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## Atopic Dermatitis

Publication Date: May 2009

### Handout on Health: Atopic Dermatitis

This booklet is for people who have atopic dermatitis (often called “eczema”), parents and caregivers of children with atopic dermatitis, and others interested in learning more about the disease. The booklet describes the disease and its symptoms and contains information about diagnosis and treatment as well as current research efforts supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and other components of the Department of Health and Human Services’ National Institutes of Health (NIH). It also discusses issues such as skin care and quality of life for people with atopic dermatitis. If you have further questions after reading this booklet, you may wish to discuss them with your doctor or your child’s pediatrician.
        - Defining Atopic Dermatitis
        - Incidence and Prevalence of Atopic Dermatitis
        - Cost of Atopic Dermatitis
        - Causes of Atopic Dermatitis
        - Symptoms of Atopic Dermatitis
        - Stages of Atopic Dermatitis
        - Diagnosing Atopic Dermatitis
        - Factors That Make Atopic Dermatitis Worse
        - Treatment of Atopic Dermatitis
        - Atopic Dermatitis and Quality of Life
        - Atopic Dermatitis and Vaccination Against Smallpox
        - Current Research
        - Hope for the Future
        - For More Information
        - Acknowledgments

#### Defining Atopic Dermatitis

Atopic dermatitis is a chronic (long-lasting) disease that affects the skin. It is not contagious; it cannot be passed from one person to another. The word “dermatitis” means inflammation of the skin. “Atopic” refers to a group of diseases in which there is often an inherited tendency to develop other allergic conditions, such as asthma and hay fever. In atopic dermatitis, the skin becomes extremely itchy. Scratching leads to redness, swelling, cracking, “weeping” clear fluid, and finally, crusting and scaling. In most cases, there are periods of time when the disease is worse (called exacerbations or flares) followed by periods when the skin improves or clears up entirely (called remissions). As some children with atopic dermatitis grow older, their skin disease improves or disappears altogether, although their skin often remains dry and easily irritated. In others, atopic dermatitis continues to be a significant problem in adulthood.

Atopic dermatitis is often referred to as “eczema,” which is a general term for the several types of inflammation of the skin. Atopic dermatitis is the most common of the many types of eczema. Several have very similar symptoms. Types of eczema are described in the  box below.

#### Information Boxes

        - Types of Eczema (Dermatitis)
        - Skin Features Associated With Atopic Dermatitis
        - Major and Minor Features of Atopic Dermatitis
        - Common Irritants
        - Treating Atopic Dermatitis in Infants and Children
        - Tips for Working With Your Doctor
        - Controlling Atopic Dermatitis

#### Incidence and Prevalence of Atopic Dermatitis

Atopic dermatitis is very common. It affects males and females at about the same rate. Although atopic dermatitis may occur at any age, it most often begins in infancy and childhood. Scientists estimate that 65 percent of patients develop symptoms in the first year of life, and 85 percent develop symptoms before the age of 5. Onset after age 30 is less common and is often caused by exposure of the skin to harsh or wet conditions. Atopic dermatitis is a common cause of workplace disability. People who live in cities and in dry climates appear more likely to develop this condition.

It is difficult to identify exactly how many people are affected by atopic dermatitis. Many people report that they have symptoms, but never have received a diagnosis from a doctor. An estimated 10 to 20 percent of infants and young children experience symptoms of the disease. Roughly 60 percent of these infants continue to have one or more symptoms of atopic dermatitis in adulthood. In adults, the prevalence is thought to be 1 to 3 percent, with an overall lifetime prevalance of about 7 percent.

##### Types of Eczema (Dermatitis)

          - Allergic contact eczema (dermatitis).  A red, itchy, weepy reaction where the skin has come into contact with a substance that the immune system recognizes as foreign, such as poison ivy or certain preservatives in creams and lotions.
          - Atopic dermatitis.  A chronic skin disease characterized by itchy, inflamed skin.
          - Contact eczema.  A localized reaction that includes redness, itching, and burning where the skin has come into contact with an allergen (an allergy-causing substance) or with an irritant such as an acid, a cleaning agent, or other chemical.
          - Dyshidrotic eczema.  Irritation of the skin on the palms of hands and soles of the feet characterized by clear, deep blisters that itch and burn.
          - Neurodermatitis.  Scaly patches of the skin on the head, lower legs, wrists, or forearms caused by a localized itch (such as an insect bite) that become intensely irritated when scratched.
          - Nummular eczema.  Coin-shaped patches of irritated skin—most common on the arms, back, buttocks, and lower legs—that may be crusted, scaling, and extremely itchy.
          - Seborrheic eczema.  Yellowish, oily, scaly patches of skin on the scalp, face, and occasionally other parts of the body.
          - Stasis dermatitis.  A skin irritation on the lower legs, generally related to circulatory problems.

#### Cost of Atopic Dermatitis

In a recent analysis of the costs associated with atopic  dermatitis in the United States, researchers reviewed studies  evaluating both direct costs (doctor visits, hospitalizations,  and medicine) and indirect costs (over-the-counter remedies, lubricants, and  days lost from work). They found that  direct costs totaled about 25 percent, and  indirect costs totaled about 75 percent  of costs. Per patient, the costs averaged  about $600 per year. On the whole,  direct costs alone may exceed  $3 billion per year.

#### Causes of Atopic Dermatitis

The cause of atopic dermatitis is not  known, but the disease seems to  result from a combination of genetic  (hereditary) and environmental factors.

