AtopicDermatitis

U.S. Department of Health andHuman Services

National Institutes of HealthNational Institute of Arthritis and

Musculoskeletal and Skin Diseases

(A type of eczema)

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This booklet is not copyrighted. Readers areencouraged to duplicate and distribute as manycopies as needed.

Additional copies of this booklet are availablefrom the National Institute of Arthritis andMusculoskeletal and Skin Diseases, NIAMS/NationalInstitutes of Health, 1 AMS Circle, Bethesda, Maryland20892-3675, and on the NIAMS Web site at http://www.niams.nih.gov/hi/topics/dermatitis/index/html.

Table of Contents

Defining Atopic Dermatitis ............................................ 3

Incidence and Prevalence of Atopic Dermatitis ............. 4

Cost of Atopic Dermatitis............................................... 6

Causes of Atopic Dermatitis........................................... 6

Symptoms of Atopic Dermatitis ..................................... 9

Stages of Atopic Dermatitis........................................... 11

Diagnosing Atopic Dermatitis ....................................... 12

Factors that Make Atopic Dermatitis Worse ................. 15

Treatment of Atopic Dermatitis..................................... 18

Atopic Dermatitis and Quality of Life .......................... 24

Atopic Dermatitis and VaccinationAgainst Smallpox .......................................................... 25

Current Research ........................................................... 27

Hope for the Future ....................................................... 31

Additional Resources..................................................... 32

Types of Eczema (Dermatitis) ........................................ 5

Skin Features Associated With Atopic Dermatitis ......... 8

Major and Minor Features of Atopic Dermatitis........... 14

Common Irritants .......................................................... 16

Treating Atopic Dermatitis in Infants and Children...... 22

Tips for Working With Your Doctor..............................26

Controlling Atopic Dermatitis ....................................... 28

3

Atopic Dermatitis

This booklet is for people who have atopic dermatitis

(often called “eczema”), parents and caregivers of

children with atopic dermatitis, and others interested in

learning more about the disease. The booklet describes

the disease and its symptoms and contains information

about diagnosis and treatment as well as current

research efforts supported by the National Institute of

Arthritis and Musculoskeletal and Skin Diseases

(NIAMS) and other components of the Department of

Health and Human Services’ National Institutes of

Health (NIH). It also discusses issues such as skin care

and quality of life for people with atopic dermatitis. If

you have further questions after reading this booklet, you

may wish to discuss them with your doctor or your

child’s pediatrician.

A topic dermatitis is a chronic (long-lasting) diseasethat affects the skin. It is not contagious; it cannot be

passed from one person to another. The word “dermatitis”means inflammation of the skin. “Atopic” refers to agroup of diseases where there is often an inheritedtendency to develop other allergic conditions, such asasthma and hay fever. In atopic dermatitis, the skinbecomes extremely itchy. Scratching leads to redness,swelling, cracking, “weeping” clear fluid, and finally,crusting and scaling. In most cases, there are periods of

4

Although atopic

dermatitis may

occur at any age,

it most often

begins in infancy

and childhood.

time when the disease is worse (called exacerbations orflares) followed by periods when the skin improves orclears up entirely (called remissions). As some childrenwith atopic dermatitis grow older, their skin disease

improves or disappears altogether,although their skin often remains dryand easily irritated. In others, atopicdermatitis continues to be a significantproblem in adulthood.

Atopic dermatitis is often referred toas “eczema,” which is a general termfor the several types of inflammationof the skin. Atopic dermatitis is themost common of the many types ofeczema. Several have very similarsymptoms. Types of eczema aredescribed in the box on page 5.

A topic dermatitis is very common.It affects males and females and

accounts for 10 to 20 percent of allvisits to dermatologists (doctors whospecialize in the care and treatment of

skin diseases). Although atopic dermatitis may occur atany age, it most often begins in infancy and childhood.Scientists estimate that 65 percent of patients developsymptoms in the first year of life, and 90 percent developsymptoms before the age of 5. Onset after age 30 is lesscommon and is often due to exposure of the skin to harshor wet conditions. Atopic dermatitis is a common causeof workplace disability. People who live in cities and indry climates appear more likely to develop this condition.

5

Types of Eczema (Dermatitis)

■ Allergic contact eczema (dermatitis): a red, itchy,weepy reaction where the skin has come intocontact with a substance that the immune systemrecognizes as foreign, such as poison ivy orcertain preservatives in creams and lotions

■ Atopic dermatitis: a chronic skin diseasecharacterized by itchy, inflamed skin

■ Contact eczema: a localized reaction that includesredness, itching, and burning where the skin hascome into contact with an allergen (an allergy-causing substance) or with an irritant such as anacid, a cleaning agent, or other chemical

■ Dyshidrotic eczema: irritation of the skin on thepalms of hands and soles of the feet characterizedby clear, deep blisters that itch and burn

■ Neurodermatitis: scaly patches of the skin on thehead, lower legs, wrists, or forearms caused by alocalized itch (such as an insect bite) that becomeintensely irritated when scratched

■ Nummular eczema: coin-shaped patches ofirritated skin—most common on the arms, back,buttocks, and lower legs—that may be crusted,scaling, and extremely itchy

■ Seborrheic eczema: yellowish, oily, scaly patchesof skin on the scalp, face, and occasionally otherparts of the body

■ Stasis dermatitis: a skin irritation on the lowerlegs, generally related to circulatory problems

6

More than

15 million people

in the U.S. have

symptoms

of atopic

dermatitis.

