopic dermatitis. Some people have died in that rare setting. This became a big issue with terrorism in the USA and in the Iraq war. If you have atopic dermatitis, do not get a smallpox vaccination.
Anxiety
When people are under stress or upset, itching becomes more pronounced, and the rash becomes worse. Anxiety is not the cause of atopic dermatitis. It just makes it worse. It is necessary to solve the problems causing the anxiety. People with atopic dermatitis cannot afford the luxury of hiding and running away from their problems. These people must deal with these problems before they reach massive proportions. This is especially true with alcoholism.
Itching
Since 1972, I have become more impressed by the role of itching. I have found that it is very important to control the itch.
  1. Anti-itch pills- Antihistamine pills usually help a lot. The old standard is Atarx, but it makes some people sleepy. In a pinch, Benadryl will work, but it makes some people extremely sleepy. Atarax is better. Do not drive a car or operate heavy equipment when sleepy. Newer antihistamines make people less sleepy. Claritin, for example, is less likely to cause itching, but, in my experience, the recommended dose of 10 mg once a day is not enough. Often people must take one 2 to 4 times a day. The advantage to Claritin is that you can get it without a prescription.
  2. Topicals- Sarna topical lotion will give relief for 20-60 minutes. It is safe, can be used as much as you need it, and can be purchased without a prescription. If just one spot itches, a fit of itching, you can break the itching attack by holding ice on it 30 seconds. A clean pillowcase soaked in lukewarm water, wrapped around the itchy area and refreshed with water every 20 minutes for a few hours will help. This is a non-pharmacologic treatment that drives inflammatory white blood cells out of the skin. Dry skin care is very important in controlling itching. Ultimately, the way to get rid of the itch is to get rid of the rash. Keep in mind that severe itching may be a sign of infection requiring prescription antibiotics.

Treatment

Clearing of the rash is usually achieved by the use of topical corticosteroids, sometimes combined with oral antibiotics and less commonly oral cortisone in the form of prednisone. I prefer to avoid prednisone if possible, and if necessary to limit it to 3-4 weeks. Long term use of prednsione carries risks such as increased blood pressure, increased blood sugar, softening of the bones, and upset stomach. If used in low doses a short time, it is usually safe. Generally, treatment of atopic dermatitis is a combination of things.

The way to use topical cortisones is to wet the rash and rub in a small amount 2-4 times a day. Wetting the skin first, allows 10 time more medicine to get in. Water is a lot cheaper than topical medicines. I prefer to use them a lot for a short time rather than a little for a long time. They are not dry skin lotions. Some are safer than others. The extremely strong ones (clobetasol) are used only once a day, not to exceeded 1 month straight (then take a 1 week break), and should not be used on the face or delicate areas. I have found that tar mixed with the cortisone makes it work 4 times better, but tar is messy.

Locoid Lipocream, Dermatop, and Westcort are safe to use on the face. This is important, because the very strong fluorinated topical cortisones used for a long time can cause thinning of the skin, bruising, dilate tiny blood vessels, little white stretch marks, and little red lines. I do not see this very often, and usually it goes away. However, stronger topical cortisones with fluorine used around the eyes can increased the pressure in the eyes, glaucoma, so be careful what you use around the eyes and on the face.

Starting around the turn of the century, 2000, a new category of non-steroidal creams and ointments appeared. These are medicines such as Protopic and Elidel that offer an alternative to topical steroids. Wet the skin and rub in the medicine twice a day for 6 weeks. These medicines are slower to work and must be used at least 6 weeks to get benefit from them. They offer the promise of making the rash go away for longer times such as 4 months.

When the rash gets out of control, you should come to see the doctor for his/her help. The most important thing you can do is to maintain daily skin care along the guidelines detailed above. In this way, it should be possible to control the skin disease so that your skin will once again become your friend rather than your enemy. Now think about that. You can let the atopic dermatitis control you or you can control the atopic dermatitis.

Read more about Atopic Dermatitis at DermNet NZ.

The information provided in these patient information sheets is offered for general informational and educational purposes only; it is not offered as and does not constitute medical advice. In no way are any of the materials presented meant to be a substitute for professional medical care or attention by a qualified practitioner, nor should they be construed as such.

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