Atopic Dermatitis: Diagnosis and Treatment

Diagnosis

Major diagnostic criteria for atopic dermatitis include pruritis, relapsing disease, age–appropriate distribution of lesions (face and extensor surfaces in children and flexor surfaces in adults), and a family history of atopy. Nonspecific minor criteria that may aid diagnosis include periorbital darkening, dry skin, and keratosis pilaris on the skin over the triceps region.⁴ Other diseases, such as hyperimmunoglobulin E syndrome and scabies, can resemble atopic dermatitis in appearance.

No laboratory tests definitively diagnose atopic dermatitis. However, up to 80% of patients will have an elevated serum immunoglobulin E (IgE) and positive skin tests for immediate hypersensitivity reactions to common allergens.⁵ These tests are not required for diagnosis.

Recurrent skin infections may occur in atopic dermatitis–damaged skin, and they may also exacerbate disease. Skin infections occur much more commonly in atopic dermatitis patients than in psoriasis patients,⁶ suggesting that factors aside from skin breakdown are involved in predisposition to skin infection.

Treatment

Initial treatment of atopic dermatitis should seek to eliminate exacerbating agents, such as soaps and detergents, food allergens, and cosmetics. Excessive bathing or use of lotions should be discouraged, as evaporation of water from the skin exacerbates atopic dermatitis. Some patients may be surprised to learn that water–based lotions actually increase evaporation of water from the skin, unlike emollient creams or ointments. Humidifiers may be tried in dry climates.

Emollient creams or ointments should be applied liberally, especially after bathing to lock in moisture. Occlusive bandages or gloves can be worn nightly to aid skin hydration.

Psychological approaches to mitigate stress may help avoid exacerbations.⁷

Antihistamines may relieve itching symptoms.

Antibiotics may be effective when patients develop a bacterial infection in the affected area or have pustular disease.

Topical corticosteroids should be used in the lowest possible therapeutic strength to treat active atopic dermatitis. Occasional use of topical steroids between episodes reduces the likelihood of recurrence.

Systemic corticosteroids, such as prednisone, may be used for a short duration when exacerbations occur.

Topical tacrolimus and other topical calcineurin inhibitors are second–line agents. They are used less commonly because of concerns about their carcinogenic potential. They may be used in children 2 years old and older who have not responded to other agents. Unlike corticosteroids, they do not cause skin atrophy, so they can be used on sensitive areas, such as the face, eyelids, and underarms. Patients treated with tacrolimus ointment should be aware that a facial flush reaction can occur within 5 to 15 minutes of alcohol ingestion.⁸

Oral cyclosporine and tacrolimus may be used for severe cases, with close monitoring for systemic side effects. It should be noted, however, that a possible risk of skin and lymph cancers is associated with this drug class.

Severe Disease

Immunosuppressants are sometimes used in severe refractory disease.

Phototherapy using ultraviolet light (UVA, UVB, and narrow–band UVB) is usually successful, but may raise the risk of melanoma and other skin cancer.

Desensitization through immunotherapy is not a successful treatment option.