Skin infections and allergies are common presentation in paediatrics age group in Nepal. Among many dermatological problems, bacterial skin infections, seborrheic and atopic dermatitis are common presentations.
Atopic dermatitis (AD) is a chronically relapsing skin disorder with an immunologic basis. The clinical presentation varies from mild to severe. In the worst cases, atopic dermatitis may interfere with normal growth and development.
Although often used interchangeably, the terms eczema and atopic dermatitis are not equivalent. Eczema is a reaction pattern with various causes and the most common pediatric cause is atopic dermatitis.
Significant evidence favors the hygiene hypothesis for the development of atopic dermatitis. An inverse relationship is recognized between helminth infections and atopic dermatitis but no other pathogens. In addition, early day care, endotoxin, unpasteurized farm milk, and animal exposure appear to be beneficial, likely because of a general increase in exposure to nonpathogenic microbes.
Atopic dermatitis may occur in people of any age but often starts in infants aged 2-6 months. Ninety percent of patients with atopic dermatitis experience the onset of disease prior to age 5 years. Seventy-five percent of individuals experience marked improvement in the severity of their atopic dermatitis by age 14 years; however, the remaining 25% continue to have significant relapses during their adult life. A recent study concluded that the prevalence of atopic dermatitis in children younger than 2 years was 18.6%.
Major characteristics include the following:
- Typical morphology and distribution (ie, flexural lichenification and linearity in adults, facial and extensor involvement in infants and young children)
- Chronic or chronically relapsing dermatitis
- Personal or family history of atopy (eg, asthma, allergic rhinoconjunctivitis, atopic dermatitis)
Minor characteristics are as follows:
- Xerosis (dry skin)
- Ichthyosis, palmar hyperlinearity, keratosis pilaris
- Hand dermatitis, foot dermatitis
- Nipple eczema
- Pityriasis alba
- Early age of onset
- Impaired cell-mediated immunity
- Recurrent conjunctivitis
- Orbital darkening
- Infraorbital fold (eg, Dennie pleat, Morgan fold)
- Anterior neck folds
- Anterior subcapsular cataracts
- Sensitivity to emotional factors
- Food intolerance
- Pruritus with sweating
- Intolerance of wool
- White dermographism
- Immediate type I skin test response
- Elevated total serum immunoglobulin E (IgE)
- Peripheral blood eosinophilia
The most fundamental and important step in combating atopic dermatitis (AD) is rehydration of the stratum corneum. Adequate rehydration preserves the stratum corneum barrier, minimizing the direct effects of irritants and allergens on the skin and maximizing the effect of topically applied therapies, thus decreasing the need for topical steroids.
- Lukewarm soaking baths lasting 10-20 minutes are ideal. Extremely hot water should be avoided to prevent both vasodilation, which can trigger pruritus, and the damage to the skin barrier caused by scalding.
- Small amounts of bath oils or emulsification agents may be used for added hydration benefits in older children and adolescents.
- Recommended soaps are mild and unscented with a neutral pH. If the children are prepubertal, bathing in water alone may be preferable. Postpubertal patients need to use soap in the axillae and groin but do not need it elsewhere.
- Baby shampoo may be used to manage scalp dermatitis.
Baths should be followed by the immediate application of an occlusive emollient over the entire skin surface to retain moisture in the epidermis. If an emollient is not applied within 3 minutes of leaving the bath, evaporation causes excess drying of the skin. Skin should not be completely dried with a towel prior to application of the emollient; rather, lightly patting the skin with a towel to remove excess moisture is sufficient.
Whether breastfeeding can help prevent development of atopic dermatitis in children remains unclear. A clinical report recommended exclusive breastfeeding as opposed to cow’s milk formula feeding over the first 4 months of life to prevent development of atopic dermatitis in infants at high risk of developing atopy. However, several studies have found no protective benefit of exclusive breastfeeding in the first 3-6 months of life.