Eczema (Atopic Dermatitis) | Atopic Triad, Triggers, Who gets it, Why does it happen, & Treatment

Summary

This lesson delves into atopic dermatitis, also known as eczema, a chronic autoimmune inflammatory skin condition affecting 5-20% of children worldwide. It often manifests in skin creases and is linked to the atopic triad: atopic dermatitis, allergic rhinitis, and asthma. The condition can be triggered by a defective epidermal barrier and immune dysregulation. Risk factors include family history and environmental factors, while early exposure to daycare and pets may be protective. Diagnosis is clinical, with specific criteria for a more objective approach. Treatment involves avoiding triggers, using topical corticosteroids, calcineurin inhibitors, phototherapy, and possibly melatonin for symptom relief.

Takeaways

• 🌐 Atopic dermatitis, also known as eczema, is a chronic, autoimmune, pruritic, and inflammatory skin condition.
• 👶 It is prevalent in approximately 5-20% of children worldwide and often begins in childhood.
• 🔗 Atopic dermatitis is associated with the atopic triad: atopic dermatitis, allergic rhinitis, and asthma.
• 🧬 The condition can be linked to genetic factors, including a mutation in the filaggrin gene.
• 🚫 Environmental factors like hard water can exacerbate symptoms.
• 🛡 Protective factors include early daycare attendance, pet exposure, and exposure to farm animals, which may reduce the risk.
• 👨‍⚕️ The diagnosis is typically clinical, based on the presence of pruritic skin lesions in flexural surfaces and associated atopic stigmata.
• 💊 Treatment involves avoiding triggers and allergens, and may include topical corticosteroids, calcineurin inhibitors, phototherapy, and cyclosporine for severe cases.
• 🧴 Topical calcineurin inhibitors are preferred for sensitive areas like the face to prevent skin thinning.
• 🛌 Antihistamines can help with pruritus, and melatonin might offer some relief, though more research is needed.

Q & A

What is atopic dermatitis, and what are its key characteristics?

Atopic dermatitis, also known as eczema, is a chronic autoimmune inflammatory skin condition. It is characterized by itching (pruritus), inflammation, and a tendency to affect skin creases and flexure surfaces. It typically begins in childhood and affects about 5-20% of children worldwide.

What is the atopic triad, and how is it related to atopic dermatitis?

The atopic triad refers to the association between atopic dermatitis, allergic rhinitis, and asthma. These conditions are linked to elevated levels of immunoglobulin E (IgE), and approximately 80% of individuals with atopic dermatitis will develop either allergic rhinitis, asthma, or both.

What are the two main categories of pathogenesis for atopic dermatitis?

The pathogenesis of atopic dermatitis involves two main categories: (1) a defective epidermal barrier due to issues such as filaggrin deficiency and tight junction abnormalities, and (2) immune dysregulation, involving both the innate immune system (reduced TLR-2 and TLR-9 function) and the adaptive immune system (increased expression of Th2, Th17, and Th22 cytokines).

What are some risk factors for developing atopic dermatitis?

Risk factors include a family history of atopic dermatitis or allergies, genetic mutations (such as filaggrin gene mutation), having allergies, and exposure to environmental factors like water hardness. Family history is a major factor, with about 70% of individuals with atopic dermatitis having a positive family history.

What are some protective factors against atopic dermatitis?

Protective factors include early exposure to daycare, pets, and farm animals, which may reduce the risk of developing atopic dermatitis. This aligns with the hygiene hypothesis, which suggests that exposure to diverse germs and allergens can help the immune system regulate itself more effectively.

What are some common skin findings associated with atopic dermatitis?

Common skin findings include keratosis pilaris (chicken skin), Denny-Morgan folds (wrinkling under the eyes), Hertoghe’s sign (thinning of the lateral eyebrows), pityriasis alba (whitening of the skin), palmar hyperlinearity (increased skin lines on the palms), and retroauricular fissures (chafing behind the ears).

How is atopic dermatitis diagnosed?

