AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Atopy is the hereditary predisposition to allergy or hypersensitivity. Symptoms may present as a dermatitis, hay fever, or asthma. According to Rapoza, Besnier first characterized atopic dermatitis, and many Europeans still use his name to describe the disease (prurigo Besnier). This disease was labeled eczema for many years in the United States until Coca and Cooke coined the term atopy as a skin hypersensitivity seen in patients with hereditary allergies. Wise and Sulzberger have been credited with the term atopic dermatitis to describe a group of diseases associated with atopic conditions that may be seen in all age groups.

Pathophysiology

Atopic dermatitis is primarily caused by cellular immune deficiency and elevated immunoglobulin E (IgE). The pathogenesis can be traced to a genetically inherited, bone marrow–derived cell associated with chromosome 11q. Abnormal skin reactivity also plays a major role in the development of the disease. Irritants to the skin are believed to predispose an individual to develop dermatitis more often than simply exposure to an allergenic trigger. Nonetheless, patients frequently have a history of food or inhalant allergies or eventually develop them.

Frequency

United States

An estimated 3-12% of the population will be affected at some time.

Race

The highest incidence is in urban areas and in cooler temperature zones, although no clear racial predisposition appears to exist.

Sex

According to Bezan, males appear to be affected more frequently by vernal and atopic conjunctivitis than females.

Age

Children most commonly are affected, with 80% developing the disease before age 7 years. Less than 2% will have an onset after age 20 years. Most sources agree that persistence after age 20 years is uncommon. Only an estimated 10% of patients older than 20 years continue to be symptomatic.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• The most common symptoms include pruritus, erythema, and skin lesions of the antecubital and/or popliteal skin, eyelids, corners of the mouth, neck, outer canthi, or behind the ears.
• In infants, the eruption particularly involves the face, scalp, and extensor surfaces.
• In older children and adults, the neck and antecubital or popliteal areas more commonly are involved.
• Adult patients usually have a history of infantile disease that may require anecdotal history or contacting their caregivers from infancy.
• Most patients have a familial occurrence of symptoms of atopy.

Physical

• The most common physical findings are erythematous, exudative skin lesions of the antecubital and/or popliteal skin, eyelids, corners of the mouth, neck, outer canthi, or behind the ears.
• • Scaling, lichenification (thickening of the skin due to scratching and irritation), and pigmentary changes (eg, vitiligo, hyperpigmentation [often seen in patients with darker skin types]) are common in adolescents and adults.
  • In severe cases, generalized eruptions over the entire body may occur.

• Possible physical findings on slit lamp examination include blepharitis, atopic keratoconjunctivitis (AKC), scarring of the palpebral conjunctiva, papillary conjunctival reaction, Trantas dots (limbal deposits of eosinophils), atopic cataracts, and keratoconus.
• • Unlike vernal conjunctivitis, the lower tarsus is involved more frequently.
  • Hyperemia, chemosis, and discharge are more common than papillary or cobblestone reaction.

• Atopic cataracts develop in patients with long-standing atopic disease (10 or more years).
• • These patients usually are older children or young adults.
  • The incidence of atopic cataracts is estimated to be 10%, and they are most frequently bilateral.
  • These cataracts tend to evolve rapidly and may opacify within 6 months.
  • The cataracts often begin as a posterior subcapsular opacity and develop into an anterior cortex opacity that frequently resembles the shape of a shield or a bearskin rug.

• Spontaneous retinal detachment is more common in patients with atopic disease than the general population.
• In a few rare, advanced cases, symblepharon, entropion, and trichiasis may be seen.

Causes

• Abnormal skin reactivity is a feature of the disease, and exposure to skin irritants, most frequently water and chemicals, may predispose patients to the development of atopic dermatitis.
• Additionally, since many of these patients have allergic sensitivities to food or inhaled allergens, exposure to these may increase the chances of development of the dermatitis.
• Skin irritants, thought to trigger this more frequently than other allergens, also may be more readily avoidable.
• Psychological stress also has been implicated as a major contributor to disease development.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Diagnosis of atopic dermatitis is usually a clinical one based on history and physical findings.
• Laboratory tests that may be of use early in the diagnostic process include various types of skin testing and serum testing for elevated immunoglobulin E (IgE).
• Patients with atopic dermatitis display immediate skin test reactivity and may display skin blanching to cholinergic agents.
• Culture of eyes with conjunctivitis associated with atopic dermatitis usually grows Staphylococcus aureus.
• Once a clinical diagnosis of atopic dermatitis has been established, lab testing is generally unnecessary.

