DERMATOLOGY FOCUS
atopic eczema. The impact of diet and the role of the environment and chemicals such as 58
airborne formaldehyde, harsh detergents, fragrances, and preservatives must be considered. ATOPIC ECZEMA Use of harsh alkaline detergents in skin care products can alter the skin's pH causing changes in enzyme activity and triggering inflammation. Environmental pollutants can trigger responses from both the innate and adaptive immune pathways. 3, 4
Hospital Management of Atopic Eczema
Diagnosis Diagnosis of atopic eczema is mainly based on the patient’s history, clinical findings and alterations, and dehydration. No standardized methods to Written by: Theresaconditions. Lowry-Lehnen exclusion of other dermatological History includes questions about the onset, diagnose AE were available until However not all patients with AE (PhD), CNS, GPN, RNP and Hanifin and Rajka developed have a FLG mutation and 60% PRO Irish General Practice pattern and severity ofNational the AE, potential trigger factors such as irritants, skin infections, diagnostic criteria in 1980. Since of patients carrying the FLG Nurses Educational Association then, the original criteria have mutation do not have an atopic contact allergens, food and inhalant allergens, theTheresponse and been modified many current times and disease. strongest risk to previous numerous experts have developed factor for AE is a positive family treatments, the impact of the condition on the patient, and personal/family history of atopic different criteria suitable for their history for atopic disease. Other own environment, and varying with genetic changes have also been diseases. The diagnosis of atopic eczema relies on the assessment of clinical features because in children. Severity can vary from age. Efforts to develop practical identified which may alter the person to person and although it criteria haveElevated proven skin's barrier function, resulting in there is no laboratory marker or definitive test available to diagnose theclinical condition. difficult, and those available are generally presents as an episodic an atopic dermatitis phenotype. not suitable for all geographic The imbalance of Th2 to Th1 repeated IgE levels may be seen indisease up towith80% of flare-ups, patients with AE, but it is not a specific test for AE and areas and age groups. The lack of cytokines observed in atopic it can also be continuous. People 3 a good biomarker for diagnosing dermatitis can create alterations with mild eczema may only is not routinely indicated. 3
have small areas of dry skin that are occasionally itchy. In more severe cases, atopic eczema can cause widespread red, inflamed skin all over the body and constant itching.2, 3
in the cell-mediated immune responses and can promote IgE mediated hypersensitivity, both of which appear to play a role in the development of atopic eczema. The impact of diet and the role of the environment and chemicals such as airborne formaldehyde, harsh detergents, fragrances, and preservatives must be considered. Use of harsh alkaline detergents in skin care products can alter the skin's pH causing changes in enzyme activity and triggering inflammation. Environmental pollutants can trigger responses from both the innate and adaptive immune pathways.3, 4
the condition is considered a major obstacle to the study of AD.7 The UK Working Party diagnostic criteria are among those most widely used. However, while the validity and reliability of these criteria have been assessed, they have not been tested extensively in non-white ethnic groups in the UK.5
No standardized methods to diagnose AE were available until Hanifin and Rajka developed diagnostic criteria in 1980. Since then, the original criteria have been modified many times and numerous experts have developed different criteria suitable for their own environment, Triggers Atopic eczema (AE) also known atopic dermatitis Common to triggers include irritants and as varying with isage. Efforts develop practical clinical criteria have proven difficult, and a chronic, inflammatory skin such as soaps and detergents: The UK Working Party diagnostic disorder environmentalfor factors as thosecharacterised availablebyare not suitable allsuch geographic areas and age groups.criteria Thestates lackthatofpatients a good intense itching, dry skin and cold and dry weather, dampness, must have a history of itchy 7 recurrent erythematous lesions, biomarker for diagnosing thedustcondition considered a major obstacle to studyat of house mites, pet fur, is pollen skinthe and include leastAD. 