Although it is difficult to identify exactly how manypeople are affected by atopic dermatitis, an estimated 20percent of infants and young children experience

symptoms of the disease. Roughly 60percent of these infants continue tohave one or more symptoms of atopicdermatitis in adulthood. This meansthat more than 15 million people in theUnited States have symptoms of thedisease.

I n a recent analysis of the healthinsurance records of 5 million

Americans under age 65, medicalresearchers found that approximately2.5 percent had atopic dermatitis.Annual insurance payments formedical care of atopic dermatitisranged from $580 to $1,250 perpatient. More than one-quarter of eachpatient’s total health care costs were

for atopic dermatitis and related conditions. Theresearchers project that U.S. health insurance companiesspend more than $1 billion per year on atopic dermatitis.

T he cause of atopic dermatitis is not known, but thedisease seems to result from a combination of genetic

(hereditary) and environmental factors.

Children are more likely to develop this disorder if one orboth parents have had it or have had allergic conditionslike asthma or hay fever. While some people outgrow skin

7

Atopic dermatitis

is also

associated with

malfunction of

the body’s

immune system.

symptoms, approximately three-fourths of children withatopic dermatitis go on to develop hay fever or asthma.Environmental factors can bring on symptoms of atopicdermatitis at any time in individuals who have inheritedthe atopic disease trait.

Atopic dermatitis is also associatedwith malfunction of the body’simmune system: the system thatrecognizes and helps fight bacteriaand viruses that invade the body.Scientists have found that people withatopic dermatitis have a low level of acytokine (a protein) that is essential tothe healthy function of the body’simmune system and a high level ofother cytokines that lead to allergicreactions. The immune system canbecome misguided and createinflammation in the skin even in theabsence of a major infection. This canbe viewed as a form of autoimmunity,where a body reacts against its owntissues.

In the past, doctors thought that atopic dermatitis wascaused by an emotional disorder. We now know thatemotional factors, such as stress, can make the conditionworse, but they do not cause the disease.

8

Skin Features AssociatedWith Atopic Dermatitis

■ Atopic pleat (Dennie-Morgan fold): an extrafold of skin that develops under the eye

■ Cheilitis: inflammation of the skin on andaround the lips

■ Hyperlinear palms: increased number of skincreases on the palms

■ Hyperpigmented eyelids: eyelids that havebecome darker in color from inflammation orhay fever

■ Ichthyosis: dry, rectangular scales on the skin

■ Keratosis pilaris: small, rough bumps,generally on the face, upper arms, and thighs

■ Lichenification: thick, leathery skin resultingfrom constant scratching and rubbing

■ Papules: small raised bumps that may openwhen scratched and become crusty andinfected

■ Urticaria: hives (red, raised bumps) that mayoccur after exposure to an allergen, at thebeginning of flares, or after exercise or ahot bath

9

S ymptoms (signs) vary from person to person. Themost common symptoms are dry, itchy skin and

rashes on the face, inside the elbows and behind theknees, and on the hands and feet. Itching is the mostimportant symptom of atopicdermatitis. Scratching and rubbing inresponse to itching irritates the skin,increases inflammation, and actuallyincreases itchiness. Itching is aparticular problem during sleep whenconscious control of scratching is lost.

The appearance of the skin that isaffected by atopic dermatitis dependson the amount of scratching and thepresence of secondary skin infections.The skin may be red and scaly, bethick and leathery, contain smallraised bumps, or leak fluid andbecome crusty and infected. The boxon page 8 lists common skin featuresof the disease. These features can alsobe found in people who do not haveatopic dermatitis or who have othertypes of skin disorders.

Atopic dermatitis may also affect theskin around the eyes, the eyelids, andthe eyebrows and lashes. Scratchingand rubbing the eye area can causethe skin to redden and swell. Some people with atopicdermatitis develop an extra fold of skin under their eyes.Patchy loss of eyebrows and eyelashes may also resultfrom scratching or rubbing.

The most common

symptoms are

dry, itchy skin

and rashes on

the face, inside

the elbows and

behind the knees,

and on the hands

and feet.

10

Researchers have noted differences in the skin ofpeople with atopic dermatitis that may contribute to thesymptoms of the disease. The outer layer of skin, calledthe epidermis, is divided into two parts: an inner part

containing moist, living cells, andan outer part, known as the hornylayer or stratum corneum,containing dry, flattened, dead cells.Under normal conditions thestratum corneum acts as a barrier,keeping the rest of the skin fromdrying out and protecting otherlayers of skin from damage causedby irritants and infections. Whenthis barrier is damaged, irritants actmore intensely on the skin.

