Atopic Dermatitis In Children - Symptoms, Treatment, Diet, Causes

2024 Author: Rachel Wainwright | [email protected]. Last modified: 2023-12-15 07:39

Atopic dermatitis in children

The content of the article:

1. Causes of atopic dermatitis in children and risk factors for its development
2. Forms of the disease
3. Stages
4. Symptoms of atopic dermatitis in children
5. Diagnostics
6. Treatment of atopic dermatitis in children
7. Possible complications and consequences
8. Forecast
9. Prevention

Atopic dermatitis in children is a genetically determined chronic allergic inflammation of the skin, which is characterized by intense itching, accompanied by rashes specific to certain age periods.

Food allergens often play a role as a trigger for the development of atopic dermatitis in children.

Atopic dermatitis in children is a disease that is extremely common in pediatric practice (according to a global international study, it accounts for every fifth case of allergic dermatoses), occurs on all continents, in representatives of all races.

Currently, there is a steady trend towards an increase in the incidence (at least a two-fold increase over the past 30 years has been reliably confirmed), in Europe the number of children with this diagnosis is 15.6%, in the USA 17.2% are carriers of the disease, in Japan - 24%, in Russia - 30-35% of children. Girls get sick more often.

In recent years, researchers have associated the high incidence of atopic dermatitis in children with an unfavorable environmental situation, the spread of artificial feeding, mass vaccination, poor nutrition with a large proportion of refined foods and the presence of bad habits in parents, although the reliable reasons are unknown.

In addition to the higher frequency of occurrence in recent years, there has been an increase in the manifestation of atopic dermatitis in children:

• a more extensive area of damage to the skin;
• an increase in the morbidity structure of forms with a severe course;
• an increase in the proportion of atopic dermatitis, complicated by the addition of a secondary infection;
• rejuvenation of the disease (in almost half of the cases, painful manifestations of atopic dermatitis in children make their debut in the first month of life).

In the mid-90s of the last century, the role of immune mechanisms in the formation of the disease (high readiness of the body for allergic reactions) was unequivocally proven. Then the proposed term “atopic dermatitis” combined the following disparate nosologies: neurodermatitis, endogenous eczema, exudative eczematoid, asthma-eczema, constitutional eczema, exudative diathesis, allergic diathesis, childhood eczema, true eczema, diaper dermatitis.

Atopic dermatitis in children is a serious medical and social problem both for the child and for family members, since it significantly reduces the quality of life and impairs social activity, which is facilitated by cosmetic imperfections, itching discomfort, the possibility of infection of skin lesions, etc.

In recent studies, it has been proven that atopic dermatitis in children is the first manifestation of the so-called allergic (atopic) march - a progressive process characterized by the progressive development of allergic symptoms (conjunctivitis, hay fever, urticaria, rhinitis, bronchial asthma, food allergies).

Causes of atopic dermatitis in children and risk factors for its development

Genetic predisposition to the development of atopic dermatitis in children was confirmed in more than 80% of cases (according to other sources - more than 90%). If both parents show signs of atopy, the risk of having a child with the corresponding disease increases by almost 5 times and amounts to 60-80%, but if one of the parents is the carrier of the disease, the risk of hereditary transmission of atopic dermatitis is 30-50%.

In most cases, atopic dermatitis is due to a hereditary predisposition

Recent studies in the field of allergology and dermatology have identified 3 main genetically determined factors that determine the development of atopic dermatitis in children:

• predisposition to allergic reactions;
• violation of the functioning of the epidermal barrier;
• a chain of pathological reactions of the immune system, provoking allergic changes in the skin.

The congenital tendency to atopic dermatitis in children is explained by the following reasons:

• damage to genetic control of cytokine formation (mostly IL-4, IL-17);
• increased synthesis of immunoglobulin E;
• the originality of the response to the effects of allergens;
• hypersensitivity reactions to allergens.

Currently, more than 20 genes are known (SELP, GRMP, SPINK5, LEKTI, PLA2G7 and others, loci 1q23-q25, 13q14.1, 11q12-q13, 6p21.2-p12, 5q33.2, 5q32), conventionally divided into 4 the main classes, with mutations in which there is a high probability of developing atopic dermatitis in children:

1. Genes whose presence increases the risk of developing the disease due to an increase in total immunoglobulin E.
2. Genes responsible for the IgE response.
3. Genes that cause an increased response of the skin to stimuli not associated with atopy.
4. Genes involved in the implementation of inflammation with the participation of interleukins, without connection with immunoglobulin E.

In addition to the features of the immune response, local mechanisms of the formation of atopic dermatitis in children are hereditarily predetermined:

• massive accumulation of Langerhans cells (intraepidermal macrophages) and eosinophils in the skin, which are resistant to apoptosis for a long time;
• a greater number of receptors for immunoglobulin E on the membranes of these cells in comparison with healthy children;
• insufficient production of ceramides, which are an essential component of cell walls;
• excessive sensitive innervation of the skin;
• violation of the permeability of the skin barrier.

