What is atopic dermatitis?

Atopic dermatitis (AD; atopic eczema, eczema, neurodermatitis, neurodermitis) is an inflammatory, chronically relapsing, and intensely pruritic skin disease occurring often in families with atopic diseases (atopic dermatitis, bronchial asthma, and/or allergic rhino-conjunctivitis).

Atopy is an abnormal change in the immune system when it starts attacking normal proteins that exist in our environment. This is an opposite state of the normal immunity which is called tolerance. People who have balanced immune responses are well-protected from infection but at the same time do not have allergies.

The atopic diseases are genetically linked, and the concordance in monozygotic twins is 80% versus 30% in dizygotic twins. When we say that atopy is genetic, indeed the ‘bad genes’ only can lead to increased reactivity of the immune cells, and sometimes lead to familial “cheap skin”. What that actually mean is that if some time in life the environment will contain too much of the chemicals or certain allergenic proteins, that can turn the genes ‘on’ and start inflammation.

After allergic proteins enter the skin layers and can be seen by immune cells that sit there on guard, the allergic reaction can start. It is much easier to prevent the reactions by keeping the skin healthy and tight, then to stop the allergic inflammation after it began.

Can atopic dermatitis affect the face?

Skin features of atopic dermatitis are actually similar on all parts of the body. Why is that? Skin is considered one whole organ of the body, so the cells are the same. While atopic dermatitis can start any place, there are certain locations on the body that seem to be affected first:

• Eyelids
• Antecubital folds (the fold where the elbow joint is)
• Popliteal folds (the fold behind the knee joint)
• Hands
• Neck

In the first months of life, a yellowish desquamation on the scalp, known as “cradle cap,” may be a presentation of AD. The disease may then spread to the face and extensor surfaces of the arms and legs of toddlers, sometimes showing extensive oozing and crusting.

Later on, the typical preferential pattern develops with eczematous involvement of flexures, neck, and hands, accompanied by dry skin and skin barrier dysfunction reflected by an increased transepidermal water loss.

Lichenification is a result of scratching and rubbing, and most frequently in adults, this may result in the prurigo type of AD with predominant excoriated nodular lesions. Exacerbations often start as increased itch without visible skin lesions. This is followed by erythema, papules, and infiltration.

What are the symptoms and signs of atopic dermatitis?

AD is a non-contagious inflammation of the epidermis and dermis, which are the upper layers of the skin.

It has distinct signs and characteristic when appears on the eyelids:

• itch, sometimes very intense
• erythema (redness)
• papule, seropapule, vesicle formation
• crusting and dry flaky skin
• swelling of the eyelids
• loosing eyelashes and eyebrows

Same symptoms usually are present everywhere on the body. If the rash is isolated to the eyelids only, it can also be a chemical contact dermatitis or even a demodex mite infestation. When in doubt, a dermatologist needs to take a skin biopsy, and pathologist examines results. Then they can decide that it is atopic dermatitis by seeing certain skin changes:

• spongiosis
• acanthosis
• hyper- and parakeratosis
• lymphocytic infiltrates
• exocytosis
• eosinophils infiltration

What causes atopic dermatitis on eyelids?

As we already discussed, the same reasons that made the eczema appear on the rest of the body are responsible for the atopic dermatitis of the eyelids and face. Here are some allergens that are known to cause skin allergic eczema:

• dust mites
• cat and dog allergen
• grass and trees pollen
• food allergies
• cockroach and mice allergens

Risk Factors

When trying to figure out why the problem started, we focus on the following:

• timing and location of the rash
• when the symptoms are more bothersome (indoors or outdoors, all year or during a certain season)
• Family and/or personal history of the atopic triad
• Presence of contact allergens (soaps, shampoos, cleaning materials)
• The presence of triggers including allergens (e.g., dust mites, animal dander), hot showers/sweating, soaps, fragrances, food hypersensitivities, and synthetic fabrics such as polyester.

One of the biggest risk factors is using the antibacterial harsh soaps and shampoos that destroy the upper oily layer and kills all good protective bacteria on the skin. That ruins the balance and opens up the skin. That is when the sensitization happens and the allergy starts.

Genetic factors may predispose to the “cheap” quality of the skin – dry skin has upper layers that come apart and do not hold the internal moisture. The natural oils that are produced by the skin is the most important barrier that keeps the dermis cells soft and connected.

Is atopic dermatitis contagious?

No, atopic and allergic conditions are not contagious. You might think they are because many people in the same household may get the rash at the same time. If that happens – look for something common in use or contact. Maybe you got the new puppy? Or, did the spring bring tons of pollen in the air? If also all of you suddenly started sneezing or coughing without fever – it is time to see an allergist!

Atopic dermatitis vs. Eczema

Atopic dermatitis is the same as eczema. There are other names that are used for it.