Histologic Findings

Examination of histopathologic sections early in the disease process shows parakeratosis, hyperkeratosis, acanthosis, intercellular and intracellular fluid accumulation, and perivascular infiltration of the dermis and epidermis by lymphocytes, monocytes, and macrophages. Later in the disease, observation reveals hyperkeratosis, dyskeratosis, acanthosis, and a thickened epidermis. Lysosomes have been demonstrated by electron microscopy.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• No cure exists, and treatment is aimed at the multifactorial nature of the disease.
• The most commonly used treatments include stress control, avoidance of allergens (most commonly dust mites, peanuts, egg, milk, fish, rice, soy, and wheat), and irritants (particularly chemicals, soaps, heat, humidity, wool, and acrylic).
• Atopic dermatitis frequently can be controlled with topical steroids.
• Management of atopic dermatitis and AKC is similar to management of vernal keratoconjunctivitis (VKC), but the chronic nature of AKC requires more prolonged treatment.
• The treatment regimen for AKC typically consists of topical steroids, mast cell stabilizers, systemic antihistamines, and systemic and topical antibiotics.
• Recent studies have shown that patients with eye involvement may have an increased likelihood of food sensitivity.

Consultations

Ophthalmic consultation is recommended if eye involvement is noted. Dermatology consultation may be necessary to confirm a diagnosis of atopic dermatitis.

Diet

Patients with known atopic disease may have various food allergies that trigger or exacerbate their disease. Avoidance of these foods is essential.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The most commonly used treatment strategies include antibiotics, corticosteroids, antihistamines, and, less commonly, immunosuppressives (other than steroids), UV light, and hospitalization (rare). For most cases of atopic dermatitis (without AKC), application of topical steroids to the affected area is usually sufficient. Eye involvement may be treated with topical steroids alone, or if symptoms persist, additional mast cell stabilizers (topical), and oral antihistamines (eg, over-the-counter diphenhydramine). AKC may require all of these, and some ophthalmologists recommend that an oral antibiotic be given in addition to a topical antibiotic for the affected eye(s). Antibiotic treatment should target S aureus, the most likely pathogen, and should be chosen based on the patient's allergies and compliance. Immunosuppressives, other than steroids, will only very rarely be required, and these likely will not be prescribed by the ophthalmologist.

Drug Category: Corticosteroids

As anti-inflammatory and immunosuppressive agents, corticosteroids are beneficial in treating atopic dermatitis. Dexamethasone, fluorometholone, hydrocortisone, and prednisolone are the most commonly available preparations of ophthalmic steroids in the United States. Preparations range from 0.05-2.5%. For most topical purposes, a 0.5% preparation of prednisolone, cortisone, or hydrocortisone is adequate.

Drug Category: Mast cell stabilizers

May be useful as prophylaxis against exacerbation of the disease.

Drug Name	Cromolyn (Crolom, Opticrom)
Description	Inhibits degranulation of sensitized mast cells following exposure to specific antigens.
Adult Dose	Not to exceed 1-2 gtt in each eye 4-6 times/d at regular intervals
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Often experience transient burning or stinging from instillation; soft contact lens wearers should refrain from using them while under treatment

Drug Category: Oral antihistamines

Useful in decreasing itching and scratching associated with atopic dermatitis.

Drug Category: Topical antibiotics

Atopic conjunctivitis requires the use of topical antibiotics that particularly target S aureus, the most common pathogen. Since most ophthalmic antibiotics will target this bacterium, physician discretion, reference to package inserts, and the ophthalmic Physicians' Desk Reference are recommended. Patients' allergies and compliance should be considered.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Prophylaxis against scratching should be taken.
• • Scratching the lesions can worsen them and lead to the lichenification process characteristic of long-standing disease.
  
  
  • Corneal abrasions and further eye irritation also may occur. Antihistamines, mast-cell stabilizers, and corticosteroids will aid in reducing the itching but may require some time to take effect.
  
