Atopic dermatitis (AD), commonly known as eczema, is the most common chronic skin disease in children. It affects 25% of young children and 10 to 15% of older children. Studies show that prevalence of eczema has increased over the last 20 years. The increasing trend of eczema is in line with the global increase of allergy (or atopy). A number of environmental factors have been implicated. On-going research efforts are evaluating these hypotheses but presently there is insufficient evidence for recommendation of any measures to avoid the development of allergies including eczema.
Eczema has no specific skin signs and comprises of a number of characteristics such as redness (erythema), loss of epidermis (excoriation), scratching lesions, thickening of the skin (lichenification), and areas of increased or decreased pigmentation (hyperpigmentation or hypopigmentation). Children do not have the symptoms from birth, but symptoms usually appear before they are three months old. The lesions start before the age of one in 80% of the children and before the age of five in 90%. The most invariable and troublesome symptom is the itch (pruritus) which can sometimes be very intense and cause severe disturbance of sleep. The asymptomatic intervals can become longer as the child ages. It is estimated that in 60% of children with severe eczema requiring hospitalisation, symptoms will persist beyond the age of 20 years. In 95% of milder cases, symptoms disappear before the age of 20 years.
Causes or triggers of eczema are multiple and differ from child to child. In some children food allergy can be involved. However, this is not common and primarily involves very young children with severe lesions. Foods that are most commonly involved are: eggs and cow's milk. In older children, food allergy is rarely involved. Most older children with eczema experience exacerbations of their disease when exposed to house dust mite allergens or bacteria infections of the skin. Certain bacteria (especially Staphylococcus aureus) can colonise the skin, resulting in persistent and infected lesions. Therefore, infection is now considered a most important maintenance factor of eczema in older children. Apart from allergy, other triggers have been identified, including stress and sweating.
There is no cure for eczema. However, by controlling the condition, children can easily outgrow it. Apart from avoiding triggers, treatment of eczema is focused on treating the symptoms (i.e. symptomatic treatment), especially reducing sleep disturbances and treating facial lesions. Treatment of eczema is complex, and includes different aspects. Schematically, the following four areas of treatment are advocated, adapted from child to child:
Eczema is a complex disease in which a great number of environmental factors are involved, including food allergens and inhalant allergens. In young children with severe eczema, food allergens, such as cow's milk and eggs, should be considered as triggering factors. In older children, however, the role of food seems to be less important. In these patients allergens, such as house dust mite, and bacterial infections might trigger the chronic lesions. Treatment of eczema is mainly symptomatically, and made up by four different aspects of treatment. Casual treatments (of the underlying mechanisms) are now under study, and, hopefully, will become available in the near future.
This article was first published in I CAN! Newsletter January 2005 issue. Used with permission.
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