By Faraz Yousefian, DO and Liliana Espinoza, BS

Manifestation and Management of Atopic Dermatitis in the Pediatric Population

By Faraz Yousefian, DO and Liliana Espinoza, BS

topic dermatitis (AD), or eczema, is one of the most common dermatological conditions physicians encounter in the pediatric population. The standard of care for these dermatological conditions can provide both physical and psychosocial relief to the patients and their caregivers. For this reason, it is of paramount importance to understand its causes, symptoms and best treatment options available to mitigate its effects. AD is an allergic spectrum disorder that affects 20% of children with a prevalence of 60% in the first year of life and 90% in the first five years of life.1-3 Additionally, approximately 60% of AD cases persist into adulthood, with 15% of patients later developing a food allergy, allergic rhinitis and/or asthma.1-3 The majority of AD patients have a family history of AD, as the risk of developing AD can increase 2-5-fold if both parents have AD.1,3 The pathophysiology of this disease is characterized by a decreased expression of the structural protein filaggrin, a decrease in ceramide lipid, increased protease expression, and immunologic abnormalities related to interleukin 4 and 13, which in conjunction affect the integrity of the skin barrier.3 Namely, these abnormalities lead to increased skin pH, decreased hydration, decreased S. aureus resistance, increased susceptibility to allergens and disorders of keratinization.1,3

AThe Hanifin-Rajka (H-R) criteria is considered the gold standard diagnostic criteria for AD; however, it is not utilized by all allergists or dermatologists.2,4,5 AD is commonly diagnosed based on history and physical presentation; however, immunodeficiency conditions such as Hyper-IgE syndrome and Omenn syndrome should be ruled out initially.3 The cutaneous findings resulting from AD are commonly located on the face, scalp and flexor body surfaces.1,3,5 AD manifestations include dry skin accompanied with severe pruritis; erythematous maculo-papular rashes; vesicles that can have exudate and crusting (acute flare); dry, scaly excoriated patches (more chronic lesions);

lichenification (chronic); hyper/hypopigmentation; and excoriations at various stages of healing.4 In addition to the classic clinical features of AD, a patient can also experience extensive psychosocial discomfort. For example, patients with AD may exhibit persistent fidgeting due to pruritis, irritability, insomnia due to pruritis at night and decreased concentration.4,5 AD complications can also include an increased susceptibility to contracting infections with bacteria, herpes simplex infections, molluscum contagiosum and warts.4

Management of AD is multifaceted. Treatment can be given daily based on the chronicity of the disease, is highly personalized to the patient based on its severity and often requires review at follow-up visits to ensure patient compliance. First and foremost, avoidance of triggers (allergens and irritants) in fragrances, clothing, temperature extremes, foods and soaps/detergents can reduce the incidence and severity of AD.2,4 To help stabilize and reduce acute flares, patients can benefit from moisturization of the skin and application of topical steroids, topical calcineurin inhibitors (pimecrolimus and tacrolimus), topical phosphodiesterase-4 inhibitor (Crisaborole), injectable Dupilumab and/or oral antihistamines.2,5 Moreover, early evidence suggests that limiting the use of skin cleansers and applying an oil-in-water emollient at least once daily may lower the risk or decrease the severity of AD.2,4 In general, the thicker and greasier the emollient, the higher the content of oil relative to water and the more effective the emollient (e.g., ointment is better than cream, which is better than lotion). Although water exposure can increase xerosis through evaporative loss, daily baths hydrate the skin, especially if the water loss is prevented by emollient application within a few minutes after bathing.2,4 In severe cases, there are other treatment options that can be implemented such as bleach baths, phototherapy, hospitalization for intense eczema care and systemic immunosuppressants (Cyclosporine and Methotrexate).2,4,5 Once the eczema is stable, food allergy concerns should be addressed. Lasty, topical and oral antibiotics can also be prescribed as needed to treat superinfections.4

AD is one of the most common ailments affecting the skin, especially in children. Treatment options are varied and can be highly customized for a patient, depending on the severity of his or her AD. Still, new therapeutic avenues are constantly being explored, such as those investigating the role of probiotics in treating AD, to ensure that patients achieve more efficacious management of their condition.4

References: 1. Hanifin JM. Atopic dermatitis. Journal of the American Academy of Dermatology. 1982;6(1):1-13. doi:10.1016/S01909622(82)70001-5 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. Journal of the American Academy of Dermatology. 2014;70(2):338-351. doi:10. 1016/j.jaad.2013.10.010 3. Abramovits W. Atopic dermatitis. Journal of the American Academy of Dermatology. 2005;53(1):S86-S93. doi:10.1016/ j.jaad.2005.04.034 4. Fishbein AB, Silverberg JI, Wilson EJ,

Ong PY. Update on Atopic Dermatitis:

Diagnosis, Severity Assessment, and

Treatment Selection. J Allergy Clin Immunol Pract. 2020;8(1):91-101. doi:10.1016/j.jaip.2019.06.044 5. Schneider L, Tilles S, Lio P, et al. Atopic dermatitis: a practice parameter update 2012. J Allergy Clin Immunol. 2013;131 (2):295-299.e1-27. doi:10.1016/j.jaci.20 12.12.672

Faraz Yousefian, DO is an intern at the Texas Institute for Graduate Medical Education and Research (TIGMER) in San Antonio, Texas. He is very passionate about mentoring nascent physicians and educating the general populous about skin diseases and the steps they can take to prevent them. Dr. Yousefian is a member of Bexar County Medical Society.

Liliana Espinoza, BS is currently a Ph.D. candidate in the field of neuroscience at UT Health San Antonio where she studies the early effects of a high fat diet on the motor neurons that innervate the heart. She will be pursuing a medical degree upon completion of her doctoral degree.