CLINICAL DERMATOLOGY > DERMATITIS
What is atopic dermatitis?
Atopic dermatitis is a chronic inflammatory skin disease that is characterised by dry skin, redness, and sharp itching sensations which then encourage the appearance of scabs (lichenification) as a result of the person affected not being able to control the urge to scratch the lesions.
The consequences are the appearance of plaques of eczema and excoriation (excessive flaking) that, in turn, make the skin vulnerable to infections causing exudation and scabs. Reoccurrences happen at unpredictable intervals and the most affected areas are face, neck, and arms and legs bends, although the whole body may actually be affected.
With children, the intense itching (they cannot stop scratching, even when asleep) causes wounds and pain, leading to a stressful condition that worsens the crisis, thus leading to failure at school, rejection by their class-mates, introversion, and a great difficulty to lead a normal life. In adults, the loss of quality of life is significant.
Which bacteria infect the skin in atopic eczema?
Eczema usually causes the cracking of the superficial layer of the skin and, therefore, provides an ideal environment for germs to grow in and around the skin cracks, and, in particular, a germ called S. aureus. It has been demonstrated that this germ is present in 80% of eczema lesions. Furthermore, the itching caused by eczema contributes to the skin’s superficial layers to be damaged and to fail its protective role by triggering or provoking the scratching of the lesions, thus fostering the contamination of the area by germs (S aureus). Bacteria can be found everywhere on the skin, but they do not normally cause any issues. The bacteria that may cause problems to the atopic patient is called Staphylococcus aureus. “Aureus” means “golden” and, when the skin is infected, yellowish-golden scabs appear on the eczema. In order to avoid the process to become chronic and to act on the factors involved in eczema such as inflammation and germs, it is advisable to use products that act upon both factors at the same time:
- Inflammation, topical corticoids.
- Topical anti-inflammatory drugs.
- Topical anti-infectious germs.
When does it appear?
In most patients, the condition starts during their infancy. Atopic dermatitis is a condition that starts and is diagnosed in almost half of all patients during their first year of life. The condition disappears spontaneously in 40% of cases before adolescence, while the remaining 60 % of patients suffer the condition for the rest of their lives. Between 10 and 15% of children in the developed world suffer from this condition. Having 4 million children affected by the condition in Spain is worrying, and the number will undoubtedly increase as the quality of life improves. This is because, curiously enough, this is a medical condition associated with wealthy societies even though it has a genetic base (70% of patients live in urban areas and are from middle-upper classes). Studies have shown that factors such as stress and physical exercise may trigger the condition by 48% and 38% of the cases respectively. It is a condition that affects genders equally, as both men and women can suffer from it to the same degree.
In general, circumstances that would normally cause pruritus should be avoided, as the effect is much worse in atopic patients. These measures include:
- Environmental temperature. Patients with atopic dermatitis do not tolerate heat well. High environmental temperatures and the use of excessive clothing must be avoided.
- Environmental humidity. Environmental dryness increases xerosis and pruritus in atopic dermatitis. Hot air heating (e.g.: the heating system in a car) may be a significant aggravating factor. Environmental humidification using the proper apparatus is beneficial. On the other hand, home-made remedies such as small dehumidifiers or water-filled containers are not very effective.
- Sun exposure. It is normally beneficial in atopic dermatitis, but sunburn must be avoided with the use of an appropriate sunscreen. Some patients do not tolerate the sun and may even suffer a worsening of their lesions.
- Clothes: Direct contact with wool, plastics, rubber, etc., should be avoided. Tolerance to synthetic fibres varies widely and should be evaluated in a case by case basis. The most recommended fabric is cotton. Use gentle liquid washing detergents and make sure they are rinsed well. are rinsed well.
- Foods: Some acidic foods (e.g.: citrus fruits, tomato) may irritate the skin in atopic patients if they are eaten or handled. Stimulants, such as coffee, chocolate, and alcohol, increase pruritus and are counterproductive. Some foods may also trigger pruritus due to their histamine content or because they release it, especially if eaten in large quantities (e.g.: strawberries, seafood). There is no need for any dietary restrictions in atopic dermatitis, apart from these circumstances.
- Vaccines: Children with atopic dermatitis should receive the vaccines full calendar at the right time if there are no other contraindications. Live virus vaccines (poliomyelitis, measles-mumps-rubella, and chicken pox) should not be administered while undergoing treatment with systemic corticoids.
- Associated illnesses: Other conditions that are part of the atopic spectrum may trigger pruritus (e.g.: asthma attacks, urticaria). It is important to control them properly so as to avoid atopic dermatitis.
- Hygiene: Baths, especially those with very hot water and strong soaps, increase xerosis and irritate the skin in atopic patients. However, good hygiene should be maintained, using a combination of gentle treatment and the use of emollients (see emollients). It is preferable to shower rather than bathe, using warm water and bath gels with an acidic pH.
