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One of the most common childhood dermatological diseases is atopic dermatitis. Congenital, non-infectious, but very capricious in its symptoms - it may pass spontaneously or recall the whole life, during periods of exacerbation of the disease - explains Prof. extra dr hab. med. Beata Kręcisz, head of the Dermatology Clinic of the Provincial Complex Hospital in Kielce.
- Professor, who can get AD?
This is an inherited disease with a genetic background. Atopic dermatitis affects approximately 80 percent of patients by the age of five. It is mainly a childhood disease, because in about 70-80% of cases, i.e. in the vast majority of patients, the clinical symptoms of skin inflammation disappear during adolescence ( although the skin remains dry and hypersensitive throughout life). Thus, there is a high probability that the disease will resolve on its own. Unfortunately, in some cases it may persist throughout life or take other clinical forms, such as allergic rhinitis. A doctor examining a patient for the first time never knows with certainty what the course of the disease will be and what the prognosis can be. Sometimes atopic dermatitis does not appear until adults.
In various studies, it is estimated that from 1 to 20 percent of the Polish population suffers from AD, regardless of the stage of the disease severity. Adult patients with AD make up 1-2 percent of this number.
- The predisposition to the disease is shown more often by boys or girls?
Girls get sick a little more often, although in various studies these data are divergent. There is some variability that results from both the geographic area and the habits of the captain. Undoubtedly, atopic dermatitis is modified by external factors, including environmental ones. For example, the latest research shows that excessive hygiene is not so beneficial for our immune system. In this way, we limit the production of our natural immune tolerance to various allergens and pathogens.
- In a way, it's a paradox after all. After all, our civilization strives to ensure that everything is hygienic, he althy …
In highly industrialized countries, the incidence of AD is higher than in less countriesindustrialized. Moreover, AD is more common in cities than in the countryside. At the moment, this is explained by the fact that when children are raised in an environment where they have natural access to more bacteria and pathogens, they develop a natural immune tolerance. They are more prepared for the different types of allergens they face. On the other hand, children "raised" in sterile conditions are more prone to allergic diseases.
In Scandinavia, there were also studies which showed that children from households with dishwashers (i.e. better removal of bacteria and fungi from the dishes) more often suffer from allergic diseases, compared to children from households where is washed off traditionally. All this gives modern dermatologists food for thought. Also in the context of factors exacerbating AD.
- Is it difficult to diagnose AD?
The diagnosis is made mainly on the basis of the clinical picture. The features of atopic dermatitis appear around 6 months of age. The symptoms that appeared earlier in toddlers more often indicate seborrheic dermatitis, which occurs in children between the ages of 2 and 3 months. Nevertheless, the differentiation of these 2 disease entities is sometimes difficult. Therefore, the view that more and more often dominates among dermatologists is to talk about infantile eczema in children under 1 year of age. It is only when more symptoms appear that it is more likely to be diagnosed with AD or another skin disease.
- AZS, once it shows up, has many symptoms, some of them very characteristic …
Yes, it is a very symptomatic disease. To sort this out, major and minor criteria for atopic dermatitis have been defined. One of the four larger ones is itchy skin. It is believed that there is no AD without itching. In sick, very young children, it can be observed that they are restless, tearful - the cause of this discomfort is itching. The second major criterion of the disease is the recurrent nature of skin lesions.
The third is the typical localization of skin lesions, which varies depending on the patient's age. In babies there is reddening of the skin of the face and cheeks, which are also often cracked. The leather on them is as if varnished, because the child instinctively rubs the skin. And rubbing it can lead to erosions that cause secondary bacterial superinfection of the skin.
In older children, typical locations are the elbows, knee bends, side surfaces of the neck and wrists. In adults, the lesions are located on the skin of the hands and feet, and may also be scattered.
- And the fourth disease criterion?
The fourth criterion is atopy in the family or in a given patient - that is, the innate predisposition of the body to the increased production of IgE antibodies in relation to the common allergens around us. It is not synonymous with the disease, because atopic dermatitis is not always associated with hypersensitivity to these allergens. About 30-40 percent of people with AD do not have atopy. To sum up: in order to diagnose AD, it is enough to recognize three of the four symptoms mentioned above.
- The professor spoke about further, smaller criteria helping doctors to make an accurate diagnosis of AD …
There are 23 smaller criteria that make the diagnosis easier for the doctor. These include, for example, brown discoloration of the eyelids, tearing of the earlobe, recurrent cheilitis, and natural wool intolerance. Children with atopic dermatitis hate woolen clothes. This must be respected and they must not be forced to wear such clothes.
- What can make my illness worse?
AD often worsens under stress. This can be seen, for example, when children start their education in the first grade and the related experiences worsen the symptoms of the disease.
