Atopic Dermatitis and Eczema

  • Overview

    "Patients with atopic dermatitis often scratch in their sleep and have very disordered sleep patterns. After coming to Children's Atopic Dermatitis Center, we've had parents call us to say, 'My child has never slept through the night before we saw you and listened to what you told us to do.'"

    Lynda Schneider, MD, director of Children's Allergy Program and Atopic Dermatitis Center

    About atopic dermatitis

    Atopic dermatitis is an inflammatory, allergic, non-contagious skin disorder that causes itchy, scaly, flaky skin. It:



    click to enlarge

    • is the most common chronic skin disorder in children
    • occurs in 10 to 20 percent of children
    • usually affects babies or very young children
    • may last until adolescence or adulthood
    • causes the skin to itch, scale and flake
    • can lead to permanent scars if your child scratches too much
    • lowers a child’s quality of life because the itching feeling is constant
    • is not curable
    • can get better as a child grows older
       

    Atopic dermatitis is a type of inflammation of the skin often connected to allergies. Physicians often use the terms eczema and atopic dermatitis interchangeably because most cases of eczema in children are caused by atopic dermatitis. Eczema is a general term for inflamed, itchy skin, which can sometimes be caused by something other than atopic dermatitis.

    Food allergies are a trigger for some patients with atopic dermatitis.

    How Boston Children's Hospital approaches atopic dermatitis

    Children’s Allergy and Dermatology Programs see many children with atopic dermatitis and ensure your child's treatment plan is well thought out from start to finish.  For children with difficult to control atopic dermatitis, Children’s has an Atopic Dermatitis Center, which is part of the Allergy Program, Our center has a pediatric allergist, a pediatric nurse practitioner, a pediatric nutritionist and a pediatric psychologist or a behavioral therapist who helps your child learn ways to cope with the itching and scratching.

    Our multidisciplinary approach is the key to our treatment, and the Atopic Dermatitis Center teams up with pediatric dermatologists regularly to find the best treatments for patients. In addition to atopic dermatitis, the center also treats allergies and asthma.

     

     The impact of infant atopic dermatitis on a family

     At 1 year old, Brett Nasuti developed atopic dermatitis, which his doctor diagnosed as a result of food allergies. Read more about their success story and the impact atopic dermatitis can have on a family. Join the conversation or share your story on Children’s Thriving blog.

    Atopic dermatitis: Reviewed by Dale Umetsu, MD and Lynda Schneider, MD

    © Children’s Hospital Boston; posted in 2011

    Contact us text

  • In-Depth

    If your child has atopic dermatitis, you’ve probably struggled with how you can stop her skin from itching and causing painful irritation. At Children’s Hospital Boston’s Atopic Dermatitis Center, within the Division of Allergy and Immunology,  we help you every step of the way. We understand that you may want to learn more about your child’s atopic dermatitis in order to fully understand the condition and get her the most appropriate treatment.   

    What is atopic dermatitis?

    Atopic dermatitis is a chronic and relapsing inflammatory condition of the skin. Children with atopic dermatitis often have skin barrier dysfunction which causes dry, itchy, scaly skin. They can also have associated environmental and food allergies.  Of children who have atopic dermatitis, 65 percent show signs in the first year of life and 90 percent show signs within the first five years. Half of all affected children improve between ages 5 and 15. Parents with atopic dermatitis are more likely to have children with atopic dermatitis.

    What triggers it?

    The main triggers of atopic dermatitis are dry skin, irritants, stress, allergies, infection and heat/sweating. It’s important to note that these are triggers that worsen the symptoms of atopic dermatitis, and don’t necessarily cause atopic dermatitis.

    Is my child at risk for having atopic dermatitis?

    Children with a family history of allergies, asthma and atopic dermatitis are more likely to have atopic dermatitis.  In research studies, mutations in skin barrier genes such as filaggrin are commonly associated with atopic dermatitis.

    What does it look like?

