Atopic dermatitis

Atopic Dermatitis (AD) is the most common inflammatory skin disease with a prevalence in the various populations ranging from 15 to 20% in children and from 2 to 20% in adults. It is most prevalent in Northern European countries, and is significantly lower in rural areas, showing the importance of lifestyle and environment on the development of atopy.

Its incidence has shown a 2-3-fold increase over the last three decades in industrialised countries.

The onset is usually early, during the first few months of life; in 90% of cases it presents before the age of 5.

AD results from the interaction between environment factors and genetic factors which cause changes to the skin barrier, immunological changes and hyper reactivity to environmental stimuli. It has recently been shown that functional anomalies of the epidermal barrier precede the inflammatory processes.

Signs and symptoms

The disease presents as a chronic-recurring course and is characterised by eczematous lesions which in the acute phase are erythematous-exudative and in the sub-acute and chronic phase become erythematous-squamous and lichenified. Pruritus is the predominant symptom. The morphology of the lesions and the affected locations vary depending on the age, and for this reason 3 stages are distinguished: a) infant (first months of life to 2 years); b) child (from 3 to 12 years); c) adolescent and adult (after the age of 10 years).

The diagnosis is clinical and is based on Hanifin and Rajka diagnostic criteria (Table 1); in the first 3 months of life on Bonifazi criteria (Table 2).

Source Hanifin and Rajka. Acta Derm Venereol (Stockh) 1980;92:44-7

To determine a diagnosis of atopic dermatitis in the first three months, criterion 1 must be present together with criterion 2a and/or 2b.

Source Bonifazi E. Infantile eczema. Acta Dermato-Venereol 1994;(Suppl 196):12

Baby and infancy stage

It is clinically manifested by red, oedematous patches, often superimposed with blisters (eczema madidans).

Locations. Typically on the face, particularly the cheeks, forehead and chin, and typically not involving the perioral region. The lesions are usually bilateral and symmetrical. Other locations are the scalp, extensor surface of limbs and trunk. The extent of the lesions varies from clearly defined shapes to diffuse shapes; however, erythrodermic shapes are rare. There is accompanying pruritus and in the youngest skin discomfort and sleep disturbances.

Baby phase

It is clinically manifested by dry eczematous lesions characterised by redness, slight desquamation and infiltration with increase in the normal skin profile due to scratching.

Locations.The symptoms affect the face, and predominantly the periorificial, periocular, and perioral locations, the neck, antecubital and popliteal fossae, the back of the hands and the wrists and ankles. The pruritus is usually intense.

AD in all its forms requires adequate skin hydration. Emollients should be applied both in combination with topical steroids and as monotherapy, in cases of remission of the disease. As amply demonstrated by clinical studies, emollients can reduce the use of steroids, reduce the number of relapses and have a role in primary prevention, in other words if applied as a preventative measure in subjects at risk of developing AD, they can prevent onset.

Adolescence and adulthood

Eczematous lesions tend to be more infiltrated and there may be papules, sometimes excoriated, or plaques. The most common locations are the face, especially the periorificial regions, the fold of the neck, the nape, the flexural areas of the limbs and the hands Pruritus is usually intense and lesions from scratching are usually present.

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