The main factor determining the inadequacy of the functioning of the skin barrier in children with atopic dermatitis is mutations in the gene encoding the flaggrin protein (FLG), the main hydrophilic protein of the epidermal layer. This protein is concentrated in skin cells and performs a protective barrier function, preventing the penetration of aggressive substances from the outside through the epidermis. In the presence of defective genes responsible for the coding of flaggrin, the mechanical protective function of the skin suffers, which causes the passage of various allergens through them, with the concomitant development of allergic skin inflammation.

In addition to reducing the effectiveness of physical protection, defects in the flaggrin gene lead to an increase in the percutaneous loss of endogenous water and damage to the epidermal cells responsible for the synthesis of keratin, which is the cause of changes in the state of the skin in children with atopic dermatitis.

Recent studies have also confirmed a genetically determined defect in the synthesis of antimicrobial peptides in the structures of the skin, which are necessary for full antiviral, antifungal and antibacterial protection.

Despite the presence of defective genes, mutations of which can lead to the development of the disease, atopic dermatitis in children does not develop in 100% of cases. For the realization of a genetic predisposition to atopic dermatitis, the influence of certain factors of the external and internal environment is necessary, the main of which are:

• unfavorable pregnancy, childbirth, postpartum period;
• incorrect feeding behavior of the mother during pregnancy and during breastfeeding: the use of foods rich in antigens, which include, for example, citrus fruits, strawberries, chocolate, red fish, ethanol-containing drinks, egg white, nuts, etc. (provokes manifestation atopic dermatitis in more than half of cases);
• late attachment to the breast or refusal to breastfeed from the first days;
• the use of unadapted formula for artificial feeding;
• introduction of prohibited (or not recommended for his age) foods into the child's diet;
• diseases of the digestive tract;
• dysbiosis of the intestinal flora (deficiency of lacto- and bifidobacteria, along with an excessive growth of populations of Staphylococcus aureus, Escherichia coli, Candida fungi, etc.), which creates a condition for the penetration of food allergens through the intestinal epithelium (determined in approximately 9 out of 10 children with atopic dermatitis);
• autonomic dysfunction;
• high antigenic load;
• unfavorable ecological situation;
• the presence of foci of chronic infection in the child (contributes to the development of bacterial sensitization).

Food allergens, most often provoking the launch of pathological immunochemical reactions and playing the role of a trigger factor for the development of atopic dermatitis in children, are often the following:

• cow's milk proteins (86%);
• chicken egg (82%);
• fish (63%);
• cereals (45%);
• vegetables and fruits of orange and red color (43%);
• peanuts (38%);
• soy proteins (26%).

Maternal malnutrition while breastfeeding is a predisposing factor for atopic dermatitis

The significance of food allergy as a cause of atopic dermatitis in children significantly decreases with age, but at the same time, the significance of inhalation allergens increases: household (38%), epidermal (35%) and pollen (32%).

Forms of the disease

Depending on the morphological picture of atopic dermatitis in children, the following forms are distinguished:

• exudative - redness of varying severity and swelling of the skin, multiple itchy rashes (often symmetrical) in the form of papules, vesicles against the background of wetness, transforming into erosion, covered with crusts during the healing process;
• erythematous-squamous - papular rash, accompanied by severe itching, the formation of multiple scratching against the background of dry skin;
• lichenoid - thickening and strengthening of the skin pattern, moderate infiltration, dryness prevail;
• prurigoid - multiple isolated dense papules, crowned with small vesicles, against a background of enhanced skin pattern, more often changes are noted in the projection of natural folds and folds.

According to the severity, atopic dermatitis in children is divided into mild, moderate and severe.

With mild atopic dermatitis, there is a local skin lesion (not exceeding 5% of the total area), non-intense itching that does not affect the child's sleep, mild skin manifestations (slight redness, pastiness, single papules and vesicles), exacerbations no more than twice a year.

The moderate form of the disease is characterized by widespread skin lesions, rather intense itching, which negatively affects the patient's quality of life, pronounced inflammatory skin changes, an increase in regional lymph nodes, exacerbations develop 3-4 times a year.

Common Areas of Atopic Dermatitis

The severe form is characterized by the involvement of more than 50% of the skin in the inflammatory process, intense, exhausting, severely disturbing the quality of life itching, intense redness and swelling of soft tissues, multiple scratching, cracks, erosion, involvement of all groups of lymph nodes in the pathological process, continuously recurrent course.

Disease periods:

• acute;
• subacute;
• remission (complete or incomplete).