The skin of a person with atopicdermatitis loses moisture from theepidermal layer, allowing the skin tobecome very dry and reducing itsprotective abilities. Thus, whencombined with the abnormal skinimmune system, the person’s skin ismore likely to become infected bybacteria (for example, Staphylo-

coccus and Streptococcus) or viruses, such as those thatcause warts and cold sores.

Atopic dermatitis

may also affect

the skin around

the eyes, the

eyelids, and the

eyebrows

and lashes.

11

W hen atopic dermatitis occurs during infancy andchildhood, it affects each child differently in terms

of both onset and severity of symptoms. In infants,atopic dermatitis typically begins around 6 to 12 weeksof age. It may first appear around the cheeks and chin asa patchy facial rash, which can progress to red, scaling,oozing skin. The skin may become infected. Once theinfant becomes more mobile and begins crawling,exposed areas, such as the inner and outer parts of thearms and legs, may also be affected. An infant withatopic dermatitis may be restless and irritable because ofthe itching and discomfort of the disease. The skin mayimprove by 18 months of age, although the infant has agreater than normal risk of developing dry skin or handeczema later in life.

In childhood, the rash tends to occur behind the kneesand inside the elbows; on the sides of the neck; aroundthe mouth; and on the wrists, ankles, and hands. Often,the rash begins with papules that become hard and scalywhen scratched. The skin around the lips may beinflamed, and constant licking of the area may lead tosmall, painful cracks in the skin around the mouth.

In some children, the disease goes into remission for along time, only to come back at the onset of pubertywhen hormones, stress, and the use of irritating skin careproducts or cosmetics may cause the disease to flare.

Although a number of people who developed atopicdermatitis as children also experience symptoms asadults, it is also possible for the disease to show up firstin adulthood. The pattern in adults is similar to that seenin children; that is, the disease may be widespread orlimited to only a few parts of the body. For example,

12

It is also possible

for the disease to

show up first in

adulthood.

only the hands or feet may be affected and become dry,itchy, red, and cracked. Sleep patterns and work

performance may be affected, andlong-term use of medications to treatthe atopic dermatitis may causecomplications. Adults with atopicdermatitis also have a predispositiontoward irritant contact dermatitis,where the skin becomes red andinflamed from contact withdetergents, wool, friction fromclothing, or other potential irritants. Itis more likely to occur in occupationsinvolving frequent hand washing orexposure to chemicals. Some peopledevelop a rash around their nipples.These localized symptoms are

difficult to treat. Because adults may also developcataracts, the doctor may recommend regular eye exams.

E ach person experiences a unique combination ofsymptoms, which may vary in severity over time. The

doctor will base a diagnosis on the symptoms the patientexperiences and may need to see the patient several timesto make an accurate diagnosis and to rule out otherdiseases and conditions that might cause skin irritation.In some cases, the family doctor or pediatrician mayrefer the patient to a dermatologist (doctor specializing inskin disorders) or allergist (allergy specialist) for furtherevaluation.

A medical history may help the doctor better understandthe nature of a patient’s symptoms, when they occur, andtheir possible causes. The doctor may ask about family

13

Currently, there

is no single test

to diagnose

atopic dermatitis.

history of allergic disease; whether the patient also hasdiseases such as hay fever or asthma; and about exposureto irritants, sleep disturbances, any foods that seem to berelated to skin flares, previoustreatments for skin-relatedsymptoms, and use of steroids orother medications. A preliminarydiagnosis of atopic dermatitiscan be made if the patient hasthree or more features from eachof two categories: major featuresand minor features. Some ofthese features are listed in thebox on page 14.

Currently, there is no single testto diagnose atopic dermatitis.However, there are some teststhat can give the doctor anindication of allergic sensitivity.

Pricking the skin with a needle that contains a smallamount of a suspected allergen may be helpful inidentifying factors that trigger flares of atopic dermatitis.Negative results on skin tests may help rule out thepossibility that certain substances cause skininflammation. Positive skin prick test results are difficultto interpret in people with atopic dermatitis because theskin is very sensitive to many substances, and there canbe many positive test sites that are not meaningful to aperson’s disease at the time. Positive results simplyindicate that the individual has IgE (allergic) antibodiesto the substance tested. IgE (immunoglobulin E) controlsthe immune system’s allergic response and is often highin atopic dermatitis.

14

Major and Minor Features of Atopic Dermatitis

■ Intense itching

■ Characteristic rash in locations typical of thedisease

■ Chronic or repeatedly occurring symptoms

■ Personal or family history of atopic disorders(eczema, hay fever, asthma)

■ Early age of onset

■ Dry skin that may also have patchy scales orrough bumps

■ High levels of immunoglobulin E (IgE), anantibody, in the blood

■ Numerous skin creases on the palms

■ Hand or foot involvement

■ Inflammation around the lips

■ Nipple eczema

■ Susceptibility to skin infection

■ Positive allergy skin tests

15

Recently, it was shown that if the quantity of IgEantibodies to a food in the blood is above a certainlevel, it is diagnostic of a food allergy. If the level ofIgE to a specific food does not exceed the level neededfor diagnosis but a food allergy is suspected, a personmight be asked to record everything eaten and note anyreactions. Physician-supervised food challenges (that is,the introduction of a food) following a period of foodelimination may be necessary to determine ifsymptomatic food allergy is present. Identifying thefood allergen may be difficult when a person is alsobeing exposed to other possible allergens at the sametime or symptoms may be triggered by other factors,such as infection, heat, and humidity.