- Emollient creams: The use of an emollient (moisturising) cream over the whole body once or several times a day is an important measure in the treatment of atopic dermatitis. The best time to use the cream is immediately after the shower or bath. It must be taken into account that many atopic patients do not tolerate some of the more widely used compounds in this group, such as urea.
- Scratching: It is important to inform the patient and family members that scratching and rubbing should be avoided as they are decisive factors in maintaining lesions. It is important to control the itching. When a child has an itch, you must prevent the scratching of it. In order to avoid them hurting themselves when they scratch, nails should be kept short and clean. It is advisable to file nails every 2 to 3 days. At night, cotton gloves may be worn by children to avoid skin damage by them involuntarily scratching during sleep.
- Allergens: Dust mites are allergens and may cause eczema. They live in bedding, soft furniture, carpets, and curtains. The effect can be reduced by vacuuming daily, dusting with a damp cloth, airing the mattresses periodically, and washing all bedding and plush toys at a minimum temperature of 60°C. If your child has a favourite cuddly toy, you can also put it in a bag in the freezer for a few hours to kill off the mites. The chlorine in swimming pool water worsens atopic eczema. If you cannot avoid going to the swimming pool, then shower immediately after and make sure you apply an emollient or barrier cream after swimming.
What is seborrhoeic dermatitis?
Seborrhoeic dermatitis is a condition that makes the skin become flaky. It normally affects the scalp. In adolescents and adults it is known as dandruff. In babies it is known as cradle cap.
Seborrhoeic dermatitis usually affects areas of the body such as the face, the chest and folds in the arms, legs, and groin. Seborrhoeic dermatitis usually causes the skin to look a little greasy and scaly or flaky. It is a common inflammatory skin condition which forms flakes which go from white in colour to yellow, on oily areas such as the scalp or inside the ear, and it may or may not produce skin redness. Cradle cap is the term used when seborrhoeic dermatitis affects babies’ scalps.
Causes, incidences, and risk factors
Seborrhoeic dermatitis and dandruff are produced by a fungus that normally exists in the skin, the Pityrosporum ovale. This organism is a secondary coloniser of the scaly lesions. Seborrhoeic dermatitis seems to be transmitted from parents to children. Stress, fatigue, extreme climates, oily skin, or the lack of proper hygiene of the skin and scalp, the use of alcohol-based lotions, skin disorders such as acne and obesity are all risk factors. The HIV virus is also associated with an increase in cases of seborrhoeic dermatitis.
Seborrhoeic dermatitis may appear on many areas of the body and, characteristically, on those areas where there are a larger number of sebaceous glands which produce an excessive amount of oil. The areas commonly affected are the scalp, the eyebrows, eyelashes, nose folds, the back of the ears, the outer ear, and along the folds of the skin around the torso. Seborrhoeic dermatitis in babies, also called cradle cap, is a harmless and temporary condition. It appears on the child’s scalp in the form of yellowish flakes and cradle cap. It can be seen in new-borns and small children up to the age of three. Cradle cap is not contagious nor caused by a lack of hygiene; neither is it an allergy or is dangerous, but it may or may not cause itching. If there is itching, excessive scratching may cause additional inflammation and cracks in the skin may become mildly infected or start bleeding. Generally, the symptoms of seborrhoeic dermatitis are:
- Skin lesions.
- Patches over a large area.
- Area with oil excess.
- White or yellowish skin flakes.
- Pruritus: it may cause more itching if it becomes infected.
- Slight redness.
- Hair loss.
Signs and tests
What is contact dermatitis?
Contact dermatitis is a common allergic reaction produced when the skin comes into direct contact with an allergen: soaps, detergents, medication, etc. This reaction induces inflammation in the area of contact although, depending upon the sensitivity of the skin and on the irritant in question, the reaction may even produce open ulcers.
Usually, the most common allergies associated with this type of dermatitis are: some plants such as holm oak or ivy, metals such as nickel or silver, antibiotic medication -especially those of topical use-, topical anaesthetics, materials such as latex or rubber, some types of cosmetics, certain fabrics, detergents, solvents, glues, perfumes and colognes etc. Symptoms always arise in the affected area: itching, redness, inflammation, hypersensitivity and, in extreme case, rashes and skin lesions that may produce infections if not treated accordingly. Treatment to eliminate symptoms and cure any lesions is simple. However, allergies are not curable, and the person affected is therefore responsible for avoiding contact with those elements or substances that trigger a reaction.
What is dyshidrosis?
Dyshidrosis is a chronic, recurrent dermatitis that affects the palms of the hands and fingers as well as the soles of the feet.
It is characterised by the initial appearance of small blisters (vesicles) that itch and later evolve into a collar-shaped flaking. If the process becomes chronic, it leads to the appearance of cracks and also frequent bacterial infection. Incidence is the same in both sexes and it especially affects people over 40.
Diagnosis and treatment of dermatitis in Valencia
• Dr. Gabriel Serrano Sanmiguel