Atopic dermatitis, or atopic eczema, is a chronic inflammatory condition of the skin. The disease is characterized by episodic symptoms with intermittent periods of flares and remissions. However, in severe cases the repertoire of symptoms is chronic. Treatment of the disease depends on the type and severity of symptoms. Therefore, a comprehensive assessment of the disease is critical to the management of atopic dermatitis.
Key words: eczema, atopic dermatitis, allergan, irritant
Atopic Dermatitis: Assessment Guide and Overall Plan of Care
Atopic dermatitis (AD) is a multi-faceted disease and as such requires the adoption of a multi-factorial approach from its diagnosis, to its assessment, and throughout its management. The first step in the management of AD is to take the patient’s medical history and assess the severity of symptoms. The impact of these symptoms on the wellbeing of the child should be assessed next. This assessment should drive therapeutic decisions.
Medical History
Symptomatic AD is characterized by itching plus three or more symptoms including (1) current flexural dermatitis, (2) past flexural dermatitis, (3) history of dry skin within the past 12 months, (4) history of asthmas or allergic rhinitis, (5) history of parental AD, and (6) age of child at onset of disease (Krafchik, 2011).
Severity of Symptoms
Symptoms are to be categorized as (1) clear, no evidence of AD; (2) mild, presence of dry skin and some itching; (3) moderate, presence of dry skin and frequent itching and redness; or (4) severe, large areas of dry skin and chronic itching with redness. The most severe cases exhibit extreme loss of integrity of the skin, including cracking, bleeding and changes in pigmentation. Bacterial infection may also be present (Krafchik, 2011).
Impact of AD on QOL
Symptomatic AD is a debilitating disease that can impact a child’s quality of life. Its impact on the child’s QOL can vary from (1) none, no impact; (2) mild, small impact on daily activities and psychosocial wellbeing with disturbed sleep; (3) moderate, some impact on daily activities and psychosocial wellbeing with frequent sleep disturbance; (4) severe, great impact on daily activities and psychosocial well being with chronic sleep disturbance (Stein, 2012). Parents and caregivers of patients with AD can also suffer from diminished QOL (Stein, 2012). A nurse should adopt a holistic approach to care and assess the QOL of family members, especially since the QOL of the parent impacts the QOL of the affected child.
Management of AD
The first step in the management of AD is to identify the triggering factors, including irritants and allergens (Kawamoto, 2012). Allergens can include contact, food, and inhalant allergens (Marini, 1996).
Dust mites are a serious potential problem that should be investigated. Parents should be advised to keep a food diary to isolate offending foods and eliminate them from the child’s diet.
Emollients may be used in clear-mild cases of AD. Emollients may be used in conjunction with other treatments, such as topical corticosteroids or calcineurin inhibitors. Topical antibiotics should be included in the treatment regimen when skin infection is present and these may be used along with corticosteroids. Severe cases in children over 6 months old may benefit from antihistamines (Krafchik, 2011).
Stepped approach to management of AD
Treatment should be tailored according to the severity of symptoms and adjusted up or down depending on clinical response. Wide use of emollients is recommended even in clear cases of AD. Use low-dose topical corticosteroids in mild cases of AD, and mid-dose topical corticosteroids with topical calcineurin inhibitors in moderate cases. Severe cases require high-dose topical costeroids and topical calcineurin inhibitors. Phototherapy and/or systemic therapy may also be necessary (Krafchik, 2011).
Referrals
Referrals may be immediate, urgent, or routine. Severe cases with eczema herpeticum are to be immediately referred to a dermatologist. Urgent referrals are indicated in cases of severe AD that have shown no response to therapy or if antibiotics failed to cure infected AD. Non-urgent routine referrals are indicated in cases of uncertain diagnosis, non-responsive facial AD, severe infections, contact allergic dermatitis, serious impact of AD on QOL, failed management of AD (Krafchik, 2011).
In certain cases, it might also be advisable to refer parents for psychological treatment.
Parental Education
The successful management of AD requires constant vigilance and intervention. Parents should be taught how and when to apply topical treatments and warned about the escalating signs of bacterial infection of AD, or more important, how to recognize the signs of eczema herpeticum (Krafchik, 2011). Find out if the parents are using complementary therapies, and if the are, ask them not discontinue the use of emollients. There are also environmental factors that should be assessed and discussed with the parents, including those dealing with hygiene (Kawamoto, 2012).
Economic Impact
Relative to other medications, AD treatments may not seem expensive, but AD is a pernicious and recurrent disease that may come and go during a few days in the life of the individual, or last throughout a lifetime. As the child grows, therapeutic protocols may have to be re-evaluated and a new regimen of medications prescribed.
Conclusion
Atopic dermatitis is an allergic disease, and as such treatment of AD may be specific or non-specific, and may be symptomatic or asymptomatic. There is also a wide variation in the factors that may trigger or exacerbate AD and specific treatments for AD depend on the irritant or allergen involved. Therefore, a detailed assessment of the disease, and factors associated with the disease are paramount for successful treatment. A truly comprehensive medical plan would also include tests for sensitization. On rare and fortunate occasions, the specific allergen or irritant can be identified and the patient can be freed from the disease.
References
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Immunol,22(2):116-25.
Krafchik, B., (2011). Atopic Dermatitis. Medscape Reference Drugs, Diseases &
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Retrieved June 5, 2012 from
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Marini A, Agosti M, Motta G, Mosca F (1996). Effects of a dietary and environmental
prevention programme on the incidence of allergic symptoms in high atopic risk
infants: three years' follow-up. Acta Paediatr Suppl, 414:1-21.
Stein TR, Sonty N, Saroyan JM. (2012)."Scratching" beneath the surface: an integrative
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