    Atopic dermatitis often causes itching which leads to scaly, bumpy, red and/or swollen skin. If chronic scratching occurs, the skin becomes thickened and or hardened. It manifests on different parts of the body depending on the person’s age. In older children and adults, atopic dermatitis tends to appear on the creases of the arms and the back of the knees. In infants, it affects the face, trunk and extremities



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    How serious is it?

    Atopic dermatitis is not a life-threatening condition. The usual cause for concern is a severe skin infection.

    Is it curable?

    It is not curable, but with proper treatment and medication, the disease can be well controlled.

    Is atopic dermatitis the same thing as eczema?

    Physicians often use the terms eczema and atopic dermatitis interchangeably because most cases of eczema are caused by atopic dermatitis. Eczema is a general term for dry flaky inflamed skin, which can sometimes be caused by something other than atopic dermatitis.

    How does atopic dermatitis relate to food allergies?

    About 25 percent of children with atopic dermatitis have a food allergy.

    Who does atopic dermatitis mostly affect?

    Atopic dermatitis usually affects babies or very young children, but it sometimes lasts until adolescence or adulthood.

    What happens if my child doesn’t stop itching affected areas?

    Prolonged itching of the skin can lead to lichenification, which means the skin becomes thick and leathery. Intense itching may break the skin, and lead to infections and or permanent scars. While atopic dermatitis is not a life-threatening condition, many patients with atopic dermatitis have an underlying skin barrier defect that requires them to take special care of their skin for their whole lives.

    What impact can climate have on atopic dermatitis?

    Extreme levels of dry climate, or hot and humid climates can trigger atopic dermatitis. For example, the cold dry air of winter in New England can trigger an outbreak of atopic dermatitis as well as the heat and humidity of summer. We recommend that parents find ways to help their child avoid exposure to extreme weather, such as using air conditioners in summertime.

    What can children do to help reduce their atopic dermatitis while playing sports?

    Sports equipment can be an irritant to areas affected by atopic dermatitis. Wearing moisture wicking clothes, taking a bath right after sports and taking medicine can help.

    Triggers and Symptoms

    What triggers atopic dermatitis?

    • stress
    • allergies
    • sweating
    • certain soaps, cleaners or detergents
    • long, hot baths or showers
    • rapid changes in temperature
    • low humidity
    • wool or man-made fabrics or clothing
    • dust or sand
    • cigarette smoke
    • certain foods, such as eggs, milk, fish, soy or wheat
    • bacterial skin infection or colonization

    What parts of the body are affected?

    • The part or parts of the body affected by atopic dermatitis tends to change as a child ages. In infants and young children, it's usually the face, trunk and extremities. In older children and adults, atopic dermatitis tends to appear on the creases if the arms and back of the legs.

    What are the symptoms of atopic dermatitis?

    • dry, scaly skin
    • small bumps
    • redness and swelling of the skin
    • a thickening and hardening of the skin
    • raw and sensitive skin

    When should my child see a doctor about her atopic dermatitis?

    • child is irritable and uncomfortable
    • child has trouble sleeping
    • rash spreads
    • child has a fever
    • child has pus or yellow crusts from affected areas

    FAQ

    Q: What is atopic dermatitis?

    A: Atopic dermatitis is a chronic and relapsing inflammatory condition of the skin. Children with atopic dermatitis often have skin barrier dysfunction which causes dry, itchy, scaly skin. They can also have associated environmental and food allergies.  Usually it affects babies and young children, but sometimes it can last until adolescence or adulthood.

    Q: Why is it a cause for concern, other than being itchy and uncomfortable?

    A: Severe atopic dermatitis can make it very hard for your child to enjoy school and play. Too much scratching or itching can lead to a severe skin infection.  Additionally, the discomfort of atopic dermatitis can ruin sleep, which can affect your child.

    Q: Can other children contract my child’s atopic dermatitis?

    A:No. Atopic dermatitis is not contagious; however, if an allergen is a source of your child’s atopic dermatitis, it is important to avoid it.

    Q: If my child has atopic dermatitis, will he be OK?

