Eczema: symptoms, diagnosis, treatment
Atopic dermatitis is an inflammatory disease of the skin, which occurs especially in infancy and childhood and is noticeable by dryness, scaling, redness and a strong itching of the affected skin areas. Neurodermatitis, also known as atopic dermatitis, is the most common skin disease in childhood. In most cases, it begins between the ages of 3 and 6 and improves markedly with the onset of puberty or adulthood.
Interplay of genes and external influences
Why it comes to the development of atopic dermatitis has not yet been conclusively clarified. However, certain genes appear to be causally involved in the development of the disease, since children with two diseased parents are at risk of developing up to 70% of their disease, even developing atopic dermatitis.
Genetic disposition, however, requires certain factors that exert stress on the skin and trigger a disease outbreak. In addition to mechanical skin irritations, the most important provocation factors include heat stress, mental stress or infections of other organ systems such as influenza or gastrointestinal diseases.
Reddened skin, tormenting itching
The atopic dermatitis is usually characterized by itchy, dry and very reddened skin, which tends to tear and ooze and crust. Even small nodules and pustules and pigmentation can occur on or around affected skin. Furthermore, there may be thickening of affected skin areas as well as due to the many scratching to shiny fingernails. As the atopic dermatitis belongs to the allergic group, it is often associated with the occurrence of other diseases such as food allergies or animal allergies.
The diagnosis of eczema is usually made by a dermatologist. He collects a detailed medical history during the initial examination and then looks closely at the affected skin areas. The localization and appearance of the eczema, together with an often supplementary blood test, generally leads to the correct diagnosis.
Individual treatment depending on severity
The treatment of eczema is very complex and depends on the severity of the disease and the existing suffering. While mild stages can be treated by thorough skin care and avoidance of provocative factors, in severe cases it requires increased immunosuppressive therapy to control the symptoms.
Atopic dermatitis is one of the most common skin inflammatory diseases, characterized by dryness, redness, scaling and severe itching of certain parts of the skin. It usually begins in infancy and childhood and is neither curable nor contagious.
At 10-15%, atopic dermatitis is the most common skin disorder in childhood. It usually begins as early as infancy and usually returns to adolescence or early adulthood. Only 1-3% of those who suffered from atopic dermatitis in childhood show symptoms as adults.
The exact causes of eczema are not yet clear. Discussed are different or a combination of several factors. In addition to a genetic predisposition, there seem to be a variety of factors that promote the development of atopic dermatitis.
Genetic factors seem to play a major role in the development of atopic dermatitis. For example, children with two diseased parents have an approximately 70% risk of developing atopic dermatitis in their lives as well.
People who suffer from atopic dermatitis show a genetic hereditary increased formation of so-called IgE antibodies to certain stimuli, which are ultimately responsible for the symptoms of atopic dermatitis. There appear to be several genes that lead to increased formation of IgE antibodies. Which genes are in detail, has not yet been clarified with final certainty and remains the subject of further investigation.
A hereditary predisposition alone does not lead to a disease. However, it makes you more vulnerable and may influence the development of atopic dermatitis when exposed to certain environmental factors.
Provocation factors are certain stimuli that can trigger or aggravate symptoms of eczema. Not all the same stimulus triggers the same response, and not all people who suffer from atopic dermatitis react in the same way to provocation factors. Nevertheless, it is helpful to know the most important factors and to be able to avoid them if necessary.
Typical is a provocation of the disease symptoms by:
- Skin irritations such as scratches or dryness
- Dust pollution, for example due to exhaust gases, sand or smoke
- Climate (especially high humidity)
- heat accumulation
- emotional stress situations like stress
- Infections such as colds, flu or gastrointestinal infections
Questions and answers about the causes
Atopic dermatitis is a very complex disease of the skin, which is triggered only by the interaction of several factors. Due to various genes, the skin can not properly perceive its natural protective function.
In particular, a deficiency of certain proteins is responsible for the fact that the protective horny layer of the skin is not built up sufficiently, is repelled too quickly and is constantly drying out. Especially dry and chapped skin is susceptible to environmental influences that can lead to inflammation. The most important symptoms of atopic dermatitis can be easily deduced from the described mechanism of disease development.
The main symptoms of atopic dermatitis are:
- dry, itchy skin
- Fine blotchy redness of the affected skin (eczema), which tend to crust, wet and break again
- Formation of nodules and pustules
- Pigmentation of affected skin
Skin changes depending on the age
Typical changes in the skin occur at different parts of the body, depending on the age or stage of the disease. An onset of infancy typically manifests itself in the heavy buildup of milk scab on the scalp. The classic eczema of atopic dermatitis continues to exist mainly in the area of the head and especially the face and on the extensor sides of the arms and legs. The chest and abdomen may also be affected, while the nappy region is usually left out.