3 of which usually develops in early and mould: food allergies such as the following: The UKThe Working Party diagnostic criteria childhood. causes remain cows' milk, eggs, peanuts, are soya among those most widely used. However, while • Visible flexural dermatitis unclear, but are multifactorial or wheat: certain materials worn involving skin creases, such the validity and reliability these criteria not the been tested in nature, involving genetic, nextof to the skin such as wool have been assessed, they have as the bends of the elbows or socioeconomic, and environmental 5 and synthetic fabrics: hormonal extensively non-whitechanges; ethnicskingroups in the UK.Diagnosis behind the knees (or visible factors. It can run inin families, infections and dermatitis on the cheeks and often develops alongside psychological stress. Theatopic UK Working Party diagnostic criteria states that patients mustishave a history of itchy and/or extensor areas inskin Diagnosis of atopic eczema other conditions such as children ≤ 18 months) mainly based on the patient’s Pathophysiology 3, 5, 6 asthma and allergic rhinitis. The and include at least 3 of the following: history, clinical findings and prevalence of AE in adults is • Personal history of flexural The pathophysiology of atopic exclusion of other dermatological about 1%-3%, and 10%-20%, in • Visible flexural dermatitis the skin creases, such as the bends of the(or elbows dermatitis dermatitis onor the eczemainvolving is complex, involving conditions. History includes children. It affects approximately 1 cheeks and/or extensor areas in elements of barrier dysfunction, questions about the onset, pattern in 5 childrenthe and 1 knees in 12 adults in visible dermatitis on the cheeks and/or extensor areas behind (or in ≤children children 18 months) ≤ 18 alterations in cell mediated and severity of the AE, potential Ireland. Although it can present immune responses, IgE mediated trigger factors such as irritants, • Personal history of dry skin in the at any age, up to 85% of patients months) hypersensitivity, and environmental skin infections, contact allergens, last 12 months with AE are symptomatic before 5 factors. Key components are food andon inhalant allergens, the and/or extensor areas in • Personal the cheeks years of age. The history condition isof mildflexural dermatitis (or dermatitis • Personal history of asthma or epidermal barrier dysfunction and response to previous and current in up to 80% of patients; however, allergic rhinitis (or history of cutaneous inflammation due to treatments, the impact of the ≤ 18 months) itchildren can have a significant negative atopic disease in a first-degree heightened immune response. condition on the patient, and impact on an individual’s quality of relative if the patient is <4 years) The epidermal barrier is made • Personal history of dry skin in the last 12 months personal/family history of atopic life due to itch, sleep deprivation of structural proteins including diseases. The diagnosis of atopic and social embarrassment. • Onset of signs and symptoms <2 filaggrin (FLG), whose rolerhinitis is to • Personal history of asthma or allergic (or history atopic disease in a first-degree eczema relies on of the assessment of years (this criterion should not prevent water loss and penetration Atopic eczema causes areas of clinical features because there is no be used in children <4 years) relative if the patient years) antigens, irritants laboratory marker or definitive test of environmental skin to become itchy, dry, cracked,is <4 and microbes. Loss of function red and sore. It can occur all over available to diagnose the condition. • Onset signs andonsymptoms <2 years (this notbebe in children <4 years) mutations in filaggrin have been criterion the body, butof is most common Elevatedshould IgE levels may seenused in 3, 5, 6
2, 3
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1, 2, 3
the hands especially the fingers, insides of the elbows or backs of the knees, and the face and scalp
implicated in severe atopic eczema due to a potential increase in trans-epidermal water loss, pH
up to 80% of patients with AE, but it is not a specific test for AE and is 3 not routinely indicated. 3
Atopic eczema is classified according to clinical severity
Atopic eczema is classified according to clinical severity3
Severity of skin presentation
Clear Mild
Normal looking skin and no itch, no evidence of active atopic eczema Areas of dry skin, infrequent itching (with or without small areas of redness)
Moderate
Areas of dry skin, frequent itching, redness (with or without excoriation and localised skin thickening)
Severe
Widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation)
JUNE 2022 • HPN | HOSPITALPROFESSIONALNEWS.IE
