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The infantile phase of atopic dermatitis starts changing the characteristics of the itchy skin rashes by the age of 18 months to 24 months, the beginning of childhood atopic dermatitis. However, some dermatologists consider childhood eczema cut off period as 4 years.
In place of the face, forehead, scalp, outer limbs distribution of the skin rashes in infantile atopic dermatitis, the sites most often involved in childhood atopic eczema are the elbow and knee flexures, sides of neck, the wrist and ankles.
Signs and Symptoms of Childhood Atopic Dermatitis
The itchy skin rashes of childhood atopic dermatitis consist of eczematous changes of all phases of eczema, the acute, sub acute and chronic skin changes.
In acute childhood eczema, following eczema triggers like food, wool and other environmental factors, there is blistering, swelling and weeping skin rashes with a stinging and burning sensation.
In sub acute childhood atopic dermatitis, the most common presentation, the skin dries up, showing crusts, scaling and dryness. There is incessant itching which leads to thickening or lichenification of the skin, the chronic eczema. The itching of the chronic eczema is intense enough to interfere with the normal daily activities of the child.
The sides of the neck may show a characteristic black color, sometimes called the atopic dirty neck.
The outer aspect involvement of the infantile atopic eczema may continue in some children, especially in Asians and African Americans. These cases are more difficult to treat than the common variety.
Hand, finger and nail involvement may also be present. The course of the disease is dotted with remissions and acute exacerbations. Sudden localized or generalized eruption of oozing itchy skin rashes usually indicate underlying bacterial infections, which have to be treated before instituting specific eczema treatments.
Differential Diagnosis of Childhood Eczema
The following diseases have to be ruled out in children presenting with eczematous itchy skin rashes:
Scabies: Severely itchy skin bumps, involving the whole body, with predilection to finger webs, wrist, inner elbow, lower chest and abdomen. The pustular lesions on the palms and soles are characteristic of scabies in infants.
Icthyosis vulgaris, associated with atopic dermatitis, when severe, may mimic the eczema. Scaling is prominent in icthyosis, not redness or itching.
Allergic and irritant contact dermatitis can present as acute itchy skin rashes in children.
Treatment of the Childhood Atopic Eczema
Treatment of childhood atopic dermatitis depends upon the stage of the eczema, whether acute, sub acute or chronic.
Short acting antihistamines are given 2-3 times daily to relieve itching.
In acute flare ups the doctor will prescribe a course of antibiotics.
An oatmeal bath followed by liberal application of emollients once daily.
In the initial stages, lower strength or moderate strength topical steroids like 1% hydrocortisone, fluticasone, mometasone etc are used for shorter periods, depending upon the site and severity of the itchy skin rash. Once the inflammation is under control, the least strength steroid is used as intermittent application to maintain the remissions.
The parents should know how to avoid the side effects of the topical steroids. After two weeks of continuous application, one week period of steroid free emollient applications will help in avoiding the systemic side effects of topical steroids.
Once the dermatitis is under control and the redness and scaling and itching has stopped, the emollient applications should continue without break. Careful recording of food intolerance will help in avoiding the food triggers.
Recurrences can be controlled with the use of immunemodulators tacrolimus and pimecrolimus.
Exposure to environmental irritants, soaps, woolen dresses, milk and soy products, chocolates, fast foods etc should be controlled to avoid flare ups.
Natural Course of Childhood Atopic Eczema
20% of cases clear by the age of 4-6 Years
Another 20% cases by the age of 8-10 years
20% of remaining clear by 12-14 years of age
20% clear by age of 21 years.
20% of the atopic dermatitis goes into the adult phase with relapses and recurrence throughout life, though most patients are free of the skin rashes by the age of 30 years.
Around 30-50% of atopic eczema patients develop asthma, nasal allergy (allergic rhinitis, hay fever) or eye allergy later in life.