What are the typical presentation and treatment options for eczema (atopic dermatitis)?

Atopic Dermatitis (Eczema): Presentation and Treatment

Atopic dermatitis presents as an itchy skin condition with characteristic distribution patterns that vary by age, and treatment should focus on liberal emollient use, appropriate topical corticosteroids, and avoidance of triggers to effectively manage this chronic inflammatory skin disease. 1, 2, 3

Diagnostic Presentation

Key Diagnostic Criteria

• An itchy skin condition plus three or more of the following:
  • History of itchiness in skin creases (folds of elbows, neck) or cheeks in children under 4 years
  • History of asthma/hay fever or atopic disease in first-degree relatives (for children under 4)
  • General dry skin in the past year
  • Visible flexural eczema (or affecting cheeks/forehead in children under 4)
  • Onset in first two years of life 1

Age-Specific Distribution

• Infants: Cheeks, scalp, and forehead (diaper area rarely affected)
• Young children: Extremities, cheeks, forehead, and neck
• Older children and adults: Flexural areas (antecubital and popliteal fossae), head and neck 3, 4

Clinical Appearance

• Acute lesions: Erythematous papules with serous exudates
• Subacute lesions: Erythematous scaling papules and plaques
• Chronic lesions: Lichenification with accentuated skin markings and hyperpigmentation 4

Treatment Algorithm

First-Line Approach

1. Emollients and Skin Care:

   • Apply liberally and frequently, especially after bathing to lock in moisture
   • Use soap-free cleansers for bathing
   • Consider dispersible creams as soap substitutes 1, 2, 3

2. Topical Corticosteroids:

   • First-line treatment for flare-ups
   • Select potency based on:
     • Age: Lower potency for children
     • Location: Lower potency for face, genitals, skin folds
     • Severity: Higher potency for thickened areas
   • Apply once daily for 2-4 weeks for active lesions 2, 3

3. Topical Calcineurin Inhibitors (e.g., pimecrolimus, tacrolimus):

   • Alternative to corticosteroids, especially for sensitive areas
   • Suitable for patients 2 years and older
   • Not for continuous long-term use due to safety concerns
   • Can be used in conjunction with topical corticosteroids 5, 3

Proactive Maintenance Therapy

• Apply low-dose topical corticosteroids or calcineurin inhibitors twice weekly to previously affected areas to prevent relapse
• Continue regular emollient use on all skin 2, 6

Second-Line Treatments

1. Phototherapy (for moderate to severe cases):

   • PUVA therapy (oral preferred over topical) when first-line treatments fail
   • UVB therapy as an alternative 2, 6

2. Systemic Treatments (for severe, refractory cases):

   • Immunosuppressants
   • Newer targeted therapies like dupilumab (though cost may be prohibitive) 2, 3

Management of Complications

Secondary Infections

• Bacterial infections (usually Staphylococcus aureus):

  • Obtain bacterial cultures
  • Administer appropriate antibiotics 2, 4

• Viral infections (e.g., herpes simplex - eczema herpeticum):

  • Requires prompt systemic antiviral therapy
  • Intravenous acyclovir for severe cases
  • Oral acyclovir as standard first-line treatment 2, 4

Avoidance of Triggers

• Identify and eliminate triggering substances
• Avoid irritant clothing (wool) - cotton clothing recommended
• Avoid extremes of temperature
• Keep nails short to minimize damage from scratching 1, 2

Common Pitfalls to Avoid

• Using potent topical corticosteroids on the face for prolonged periods
• Neglecting to identify and avoid triggers
• Using topical antihistamines (ineffective and may cause sensitization)
• Long-term use of topical antibiotics (risk of resistance)
• Oral antihistamines are not recommended for pruritus control 2, 3

Special Considerations

• Deterioration in previously stable eczema may indicate secondary infection or contact dermatitis
• Dietary restriction has little benefit in adults; consider only in selected infants under professional supervision
• Adequate time for patient education regarding proper application of treatments is essential 1, 2

Atopic dermatitis is a chronic relapsing condition affecting 5-15% of children and 2-10% of adults, with significant impact on quality of life. Proper management requires consistent skin care, appropriate anti-inflammatory treatment, and vigilance for complications 1, 3, 7.