Atopic dermatitis appears after the second or third month of life, sometimes as early as second or third week. Much such early onset atopic eczema has features of seborrheic dermatitis with greasy scales on the scalp and later spreads to forehead and face. One fourth of all cases of sebrroheic dermatitis in infants later develop atopic dermatitis. Some call it the seborrheic dermatitis variant of atopic dermatitis.
Signs and Symptoms of Infantile Atopic Dermatitis
The itchy skin rashes of infantile atopic dermatitis appear as weeping, red patches on the cheeks first, spreading onto the forehead and scalp in a week or two. Most cases of atopic eczema remain on the face, while severe cases later involve the body and extremities.
The outer aspect of the arms, forearms, legs and thighs are involved in the infantile phase of atopic eczema. In some infants, the areas behind ears and in between the buttocks are also involved as itchy skin rashes. The intense itching causes incessant crying, irritability and restlessness in the infant.
The oozing acute rashes start drying up and form crusts and erosive lesions on the involved area. The skin in general is dry and flaky all over the body. Involvement of the skin around the eye leads to vigorous rubbing resulting in edematous swelling of the skin surrounding. The formation of the so called Dennie-Morgan fold, a double line seen under the eye was previously thought to be a distinctive feature of atopic dermatitis. It is also found in other allergic skin conditions around the eye.
Differential Diagnosis of Infantile Eczema
The following diseases have to be ruled out in infants presenting with eczematous skin rashes:
- Scabies: Severely itchy skin bumps, involving the whole body, face, and even scalp in infants. The pustular lesions on the palms and soles are characteristic of scabies in infants.
- Seborrheic dermatitis (Cradle Cap): Greasy scales on red skin, on scalp, forehead and face.
- Icthyosis vulgaris, associated with atopic dermatitis, when severe, may mimic the eczema. Scaling is prominent in icthyosis, not redness or itching.
- Other diseases that presents with eczematous skin rashes are: Letterer Siwe Syndrome, Leiner’s disease, acrodermatitis enteropathica, agammaglobulinemia, ahistidinemia, ataxia telangiectasia, Hartnup’s disease, Hurler’s syndrome, phenylketonuria and Wiskott-Aldrich syndrome.
Treatment of the Infantile Atopic Eczema
Treatment of infantile eczema is the same as acute eczema treatment. Short acting antihistamines are given 2-3 times daily to relieve itching. An oatmeal bath followed by liberal application of emollients once daily, and, in the initial stages, lower strength or moderate strength topical steroids like 1% hydrocortisone, fluticasone, mometasone etc are used for shorter periods.
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 in infants. 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.
Topical immunemodulators like tacrolimus and pimecrolimus are avoided in infants below the age of 2 years because of the rare lymphoma complication reported for these calcineurin inhibitors.
When the itchy skin rash is brought 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. Introduction of new food items should be done one at a time, at weekly intervals. Bathing should be in lukewarm water, with soap free cleansers in the first year of life.
Natural Course of Infantile 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.
- At around the age of 2 years, the distribution of the skin rashes change from the face to the flexural areas like the elbow, neck, and behind the knee.
- Around 30-50% of atopic eczema patients develop asthma, nasal allergy (allergic rhinitis, hay fever) or eye allergy later in life.
Atopic dermatitis patients are more prone for allergic contact dermatitis like hand eczema from occupational exposure to allergens in adult life.
Reference
Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or Suite101 will not be responsible for any consequences. The images provided are for illustration purpose only.
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