M any factors or conditions can make symptoms ofatopic dermatitis worse, further triggering the

already overactive immune system, aggravating the itch-scratch cycle, and increasing damage to the skin. Thesefactors can be broken down into two main categories:irritants and allergens. Emotional factors and someinfections and illnesses can also influence atopicdermatitis.

Irritants are substances that directly affect the skin and,when present in high enough concentrations with longenough contact, cause the skin to become red and itchyor to burn. Specific irritants affect people with atopicdermatitis to different degrees. Over time, many patientsand their family members learn to identify the irritantscausing the most trouble. For example, frequent wettingand drying of the skin may affect the skin barrierfunction. Also, wool or synthetic fibers and rough or

16

poorly fitting clothing can rub the skin, triggerinflammation, and cause the itch-scratch cycle to begin.Soaps and detergents may have a drying effect andworsen itching, and some perfumes and cosmetics mayirritate the skin. Exposure to certain substances, such assolvents, dust, or sand, may also make the conditionworse. Cigarette smoke may irritate the eyelids. Becausethe effects of irritants vary from one person to another,each person can best determine what substances orcircumstances cause the disease to flare.

Allergens are substances from foods, plants, animals, orthe air that inflame the skin because the immune systemoverreacts to the substance. Inflammation occurs evenwhen the person is exposed to small amounts of thesubstance for a limited time. Although it is known thatallergens in the air, such as dust mites, pollens, molds,and dander from animal hair or skin, may worsen thesymptoms of atopic dermatitis in some people, scientistsaren’t certain whether inhaling these allergens or their

Common Irritants

■ Wool or synthetic fibers

■ Soaps and detergents

■ Some perfumes and cosmetics

■ Substances such as chlorine, mineral oil,or solvents

■ Dust or sand

■ Cigarette smoke

17

actual penetration of the skin causes the problems.When people with atopic dermatitis come into contactwith an irritant or allergen they are sensitive to,inflammation-producing cells become active. These cellsrelease chemicals that cause itching and redness. As theperson responds by scratching and rubbing the skin,further damage occurs.

A number of studies have shown that foods may triggeror worsen atopic dermatitis in some people, particularlyinfants and children. In general, the worse the atopicdermatitis and the younger the child, the more likelyfood allergy is present. An allergic reaction to food cancause skin inflammation (generally an itchy red rash),gastrointestinal symptoms (abdominal pain, vomiting,diarrhea), and/or upper respiratory tract symptoms(congestion, sneezing, and wheezing). The mostcommon allergenic (allergy-causing) foods are eggs,milk, peanuts, wheat, soy, and fish. A recent analysis ofa large number of studies on allergies and breastfeedingindicated that breastfeeding an infant for at least 4months may protect the child from developing allergies.However, some studies suggest that mothers with afamily history of atopic diseases should avoid eatingcommon allergenic foods during late pregnancy andbreastfeeding.

In addition to irritants and allergens, emotional factors,skin infections, and temperature and climate play a rolein atopic dermatitis. Although the disease itself is notcaused by emotional factors, it can be made worse bystress, anger, and frustration. Interpersonal problems ormajor life changes, such as divorce, job changes, or thedeath of a loved one, can also make the disease worse.

18

Treatment is more

effective when a

partnership

develops that

includes the

patient, family

members, and

doctor.

Bathing without proper moisturizing afterward is acommon factor that triggers a flare of atopic dermatitis.The low humidity of winter or the dry year-roundclimate of some geographic areas can make the disease

worse, as can overheated indoorareas and long or hot baths andshowers. Alternately sweating andchilling can trigger a flare in somepeople. Bacterial infections can alsotrigger or increase the severity ofatopic dermatitis. If a patientexperiences a sudden flare of illness,the doctor may check for infection.

Treatment is more effective when apartnership develops that includes

the patient, family members, anddoctor. The doctor will suggest atreatment plan based on the patient’sage, symptoms, and general health.The patient or family memberproviding care plays a large role inthe success of the treatment plan bycarefully following the doctor’sinstructions and paying attention towhat is or is not helpful. Most

patients will notice improvement with proper skin careand lifestyle changes.

The doctor has two main goals in treating atopicdermatitis: healing the skin and preventing flares.These may be assisted by developing skin care routines

19

and avoiding substances that lead to skin irritation andtrigger the immune system and the itch-scratch cycle. Itis important for the patient and family members to noteany changes in the skin’s condition in response totreatment, and to be persistent in identifying thetreatment that seems to work best.

Medications: New medications known as immuno-modulators have been developed that help controlinflammation and reduce immune system reactionswhen applied to the skin. Examples of these medicationsare tacrolimus ointment (Protopic*) and pimecrolimuscream (Elidel). They can be used in patients older than 2years of age and have few side effects (burning oritching the first few days of application). They not onlyreduce flares, but also maintain skin texture and reducethe need for long-term use of corticosteroids.

