Residency · Residency · Medicine Pediatrics
Atopic Dermatitis and Eczema: Childhood to Adulthood
Introduction
Atopic dermatitis (AD) is the most common chronic inflammatory skin disease, affecting up to 20% of children and 10% of adults worldwide. It is a key component of the atopic triad (atopic dermatitis, allergic rhinitis, asthma) and often represents the first manifestation of the atopic march. Med-peds physicians manage AD across all ages and must understand how the disease evolves from infancy through adulthood.
Pathophysiology
Skin barrier dysfunction: Filaggrin gene mutations lead to impaired epidermal barrier, increased transepidermal water loss (TEWL) Immune dysregulation: Th2-skewed immune response with elevated IgE, IL-4, IL-13, IL-31. Microbiome alterations: Decreased microbial diversity; Staphylococcus aureus colonization in >90% of AD patients. Neuroinflammation: IL-31 drives pruritus through sensory nerve activation. Gene-environment interaction: Filaggrin loss-of-function mutations are the strongest genetic risk factor.
Age-Specific Presentations
Infants (0-2 years)
Affects face, scalp, and extensor surfaces; Erythematous, weeping, crusted plaques; Often spares diaper area (moisture-protected); Onset typically between 3-6 months.
Children (2-12 years)
Shifts to flexural distribution: antecubital and popliteal fossae, wrists, ankles. Lichenification from chronic scratching; Periorbital darkening (allergic shiners); Dennie-Morgan infraorbital folds.
Adolescents and Adults
Flexural involvement persists; also affects hands, eyelids, neck; May present with predominantly hand eczema; More lichenified, excoriated plaques; Prurigo nodularis as a complication of chronic scratching; Significant psychosocial impact: sleep disruption, anxiety, depression.
Diagnosis
Clinical Criteria (Hanifin and Rajka)
Must have 3 of 4 major criteria: pruritus, typical morphology and distribution, chronic/relapsing course, personal or family history of atopy. Plus 3 or more minor criteria (xerosis, elevated IgE, early age of onset, etc.)
Severity Assessment
SCORAD (Scoring Atopic Dermatitis) or EASI (Eczema Area and Severity Index) Patient-reported outcomes: POEM (Patient-Oriented Eczema Measure), DLQI (Dermatology Life Quality Index) Classify as mild, moderate, or severe to guide treatment.
Differential Diagnosis
Seborrheic dermatitis (especially in infants); Contact dermatitis; Psoriasis; Scabies; Tinea corporis; Cutaneous T-cell lymphoma (adults with refractory "eczema").
Management: Stepwise Approach
Step 1: Skin Care Fundamentals (All Patients)
Emollients: Apply liberally 2+ times daily; fragrance-free, heavy creams or ointments. Bathing: Short lukewarm baths (5-10 minutes); apply moisturizer within 3 minutes of bathing ("soak and seal") Trigger avoidance: Fragrances, harsh soaps, wool, extreme temperatures. Bleach baths: 0.5 cup household bleach in full bathtub, 2-3 times per week; reduces S. aureus colonization.
Step 2: Topical Anti-Inflammatory Therapy (Mild-Moderate)
| Agent Class | Examples | FDA-Approved Age | Best Use |
|---|---|---|---|
| TCS (low potency) | Hydrocortisone 1-2.5% | Any age | Face, intertriginous areas, infants |
| TCS (medium potency) | Triamcinolone 0.1% | Any age | Body/trunk |
| TCS (high potency) | Fluocinonide, clobetasol | Limited to short-term | Lichenified areas |
| Calcineurin inhibitors | Tacrolimus, pimecrolimus | ≥2 years | Steroid-sparing for face/folds |
| PDE4 inhibitor | Crisaborole | ≥3 months | Mild-moderate AD |
| Topical JAK inhibitor | Ruxolitinib cream | ≥12 years | Steroid-sparing |
Topical corticosteroids (TCS): Mainstay of therapy. Topical calcineurin inhibitors (TCIs): Tacrolimus, pimecrolimus; steroid-sparing for face and skin folds. PDE4 inhibitor: Crisaborole ointment. JAK inhibitor: Ruxolitinib cream.
Step 3: Phototherapy (Moderate-Severe)
Narrowband UVB: Effective for widespread disease; used in adolescents and adults. Practical limitations in young children.
Step 4: Systemic Therapy (Severe/Refractory)
Dupilumab (anti-IL-4/IL-13): FDA-approved for ages 6 months+; first-line biologic. Tralokinumab (anti-IL-13): FDA-approved for adults; JAK inhibitors: Abrocitinib, upadacitinib (adults and adolescents 12+); baricitinib. Traditional immunosuppressants (used less frequently since biologics):; Cyclosporine (most rapid onset); Methotrexate; Azathioprine; Mycophenolate mofetil.
Complications
Secondary infection: S. aureus impetiginization; eczema herpeticum (HSV superinfection -- dermatologic emergency) Eczema herpeticum: Grouped vesicles/punched-out erosions; treat with IV acyclovir. Sleep disturbance and behavioral issues in children. Growth concerns with prolonged systemic corticosteroid use. Ocular complications: keratoconjunctivitis, cataracts (both disease-related and steroid-related)
The Atopic March
AD is often the first step: AD leads to food allergy, then allergic rhinitis, then asthma. Early aggressive treatment of AD may modify the atopic march (under investigation) Early introduction of allergenic foods (peanut at 4-6 months per LEAP trial) may reduce food allergy risk in infants with AD.
Transition Considerations
Adolescents need education on self-management, trigger avoidance, and medication adherence. Address psychosocial impact: body image, peer relationships, mental health screening. Transition medication plans from pediatric to adult dermatology or primary care.
Clinical Pearls
Emollients are the foundation of AD management at every age and severity level; they should never be omitted. Topical corticosteroid phobia is common among parents; educate on appropriate use, potency selection, and safety. Dupilumab has transformed severe AD management with an excellent safety profile across ages. Always consider eczema herpeticum in AD patients with sudden worsening, vesicles, or punched-out erosions. Med-peds physicians are uniquely equipped to manage the atopic march longitudinally, from infant eczema through adult asthma.
References
- Eichenfield LF, Tom WL, Chamlin SL, et al. Guidelines of care for the management of atopic dermatitis. J Am Acad Dermatol. 2014;70(2):338-351.
- Simpson EL, Bieber T, Guttman-Yassky E, et al. Two phase 3 trials of dupilumab versus placebo in atopic dermatitis (SOLO 1 and SOLO 2). N Engl J Med. 2016;375(24):2335-2348.
- Du Toit G, Roberts G, Sayre PH, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy (LEAP). N Engl J Med. 2015;372(9):803-813.
- Wollenberg A, Barbarot S, Bieber T, et al. Consensus-based European guidelines for treatment of atopic eczema in adults and children. J Eur Acad Dermatol Venereol. 2018;32(6):850-878.