© Springer Nature Switzerland AG 2021

P. Treadwell et al. (eds.)Atlas of Adolescent Dermatologyhttps://doi.org/10.1007/978-3-030-58634-8_11

11. Atopic Dermatitis

Julie Prendiville¹  

(1)

Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada

 

 

Julie Prendiville

Email: jprendiville@sidra.org

Keywords

Atopic DermatitisEczemaEczema HerpeticumMethotrexateCyclosporineAzathioprineDupilumab

11.1 Introduction

Atopic dermatitis (AD) (aka eczema) is a common inflammatory skin disorder of variable severity, characterized by pruritus and a chronic, relapsing course. It is associated with other atopic disorders, such as asthma, food allergy, and allergic rhinoconjunctivitis. Moderate to severe AD significantly affects the health, quality of life, and emotional well-being of adolescent patients.

11.2 Epidemiology

Childhood AD may persist or reemerge in adolescence. The prevalence of AD in the 13–17 age group in the United States is estimated to range from 7% to 8.6%, with up to one-third suffering from moderate to severe disease [1]. It affects all ethnic groups.

11.3 Clinical Findings

Atopic dermatitis lesions may be categorized as acute, with weeping, inflamed eczema (Fig. 11.1); chronic, with lichenification, excoriation, and pigmentary change (Fig. 11.2); or subacute, an intermediate appearance. The skin is often dry and may show follicular prominence or, in some cases, features of ichthyosis vulgaris. Mild eczema in adolescents is generally localized, with a predilection for the limb flexures and neck (Fig. 11.3). Moderate to severe AD is more extensive with acute, subacute, and/or chronic eczematous change, and sometimes a nodular morphology called prurigo. Pruritus is the predominant symptom. Pain or severe discomfort occurs with secondary infection. Organisms causing infection in AD are Staphylococcus aureus (either methicillin-sensitive MSSA or methicillin-resistant MRSA), Streptococcus pyogenes, and Herpes simplex virus (Fig. 11.4). Warts and molluscum papules may also be more prevalent.

Fig. 11.1

Inflamed eczema with weeping and crusting

Fig. 11.2

Chronic atopic dermatitis with lichenification and dyspigmentation

Fig. 11.3

Circular eczema lesion with mild erythema and scale

Fig. 11.4

Eczema herpeticum: infection of an area of eczema with herpes simplex virus

11.4 Laboratory

Atopic diagnosis is a clinical diagnosis. Laboratory investigation may be indicated to investigate comorbidities. Skin cultures and viral studies are needed to identify secondary infections.

11.5 Treatment

Basic treatment of AD consists of avoidance of irritants, hydration of the skin by bathing and application of emollients, and judicious use of topical steroids. Topical calcineurin inhibitors are helpful for chronic dermatitis but are not suitable for acute flares. Secondary infection requires treatment with an antibiotic or antiviral medication.

Whereas treatment of mild AD is straightforward, moderate or severe AD in adolescents can be very challenging to manage. Teenagers are particularly susceptible to developing striae from application of topical steroids. Adherence to a topical treatment regimen may be difficult, and emotional distress and discouragement are common. It is necessary to determine a treatment plan that is safe and acceptable to the patient. Psychosocial support is important.

Oral steroids are only rarely justified as short-term therapy for generalized acute AD flares. Systemic anti-inflammatory agents for severe AD include low-dose weekly methotrexate, cyclosporine or azathioprine. Dupilumab, a human monoclonal antibody targeting the IL-4 receptor alpha subunit, has been shown to significantly improve AD signs and symptoms and quality of life in adolescents with moderate and severe AD [1].

11.6 Prognosis

The prognosis is very variable. Many patients show improvement with time. Others continue to suffer from eczema into adult life.

References

1. 1.
   Simpson EL, Paller AS, Siegfried EC, Boguniewicz M, Sher L, Gooderhamet MJ, et al. Efficacy and safety of dupilumab in adolescents with uncontrolled moderate to severe atopic dermatitis: a phase 3 randomized clinical trial. JAMA Dermatol. 2020;156(1):44–56.Crossref

Suggested Reading

1. Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis section 2: management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014;71(1):116–32.Crossref
2. Eichenfield LF, Tom WL, Chamlin SL, et al. Guidelines of care for the management of atopic dermatitis section 1: diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014;70(2):338–51.Crossref