Corticosteroid creams and ointments have been used formany years to treat atopic dermatitis and otherautoimmune diseases affecting the skin. Sometimesover-the-counter preparations are used, but in manycases the doctor will prescribe a stronger corticosteroidcream or ointment. When prescribing a medication, thedoctor will take into account the patient’s age, locationof the skin to be treated, severity of the symptoms, andtype of preparation (cream or ointment) that will bemost effective. Sometimes the base used in certainbrands of corticosteroid creams and ointments irritates

*Brand names included in this booklet are provided as examples only, and their inclusion does

not mean that these products are endorsed by the National Institutes of Health or any other

Government agency. Also, if a particular brand name is not mentioned, this does not mean or

imply that the product is unsatisfactory.

20

Corticosteroid

creams and oint-

ments have been

used for many

years to treat

atopic dermatitis

and other autoim-

mune diseases af-

fecting the skin.

the skin of a particular patient. Side effects of repeated orlong-term use of topical corticosteroids can includethinning of the skin, infections, growth suppression (inchildren), and stretch marks on the skin.

When topical corticosteroids are noteffective, the doctor may prescribe asystemic corticosteroid, which istaken by mouth or injected insteadof being applied directly to the skin.An example of a commonlyprescribed corticosteroid isprednisone. Typically, thesemedications are used only inresistant cases and only given forshort periods of time. The sideeffects of systemic corticosteroidscan include skin damage, thinned orweakened bones, high bloodpressure, high blood sugar,infections, and cataracts. It can bedangerous to suddenly stop takingcorticosteroids, so it is veryimportant that the doctor and patientwork together in changing thecorticosteroid dose.

Antibiotics to treat skin infectionsmay be applied directly to the skinin an ointment, but are usually moreeffective when taken by mouth. Ifviral or fungal infections are present,

the doctor may also prescribe specific medications totreat those infections.

21

Certain antihistamines that cause drowsiness can reducenighttime scratching and allow more restful sleep whentaken at bedtime. This effect can be particularly helpfulfor patients whose nighttime scratching makes thedisease worse.

In adults, drugs that suppress the immune system, suchas cyclosporine, methotrexate, or azathioprine, may beprescribed to treat severe cases of atopic dermatitis thathave failed to respond to other forms of therapy. Thesedrugs block the production of some immune cells andcurb the action of others. The side effects of drugs likecyclosporine can include high blood pressure, nausea,vomiting, kidney problems, headaches, tingling ornumbness, and a possible increased risk of cancer andinfections. There is also a risk of relapse after the drug isstopped. Because of their toxic side effects, systemiccorticosteroids and immunosuppressive drugs are usedonly in severe cases and then for as short a period oftime as possible. Patients requiring systemiccorticosteroids should be referred to dermatologists orallergists specializing in the care of atopic dermatitis tohelp identify trigger factors and alternative therapies.

In rare cases, when home-based treatments have beenunsuccessful, a patient may need a few days in thehospital for intense treatment.

Phototherapy: Use of ultraviolet A or B light waves,alone or combined, can be an effective treatment for mildto moderate dermatitis in older children (over 12 yearsold) and adults. A combination of ultraviolet lighttherapy and a drug called psoralen can also be used incases that are resistant to ultraviolet light alone. Possiblelong-term side effects of this treatment include premature

22

skin aging and skin cancer. If the doctor thinks thatphototherapy may be useful to treat the symptoms ofatopic dermatitis, he or she will use the minimumexposure necessary and monitor the skin carefully.

Skin Care: Healing the skin and keeping it healthy areimportant to prevent further damage and enhance qualityof life. Developing and sticking with a daily skin careroutine is critical to preventing flares.

Treating Atopic Dermatitisin Infants and Children

■ Give lukewarm baths.

■ Apply lubricant immediately following thebath.

■ Keep child’s fingernails filed short.

■ Select soft cotton fabrics when choosingclothing.

■ Consider using sedating antihistamines topromote sleep and reduce scratching at night.

■ Keep the child cool; avoid situations whereoverheating occurs.

■ Learn to recognize skin infections and seektreatment promptly.

■ Attempt to distract the child with activities tokeep him or her from scratching.

■ Identify and remove irritants and allergens.

23

A lukewarm bath helps to cleanse and moisturize theskin without drying it excessively. Because soaps canbe drying to the skin, the doctor may recommend use ofa mild bar soap or nonsoap cleanser. Bath oils are notusually helpful.

After bathing, a person should air-dry the skin, or pat itdry gently (avoiding rubbing or brisk drying), and thenapply a lubricant to seal in the water that has beenabsorbed into the skin during bathing. In addition torestoring the skin’s moisture, lubrication increases therate of healing and establishes a barrier against furtherdrying and irritation. Lotions that have a high water oralcohol content evaporate more quickly, and alcoholmay cause stinging. Therefore, they generally are notthe best choice. Creams and ointments work better athealing the skin.

Another key to protecting and restoring the skin istaking steps to avoid repeated skin infections. Signs ofskin infection include tiny pustules (pus-filled bumps),oozing cracks or sores, or crusty yellow blisters. Ifsymptoms of a skin infection develop, the doctorshould be consulted and treatment should begin as soonas possible.