The disease begins later, especially in childhood, puberty or adulthood, especially the flexor muscles of the arms and legs and large body folds (eg inguinal region) and back of the hand are affected by the disease.
Thick skin and shiny nails
Accompanying the main symptoms may be the following symptoms:
- Thickening and coarsening of the skin structure from adolescence, especially in large joint bends and the lateral neck area (lichen infection)
- shiny fingernails that appear polished by constant scratching
- fine scaling of finger and toe tips (Pulpitis sicca)
The symptoms of atopic dermatitis occur changeable and in spurts. While itching and dry skin are always in the foreground of the disease, affected skin and accompanying symptoms can change over the course of life again and again.
Atopy - a neurodermatitis rarely comes alone
Neurodermatitis is one of the forms of atopy. Atopic diseases are characterized by the occurrence of allergic reactions or hypersensitivity reactions after contact with actually harmless environmental substances such as pollen, heat, animal hair and many other substances. In the context of atopy, contact with these substances leads to increased formation and release of IgE antibodies, which in turn cause the typical complaints of the respective disease.
In addition to atopic dermatitis, the following diseases form part of atopy:
- bronchial asthma
- allergic rhinitis (hay fever)
- allergic conjunctivitis
- Food Allergies
Characteristic features of the atopic
In addition to the IgE increase, certain physical stigmata occur in people who are predisposed to atopic diseases. If you suffer from atopic dermatitis, these features may be present:
- a double lower eyelid crease (Dennie Morgan sign)
- a thinning of the eyebrows on the lateral edge (Hertoghe sign)
- skin bleeding after mechanical irritation (white dermographism)
- a deep hairline
- a darkening of the skin of the eye area
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Worth knowing about the symptoms
To diagnose, your dermatologist will first have a detailed consultation with you (anamnesis) and then examine the affected skin thoroughly. Furthermore, in the course of the diagnosis, various blood tests are performed, which generally lead to the correct diagnosis in combination with anamnesis and clinical examination.
In a comprehensive conversation, your dermatologist first asks about the existing symptoms. In addition, he will usually want to know if there are certain stimuli that lead to an aggravation of the symptoms. Since provocation factors play a decisive role in the development of atopic dermatitis, they must be precisely recorded.
Since the likelihood of atopic dermatitis increases, even if first-degree relatives are affected by the disease, the family history is also an important building block in the initial medical consultation.Furthermore, there is often an association with other diseases of the atopic form, which is why your dermatologist particularly addresses other existing diseases such as food allergies and hay fever.
In the physical examination, especially the affected skin areas are examined. Your doctor will pay particular attention to where the eczema is and how it is. For atopic dermatitis especially papulovesikulöse eczema, which tend to crust formation, always wet again and go along with a strong itching.
In addition, the localization is important for the diagnosis: While in adulthood, especially the flexor sides of the arms and legs, so the elbows and knees are affected by the disease, atopic dermatitis is located in infants rather on the extensor sides of the extremities.
In addition to accurately assessing the location and nature of the eczema, your attending physician will continue to examine you for the signs of atopy listed above, which are indicative of the diagnosis.
Advanced allergy diagnostics
As part of the advanced diagnostics, the doctor will take blood and examine it for specific parameters. Neurodermatitis is usually associated with an increased number of eosinophilic granulocytes, a specific population of white blood cells, and an elevated level of IgE antibodies in the blood.
Finding Triggers: Prick Test
In addition to the examination of the blood, a prick test can be carried out for allergy diagnostics. This should only be carried out at a symptom-free interval and provides information on which substances in your body can lead to a disease.
In the prick test, substances dissolved in water are applied to the skin, which can potentially lead to a reaction. In addition to these so-called allergens are also a negative control (usually a saline solution), which should lead to no reaction, and a positive control (usually a histamine-containing solution), which always triggers a reaction, applied to the skin. Subsequently, the wetted skin areas are slightly pricked with a lancet, so that the fluids can penetrate into deeper skin layers. After a while, your doctor can tell you which substances have led to wheals and redness and are therefore allergens for you.
The prick test is usually performed in the course of atopic dermatitis and should help you to avoid those substances and substances that can cause an allergic reaction and thus a boost of eczema.
Since atopic dermatitis is sometimes hereditary and can not be cured easily, you may be living with relapses of the disease for a lifetime. For this reason, the aim of the treatment is not healing in the true sense of the word, but the achievement of as many symptom-free phases as possible.