Atopic dermatitis is generally diagnosed clinically, based on characteristic symptoms such as itchy skin lesions in flexural surfaces, dry skin, and a history of asthma or hay fever. Alternatively, the UK Working Group's diagnostic criteria can be used, requiring pruritus and at least three other features like skin creases, early onset, or a family history of atopic conditions.

What are the common triggers of atopic dermatitis flare-ups?

Common triggers include environmental factors such as heat and low humidity, stress, and certain foods. There is debate among clinicians about whether foods like dairy worsen atopic dermatitis, so elimination diets may be considered on a case-by-case basis.

What are some treatments available for atopic dermatitis?

Treatment options include avoiding triggers, using topical corticosteroids (e.g., hydrocortisone cream), topical calcineurin inhibitors (for sensitive areas like the face and eyelids), phototherapy for severe cases, and cyclosporine for acute flare-ups. Antihistamines can help with itching, and melatonin may be considered to aid with symptoms, though more research is needed.

Why are topical calcineurin inhibitors used for atopic dermatitis on certain body areas?

Topical calcineurin inhibitors are used for areas like the face, eyelids, neck, and skin folds because prolonged use of corticosteroids in these regions can lead to skin thinning. Calcineurin inhibitors avoid this side effect while providing effective treatment.

Outlines

00:00

📚 Overview of Atopic Dermatitis (Eczema)

This paragraph introduces atopic dermatitis (eczema), describing it as a chronic, autoimmune, pruritic (itchy), and inflammatory skin condition. It highlights its prevalence, affecting 5-20% of children worldwide, and its tendency to affect skin creases and flexure surfaces. It also explains the atopic triad, consisting of atopic dermatitis, allergic rhinitis, and asthma, where 80% of those with atopic dermatitis may develop one or both of the other conditions. Additionally, it touches on the association with food allergies, especially when atopic dermatitis appears early in life.

05:01

🔍 Causes and Pathogenesis of Atopic Dermatitis

Here, the pathogenesis of atopic dermatitis is detailed, focusing on two main causes: a defective epidermal barrier and immune dysregulation. The defective barrier relates to proteins like filaggrin and imbalances in protease activity, leading to skin issues. The immune dysregulation involves both innate (reduced TLR-2 and TLR-9 functions) and adaptive immune responses (increased expression of cytokines like TH2, TH17, and TH22). These factors combined contribute to the onset and symptoms of atopic dermatitis.

10:04

⚠️ Risk Factors and Triggers of Atopic Dermatitis

The paragraph outlines several risk factors for atopic dermatitis, such as family history, genetic mutations (like filaggrin deficiency), and allergies. Interestingly, environmental factors like water hardness also play a role. On the other hand, protective factors include early exposure to daycare, pets, and farm animals, which support the hygiene hypothesis, suggesting that exposure to allergens early on may reduce the likelihood of developing atopic dermatitis.

👁️ Skin Findings and Stigmata of Atopic Dermatitis

This section discusses various skin findings related to atopic dermatitis, termed 'atopic stigmata.' These include conditions like keratosis pilaris (chicken skin), Denny-Morgan folds (wrinkles under the eyes), Hertoghe sign (thinning of the lateral eyebrow), pityriasis alba (whitening of skin areas), palmar hyperlinearity (excessive palm lines), and retroauricular fissuring (behind-the-ear chafing or scarring). These are physical manifestations that can help in diagnosing the condition.

🩺 Diagnostic Criteria for Atopic Dermatitis

Diagnosis of atopic dermatitis is often clinical, based on symptoms like itchy lesions in skin folds or creases. However, more objective criteria, like the UK Working Group’s method, require at least one mandatory criterion (itchy skin lesions) and three or more additional factors (skin creases, history of asthma/hay fever, dry skin, onset before age two, visible dermatitis on flexural surfaces) for a formal diagnosis.

