Atopic Dermatitis

Introduction
Atopic Dermatitis (AD) is the most common chronic inflammatory skin disease. The U.S. prevalence of AD was reported to be 11.3–12.7% and 6.9 –7.6% in children and in adults, respectively. The epidermis plays an important role as physical and functional barrier, and skin barrier defects are the most significant pathologic findings in AD skin. Filaggrin (FLG), transglutaminases, keratins, and intercellular proteins are key proteins responsible for epidermal function. Defects in these proteins facilitate allergen and microbial penetration into the skin. Skin barrier dysfunction has been considered to be the first step in the development of atopic march as well as AD. However, it is also now evident that immune dysregulation, including the activation of type 2 immune responses, results in impairment of the epidermal barrier. Recently, new insights into the pathophysiology of the development of AD focused on an important role of abnormalities in epidermal lipid layer as well as neuroimmune interactions and microbial dysbiosis. These factors have been used to develop novel therapeutic and preventative strategies of AD.

Prevalence in Children
Although AD can appear at any time during an individual's life, about 60% of cases are thought to present during the first year, and 60%-74% of cases in children resolve before the age of 16, with the rest persisting into adulthood. However, this supposed rate of clearance is probably around 53% owing to relapses over the course of adolescence and early adulthood. It is worth noting that that a fair percentage of people with childhood. AD experience recurrence when they enter the workforce. Most cases take the form of hand eczema, but some are more extensive.

AD in adults: The course of AD can be continuous for many years but can also show a relapsing-remitting pattern. Early studies had suggested that the disease clears in > 50% of affected children, with just the more severe cases persisting into adulthood. But more recent cross-sectional studies showed that the proportion of patients with persistent or adult-onset disease or with relapses after long asymptomatic intervals is much higher than previously thought. One in four adults with AD report adult-onset disease, which appears to be associated with a different disease phenotype compared with childhood-onset AD and recovery, the microbiota composition reverts to the pre-flare composition.

Symptoms
•    Atopic dermatitis (eczema) signs and symptoms vary widely from person to person and include:
•    Dry skin
•    Itching, which may be severe, especially at night
•    Red to brownish-gray patches, especially on the hands, feet, ankles, wrists, neck, upper chest, eyelids, inside the bend of the elbows and knees, and in infants, the face and scalp
•    Small, raised bumps, which may leak fluid and crust over when scratched
•    Thickened, cracked, scaly skin
•    Raw, sensitive, swollen skin from scratching

What Causes Itching and Rash?
The exact cause of AD is not known. Research has shown that a person is more likely to have AD if parents or other family members have ever had AD, hay fever, asthma, or food allergies. In the past few years, mutations in the gene for Filaggrin protein which is important in building a healthy skin barrier have been described in some patients with atopic dermatitis. These patients appear to have atopic dermatitis that is earlier in onset, more severe and persistent and associated with asthma and allergic sensitization. There are many things that worsen the itching and rash of AD. These are different for each person. It's important to work closely with your health care provider to try to figure out what makes your itching and rash worse.

What Are My Treatment Options?
It is important to have a regular schedule with AD care that includes bathing with a gentle cleanser and moisturizing to lock water into the skin and repair the skin barrier. Moisturized skin helps control flares by combating dryness and keeping out irritants and allergens. Depending on severity of symptoms and age, AD treatments include lifestyle changes, over-the-counter (OTC) and natural remedies, prescription topical medications, which are applied to the skin; biologics, given by injection; immunosuppressants, usually taken by mouth in the form of a pill; and phototherapy, a form of ultraviolet light treatment.

Dos and Don'ts
Bathing tips:
•    Bathe your child in warm — not hot — water.
•    Limit your child's time in the bath to 5 or 10 minutes.
•    Use cleanser only when needed and make sure the cleanser is mild and fragrance-free. Do not use bubble bath. (If your child's eczema is frequently infected, twice-weekly bleach baths may be beneficial. Discuss this option with your child's dermatologist).
•    After bathing, gently pat your child's skin partially dry.
•    If your child has medicine that you apply to the skin, apply medicine when your child's skin is almost dry and use the medicine as directed.
•    Apply moisturizer on top of the medicine and to the rest of your child's skin.

Tips for choosing a moisturizer:
•    When selecting a moisturizer, consider choosing a thick cream or ointment.
•    Some children do better with fragrance-free products, so consider petroleum jelly — an inexpensive, fragrance-free product that works well for many children.
•    When selecting a product, “trial and error” sampling of different types may help to identify the best moisturizer for your child.

Tips to ease discomfort:
•    For best results, apply moisturizer at least twice a day. This prevents dryness and cracking. It also can decrease the need for eczema medications.
•    If your child has severe itching and scratching, ask your child's dermatologist about wet wrap therapy. This can reduce swelling and lessen the desire to scratch.
•    Keep your child's fingernails short and smooth. This decreases the likelihood that scratching will puncture the skin. Putting cotton gloves on your child's hands at night may help prevent scratching during sleep.
•    Keep temperature and humidity levels comfortable. Avoid situations in which the air is extremely dry, or where your child may sweat and overheat. This is the most common trigger of the itch/scratch cycle.

Clothes-washing tips:
•    Using a laundry detergent made for sensitive skin may be beneficial. Scented fabric softener or dryer sheets may contribute to irritation.
•    Only use the recommended amount of detergent.
•    Use enough water for adequate rinsing.
•    Buy clothes without tags because tags can rub against the skin, causing irritation.
•    Wash your child's new clothes before wearing. This will remove excess dyes and fabric finishers, which can irritate the skin.

Conclusion
AD is one of the most prevalent diseases worldwide and is associated with a very burdensome impact on health-care resources and patients and caregivers' QoL. Moreover, AD is associated with numerous medical and mental health comorbidities, with important implications for its management and treatment. Considering there is also increasing evidence that AD may progress to other allergic phenotypes, a clear need to improve disease prevention arises. There is urgent need for a more systemic approach to establish safe and effective therapies that target its pathophysiology. Future research in AD must now focus on exploring gene-environment interactions and its effect on pathophysiology, disease severity, and treatment outcomes.

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