Protection from Allergen Exposure: The doctor maysuggest reducing exposure to a suspected allergen. Forexample, the presence of the house dust mite can belimited by encasing mattresses and pillows in specialdust-proof covers, frequently washing bedding in hotwater, and removing carpeting. However, there is noway to completely rid the environment of airborneallergens.

24

Changing the diet may not always relieve symptoms ofatopic dermatitis. A change may be helpful, however,when the medical history, laboratory studies, and specificsymptoms strongly suggest a food allergy. It is up to thepatient and his or her family and physician to decidewhether the dietary restrictions are appropriate. Unlessproperly monitored by a physician or dietitian, diets withmany restrictions can contribute to serious nutritionalproblems, especially in children.

D espite the symptoms caused by atopic dermatitis, itis possible for people with the disorder to maintain a

good quality of life. The keys to quality of life lie inbeing well-informed; awareness of symptoms and theirpossible cause; and developing a partnership involvingthe patient or caregiving family member, medical doctor,and other health professionals. Good communication isessential. (See “Tips for Working With Your Doctor” onpage 26.)

When a child has atopic dermatitis, the entire family maybe affected. It is helpful if families have additionalsupport to help them cope with the stress and frustrationassociated with the disease. A child may be fussy anddifficult and unable to keep from scratching and rubbingthe skin. Distracting the child and providing activitiesthat keep the hands busy are helpful but require mucheffort on the part of the parents or caregivers. Anotherissue families face is the social and emotional stressassociated with changes in appearance caused by atopicdermatitis. The child may face difficulty in school orwith social relationships and may need additional supportand encouragement from family members.

25

Adults with atopic dermatitis can enhance their qualityof life by caring regularly for their skin and beingmindful of the effects of the disease and how to treatthem. Adults should develop a skin care regimen as partof their daily routine, which can be adapted ascircumstances and skin conditions change. Stressmanagement and relaxation techniques may helpdecrease the likelihood of flares. Developing a networkof support that includes family, friends, healthprofessionals, and support groups or organizations canbe beneficial. Chronic anxiety and depression may berelieved by short-term psychological therapy.

Recognizing the situations when scratching is mostlikely to occur may also help. For example, manypatients find that they scratch more when they are idle,and they do better when engaged in activities that keepthe hands occupied. Counseling also may be helpful toidentify or change career goals if a job involves contactwith irritants or involves frequent hand washing, such askitchen work or auto mechanics.

A lthough scientists are working to develop safervaccines, persons diagnosed with atopic dermatitis

(or eczema) should not receive the current smallpoxvaccine. According to the Centers for Disease Controland Prevention (CDC), a U.S. Government organization,persons who have ever been diagnosed with atopicdermatitis, even if the condition is mild or not presentlyactive, are more likely to develop a serious complicationif they are exposed to the virus from the smallpoxvaccine.

26

People with atopic dermatitis should exercise cautionwhen coming into close physical contact with a personwho has been recently vaccinated, and make certain thevaccinated person has covered the vaccination site ortaken other precautions until the scab falls off (about 3weeks). Those who have had physical contact with avaccinated person’s unhealed vaccination site or to theirbedding or other items that might have touched that siteshould notify their doctor, particularly if they develop anew or unusual rash.

During a smallpox outbreak, these vaccinationrecommendations may change. Persons with atopicdermatitis who have been exposed to smallpox shouldconsult their doctor about vaccination.

Tips for Working With Your Doctor

■ Provide complete, accurate medical information.

■ Make a list of your questions and concerns inadvance.

■ Be honest and share your point of view with thedoctor.

■ Ask for clarification or further explanation ifyou need it.

■ Talk to other members of the health care team,such as nurses, therapists, or pharmacists.

■ Don’t hesitate to discuss sensitive subjects withyour doctor.

■ Discuss changes to medical treatment ormedications with your doctor.

27

Additional information about atopic dermatitis andsmallpox vaccination is available from CDC. (See“Additional Resources” section of this booklet.)

R esearchers supported by the National Institute ofArthritis and Musculoskeletal and Skin Diseases and

other institutes of the National Institutes of Health aregaining a better understanding of what causes atopicdermatitis and how it can be managed, treated, and,ultimately, prevented. Some promising avenues ofresearch are described below.

Genetics: Although atopic dermatitis runs in families, therole of genetics (inheritance) remains unclear. It doesappear that more than one gene is involved in the disease.

Research has helped shed light on the way atopicdermatitis is inherited. Studies show that children are atincreased risk for developing the disorder if there is afamily history of other atopic disease, such as hay feveror asthma. The risk is significantly higher if both parentshave an atopic disease. In addition, studies of identicaltwins, who have the same genes, show that in anestimated 80 to 90 percent of cases, atopic diseaseappears in both twins. Fraternal (nonidentical) twins, whohave only some genes in common, are no more likelythan two other people in the general population to bothhave an atopic disease. These findings suggest that genesplay an important role in determining who gets thedisease.