  
  • Nails should be kept clean and trimmed.
  
  
  • In pediatric patients, mittens may be used at night or even daily, when possible, if itching and scratching are severe.

Deterrence/Prevention

• Stress control, avoidance of allergens (most commonly dust mites, peanuts, egg, milk, fish, rice, soy, and wheat), and irritants (particularly chemicals, soaps, heat, humidity, wool, and acrylic) may help control the disease.

Complications

• The use of corticosteroids is fraught with potential ocular and systemic complications. In particular, cataract formation, glaucoma development, and potential corneal thinning must all be considered when deciding to use steroids for this disease. Long-term use should be avoided if at all possible.

Prognosis

• The prognosis is good if the inflammation can be kept under control with therapy. Patients need to understand that atopic disease cannot be cured, but rather controlled. However, some patients have such severe disease that treatment will not prevent vision loss and other potential complications.

Patient Education

• For excellent patient education resources, visit eMedicine's Skin, Hair, and Nails Center. Also, see eMedicine's patient education article Eczema.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Steroid use is probably the biggest area of concern because of the complications that can result from steroid use. Corneal scarring and long-term vision loss can result. The potential exists for corneal perforation and loss of an eye with, or even without, the use of steroids.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Bezan DJ. Eye itch. In: Bezan DJ, Larussa FP, Nishimoto JH, et al, eds. Differential Diagnosis in Primary Eye Care. Boston: Butterworth-Heinemann; 1999:67-71.
• Clark RAF, Kristal L. Atopic dermatitis. In: Sams J, Lynch PJ, eds. Principles and Practice of Dermatology. 2^nd ed. New York: Churchill Livingstone Inc; 1996:403-418.
• Friedlander MH. Diseases affecting the eye and the skin. In: Allergy and Immunology of the Eye. 2^nd ed. 1993:75-106.
• Friedlander MH. Atopic dermatitis. In: Current Ocular Therapy. 5^th ed. Philadelphia: WB Saunders Co; 2000:143-144.
• Furue M, Terao H, Moroi Y, et al. Dosage and adverse effects of topical tacrolimus and steroids in daily management of atopic dermatitis. J Dermatol. Apr 2004;31(4):277-83. [Medline].
• Guin JD. Eyelid dermatitis: experience in 203 cases. J Am Acad Dermatol. Nov 2002;47(5):755-65. [Medline].
• Hanifin JM. Atopic dermatitis: broadening the perspective. J Am Acad Dermatol. Jul 2004;51(1 Suppl):S23-4. [Medline].
• Kanski JJ. Disorders of the conjunctiva. In: Clinical Ophthalmology. 4^th ed. Boston: Butterworth-Heinemann; 1999:69-71.
• Liesegang TJ. Atopic keratoconjunctivitis. In: Pepose JS, Holland GN, Wilhelmus KR, eds. Ocular Infection and Immunity. St. Louis: Mosby; 1996:376-390.
• Rapoza PA, Chandler JW. Atopic dermatitis. In: Weingeist T, Gould D, eds. The Eye in Systemic Disease. Philadelphia: Lippincott; 1990:606-609.
• Roy FH. Ocular Differential Diagnosis. 7^th ed. Philadelphia: Williams & Wilkins; 2002.
• Shelley WB, Shelley EB. Atopic dermatitis. In: Advanced Dermatologic Diagnosis. Philadelphia: WB Saunders Co; 1992:285-291.
• Uchio E, Miyakawa K, Ikezawa Z, Ohno S. Systemic and local immunological features of atopic dermatitis patients with ocular complications. Br J Ophthalmol. Jan 1998;82(1):82-7. [Medline].
• Weisbecker CA, Fraunfelder FT, Rhee D. Physicians' Desk Reference for Ophthalmology. 28^th ed. Oradell, NJ: Medical Economics Co; 2000.
• Zimmerman TJ, Kulkarni PS, Meredith TA. Steroids in ocular therapy, antibiotics and antifungals, antiallergic therapies. In: Zimmerman TJ, Kooner KS, Shariv M, Fechtner RD, eds. Textbook of Ocular Pharmacology. Philadelphia: Lippincott-Raven; 1997:61-74, 363-385, 609-633,683-701, 801-804.

Article Last Updated: Nov 21, 2006