For example, adults with AD, often unfortunately choose occupations that force them to come into contact with factors that irritate the skin. If a patient with AD works as a hairdresser, often washes her head, comes in contact with wet hair, these factors exacerbate the disease. There are a few professions that are not recommended for people with active atopic dermatitis. These are all professions requiring work in impermeable protective gloves, e.g. latex, vinyl, nitrile - which themselves can be irritating and damage the epidermal barrier. Among other things, this applies to doctors, nurses, beauticians, veterinarians, all those who have professional contact with food, i.e. cooks, employees of processing plants. Unfortunately, this is a topic that is not often raised when choosing a profession. And it is worth taking it into account when diagnosed with AD. Before starting education, it is worth disclosing the fact of your illness during qualification with an occupational medicine physician. However, many people in pursuit of their dream job do not accept that AZS may be an obstacle in taking up such a job. And then life writes its script, because every day the skin is irritated in the course of inappropriately selected work.
- Are emollients the golden mean in AD?
All studies conducted so far indicate so, because it is proven above all elseit is doubtful that one of the basic problems associated with atopic dermatitis is damage to the epidermal barrier. People with AD have improperly functioning epidermal cells, i.e. keratinocytes, and in particular they lack the so-called intercellular mortar consisting of ceramides, lipids and fatty acids, which make the epidermis quite tight. Once upon a time, the construction of the epidermis was compared to the construction of a wall. Patients with AD have damaged bricks and mortar.
Emollients are used to rebuild the correct epidermal barrier. Damaged skin causes the loss of water from the epidermis up to 10 times, but also due to barrier dysfunction from the external environment, chemical agents, bacteria, viruses and fungi get into the epidermis, which drive the allergy process and the inflammatory process of the skin. It's a vicious circle. So emollients are key here. Regardless of the severity of AD, they are the first line of defense. Individually selected, personalized emollients rebuild the epidermal barrier and restore the basic functions of the epidermis, greatly facilitating AD therapy. At the moment, emollient therapies are treated almost on a par with conventional drugs such as corticosteroids or calcineurin inhibitors in topical treatment.
Fortunately, most patients generally require skilful local treatment. Only 10-15% of patients with AD require systemic treatment - these are severe cases. For most, however, it is enough to avoid exacerbating factors, plus emollient therapy, plus periodic medications, and from time to time local antibiotics - because sick people are prone to superinfection.
- The emollient market is huge, however, it is growing every year …
It is even difficult to control, because new products appear every year. The search for a "miracle" drug continues. In this group, I am not particularly familiar with long-term studies of the effects of using one emollient line - whether it is effective, for example, for a period of 5 years. I recommend dermocosmetics to patients, the effectiveness of which is documented in clinical trials. In addition, good emollients should not contain allergenic fragrances and preservatives.
- Does diet play a big role in AD treatment?
Yes, that's true. However, I know from experience that parents often unnecessarily use very restrictive, improperly balanced diets, which may even lead to developmental disorders of children. I've had such little patients. In young children, they most often eat cow's milk proteins, but it must be remembered that this food hypersensitivity usually gradually fades away.around 5-6 years old.
The most reliable method to determine whether or not a child is clinging to something is to try to elimination or food exposure. We can eliminate some food from the current diet, but for a period not longer than 2-3 weeks. And if, after excluding a nutrient that we believe to be the cause of AD exacerbations, there is no improvement in the condition of the skin, let us realize that there is no cause-and-effect relationship. A more drastic way is to administer a potentially sticky product, but if AD does not worsen within 24-48 hours, do not get attached to the fact that this product affects the course of the disease. Unfortunately, this is a trial and error method. This is a disciplined method.
- The entire AD therapy requires great discipline and regularity. Guardians and parents of sick children should be patient?
Parents' education is very important. They need to be made aware that AD is a recurrent disease, because it is often the parents who get irritated and impatient that the therapy proposed by the doctor gave a short effect. They are looking for new specialists, they want an effect here and now. A deeply educated parent should perceive the course of the disease more calmly and help in the child's treatment. There are schools of atopy in Poland, where such classes are organized periodically, it is worth looking for such places.
- Professor, using emollients, sometimes topical medications, limiting exacerbating factors, patients with atopic dermatitis can live as normal as possible?
Actually, yes, especially people with mild disease. In addition, hope is raised by the ongoing research to confirm that in children genetically predisposed to AD, supplementing the epidermal barrier by using appropriate emollients from the first day of life will probably reduce the risk of developing AD and it may also translate into reducing the possibility of the so-called allergological march. The point is that children with atopic dermatitis may later develop allergies to pollen of plants, grasses, trees, dust, etc. And then it turns into allergic rhinitis, allergic conjunctivitis, or bronchial asthma. Inhibiting this march at the beginning by using emollient therapy would be a real breakthrough in the treatment of both small and then large patients.