Skin-Directed Management of Atopic Dermatitis Focus of New Report

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By Mary McGrath

Published On: Dec 8, 2014

Last Updated On: Jul 15, 2021

Pediatricians should seek a skin-directed approach to the treatment of atopic dermatitis (AD), according to an updated AAP clinical report that outlines research linking the disease to abnormalities in the skin barrier.

At least 10% of U.S. children suffer from atopic dermatitis, often before age 5. Pediatricians should remain up-to-date on developments in the dermatological field, as they are nearly always a child’s first line of treatment, according to Megha Tollefson, M.D., FAAP, co-author of Atopic Dermatitis: Skin-Directed Management.

Atopic dermatitis diagnosis is based on chronically recurring itching/pruritus located in different areas of the body based on a child’s age. Other telling factors of AD include onset of the condition at an early age and a family history of atopy and xerosis.

“In many cases, AD and eczema are used interchangeably,” said co-author Anna Bruckner, M.D., FAAP, noting that the term eczema simply describes the visual rash that accompanies atopic dermatitis.

The report describes how atopic dermatitis has “severely negative” effects on the quality of life of patients and families. The itchiness and discomfort correlate with patients’ sleep deprivation and a decrease in physical and group activities.

“There are likely feelings of embarrassment and difficulty in social situations,” said Dr. Tollefson. Visible rashes may cause children to avoid their peers with atopic dermatitis. In addition to treating and preventing AD, the report urges pediatricians to refer families to community and support groups like the National Eczema Association.

Many factors contribute to the pathogenesis of atopic dermatitis. Past theories linked the disease with helper T cell dysregulation, immunoglobulin E (IgE) production and exacerbation from food allergens.

New evidence points toward skin barrier dysfunction with regard to the protein filaggrin. According to the report, up to 50% of atopic dermatitis patients have mutations in the FLG gene, which encodes filaggrin. Dysfunctional filaggrin may contribute to the progression of AD in several ways. Low filaggrin levels affect keratinocyte ability to hold water in the skin, leading to xerosis, pruritus and ultimately, atopic dermatitis. An ineffective skin barrier also allows airborne allergens to enter the skin easily and cause irritation. Faulty filaggrin production may cause changes in the skin’s pH, resulting in rapid growth of bacteria. This may activate an immune response, leading to inflamed skin and AD.

The report also explores the common misunderstanding that AD is food-induced. In reality, the association between atopic dermatitis and food allergy is “complex but likely overemphasized.” While food allergies are 25%-35% more common in children with AD than in those without, allergies may be correlated with atopic dermatitis, but not necessarily a cause.

“We are now less convinced that allergies are causing eczema,” said Dr. Bruckner.

The report also offers clarity on the use of topical steroids to treat atopic dermatitis in children. “Steroid phobia” has resulted from the adverse side effects sometimes seen after use of high- and super-potency steroids. However, according to the report, low- to mid-potency topical steroids are effective and safe when used appropriately.

Finally, pediatricians can educate parents on how to reduce common recurrences, by watching for and avoiding triggers that set off a flare-up: pollen, mold, dust, harsh skin products and detergents, coarse fabrics, heat and stress.

The report outlines recommended treatment measures, including:

Skin care maintenance, including baths in lukewarm water and mild soap, followed by moisturizer. Use of high-lipid, fragrance-free ointment or cream at least daily.
Use of topical anti-inflammatory medications such as low- to moderate-potency topical steroid, with low-potency steroid on the face, neck and skin folds. Consider wet wrap therapy or topical calcineurin inhibitors. Re-evaluate if AD does not respond to treatment after one to two weeks.
Control of itching with non-drowsy oral antihistamines, not topical antihistamines. Note that most itching occurs at night.
Management of infectious triggers, watching for bacterial infection (e.g., Staphylococcus aureus) and use of antibiotic therapy, if necessary. Consider bleach baths for infection-prone children.