💊 Treatment and Management of Atopic Dermatitis

The paragraph details treatment options for atopic dermatitis, focusing on avoiding triggers (like heat, low humidity, stress, and certain foods) and using treatments such as topical corticosteroids or calcineurin inhibitors for different severity levels. Phototherapy is suggested for severe cases, and cyclosporine is recommended for acute flare-ups. Antihistamines can help with itching, and there’s mention of melatonin as a possible aid, though more research is needed. The overall goal is to manage the condition through a combination of trigger avoidance and therapeutic interventions.

Keywords

💡Atopic Dermatitis

Atopic Dermatitis, also known as eczema, is a chronic skin condition characterized by inflammation and itching. It is a central theme of the video as the speaker discusses its nature, causes, and treatments. The condition is part of the atopic triad and is associated with other allergic diseases. The video mentions that it affects approximately 5 to 20 percent of children worldwide.

💡Atopic Triad

The Atopic Triad refers to a group of conditions that often occur together: atopic dermatitis, allergic rhinitis, and asthma. The video explains that individuals with atopic dermatitis have a higher likelihood of developing the other two conditions, with around 80% of them experiencing either allergic rhinitis or asthma.

💡Autoimmune

The term 'autoimmune' is used to describe conditions where the immune system mistakenly attacks the body's own tissues. In the context of the video, atopic dermatitis is described as an autoimmune condition, implying that it involves immune dysregulation and can lead to chronic inflammation of the skin.

💡Epidermal Barrier

The epidermal barrier refers to the outermost layer of the skin that provides a protective function. The video script highlights that a defective epidermal barrier is a key factor in the pathogenesis of atopic dermatitis, often related to a protein called filaggrin, which when deficient can lead to skin issues.

💡Immunoglobulin E (IgE)

Immunoglobulin E is an antibody associated with allergic reactions. The video mentions that conditions within the atopic triad are linked with increased levels of IgE, suggesting that an overactive immune response involving IgE plays a role in atopic dermatitis.

💡Pathogenesis

Pathogenesis refers to the cellular and physiological processes that lead to disease. The video discusses the pathogenesis of atopic dermatitis, highlighting two main categories: defective epidermal barrier and immune dysregulation, both of which contribute to the development of the condition.

💡Triggers

Triggers are factors that can provoke or exacerbate symptoms of a condition. In the video, triggers for atopic dermatitis include environmental factors like hard water and heat, and certain foods. Understanding and avoiding these triggers is part of managing the condition.

💡Atopic Stigmata

Atopic Stigmata are characteristic skin findings associated with atopic dermatitis. The video describes several stigmata such as keratosis pilaris ('chicken skin'), Dennie-Morgan folds, and pityriasis alba, which are visible signs that can aid in diagnosing atopic dermatitis.

💡Diagnosis Criteria

The video outlines specific criteria for diagnosing atopic dermatitis, including the mandatory symptom of itchy skin lesions and three additional criteria such as skin creases involvement, history of asthma or hay fever, and symptoms beginning before the age of two. These criteria are used for a more objective diagnosis.

💡Treatment

Treatment approaches for atopic dermatitis discussed in the video include avoiding allergens and triggers, using topical corticosteroids for mild cases, topical calcineurin inhibitors for sensitive areas, phototherapy for severe disease, and systemic treatments like cyclosporine for acute flares. These treatments aim to manage symptoms and improve the skin condition.

💡Hygiene Hypothesis

The Hygiene Hypothesis mentioned in the video suggests that overly clean or hygienic environments might increase the risk of developing allergies and atopic conditions like dermatitis. The video implies that early exposure to germs and allergens, as in daycare or through pets, could potentially protect against atopic dermatitis.

Highlights

Atopic dermatitis, also known as eczema, is a chronic autoimmune inflammatory skin condition.

Atopic dermatitis affects approximately 5 to 20 percent of children worldwide.

The condition often starts in childhood and has a predilection for skin creases and flexure surfaces.

Atopic dermatitis is part of the atopic triad, which includes allergic rhinitis and asthma.

