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Atopic Dermatitis: Overview, Diagnosis, and Treatment

About Atopic Dermatitis

Eczema is a complex inflammatory skin disease that presents clinically with a wide spectrum of symptoms.1 Eczema is a nonspecific term synonymous with dermatitis that is often used to refer to atopic dermatitis (AD), the most common type of eczema. Also known as allergic eczema or atopic eczema, it affects about 20 percent of children and up to 3 percent of the adult population worldwide.2

AD usually starts in early childhood and is often the initial step in the atopic march.3 Skin barrier dysfunction in eczema may lead to both food and aeroallergens entering through the impaired barrier, initiating immunological reactions and inflammation.1,3  Children with early-onset eczema are three times more likely to develop allergen sensitization by the age of two.3 Food reactions can be either immunoglobulin E (IgE) mediated or non-IgE mediated (e.g., dermatitis herpetiformis).4 As the march continues, children are at increased risk to develop allergic rhinitis or asthma later in life. 3,5-7

The majority of infants and young children with eczema have an underlying allergy that contributes to disease severity.3,11 Specific IgE blood testing can help you identify these allergens and provide a personalized management plan.

300% more likely

Children with early-onset eczema are three times more likely to develop allergen sensitization by the age of two.3

When clinically assessing patients with atopic eczema, healthcare providers should seek to identify potential trigger factors, including:17

  • Irritants (e.g., soaps, detergents, toiletries, and wool)
  • Contact allergens
  • Heat
  • Perspiration
  • Cigarette smoke
  • Food allergens
  • Aeroallergens
  • Emotional stress
  • Chemicals 
  • Cleaning solutions

Eczema has several aggravating factors and triggers, such as heat, perspiration, emotional stress, and exposure to certain chemicals, cigarette smoke, or cleaning solutions.

Atopic dermatitis: Refining differential diagnosis with testing

Atopic dermatitis is a complex disease that often develops in connection with other conditions, such as asthma and rhinitis. Guidelines advise that diagnosing AD starts with a physical examination. During that evaluation, it may help to employ an allergy-focused patient history.1,12

The findings of this allergy-focused patient history may also suggest that the next best step is to order specific IgE tests. Specific IgE blood testing and skin-prick testing (SPT) can help you rule in or rule out allergen sensitization, which may give you the ability to correctly diagnose and improve clinical management.15,16 Specific IgE blood testing can be performed irrespective of skin condition, whereas SPT may not be applicable due to the skin condition of an AD patient.

Who should be tested?

With up to 70 percent of infants and young children with eczema having an underlying allergy that contributes to disease severity,13,14 healthcare providers can use specific IgE testing to enhance the diagnostic process and pinpoint those allergens. The specific information gleaned from test results can also be used to develop a personalized treatment plan.
 

The symptom threshold

Up to 80 percent of patients with allergies are sensitized to more than one allergen.18 The effect is cumulative: An individual patient may have a number of triggers, which, combined, may lead to symptoms.19, 20 The allergen symptom threshold is the point at which the cumulative allergen load leads to symptoms.19, 20

Click to View Algorithm

Atopic dermatitis and quality of life

Atopic dermatitis (AD) poses a significant burden on not only healthcare resources, but also the quality of life of your patients and their caregivers.1

  • Children with AD have a worse quality of life than children with asthma, diabetes, or epilepsy.8
  • Eczema may result in school absenteeism, activity avoidance, and social isolation.9
  • Children suffering from eczema, and their parents, can lose up to two hours of sleep per night.10

Common allergens

Specific IgE serological tests aid in the diagnosis of allergic disease. As such, anyone presenting with eczema or other allergy symptoms is a candidate for specific IgE testing. Here are common allergens that can add up to symptoms:17

  • Animal dander
  • Egg
  • Fish
  • House dust mites
  • Milk
  • Peanut
  • Pollen
  • Shellfish
  • Soy bean
  • Tree nuts
  • Wheat

Testing Confidence

Testing Increases Diagnostic Confidence

Adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis to 90 percent.i,ii Conventionally, a diagnosis of allergic or autoimmune disease relies on the case history and a physical examination. However, adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis.i,ii Diagnostic testing can also help to improve the patient’s quality of life and productivity, reduce costs associated with absenteeism, and optimize use of medication, in addition to decreasing unscheduled healthcare visits.iii,iv 

i. Duran-Tauleria E, Vignati G, Guedan MJ, et al. The utility of specific immunoglobulin E measurements in primary care. Allergy. 2004;59 (Suppl78):35-41.
ii. NiggemannB, Nilsson M, Friedrichs F. Paediatric allergy diagnosis in primary care is improved by in vitro allergen specific IgE testing. Pediatr Allergy Immunol. 2008;19:325-331
iii. Welsh N, et al. The Benefits of Specific Immunoglobulin E Testing in the Primary Care Setting. J Am Pharm Assoc. 2006;46:627.
iv. Szeinbach SL, Williams B, Muntendam P, et al. Identification of allergic disease among users of antihistamines. J Manag Care Pharm. 2004; 10 (3): 234-238