Biochemical Abnormalities: Scientists suspect thatchanges in the skin’s protective barrier make people withatopic dermatitis more sensitive to irritants. Such peoplehave lower levels of fatty acids (substances that provide

28

moisture and elasticity) in their skin, which causes drynessand reduces the skin’s ability to control inflammation.

Other research points to a possible defect in a type ofwhite blood cell called a monocyte. In people with atopicdermatitis, monocytes appear to play a role in thedecreased production of an immune system hormonecalled interferon gamma (IFN-γ), which helps regulateallergic reactions. This defect may cause exaggeratedimmune and inflammatory responses in the blood andtissues of people with atopic dermatitis.

Faulty Regulation of Immunoglobulin E (IgE): Asalready described in the section on diagnosis, IgE is a typeof antibody that controls the immune system’s allergicresponse. An antibody is a special protein produced by theimmune system that recognizes and helps fight anddestroy viruses, bacteria, and other foreign substances thatinvade the body. Normally, IgE is present in very smallamounts, but levels are high in 80 to 90 percent of peoplewith atopic dermatitis.

Controlling Atopic Dermatitis

■ Prevent scratching or rubbing wheneverpossible.

■ Protect skin from excessive moisture, irritants,and rough clothing.

■ Maintain a cool, stable temperature andconsistent humidity levels.

■ Limit exposure to dust, cigarette smoke,pollens, and animal dander.

■ Recognize and limit emotional stress.

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Researchers also

think that an im-

balance in the im-

mune system may

contribute to the

development of

atopic dermatitis.

In allergic diseases, IgE antibodies are produced inresponse to different allergens. When an allergen comesinto contact with IgE on specialized immune cells, the cellsrelease various chemicals, including histamine. Thesechemicals cause the symptoms of anallergic reaction, such as wheezing,sneezing, runny eyes, and itching.The release of histamine and otherchemicals alone cannot explain thetypical long-term symptoms of thedisease. Research is underway toidentify factors that may explain whytoo much IgE is produced and how itplays a role in the disease.

Immune System Imbalance:Researchers also think that animbalance in the immune system maycontribute to the development ofatopic dermatitis. It appears that thepart of the immune systemresponsible for stimulating IgE isoveractive, and the part that handlesskin viral and fungal infections isunderactive. Indeed, the skin ofpeople with atopic dermatitis showsincreased susceptibility to skininfections. This imbalance appears to result in the skin’sinability to prevent inflammation, even in areas of skinthat appear normal. In one project, scientists are studyingthe role of the infectious bacterium Staphylococcus aureus(S. aureus) in atopic dermatitis.

Researchers believe that one type of immune cell in theskin, called a Langerhans cell, may be involved in atopicdermatitis. Langerhans cells pick up viruses, bacteria,

30

allergens, and other foreign substances that invade thebody and deliver them to other cells in the immunedefense system. Langerhans cells appear to be hyper-active in the skin of people with atopic diseases. CertainLangerhans cells are particularly potent at activatingwhite blood cells called T cells in atopic skin, whichproduce proteins that promote allergic response. Thisfunction results in an exaggerated response of the skin totiny amounts of allergens.

Scientists have also developed mouse models to studystep-by-step changes in the immune system in atopicdermatitis, which may eventually lead to a treatment thateffectively targets the immune system.

Drug Research: Some researchers are focusing on newtreatments for atopic dermatitis, including biologic agents,fatty acid supplements, and new forms of phototherapy.For example, they are studying how ultraviolet lightaffects the skin’s immune system in healthy and diseasedskin. They are also investigating biologic agents,including several aimed at modifying the response of theimmune system. A biologic agent is a new type of drugbased on molecules that occur naturally in the body. Onepromising treatment is the use of thymopentin toreestablish balance in the immune system.

Researchers also continue to look for drugs that suppressthe immune system. In this regard, they are studying theeffectiveness of cyclosporine A. Clinical trials areunderway with another drug called FK506, which isapplied to the skin rather than taken orally. Also, anti-inflammatory drugs have been developed that affectmultiple cells and cell functions, and may prove to be aneffective alternative to corticosteroids in the treatment ofatopic dermatitis.

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Several experi-

mental treatments

are being evalu-

ated that attempt

to replace sub-

stances that are

deficient in people

with atopic der-

matitis.

Several experimental treatments are being evaluated thatattempt to replace substances that are deficient in peoplewith atopic dermatitis. Evening primrose oil is asubstance rich in gamma-linolenic acid, one of the fattyacids that is decreased in the skin ofpeople with atopic dermatitis. Studiesto date using evening primrose oil haveyielded contradictory results. Inaddition, dietary fatty acid supplementshave not proven highly effective. Thereis also a great deal of interest in theuse of Chinese herbs and herbal teas totreat the disease. Studies to date showsome benefit, but not without concernsabout toxicity and the risks involved insuppressing the immune systemwithout close medical supervision.

A lthough the symptoms of atopicdermatitis can be difficult and

uncomfortable, the disease can besuccessfully managed. People withatopic dermatitis can lead healthy,productive lives. As scientists learnmore about atopic dermatitis and whatcauses it, they continue to move closerto effective treatments, and perhaps,ultimately, a cure.

