Atopic dermatitis: More than just a rash

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doi:10.12788/jfp.0130

Applied Evidence

Atopic dermatitis: More than just a rash

J Fam Pract. 2021 January;70(1):13-19 | 10.12788/jfp.0130

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References

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2. Ahn C, Huang W. Clinical presentation of atopic dermatitis. In: Fortson E, Feldman SR, Stroud LC, eds. Management of Atopic Dermatitis: Methods and Challenges. Springer International Publishing; 2017:38-46.

3. Eichenfield LF, Tom WL, Chamblin SL, et al. Guidelines of care for the management of atopic dermatitis. Part 1: diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014;70:338-351.

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5. Nankervis H, Pynn EV, Boyle RJ, et al. House dust mite reduction and avoidance measures for treating eczema. Cochrane Database Syst Rev. 2015:CD008426.

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7. Chang Y-S, Chiang B-L. Mechanism of sleep disturbance in children with atopic dermatitis and the role of the circadian rhythm and melatonin. Int J Mol Sci. 2016;17:462.

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9. Chamlin SL, Mattson CL, Frieden IJ, et al. The price of pruritus: sleep disturbance and cosleeping in atopic dermatitis. Arch Pediatr Adolesc Med. 2005;159:745-750.

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Food allergies

Patients with AD are at higher risk for food-induced anaphylaxis, with up to one-third of AD patients having an IgE-mediated food allergy.¹³ While it is theorized that the impaired skin barrier of an atopic child may allow for early sensitization and allergy development, a landmark 2015 study demonstrated that early allergen introduction (specifically, peanuts) may serve as a preventive strategy in those at high risk of food allergies.¹⁴ Current guidelines recommend that physicians be aware of the increased possibility of food allergies in those with AD, and consider evaluating a child for milk, egg, peanut, wheat, and soy allergy if the child is younger than 5 years and has eczema that does not resolve with treatment, or has eczema and a history of an allergic reaction to a specific food.¹⁵

Interestingly, despite the strong association between AD and food allergies, it is not clear that food allergies trigger atopic flares; as such, elimination diets are not universally recommended in those without a proven food allergy.

Psychiatric diagnoses

Children with AD have an increased prevalence of several psychiatric conditions, including ADHD, depression, anxiety, conduct disorder, and autism when compared with peers who do not have AD, and the probability correlates with the severity of AD.¹⁶ While there is a clear link—secondary to nocturnal pruritis—between AD and sleep deprivation, it is not clear whether the sleep deprivation leads to an increase in these psychiatric conditions or if AD is an independent risk factor.

Consider recommending bleach baths in cases of moderate-to-severe atopic dermatitis with frequent bacterial infections.

What we do know is that one of the strongest associations between AD and a psychiatric condition is with ADHD, with a recent pooled meta-analysis showing a 46% increase in risk.¹⁷ The incidence of depression among children with AD appears to correlate with the severity of AD symptoms: estimated at 5% with mild AD, 7% with moderate disease, and 14% with severe disease (compared with 3% without AD). Similar incremental increases are seen when correlating AD and anxiety.¹⁶

Nonpharmacologic care

Bathing

Bathing habits are critical to controlling AD. While bathing serves to both hydrate the skin and remove allergens, the water’s evaporation off the skin surface can lead to increased transepidermal water loss. Combining bathing and immediate application of a moisturizer improves skin hydration in patients with AD vs bathing alone.¹⁸ Thus, consensus guidelines recommend once-daily bathing (bath or shower) to remove scale and crust, followed by immediate application of a moisturizing emollient.¹⁹

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