    A: Although there is no cure for atopic dermatitis, it can be treated with bathing, emollients, prescription ointments and other treatments. Many children with atopic dermatitis get better as they grow older.

    Q: Can stress cause atopic dermatitis?

    A: No. Stress does not cause atopic dermatitis, however it can worsen the symptoms.

    Q: Can atopic dermatitis leave permanent scars?

    A: Yes. If your child suffers from a chronic case of atopic dermatitis and itches excessively, this can lead to permanent scarring.

    Q: Can atopic dermatitis affect my child’s mood?

    A: Yes. Atopic dermatitis is very uncomfortable, and can limit your child’s sleep, which may impact her mood, just as anyone would be affected by a lack of sleep.

    Q: Can my child still swim in chlorinated pools?                             

    A: Yes. Prolonged exposure to chlorine can make your child’s atopic dermatitis worse. However, if your child applies fragrance-free, hypoallergenic sunscreen before swimming, and quickly rinses off and applies moisturizer after getting out of the pool, her atopic dermatitis should not be aggravated.

    Q: Should my child bathe daily even if he has atopic dermatitis?

    A: Yes. It’s important for your child to bathe daily, moisturize and hydrate the skin afterward.

    Q: If I prevent my child from being exposed to allergens, will her atopic dermatitis go away?

    A:Most children have an underlying skin disorder, and their atopic dermatitis will not go away even if you limit exposure to allergens.

    Q: What’s the difference between eczema and atopic dermatitis?

    A:Physicians often use the terms eczema and atopic dermatitis interchangeably because most cases of pediatric eczema are caused by atopic dermatitis. Eczema is a general term for inflamed, itchy skin, which can sometimes be caused by something other than atopic dermatitis.  

    Questions to ask your child’s doctor

    After your child is diagnosed with atopic dermatitis, you may feel overwhelmed with information. It can be easy to lose track of the questions that occur to you.

    Lots of parents find it helpful to jot down questions as they arise- that way, when you talk to your child’s doctors you can be sure that all of your questions are answered. If your child is old enough, you may want to suggest that she writes down what she wants to ask her health care provider too.

    • How could the medication or treatments interact with my child’s current medication regiments?
    • How could creams or ointments interact with other creams or sprays, such as suntan lotion or bug repellent?
    • Are there any dietary restrictions my child needs to follow while taking atopic dermatitis medications?
    • What treatments and medications are covered by my insurer?
    • What are some things I can do to help my child’s itching and scratching?
    • How can I find out if any of the products, substances and foods around the house triggers my child’s atopic dermatitis?
    • How will atopic dermatitis impact my child’s social life?
    • What resources are available to help my child cope with the stress of having atopic dermatitis?
    • How could atopic dermatitis impact my child’s experience in the classroom?
    • How will Children’s Hospital Boston coordinate with my child’s school nurse to continue care at school?
      Managing food allergies at home
       About 25 percent of children with severe atopic dermatitis have food allergies. As many athletes know, having a game plan is crucial to winning. In managing allergies, it’s even more important. Learn new strategies for helping your child manage and cope with food allergies. Join the discussion on Children’s Thriving blog.
  • Tests

     How is atopic dermatitis diagnosed?

    At Boston Children's Hospital, your child's doctor will conduct a complete a physical examination. A diagnosis is based on:

    • family history of allergies or asthma
    • patient’s personal hertory of allergies and asthma
    • skin examination

    After we complete all necessary tests, our experts meet to review and discuss what they have learned about your child’s condition. Then we will meet with you and your family to discuss the results and outline the best treatment plan.

     Adolescent Medicine

     Atopic dermatitis is a visible condition that impacts the skin, affecting one’s appearance. Ther can be especially challenging for a teenager. Learn how Children’s Division of Adolescent Medicine can help your teen face these unique challenges.

  • At Boston Children's Hospital, we are uniquely qualified to determine the best course of care for children with skin problems. We're known for our science-driven approach – we're home to the most extensive research enterprise located in a pediatric hospital in the world, and we've partnered with a number of top biotech and health care organizations – but our physicians never forget that your child is a child, and not just another patient.

