Atopic Dermatitis in Children (2+ Years Old)

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Atopic dermatitis (AD) (also called atopic eczema) is a common chronic skin disease in children. It most commonly begins in infants, with approximately 60% of cases of AD develop in the first year of life, and 90% of all cases of AD develop by 5 years of age.1 AD is caused by a combination of factors, including a genetic predisposition, environmental factors, a dysfunction in the immune system, and a dysfunction of the skin barrier.2,3 There are some differences in AD depending on the age of the person affected. This article will focus on children age 2 years and older.

Risk factors

The majority of children who develop AD have someone in their family with the condition. A child’s chances of developing AD are 2- to 3-fold higher in children who have a parent with AD. If both parents have AD, the child’s chances of developing the skin condition increase to 3- to 5-fold.1

AD is more common in urban areas, and children living in cities are at a higher risk of developing AD. The age of the mother at the child’s birth also seems to increase a child’s risk of AD, with children being born to mothers who are later in their childbearing years being more likely to develop AD.4

Common symptoms in children

AD ranges in severity from mild to severe. In children, AD frequently appears as a rash on the inside creases of the elbows or knees, the neck, wrists, ankles, and/or the crease between the buttocks and the thighs. AD makes the skin dry, itchy, and scaly, and it may cause bumps. Areas of skin where the AD rash occurs may get lighter or darker in color. Over time, the skin affected by AD can become thickened or leathery, also called lichenification. Lichenified skin may also develop knots. The lichenified skin is itchy all of the time, and proper treatment is important to reduce the development of permanently itchy, thickened skin patches.4,5

There are several triggers that can make AD worse, including:

  • Dry skin
  • Irritants, such as harsh soaps, certain fabrics, fragrances or dust
  • Stress
  • Cold weather
  • Allergens, including some foods, pet dander, dust mites, molds, or pollens
  • Sweat
  • Excess saliva, or drooling3,5

Most children go into remission, although some experience relapses in their teen years and some (about 10-30%) continue to have symptoms into adulthood.1

Possible complications

Some children develop complications from AD, including: infection, issues with sleeping, food allergies, asthma, hay fever and/or experience psychological effects due to living with a chronic skin condition.

Infection

Because AD causes cracks and breaks in the skin and there is immunologic dysfunction in the skin, there is a greater potential for infection. In addition, the intense itching caused by AD leads to scratching, which also increases the risk of infection by bacteria, viruses, or fungi.5

Sleep problems

Many children with AD wake repeatedly during the night to scratch due to the excessive itchiness. The repeated waking and loss of sleep is one of the most distressing impacts of AD on children living with the condition, as well as their family members.5,6

Food allergies

AD puts children at a higher risk of developing food allergies, with an estimated 20-40% of children with AD having food allergies that worsen their disease. The most common food allergies that worsen AD include cow’s milk, eggs, fish, peanuts, soy, tree nuts, and wheat. Children with food allergies often outgrow their sensitivity, developing a tolerance over time. Even if a person with AD tests positive for food allergies, it does not necessarily mean that all their food allergies are relevant to their AD. Food allergies are true triggers of AD in only a small subset of patients, and experts do not generally recommend food elimination diets solely on the basis of positive food allergy testing.7,8

Asthma

Children with AD are at an increased risk of developing asthma, a chronic condition of the lungs that involves inflammation of the airways after exposure to a trigger. Asthma makes it difficult to get air in and out of the lungs and can cause symptoms such as wheezing, coughing, shortness of breath, and tightness of the chest.9,10

Hay fever

AD also puts a person at a higher risk of developing hay fever, or allergic rhinitis. Hay fever symptoms include runny and/or stuffy nose, sneezing, fatigue, and itchy eyes, mouth, or skin. Hay fever may be seasonal, with a flare in symptoms due to allergic sensitivity to airborne mold spores or pollens, or perennial, with symptoms year-round due to sensitivity to pet dander, mold, dust mites, or cockroaches.9,10

Psychological effects

Some children with AD experience teasing or bullying, and many experience poor self-esteem. Children with AD may be more likely to have behavioral problems, such as attention deficit or hyperactivity, or poor school performance, which may be linked to the disrupted sleep caused by the itch-scratch cycle.5,6,11

Treatment options

 

A key part of treating AD in children is rehydrating the skin, including:

  • Lukewarm soaking baths or showers (less than 10-20 minutes)
  • Mild soaps that are unscented and with a neutral or low pH
  • Moisturizing skin immediately after bath with an emollient8

For children who have repeated skin infections, adding 2 teaspoons of bleach per gallon of water can reduce the chance of infections, these are known as bleach baths. (A typical bathtub holds between 25-40 gallons of water.)12 Topical corticosteroids, topical calcineurin inhibitors, antibiotics, and/or antihistamines may also be prescribed for children with AD.1

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view references
  1. Eichenfield LF, Tom WL, Chamilin SL, et al. Guidelines of care for the management of atopic dermatitis. Journal of the American Academy of Dermatology 2014;70:338- 351.
  2. National Eczema Association. Accessed online on 3/20/17 at https://nationaleczema.org/.
  3. Tollefson MM, Bruckner AL. Atopic dermatitis: skin-directed management. Am Acad Pediatrics. 2014 Dec;134(6):e1735-1744. doi: 10.1542/peds.2014-2812.
  4. American Academy of Dermatology. Accessed online on 3/17/17 at https://www.aad.org/public/diseases/eczema/atopic-dermatitis.
  5. Lyons JJ, Milner JD, Stone KD. Atopic dermatitis in children: clinical features, pathophysiology, and treatment. Immunol Allergy Clin North Am. 2015;35:161-183.
  6. Mayo Clinic. Accessed online on 4/7/17 at http://www.mayoclinic.org/diseases-conditions/eczema/basics/complications/con-20032073
  7. Peterson JD, Chan LS. A comprehensive management guide for atopic dermatitis. Dermatology Nursing. 2006;18(6):531-542. Accessed online on 4/5/17 at http://www.medscape.com/viewarticle/551352_5.
  8. Sidbury R, et al. Guidelines of care for the management of atopic dermatitis. J Am Acad Dermatol. 2014;71(6):1218-1233.
  9. American Academy of Allergy, Asthma & Immunology. Accessed online on 4/8/17 at https://www.aaaai.org.
  10. Bantz SK, Zhu Z, Zheng T. The Atopic March: Progression from Atopic Dermatitis to Allergic Rhinitis and Asthma. Journal of clinical & cellular immunology. 2014;5(2):202. doi:10.4172/2155-9899.1000202.
  11. National Health Service (UK). Accessed online on 4/7/17 at http://www.nhs.uk/Conditions/Eczema-(atopic)/Pages/Complications.aspx
  12. Medscape. Accessed online on 4/10/17 at http://emedicine.medscape.com/article/911574-treatment.
View Written By | Review Date
Emily Downward | June 2017
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