There are various measures available for the treatment of atopic dermatitis, which are used according to a graduated plan. While the elimination of triggering factors as well as the application of moisturizing creams can be used as the sole treatment in mild disease episodes, in severe relapses many different medications may need to be applied to the skin to control disease activity.
Below you will find an overview of individual therapeutic measures as well as a step-by-step plan for the treatment of atopic dermatitis.
1. General measures
General measures for the treatment of atopic dermatitis should be used at every stage of therapy as they can already make an important contribution to the improvement of the condition.
The general measures include in detail:
- Avoidance of substances or influencing factors that can lead to symptoms. In general, these are substances such as animal hair, pollen, mites or certain foods. What applies to you in detail, you have to find out about the time itself or if necessary have medical tests.
- Wear only clothing that does not scratch or rub on the skin. Especially cotton clothing can cause skin irritation and thus worsen the atopic dermatitis. But also certain detergents or fabric softeners can have a skin irritant effect and should be avoided for this reason.
- Avoid heat accumulation due to too tight and warm clothing. If you sweat and the sweat then moisturizes your skin for too long, it can also cause skin irritation.
- Try to spend holidays in high mountains or by the sea. Both the mountain air and the salty air at the sea have a noticeable calming effect on your skin.
- Maintain your skin with mild products, and do not shower too often (maximum once a day). Especially in winter you should make sure that it does not dry out and enter the skin due to the dry cold.
2. Drug therapy
The pharmacological treatment of atopic dermatitis is very broad and ranges from the basic skin care with Externa on the intake of drugs for itching and inflammation to the treatment of superinfections.
The drugs used depend on the severity of the disease.Whilst creams and ointments are used for mild ailments, drugs that suppress the immune system (immunosuppressants) may have to be used in very serious cases.
a) Local treatment with Externa
Externa is a collective term for preparations that can be applied externally, ie applied directly to the skin. These include medicated ointments and creams, as well as oils and powders.
Refatting basic care
If you suffer from atopic dermatitis, it is very important to always take good care of the skin, to prolong disease-free phases and to relieve existing symptoms. For skin care are particularly suitable moisturizing creams that moisturize and promote skin regeneration. Creams that are free of fragrances and preservatives and can also be used on very sensitive skin are the most suitable. As a rule, products from fat and water are sufficient for basic care, but also urea- or ceramide-containing applications are well suited.
Avoid soap and hot water
To cleanse the skin, soap should be avoided as far as possible and if possible resorted to pH-neutral products. Low water temperatures when showering or bathing are better than too hot water. So-called "spreading" oil baths can relieve the symptoms of atopic dermatitis, as they leave a fine film of fat on the skin, which may feel unfamiliar but has calming effects on the skin.
If the discomfort can not be controlled by a thorough basic skin care, active substance-containing Externa can be used. The symptoms of eczema decide which medicine is best for you. You should only use the following creams in consultation with your attending physician.
Strong against itching: Antipruriginosa
As a particularly tormenting feature, the itching is often felt in atopic dermatitis. Not only is it very unpleasant, it also causes increased scratching, which in turn causes small skin lesions that can fuel the progression of atopic dermatitis.
For the treatment of itching are called Antipruritinosa such as Polidocanol (Thesit®, Optiderm®, Eubos®). This has a local anesthetic and so relieves the skin itch. In the case of large-scale infestation, it is advisable to use it as a bath additive; smaller areas of the skin can be treated with creams or ointments.
Cortisone only for a short time
For stronger inflammatory reactions of the skin, cortisone-containing externa may be used for a short time. They suppress the inflammation on the spot and provide a rapid relief of the symptoms in an acute episode.
A major disadvantage is that cortisone-containing creams should not be used over a long period of time, as they can lead to thinning of the skin, which should be observed especially when used on sensitive areas such as the face (especially eye areas). Depending on the severity of the symptoms, different strengths of each Cortisone preparation can be used.
The following classification according to Nieder classifies the glucocorticoids, starting with low to highly effective:
- Class I: Hydrocortisone (Cortilind®, Hydrocortisone ratiopharm®, Hydrocortisone HEXAL, Soventol®)
- Class II: betamethasone benzoate (BetaGalen® Cream, betametasone HEXAL®)
- Class III: Mometasone furoate (MomeGelen® Cream, Elocon®)
- Class IV: clobetasol propionate (Clobetasol acis® Cream)
Immunosuppressants: a question of balance
As an alternative to glucocorticoid creams, tacrolimus ointments such as Protopic® or Tacrolimus Ointment. The advantage of these preparations is that they have no thinning effect on the skin and are therefore particularly well suited to the facial area. A major disadvantage, however, is that they may not be used for more than two years due to lack of experience and strong immunosuppressive effects.
b) Systemic therapy
Systemic therapy is taken to mean the intake or intravenous administration of certain medications. By intravenous therapy, a higher drug concentration in the blood can be achieved while sparing the gastrointestinal tract.