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National Institute of Arthritis and Musculoskeletaland Skin DiseasesNIAMS/National Institutes of Health1 AMS CircleBethesda, MD 20892-3675(301) 495-4484 or(877) 22-NIAMS (226-4267) (free of charge)TTY: (301) 565-2966Fax: (301) 718-6366niamsinfo@mail.nih.govwww.niams.nih.gov

NIAMS provides information about various forms ofskin diseases; arthritis and rheumatic diseases; andbone, muscle, and joint diseases. It distributes patientand professional education materials and refers peopleto other sources of information. Additional informationand updates can be found on the NIAMS Web site.Listings of clinical trials recruiting patients who have orare at risk of developing a skin disease can be found atwww.ClinicalTrials.gov.

Centers for Disease Control and Prevention1600 Clifton RoadAtlanta, GA 30333(888) 246-2675 (free of charge)TTY: (866) 874-2646E-mail: cdcresponse@ashastd.orgwww.bt.cdc.gov/agent/smallpox/index.asp

This government organization is a focus for diseaseprevention and control, environmental health, andhealth promotion. It provides detailed information aboutsmallpox and vaccination against smallpox, including

those who should not receive the vaccine, precautionsvaccinated persons should take to prevent harm to thosewith atopic dermatitis and certain other conditions, andanswers to frequently asked questions.

American Academy of DermatologyP.O. Box 4014Schaumburg, IL 60168(847) 330-0230 or(888) 462-DERM (3376) (free of charge)Fax: (847) 330-0050www.aad.org

This national professional association can providereferrals to dermatologists. It has published a pamphleton atopic eczema/dermatitis, which is available on theorganization’s Web site or can be obtained by calling orwriting to the academy. Single copies are free.

American Academy of Allergy, Asthma,and Immunology611 East Wells StreetMilwaukee, WI 53202(414) 272-6071 or (800) 822-2762 (free of charge)E-mail: info@aaaai.orgwww.aaaai.org

This national professional association representingallergists and clinical immunologists publishes pamphletsabout allergies and atopic dermatitis. The academy canalso provide physician referrals for evaluation ofallergies.

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National Eczema Association forScience and Education4460 Redwood Highway, Suite 16-DSan Rafael, CA 94903-1953(415) 499-3474 or (800) 818-7546 (free of charge)Fax: (415) 472-5345info@nationaleczema.orgwww.nationaleczema.org

This is a national patient-oriented association devoted toeczema. It publishes a quarterly newsletter, providespatient brochures and provider educational materials,offers resource services to patients, and provides referralsto atopic dermatitis/eczema research centers.

Inflammatory Skin Disease InstituteP.O. Box 1074Newport News, VA 23601(757) 223-0795 or(800) 484-6800, Ext. 6321 (free of charge)Fax: (757) 595-1842

This national organization provides educationalinformation and support and engages in advocacy. It isdedicated to improving the lives of people withinflammatory skin disease.

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Food Allergy and Anaphylaxis Network (FAAN)10400 Eaton PlaceFairfax, VA 22030(703) 691-3179 or (800) 929-4040 (free of charge)Fax: (703) 691-2713faan@foodallergy.orgwww.foodallergy.org

The organization provides education, emotional support,and coping strategies to individuals with food allergies. Itpublishes a bimonthly newsletter and has books, videos,and other educational materials pertaining to food allergydiets and to food-related issues in schools, daycarecenters, and camps. FAAN also makes physician referrals.

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The NIAMS gratefully acknowledges the assistance ofthe following people in the preparation and review of thispublication: Joanne Cono, M.D., Sc.M., Centers forDisease Control and Prevention, Atlanta, Georgia; KevinCooper, M.D., Case Western Reserve University,University Hospitals of Cleveland, Cleveland, Ohio; JonHanifin, M.D., Oregon Health & Science University,Portland, Oregon; Donald Leung, M.D., Ph.D., NationalJewish Medical and Research Center, Denver, Colorado;Alan Moshell, M.D., NIAMS, NIH; Amy Paller, M.D.,Children’s Hospital of Chicago, Chicago, Illinois; HughSampson, M.D., Mount Sinai School of Medicine, NewYork, New York; Maria Turner, M.D., National CancerInstitute, NIH; and LaDonna Williams, InflammatorySkin Disease Institute, Newport News, Virginia.

The mission of the National Institute of Arthritis andMusculoskeletal and Skin Diseases (NIAMS), a part ofthe Department of Health and Human Services’ NationalInstitutes of Health (NIH), is to support research into thecauses, treatment, and prevention of arthritis andmusculoskeletal and skin diseases, the training of basicand clinical scientists to carry out this research, and thedissemination of information on research progress inthese diseases. The National Institute of Arthritis andMusculoskeletal and Skin Diseases InformationClearinghouse is a public service sponsored by theNIAMS that provides health information and informationsources. Additional information can be found on theNIAMS Web site at www.niams.nih.gov

U.S. Department of Health andHuman ServicesPublic Health Service

National Institutes of Health

National Institute of Arthritis andMusculoskeletal and Skin Diseases

NIH Publication No. 03-4272January 1999Revised April 2003