Around 80% of individuals with atopic dermatitis will develop allergic rhinitis or asthma.

Atopic dermatitis patients may have food-induced allergic reactions.

Early onset of atopic dermatitis is associated with specific food allergies.

The pathogenesis of atopic dermatitis involves a defective epidermal barrier and immune dysregulation.

Defective epidermal barrier is related to a protein known as filaggrin.

Immune dysregulation in atopic dermatitis involves increased expression of Th2, Th17, and Th22 cytokines.

Family history is a significant risk factor for atopic dermatitis.

Environmental factors, such as hard water, can trigger atopic dermatitis.

Early daycare and exposure to pets and farm animals may protect against atopic dermatitis.

Atopic dermatitis can cause characteristic skin findings known as atopic stigmata.

Diagnosis of atopic dermatitis is clinical, often based on the presence of itchy skin lesions and atopic stigmata.

Treatment of atopic dermatitis involves avoiding triggers and allergens, and may include topical corticosteroids.

Topical calcineurin inhibitors are used for treatment in sensitive areas like the face and neck.

Phototherapy can be helpful for severe cases of atopic dermatitis.

Cyclosporine is used for acute flares of atopic dermatitis.

Antihistamines can help with the itching associated with atopic dermatitis.

Melatonin may have a role in helping with atopic dermatitis symptoms, but more research is needed.