By the prevalence of the process:

• limited atopic dermatitis - less than 5% of the skin area is involved in the inflammatory process;
• common - no more than 50% of the skin is affected;
• diffuse - more than 50% of the skin area is involved in the inflammatory process.

Stages

Depending on age, atopic dermatitis in children goes through several stages, which are characterized by a specific morphological picture:

• infant stage - lasts from birth to 2 years and is manifested by acute weeping inflammation of the skin of the face (forehead, cheeks, sometimes neck), scalp, outer surface of the legs and buttocks;
• children's stage - lasts from 2 to 13 years, lichenification phenomena prevail, the typical location of inflammatory changes is skin folds and folds, more than half of children are involved in the inflammatory process of the soft tissues of the face (the so-called atopic face), rashes in this period are localized in areas of flexion surfaces of the limbs, ulnar and popliteal fossa;
• adolescent-adult stage - there is a sharply increased skin pattern, thickening of the skin, its dryness and peeling, typical places of the location of inflammatory changes are the skin of the face, upper body, extensor surfaces of the limbs.

Symptoms of atopic dermatitis in children

The main symptoms of atopic dermatitis in children:

• hyperemia and swelling of the skin;
• polymorphic skin rashes (papules, vesicles), usually symmetric, single or prone to fusion;
• strengthening and thickening of the skin pattern;
• weeping of the skin;
• erosion of the inflamed surface;
• excoriation (traces of scratching);
• the appearance of crusts on the surface of the vesicles during the healing of skin defects;
• dry skin, peeling, cracking;
• itching of varying severity (from insignificant to painful, disturbing sleep and significantly impairing the patient's quality of life), depending on the severity of atopic dermatitis;
• the appearance of foci of depigmentation at the site of inflammatory changes after their resolution is possible.

External manifestations of atopic dermatitis in children

The intensity of painful manifestations decreases as the inflammatory process subsides in the subacute period. With incomplete remission, minimal manifestations remain in the form of foci of desquamation, dryness, and minor traces of scratching. During the period of stable remission, residual effects in the form of peeling, dryness and foci of hyper- or depigmentation in places of inflammatory skin changes can be determined.

Diagnostics

In most cases, atopic dermatitis in children is established on the basis of a characteristic clinical picture and hereditary allergic anamnesis, since there are no laboratory or instrumental diagnostic methods that unequivocally confirm or refute the presence of the disease.

In 1980, JM Hanifin and G. Rajka proposed criteria for the diagnosis of atopic dermatitis in children (4 main and more than 20 additional). For reliable confirmation of the diagnosis, it was necessary to have at least 3 criteria from both groups; in the mid-90s of the last century, the criteria were revised due to their cumbersomeness, but even in a modified form they did not find wide application in pediatric practice.

In 2007, the UK developed the Atopic Eczema in Children Conciliation Document, which proposes to confirm the presence of atopic dermatitis in children with pruritus combined with three or more of the following:

• the presence of dermatitis in the flexor surface of the limbs, involving skin folds (elbow or popliteal folds) or the presence of dermatitis on the cheeks and / or on the extensor surfaces of the limbs in children under 18 months of age;
• a history of dermatitis;
• common dry skin over the past year;
• the presence of bronchial asthma or allergic rhinitis (or the presence of atopic diseases in first-line relatives);
• manifestation of dermatitis up to two years.

The following signs are of great importance in the diagnosis of atopic dermatitis in children: aggravated heredity for allergic diseases, signs indicating a connection between an exacerbation of dermatitis with non-infectious allergens (food, epidermal, pollen) and the positive effect of eliminating contact with the alleged allergen.

Laboratory research methods used in the diagnosis of atopic dermatitis in children:

• study of the level of general and allergen-specific immunoglobulins E (the data obtained are assessed with caution due to the large number of false-positive and false-negative results in children under 3 years of age);
• determination of class E antibodies to Staphylococcus aureus and its exotoxins, fungi (identification of possible bacterial sensitization);
• open food challenge test;
• setting of skin tests (injection test, skin scarification tests, application tests).

Treatment of atopic dermatitis in children

Treatment of atopic dermatitis in children should include measures in the following areas:

• elimination of provocateurs (both allergenic and non-allergenic) that exacerbate the disease;
• local external therapy;
• systemic therapy, which is used in the case of ineffectiveness of elimination measures and the use of external agents or when infectious complications are attached (infection of the inflamed surface).

In children under 12 months of age, the manifestation of atopic dermatitis in the overwhelming majority of cases is triggered by ingestion of food allergens; in older children, such a relationship is not clearly traced.

Elimination measures must be carried out with respect to not only food, but also household and pollen allergens. Eliminating the contact of a child with atopic dermatitis with pets, woolen, fur or downy products can significantly reduce the clinical manifestations of the disease and reduce its severity. Creating a hypoallergenic environment and diet is a prerequisite for the successful treatment of atopic dermatitis in children.