See which labs in your region have the tests you need

Learn how to interpret test results and decide on a management plan

Management and care for patients with atopic dermatitis

Skin disorders, including atopic dermatitis (eczema) and urticaria (wheals), are commonly seen by healthcare providers and managing patients with these conditions can often be challenging. Results from studies have demonstrated that atopic dermatitis and urticaria have a profoundly negative impact on health-related quality of live (HRQoL), particularly impacting social functioning and psychological well-being. And many patients with one or both conditions report problems attributable to their skin in facets of everyday life including home management, personal care, mobility, sleep, rest, school, and work.21, 22

The management of skin allergies consists of three major categories of treatment:21, 22, 23

1. Allergen avoidance and environmental control methods
2. Pharmocologic therapy
3. Immunotherapy

Guidelines suggest developing a treatment plan with intensity of management based on disease severity and fluctuation from acute flares to periods of disease control. The primary elements of the skincare plan include hydration, topical anti-inflammatory medications, and antibacterial measures.24, 25

References

 

  1. Pawankar R, Holgate S, Canonica G, at el. World Allergy Organization. White Book on Allergy (WAO). 2011. http://www.worldallergy.org/UserFiles/file/WAO-White-Book-on-Allergy_web.pdf. Accessed December 2017. 
  2. Kay J, Gawkrodger DJ, Mortimer MJ, Jaron AG. The prevalence of childhood atopic eczema in a general population. J Am Acad Dermatol. 1994;30(1):35-39.  
  3. Bantz SK, Zhu Z, Zheng T. The Atopic March: Progression from Atopic Dermatitis to Allergic Rhinitis and Asthma. J Clin Cell Immunol. 2014;5(2):202.  
  4. Spergel JM. Nonimmunoglobulin e-mediated immune reactions to foods. Allergy Asthma Clin Immunol. 2006;2(2):78-85. 
  5. Van Der Hulst AE, Klip H, Brand PL. Risk of developing asthma in young children with atopic eczema: a systematic review. J Allergy Clin Immunol. 2007;120(3):565-569.  
  6. Gustafsson D, Sjöberg O, Foucard Tet al. Development of allergies and asthma in infants and young children with atopic dermatitis―a prospective follow-up to 7 years of age. Allergy. 2000;55(3):240-245.  
  7. Kulig M,  Bergmann R, Tacke U, et al. Long-lasting sensitization to food during the first two years precedes allergic airway disease. The MAS Study Group, Germany. Pediatr Allergy Immunol.1998;9(2):61-67
  8. Beattie PE, Lewis-Jones MS. A comparative study of impairment of quality of life in children with skin disease and children with other chronic childhood diseases. Br J Dermatol. 2006;155(1):145-151
  9. Lewis-Jones S: Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. Int J Clin Pract. 2006;60:984-992. 
  10. Reid P, Lewis-Jones MS. Sleep difficulties and their management in preschoolers with atopic eczema. Clin Exp Dermatol. 1995;20(1):38-41.  
  11. European Academy of Allergy and Clinical Immunology; Global Atlas of Allergic Rhinitis and Chronic Rhinosinusitis, 2015. http://www.eaaci.org/globalatlas/ENT_Atlas_web.pdf. Accessed January 2018. 
  12. Smith HE, Hogger C, Lallemant C, et al. Is structured allergy history sufficient when assessing patients with asthma and rhinitis in general practice? J Allergy Clin Immunol.  2009;123:646-650.
  13. Spergel JM. Am J Clin Dermatol. 2008;9:233-44.
  14. Eigenmann PA, et al. Prevalence of IgE-mediated food allergy among children with atopic dermatitis. Pediatrics. 1998;101:E8.  
  15. Duran-Tauleria E, Vignati G, Guedan MJ, et al. The utility of specific immunoglobulin E measurements in primary care. Allergy. 2004;59 (Suppl 78):35-41.
  16. Niggemann B, Nilsson M, Friedrichs F. Paediatric allergy diagnosis in primary care is improved by invitro allergen specific IgE testing. Pediatr Allergy Immunol. 2008;19:325-331.
  17. NHS Eczema; www.nhs.uk/conditions/eczema-(atopic)/pages/causes.aspx; last accessed October 2017.
  18. Lewis-Jones S, Mugglestone MA, Guideline Development Group (2007) Management of atopic eczema in children aged up to 12 years: summary of NICE guidance. BMJ 335(7632):1263-1264
  19. Ciprandi G, Alesina R, Ariano R, et al. Characteristics of patients with allergic polysensitization: the POLISMAIL study. Eur Ann Allergy Clin Immunol.  2008;40(3):77-83.  
  20. Eggleston PA. Control of environmental allergens as a therapeutic approach. lmmunol Allergy Clin North Am. 2003;23(3):533-547.
  21. Lifschitz C. The Impact of Atopic Dermatitis on Quality of Life. Ann Nutr Metab. 2015;66(suppl 1):34–40 
  22. O'Donnell BF, et al. The impact of chronic urticaria on the quality of life. Br J Dermatol.1997 Feb;136(2):197-201.
  23. Schneider, et al. Atopic dermatitis: A practice parameter update 2012. J Allergy Clin Immunol 2013;131:295-9.
  24. LeBovidge J et al. Multidisciplinary interventions in the management of atopic dermatitis. J Allergy Clin Immunol. 2016 Aug;138(2):325-34.
  25. Deacock SJ. An approach to the patient with urticaria. Clin Exp Immunol. 2008 Aug;153(2):151-61.