Transcripts

hey everyone this lesson is on atopic

dermatitis otherwise known as eczema so

and this is where I talked about what

atopic dermatitis is that we're gonna

also going to talk about the atopic

triad we're also gonna discuss the risk

factors for this condition we're also

going to talk about how we can make the

diagnosis and what we can do to treat it

so atopic dermatitis is a chronic

autoimmune terrific inflammatory skin

condition so those are three or four

very key words to remember it's chronic

it's autoimmune it's pure etic and it's

inflammatory again this condition is

also called eczema and it's so prevalent

that approximately 5 to 20 percent of

children worldwide are affected with

this condition and it often has an onset

during childhood as well now atopic

dermatitis for whatever reason has a

predilection for affecting skin creases

and flexure surfaces so key points again

from this are that it's chronic

autoimmune pure etic inflammatory skin

condition and it affects the skin

creases and flexure surfaces so atopic

dermatitis is associated with other

conditions as well we call this the

atopic triad and the atopic triad is the

associated conditions that start with a

letter A and they all have an

association with increased levels of

immunoglobulin E now the a topic try

conditions include atopic dermatitis

allergic rhinitis and asthma and atopic

dermatitis is associated strongly with

allergic rhinitis and asthma and it's

been estimated that approximately 80% of

individuals with atopic dermatitis will

develop either allergic rhinitis or

asthma or both and the other a condition

that I like to kind of keep in mind as

well is other allergies or other

allergic reactions atopic dermatitis

patients have a predilection for having

food induced allergic reactions like or

to Carius so approximately 10 to 20

percent will have some issues with

allergies to foods as well and having a

very early onset of atopic dermatitis

within the

first three months of life is associated

with other specific allergies to foods

like egg milk and peanuts so these are

just some key things to take from the

slide and things to remember so what

causes atopic dermatitis in the first

place so the pathogenesis of atopic

dermatitis involves two separate

categories the first is a defective

epidermal barrier so this makes sense

atopic dermatitis is an issue with the

skin and this is a epidermal barrier is

your skin so it's something that is

defective with this it's actually

related to a protein known as pellagra

and with regards to atopic dermatitis

often cases will have a flagrant

deficiency and there are also some

issues with protease anti protease

activity imbalance there are some issues

with the proteins Calla cream and le kti

and there are also some tight Junction

abnormalities in the skin as well these

all can lead to a defective epidermal

barrier the second main category of

pathogenesis is an immune dysregulation

again this makes sense we talked about

it before it's an autoimmune condition

so there are will break down the immune

dysregulation into an eight immune

system in adaptive immune system with

regards to the innate immune system

there are reduced tlr-2 and tr9 function

and with regards the adaptive immune

system there is actually increased

expression of th2 th17 and th 22

cytokines so these are the two main

areas where the pathogenesis of atopic

dermatitis begins defective epidermal

barrier and then there's also this

immune component these don't all have to

happen to have atopic dermatitis but

they're all related and they're all

associated with thought with the onset

and the symptomatology of atopic

dermatitis so we've talked about the

pathogenesis of atopic dermatitis but

what are some of the triggers and what

are some of the risk factors and what

are some of the protective factors

against atopic dermatitis so we're going

to look at the in

wincing factors first the first one I

want to talk about is family history

this is a generally a pretty big risk

factor generally speaking approximately

70% of individuals with atopic

dermatitis have a positive family

history if you have one parent you have

a certain percentage risk and if you

have two parents even have a higher risk

of having atopic dermatitis the second

one is associated with the family

history again genetics if there's a

loss-of-function mutation of the filet

Gruden gene we talked about earlier this

has a pretty strong pretty strong risk

of having atopic dermatitis also having

allergies again we talked about the

atopic turbit atopic try it we also

talked about associated allergies if you

do have allergies there because of the

associations you're more likely to have

atopic dermatitis as well or develop it

fourth one is quite interesting and this

one is actually environmental water

sources so there has been some evidence

to show that having the hardness and so

minerals and those types of things in

water can actually worsen or be a

trigger for atopic dermatitis and

generally speaking we talk about calcium

carbonate we talk about the hardness of

the environmental water source and the

protective factor so we've talked about

the influencing factors now the

protective factors are the following the

first one is early dig here so if you

get your child in daycare early on in

life this seems to be protective against

developing atopic dermatitis again

you're getting into an environment where

you're sharing a lot of germs you're

getting a you're getting exposure to a

lot of a lot of allergens those types of

things that can actually be helpful for

protecting against atopic dermatitis the

second one is exposure to pets so having

pets can actually help reduce your risk

for atopic dermatitis and the third one

is actually exposure to fire animals

this all leads into the same type of

thing you're getting exposed to

different types of allergens and you're

generally a training immune system to be

less of that immune dysregulation we

talked about earlier and this leads into

the

hygiene hypothesis in in that having a

very controlled hygienic environment can

actually increase the risk of having

allergies and associated conditions like

atopic dermatitis

atopic dermatitis can have characters

whose skin findings that we call atopic

stigmata and these can include keratosis

pilaris or hyper keratosis pilaris this

is colloquially called chicken skin so

it's essentially a little raised red

dots that can develop on different parts

of the body you can also see what we

call Denny Morgan fold so you can see