     Although there is no cure for atopic dermatitis, treatment can decrease your child's skin dryness and irritation, making her more comfortable. In severe cases, your child's physician may prescribe your child medications to help alleviate her atopic dermatitis symptoms. Common medications include:

    • steroid creams and ointments
      • topical medications to help decrease skin inflammation
      • examples are hydrocortisone, mometasone or triamcinolone
    • antibiotics
    • topical calcineurin inhibitors such as topical tacrolimus or pimec
    • antihertamines
      • help decrease itching
      • diphenhydramine (Benadryl) or hydroxyzine (Atarax)
    • Oral immunomodulators are a last resort treatment that may reduce symptoms of atopic dermatitis, but they are used sparingly since they may also affect the immune system or cause cancer.
    • oral corticosteroids
      • oral corticosteroids are to only be used as a short term solution, as there are potential serious side effects
        • cataracts
        • osteoporosis
        • muscle weakness
        • high blood pressure
        • thinning of skin

    What can I do at home?

    • Bathe your child frequently and use moisturizers, baths are preferred over showers.
    • Use mild soaps and limit the use of soap.
    • Make sure your child's fingernails are short, as scratching may worsen atopic dermatitis.
    • Dress your child in lightweight clothes to reduce sweating.
    • Apply cool wet bandages or dressings to the affected areas.
    • Let your child play outside in the sun, but not for too long, as prolonged sun exposure can increase the risk of skin cancer.
    • Have your child avoid contact with irritants, as determined by your child's physician.
    • Use a humidifier in your home to help keep your child's skin moist but keep the humidity less than 40%.  High humidity promotes dust mite growth.
    • Use a fan or air conditioner in your child's room to keep the room cool, to help avoid sweating.

    What is the treatment plan if a food allergy is triggering the atopic dermatitis?

    • Once the food allergen is identified, it is removed from your child's diet at the same time your child receives treatment for skin inflammation.

    How long will treatment take?

    • Many children with atopic dermatitis have an underlying skin barrier defect that requires them to take special care of their skin for their whole lives. They need to avoid irritants and may need to use moisturizers daily, which helps to decrease itching and flaking.The length of treatment depends on the severity of the case of atopic dermatitis. Patients with severe atopic dermatitis in childhood are at greater risk of having atopic dermatitis in adulthood.

    How can I help prevent my child from getting skin infections from scratching?

    • It is difficult and unlikely to completely prevent your child from doing any scratching, so it is helpful to cut your child's nails so she can't dig into the skin. Additionally, her fingernails can be dirty, so cutting them removes bacteria that may infect the area affected by atopic dermatitis.   

    How can I help my child stop scratching?

    • Developing a strategy to stop the itch-scratch cycle can be helpful.  Cover your child's skin with long sleeve clothing, long pants or tights so she can't get to the lesions.  Hands on activities such as games or toys or cool compresses can be good distractions.  In older children, relaxation tapes or music work well.
      Managing food allergies: A chef's perspective
       About 25 percent of children with atopic dermatitis have food allergies. Eating out at restaurants for families of children with food allergies can be a stressful experience, rather than a relaxing time outside the home. Learn how restaurants are taking mandated measurements to accommodate children and families with food allergies. Here, you can get a chef's perspective on the importance of food allergies awareness.

    Coping & support

    Because atopic dermatitis is usually a visible condition (affecting a child's skin), your child may feel the effects of her condition socially and psychologically, as well as physically. In addition to the anxiety of fighting the urge to itch, children with facial atopic dermatitis may develop school avoidance if they are teased, and they may not want to go to school.

    Boston Children's Hospital's Atopic Dermatitis program has a psychologist, Jennifer LeBovidge, PhD, who spends a lot of time with families and developing strategies to help decrease the scratching, help with the sleep schedule and cope with any teasing that may occur at school.

