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

Atopic Dermatitis: Presentation and Treatment

Atopic dermatitis is characterized by itchy skin with age-dependent distribution patterns, affecting 5-15% of children and 2-10% of adults, and should be treated with liberal emollient application as baseline therapy, with topical corticosteroids as first-line treatment for flares. 1

Typical Presentation

Diagnostic Features

• Itchy skin condition plus three or more of the following:
  • History of itchiness in skin creases
  • History of asthma/hay fever or atopic disease in first-degree relatives
  • General dry skin
  • Visible flexural eczema
  • Onset in the first two years of life 1

Age-Dependent Distribution

• Infants: Lesions primarily on cheeks and scalp (diaper area rarely affected)
• Young children: Involvement of extremities, cheeks, forehead, and neck
• Older children and adults: Flexural areas (antecubital and popliteal fossae), head, and neck 1, 2

Lesion Characteristics

• Acute: Erythematous papules with serous exudates
• Subacute: Erythematous scaling papules and plaques
• Chronic: Lichenified skin with accentuated markings and hyperpigmentation 2

Treatment Approach

First-Line Management

1. Emollients and Skin Care

   • Apply liberally and frequently, especially after bathing
   • Use soap-free cleansers for bathing
   • Consider dispersible creams as soap substitutes 1

2. Trigger Avoidance

   • Identify and eliminate triggering substances
   • Avoid irritant clothing and extremes of temperature
   • Keep nails short to minimize damage from scratching 1

3. Topical Anti-inflammatory Therapy

   • Topical Corticosteroids (TCS):

     • Low-potency: For face, short-term use
     • Medium-potency: Once daily for 2-4 weeks for mild to moderate cases
     • High-potency: Short periods on thickened areas in severe cases 1

   • Topical Calcineurin Inhibitors (TCI) like pimecrolimus:

     • For patients 2 years and older
     • Not for continuous long-term use due to potential safety concerns
     • Should not be used in immunocompromised patients 3
     • Can be used in conjunction with TCS as first-line treatment 4

Proactive Maintenance Therapy

• Apply TCS or TCI twice weekly to previously affected areas to prevent relapse
• Continue regular emollient use on all skin 1, 5

Secondary Infection Management

• Obtain bacterial cultures if secondary infection is suspected
• Administer appropriate antibiotics based on culture results
• For eczema herpeticum: Prompt systemic antiviral therapy (IV acyclovir for severe cases) 1

Advanced Therapies for Moderate to Severe Cases

• Phototherapy: Safe and effective when first-line treatments are inadequate 4
• Systemic options:
  • Consider if more than 20% of body surface area is affected
  • Options include immunosuppressants or biologics 1
  • Oral antihistamines may help with severe itching but do not directly treat the eczema 1

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 potentially sensitizing)
• Long-term use of topical antibiotics (promotes resistance)
• Neglecting patient education about proper application of treatments 1
• Using pimecrolimus (Elidel) in children under 2 years of age 3
• Continuous long-term use of calcineurin inhibitors without breaks 3

Special Considerations

• Deterioration in previously stable eczema may indicate secondary infection or contact dermatitis
• Dietary restrictions have little benefit in adults but may be considered in selected infants under professional supervision
• The chronic nature of atopic dermatitis requires long-term management strategies 1, 6
• Atopic dermatitis increases risk of food allergy, asthma, allergic rhinitis, and other immune-mediated inflammatory diseases 6