here in this image this wrinkling effect

and some some change in the skin color

as well underneath the eyes can also get

what we call her tog G's sign I know I'm

not pronouncing this properly but it's

either her toe G's or her togs sign and

this is essentially a absence or

thinning of the lateral eyebrow so you

can see in this image here another skin

finding is what we call pityriasis Elba

Pitt arises Elba is essentially a

whitening of the skin color or skin tone

in certain parts of the body as you can

see in this image on this patients face

so what happens generally is that if you

have atopic dermatitis or eczema in

certain parts of the body for a long

time can actually cause scarring of that

that skin and it leads to a whitened or

a lighter skin tone or skin color

so that is pityriasis Alba another one

is Palmer hyper linearity so if you were

to look at a patient's hand you can

essentially see way more Palmer lines on

their hand and this is what we call

Palmer hyper linearity this is a this

could be a skin finding in atopic

dermatitis and another one is something

we call retro auricular fishery so retro

auricular fishing retro behind auricular

with regards to the ear so behind the

ear you get this fishery so if you were

to pull back on your ear and

look behind your ear you can see this

kind of almost like a chafing or a

scarring a type of fact and this is

again associated with atopic dermatitis

and this can be a skin finding with

regards to atopic dermatitis so so these

are some of the skin findings we can see

with atopic dermatitis so how to make

the diagnosis well the diagnosis of

atopic dermatitis is generally a

clinical one and from what we've seen

before we can make the clinical

diagnosis if we see you know periodic

your thinnest skin lesions in skin folds

in flexural surfaces and if you see a

lot of those other atopic stigmata we

talked about before we could essentially

make a clinical diagnosis of this

condition however there's also a more

objective criteria based diagnosis we

can use as well from a United Kingdom

working group so I generally like this

one so with this ring with this

diagnosis it's more of an objective

checklist based type of diagnosis so

with regards to this diagnosis what we

need is one mandatory and three other

criteria so the mandatory condition we

need absolutely need to make this

diagnosis is that these skin lesions

need to be pure Hritik so they need to

be itchy and then once you have that

once we say these skin lesions are

periodic we need three or more of the

following the first one is that skin

creases are involved so you have the

antecubital fossa is involved a

popliteal fossa the neck around the eyes

so a lot of those areas we talked about

before or we need a history of asthma or

hay fever this ties into the atopic

triad or we need a presence or presence

of generally dry skin within the past

year and generally we need the symptoms

begin before the age of two and we need

visible dermatitis involving flexural

surfaces so these skin lesions need to

be pure etic and then we need three of

the following skin creases involved the

history of asthma hay fever generally

dry skin over the past year symptoms

beginning before the age of two in the

visible dermatitis involving flexural

services so if you have three or more of

those with pure pure itis then we can

make the diagnosis of diatomic

dermatitis so that's how we can make the

diagnosis of atopic dermatitis but just

recognize that a lot of times clinicians

might not use this diagnosis criteria

and they will just simply diagnose it

clinically so once we make the diagnosis

how do we treat it treatment and

generally involves we want to avoid the

allergens in the triggers that can make

or cause a flare of atopic dermatitis or

make it worse

these can include heat or low humidity

environments you also want to reduce

stress and anxiety these can be triggers

as well the next thing we want to do is

we want to avoid certain foods so there

is some controversy with regards to this

some clinicians believe that eating

certain foods can actually induce or

worsen atopic dermatitis some clinicians

don't think that at all so there's this

question of you know dairy products

specifically having dairy in your diet

does this worsen atopic dermatitis

you're gonna hear certain things you're

gonna hear from other people and what

I'm gonna say here is that think about

this as something that you can remove

from your diet to see if it'll actually

help with these symptoms and then if

these don't work if the avoidance of

certain triggers and certain foods and

allergens don't work we can move on to

treatments and the treatments can

include topical corticosteroids so an

example is about 2.5% of hydrocortisone

cream another one we can use is we can

use topical calcineurin inhibitors and

topical calcineurin inhibitors are

generally used when you need to use the

steroids on the face or the eyelids or

the neck or the skin folds and the

reason for this is because using

cortical series for a long time in these

areas like the face and eyelids and skin

folds can lead to thinning of the skin

and we don't want that so if you're

needing to use steroids in these

in the body you can think about actually

changing to a topical calcineurin

inhibitor and then for severe disease we

can think about using photo photo

therapy so photo therapy can be helpful

for severe cases of atopic dermatitis

and then for certainly flares or certain

acute flare ups you can use cyclosporine

and you only use cyclosporine and very

acute settings so you would only use it

for a limited time and you wouldn't want

to use this for too long and then you

can use anteus means to help with the

pure itis and there's also some question

of well that's giving melatonin at night

help with symptoms of atopic dermatitis

or does it not or it's still not known

at this point there may be some evidence

that it does but we still need some more

research on this so just keep the

melatonin in the back of your mind as a

possible mild aid in helping with these

a topic dermatitis symptoms so these are

the main management and treatment goals

you want to avoid certain allergens

triggers and certain foods if possible

you also want to think about the

treatments and when to use a topical

corticosteroids for mild cases topical

calcineurin inhibitors for certain areas

of the body photo therapy for a severe

disease cyclosporine for acute flares

and his means for pure itis and maybe

melatonin so if you want to learn more

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