Effective, but not completely safe
Although higher doses of the respective drugs usually lead to more effective results, but also associated with an increased rate of side effects, so the administration of drugs into the vein in the context of atopic dermatitis should be done only in stage IV of the disease. In principle, many of the above preparations can also be administered systemically.
Immunosuppressants such as:
- Mycophenolate mofetil
In case of very intense itching, it is also possible to use drugs of the group of antihistamines. In case of a bacterial infection of the affected skin areas, antibiotic therapy may be necessary. Which drugs should be administered in these specific cases depends on the type and severity of the infection.
Phototherapy is understood to mean the treatment with UV light of specific wavelengths. Especially UVA and UVB radiation have an anti-inflammatory effect on the skin and can lead to a significant improvement in eczema.Moderate neurodermitic skin conditions usually require UVB therapy, whereas severe eczema requires UVA treatment.
Long-term damage can not be ruled out
Advantage of the treatment is a very high response rate with only rarely occurring acute side effects. A major disadvantage of the treatment with UV light are possible long-term consequences such as skin changes to skin cancer. Because UV light, like the light of the sun, can lead to a change in the skin cells and contribute to their degeneration. In the best case, the skin ages only slightly faster under UV therapy, in the worst case it can lead to the development of malignant skin cancer such as malignant melanoma.
Another disadvantage of the phototherapeutic treatment is that it should not be administered concomitantly with drugs that suppress the immune system and should not be used in children under the age of 12 years.
Step 4 plan for the treatment of atopic dermatitis
Stage I - dry skin
- Avoiding trigger factors such as pollen, animal hair, certain foods
- Basic therapy with moisturizing creams
Stage II-III - mild to moderate eczema of the skin
- First-stage measures plus:
- antipruritics (antipruriginosa)
- Medicines for the prevention of an infection (antiseptics)
- local use of cortisone (Class I - III glucocorticoids according to the severity of the symptoms)
- if necessary phototherapy
Stage IV - persistent pronounced eczema
- Measures of the previous levels plus:
- Systemic administration of cortisone and other immune suppressive drugs such as cyclosporin or mycophenolate mofetil
Find out what is good for you
The treatment of atopic dermatitis is very complex and always a case by case decision for or against certain drugs. Therefore, be patient, it may take some time for you to find the right therapy for yourself and know which substances you should refrain from. Find a dermatologist you trust and who can assist you with helpful advice, especially at the time of diagnosis and treatment.
Although atopic eczema is a chronic condition that affects many people throughout their lives, it does not have to affect your life and, provided you find the right form of treatment and lifestyle, can often be well-controlled.
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Frequently asked questions about the treatment
The most important complication of atopic dermatitis is superinfection. Since eczematous skin is no longer a sufficient protective barrier against pathogens, it may come to colonizing the open skin with bacteria, viruses or fungi and as a result to inflammatory foci. These usually worsen the symptoms considerably, which in turn leads to increased scratching - a vicious circle that can often only be broken through medication.
Atopic dermatitis is a chronic disease that is, among other things, hereditary and is triggered by various environmental factors. There is currently no way to heal. However, if the disease already occurs in infancy or childhood, with the onset of puberty to a significant symptom improvement, which is associated with an increase in quality of life in young adulthood.
Questions about course and prognosis
It is not possible to reliably prevent the development of atopic dermatitis with preventive measures. Nevertheless, you can do a lot to reduce the likelihood that your child is suffering from atopic dermatitis.
Breastfeeding helps, smoking hurts
Studies have shown that children who have been breastfed for 4-6 months are less likely to develop atopic dermatitis than non-breastfed children. If breastfeeding is not possible, it is possible to resort to hypoallergenic, hydrolyzed infant formulas, which split hydrolyses into foreign and thus allergenic proteins.
Important for the prevention of atopic dermatitis in children is still the absolute nicotine renunciation of expectant mother during the entire pregnancy.
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Everyday life with atopic dermatitis
Author: Lisa Wunsch
I. Minor: Dual Series Dermatology, Thieme Verlag, 2016.
F.C. Sitzmann: Dual Series Pediatrics, Thieme Verlag, 2012.
AWMF guideline: Short version of the guideline Neurodermatitis,
http://www.awmf.org/uploads/tx_szleitlinien/013-027k_S2k_Neurodermitis_2015-03-verlaengert.pdf, last accessed on 20.03.2018.