Types of eczema

Atopic dermatitis is divided into three subsets based on the age of onset:

1. Early-onset atopic dermatitis (birth to 2 years old):  most common type of atopic dermatitis, with approximately 60% of cases starting by age 1. Sixty percent of cases resolve by 12 years old
2. Late-onset atopic dermatitis:  symptoms begin after the onset of puberty
3. Senile onset atopic dermatitis: an unusual subset with onset in patients older than 60 years old.

What tests diagnose atopic dermatitis?

As atopic diseases are caused by an allergen in the environment, the tests that can point to the real problem are allergy tests:

• Allergy skin test for indoor and outdoor airborn allergens
• Allergy skin test for foods
• Allergy patch test for contact chemicals

What is the treatment for atopic dermatitis?

Treating atopic dermatitis in infants and children is difficult. Only a consistent daily regimen of treatments can successfully get rid of this chronic sickness:

1. Clean up the immediate environment from all contact harsh chemicals
2. Change body wash, shampoo and detergent to the hypoallergenic products we recommend in the office
3. Do all the dust mite protection
4. Change foods if food allergy was diagnosed
5. Use ‘soak and seal’ skin care protocol
6. Stop all baby products or skin products you used when the problem started

When atopic dermatitis is not controlled with topical agents, systemic agents include phototherapy (ultraviolet (UV) A, UVB, and narrow-band UVB), cyclosporine, azathioprine, mycophenolate mofetil, and methotrexate.

 A newly FDA-approved biologic therapy is dupilumab, which is a monoclonal antibody that blocks the IL-4 receptor and thus the effect of IL-4 and IL-13.  Other complementary therapies include bleach baths (0.5 cup bleach in full 40 gallon tub) one to two times weekly to decrease S. aureus colonization, low allergen maternal diets during breastfeeding, and probiotic and prebiotic use in pregnant mothers and at-risk infants which has shown 50% decreased frequency of atopic dermatitis at ages 1 to 4 years old compared to placebo.

Recently Crisaborole topic ointment was approved for mild to moderate AD. The drug is a phosphodiesterase inhibitor and shown to improve skin symptoms.

Antihistamines can be used to control the allergy while you are taking care of the allergens themselves or ordering dust mite-proof bed encasing and HEPA filters.

Sometimes atopic dermatitis can lead to skin infection, as natural protection of the skin is lowered. In this case you will be given topical or oral antibiotics.

How should I care for atopic skin on my eyelids?

You will need to use a great caution while treating the eyelids not to make things worse. Eyes and eyelids are the most sensitive areas of the face. The skin of the eyelids is thinner and very fragile. Also, whatever cream you will use on the eyelids will almost always get on the eyelashes and in the eyes. Certain creams must be completely avoided around the eyes. One of the safest creams to use is Vaseline – this gooey substance will allow skin to stay moist for a long time and will not irritate the eye.

You should avoid:

• Commercial cleansers and wipes
• Cosmetic products
• Commercial creams that claim “doctor recommended” that are over the counter
• Steroid OTC creams
• OTC eye drops
• Perfumes and scented products

We do not like steroidal creams on the face unless nothing else works.

You should use:

• Clear water to clean the face
• Organic natural oils and soaps
• Vinegar and soda for house cleaning and laundry

Skin reactions, including stinging, are a manifestation of worsening eczema (breakdown of the skin barrier). Emollients are the mainstay of current treatment of atopic eczema, and clinical experience is that they reduce the need for topical corticosteroids. Regular use of emollients is essential to ensure rehydration of the skin, and to give skin flexibility. It is the experience of most doctors that dry skin requires a greasy emollient preparation, whereas red inflamed eczema usually responds better to water-based products because evaporation cools the skin.

Natural therapies in children with atopic eczema that are beneficial and has no known side effects:

• homeopathy
• Chinese herbal medicine
• massage
• hypnotherapy
• aromatherapy
• honey, beeswax and olive oil mixture
• Nigella sativa (black seed) oil
• gamma linolenic acid (an essential fatty acid).

What are home remedies for atopic dermatitis?

Atopic condition is a result of the aggressive response of the immune system, imbalance of the nervous system and abnormal skin homeostasis. We never view it as a disease, but rather as a result of the series of unfortunate events. As such, you can do a lot to avoid atopic dermatitis development and make it into tolerable sporadic inconvenience. You just need to realize that natural skin defenses are of natural origin.

We recommend to step away from commercial product and use what is safe and effective:

• aloe vera juice
• avocado oil
• herbal teas (orange pekoe black tea)
• probiotics
• supplements – fish oil, cod liver oil, fennel seed, turmeric, stinging nettle.

It is best to see a functioning doctor when trying to find the best home remedies – a consultation on healthy nutrition, skin care and environment control is all you need to continue all measures successfully on your own.