    In cases that a patient develops a more severe mental illness, they'll be referred to the medical Behavioral Medicine Clinic, a multi-disciplinary team of pediatric psychologists, psychiatrists and other mental health professionals providing effective, compassionate evaluation, education, counseling and therapy to help you and your child cope with atopic dermatitis.

    There's a lot of support available here at Children's for you and your family, and here are some of the ways we can help:

    Patient education: Our nurses will be on hand to walk you through your child's treatment and help answer any questions you may have. They will also reach out to you by phone, continuing the care and support you received while at Children's.

    Parent to parent: Want to talk with someone whose child has been treated for atopic dermatitis? We can often put you in touch with other families who have been through similar experiences and can share with you their experience at Children's.

    Faith-based support: If you are in need of spiritual support, we will help connect you with the Children's chaplaincy. Our program includes nearly a dozen clergy representing Episcopal, Jewish, Lutheran, Muslim, Roman Catholic, Unitarian and United Church of Christ traditions who will listen to you, pray with you and help you observe your own faith practices during your hospital experience.

    Social work: Our clinical social workers have helped many other families in your situation. Your social worker can offer counseling and assistance with issues such as coping with your child's diagnosis, stresses relating to coping with illness and dealing with financial difficulties.

    Visit our For Patients and Families page for all you need to know about:

    • getting to Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family
      "Helping Your Child with Medical Experiences: A Practical Parent Guide"

       Download a free booklet, “Helping Your Child with Medical Experiences: A Practical Parent Guide”(.pdf) and read about topics including:

      • talking to your child about her condition
      • preparing for surgery and hospitalization
      • supporting siblings
      • taking care of yourself during your child's illness adjusting to life after treatment
  • Research & Innovation

    Children’s Hospital Boston’s Atopic Dermatitis Center is a program of the Division of Allergy and Immunology, and develops treatments informed by our research.   Dr. Lynda Schneider is a principal investigator for the NIH Atopic Dermatitis Research Network (ADRN) which is focused on atopic dermatitis (AD) and its association with both immune and skin barrier defects. Dr. Schneider is also an investigator for a long term study of children who have used topical tacrolimus ointment.  Children’s is home to the world’s most extensive research enterprise at a pediatric hospital.

     Interdisciplinary research

     Children’s is researching genetic and environmental risk factors which predispose children to developing atopic dermatitis in an interdisciplinary research project. Our Division of Allergy and Immunology and the Program in Genomics are teaming up to uncover how the disease is caused, find participants who have observable signs of atopic dermatitis and identify possible genetic mutations. Ultimately, the data collected from their study will allow researchers to pursue other hypotheses, and to look for gene-environment interactions in the development of atopic dermatitis.

    Geha Laboratory
    Dr. Geha, MD, Chief of Division of Immunology, leads the Geha laboratory on researching the molecular mechanisms of primary immunodeficiency diseases and atopic dermatitis. Dr. Geha leads animal studies under the NIH Atopic Dermatitis Research Network (ARVN), a multicenter study aimed at understanding the basis of the susceptibility of patients with AD to eczema vaccinatum (EV) and vaccinia dissemination. Read more about the Geha Laboratory.

     

    Oettgen Laboratory
    Hans Oettgen, MD, PhD, is leading the Oettgen Laboratory in researching the regulation of immune responses by IgE antibodies, immunobiology of eczema vaccinatum and mechanisms of food allergy. Read more about the Oettgen Laboratory.

     

    Lynda Schneider, MD, director of Children’s Allergy Program, discusses the landmark food allergies study

    Children’s Hospital Boston is the first to combine an allergy drug with regular milk drinking to help desensitize a child’s immune system to milk, and thus reduce the allergic reaction to milk. More specifically, the allergy drug omilzumab (marketed by Genentech under the name Xolair®) was paired with gradual increased oral consumption (drinking) of milk to help reduce the overreaction of immunoglobulin E (IgE) to the milk, and thus reduce the allergic reaction.

    Nine of the eleven child participants successfully completed the study, and are currently consuming 8 to 12 ounces of milk a day to maintain their tolerance. Learn more, and join the conversation on Children’s Vector blog.

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