Drugs used for local therapy of atopic dermatitis in children:

• hormonal (glucocorticosteroid) drugs with a minimum range of contraindications and the absence of systemic effects along with a powerful anti-inflammatory effect (methylprednisolone aceponate, alclomethasone dipropionate, mometasone furoate);
• calcineurin inhibitors;
• non-steroidal anti-inflammatory drugs;
• when an inflamed surface is infected, combined preparations are used containing, in addition to local glucocorticosteroids, antibacterial and antifungal components;
• corneotherapy [restoration of the integrity of the skin with the help of nourishing and moisturizing agents (emollients), aimed at saturating and nourishing the epidermis];
• antihistamines.

Systemic treatment of atopic dermatitis in children:

• antihistamines;
• stabilizers of mast cell membranes;
• glucocorticosteroid drugs;
• antibacterial drugs (with the addition of a bacterial infection);
• correction of concomitant pathology (treatment of diseases of the gastrointestinal tract, intake of metabolic drugs and antioxidant therapy, normalization of the functional state of the nervous system, sanitation of foci of chronic infection);
• pre- and probiotics;
• enterosorbents;
• immunomodulators;
• immunosuppressants.

In addition to drug therapy in the complex treatment of atopic dermatitis in children, physiotherapeutic methods of exposure are shown: UV-A and UV-B irradiation, acupuncture, hyperbaric oxygenation, magnetotherapy, laser therapy. Sanatorium treatment in a dry sea climate demonstrates significant positive results in reducing the severity of painful manifestations.

Treatment goals for atopic dermatitis in children

Possible complications and consequences

The most formidable complication of atopic dermatitis is infection of scratches and weeping (attachment of a bacterial, viral or fungal infection): impetigo, folliculitis, furunculosis, streptostaphylococcal impetigo, angular stomatitis, erysipelas, exudative erythema, pyiformis and ulcerative infections, herpetizoan infections, other localized in different areas of the skin, more often on the face, limbs, trunk.

The result of infection of the wound surface can be sepsis and, in extremely severe cases, death.

In addition to physical suffering, atopic dermatitis often provokes changes in the psychological state of the child. Persistent, excruciating itching and discomfort from skin rashes provoke astheno-neurotic reactions (insomnia at night, sleepiness during daylight hours, irritability, tearfulness, decreased activity, anxiety, refusal to eat, etc.), cosmetic defects make it difficult for social interactions with peers.

Forecast

The most active course of atopic dermatitis in children is observed at a young age. As they grow older, the symptoms of the disease usually fade away, become less pronounced, the frequency of exacerbations decreases significantly. In most cases, atopic dermatitis in children spontaneously resolves in 3-5 years, less often in adolescence.

If the manifestations of atopy persist in adulthood, the symptoms are noted for 30-40 years, gradually regressing, also spontaneously resolving in the future.

The prognosis is most favorable with complex treatment, adherence to nutritional recommendations and the creation of a hypoallergenic environment.

Prevention

1. Elimination of food provocateurs.
2. Providing adequate ventilation in households.
3. Maintaining optimal humidity, temperature and air purity.
4. Refusal to use furniture and interior items that can serve as dust collectors (carpets, books, flowers, heavy curtains, upholstered furniture, soft toys).
5. Banning the use of feather and down pillows and blankets.
6. Refusal to keep pets, birds and aquariums.
7. Refusal to wear clothes made of fur and wool.
8. Dispensary observation by an allergist.
9. Long-term spa treatment in the summer.
10. Conducting restorative procedures (hardening, UV irradiation, massage).

One of the main preventive measures that can significantly reduce the severity of the symptoms of the disease is adherence to a hypoallergenic diet for atopic dermatitis in children:

• a decrease in the diet or a complete rejection of foods that stimulate the production of histamine, a provocateur of allergic inflammation (citrus fruits, fish, cow's milk, overly sweet foods, spices, nuts, red fruits and vegetables, etc.);
• fractional, frequent meals;
• introduction of fermented milk products, fresh herbs, green fruits and vegetables, gluten-free cereals, beef, rabbit meat, turkey meat into the diet;
• sufficient water intake;
• refusal from sugary, carbonated or containing dyes and preservatives drinks.

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Olesya Smolnyakova Therapy, clinical pharmacology and pharmacotherapy About the author

Education: higher, 2004 (GOU VPO "Kursk State Medical University"), specialty "General Medicine", qualification "Doctor". 2008-2012 - Postgraduate student of the Department of Clinical Pharmacology, KSMU, Candidate of Medical Sciences (2013, specialty "Pharmacology, Clinical Pharmacology"). 2014-2015 - professional retraining, specialty "Management in education", FSBEI HPE "KSU".

The information is generalized and provided for informational purposes only. At the first sign of illness, see your doctor. Self-medication is hazardous to health!