Children are more likely to develop this disorder if a  parent has had it or another atopic disease like asthma  or hay fever. If both parents have an atopic disease, the  likelihood increases. Although some people outgrow  skin symptoms, approximately half of children with  atopic dermatitis go on to develop hay fever or asthma.  Environmental factors can bring on symptoms of atopic  dermatitis at any time in individuals who have inherited  the atopic disease trait.

Atopic dermatitis is also associated with malfunction of  the body’s immune system: the system that recognizes  and helps fight bacteria and viruses that invade the body.  Scientists have found that people with atopic dermatitis  have a low level of a cytokine (a protein) that is essential  to the healthy function of the body’s immune system  and a high level of other cytokines  that lead to allergic reactions.  The immune system can become  misguided and create inflammation  in the skin even in the absence of a  major infection. This can be viewed as  a form of autoimmunity, where a body  reacts against its own tissues.

In the past, doctors thought that  atopic dermatitis was caused by an  emotional disorder. We now know  that emotional factors, such as stress,  can make the condition worse, but  they do not cause the disease.

##### Skin Features Associated With Atopic Dermatitis

          - Atopic pleat (Dennie-Morgan fold) —an extra fold of skin that develops under the eye
          - Cheilitis —inflammation of the skin on and around the lips
          - Hyperlinear palms —increased number of skin creases on the palms
          - Hyperpigmented eyelids —eyelids that have become darker in color from inflammation or hay fever
          - Ichthyosis —dry, rectangular scales on the skin
          - Keratosis pilaris —small, rough bumps, generally on the face, upper arms, and thighs
          - Lichenification —thick, leathery skin resulting from constant scratching and rubbing
          - Papules —small raised bumps that may open when scratched and become crusty and infected
          - Urticaria —hives (red, raised bumps) that may occur after exposure to an allergen, at the beginning of flares, or after exercise or a hot bath 

#### Symptoms of Atopic Dermatitis

Symptoms (signs) vary from  person to person. The most  common symptoms are dry, itchy  skin and rashes on the face, inside  the elbows and behind the knees, and  on the hands and feet. Itching is the  most important symptom of atopic  dermatitis. Scratching and rubbing in response to itching  irritates the skin, increases inflammation, and actually  increases itchiness. Itching is a particular problem during  sleep when conscious control of scratching is lost.

The appearance of the skin that is affected by atopic  dermatitis depends on the amount of scratching and the  presence of secondary skin infections. The skin may be  red and scaly, be thick and leathery, contain small aised  bumps, or leak fluid and become crusty and infected. The  box above lists common skin features of the disease.  These features can also be found in people who do not have  atopic dermatitis or who have other types of skin disorders.

Atopic dermatitis may also affect the  skin around the eyes, the eyelids, and  the eyebrows and lashes. Scratching  and rubbing the eye area can cause the  skin to redden and swell. Some people  with atopic dermatitis develop an extra  fold of skin under their eyes. Patchy  loss of eyebrows and eyelashes may  also result from scratching or rubbing.

Researchers have noted differences  in the skin of people with atopic  dermatitis that may contribute to the  symptoms of the disease. The outer  layer of skin, called the epidermis, is  divided into two parts: an inner part  containing moist, living cells, and an  outer part, known as the horny layer  or stratum corneum, containing dry,  flattened, dead cells. Under normal  conditions the stratum corneum acts  as a barrier, keeping the rest of the skin from drying out  and protecting other layers of skin from damage caused  by irritants and infections. When this barrier is damaged,  irritants act more intensely on the skin.

The skin of a person with atopic dermatitis loses  moisture from the epidermal layer, allowing the skin to  become very dry and reducing its protective abilities.  Thus, when combined with the abnormal skin immune  system, the person’s skin is more likely to become  infected by bacteria (for example, *Staphylococcus* and  *Streptococcus*) or viruses, such as those that cause warts  and cold sores.

#### Stages of Atopic Dermatitis

When atopic dermatitis occurs during infancy and  childhood, it affects each child differently in terms  of both onset and severity of symptoms. In infants,  atopic dermatitis typically begins around 6 to 12 weeks  of age. It may first appear around the cheeks and chin as  a patchy facial rash, which can progress to red, scaling,  oozing skin. The skin may become infected. Once  the infant becomes more mobile and begins crawling,  exposed areas, such as the inner and outer parts of the  arms and legs, may also be affected. An infant with  atopic dermatitis may be restless and irritable because  of the itching and discomfort of the disease.

In childhood, the rash tends to occur behind the knees  and inside the elbows; on the sides of the neck; around  the mouth; and on the wrists, ankles, and hands. Often,  the rash begins with papules that become hard and  scaly when scratched. The skin around the lips may be  inflamed, and constant licking of the area may lead to  small, painful cracks in the skin around the mouth.

In some children, the disease goes into remission for  a long time, only to come back at the onset of puberty  when hormones, stress, and the use of irritating skin care  products or cosmetics may cause the disease to flare.

Although a number of people who developed atopic  dermatitis as children also experience symptoms as  adults, it is also possible for the disease to show up first  in adulthood. The pattern in adults is  similar to that seen in children; that  is, the disease may be widespread or  limited to only a few parts of the body.  For example, only the hands or feet  may be affected and become dry, itchy,  red, and cracked. Sleep patterns and  work performance may be affected,  and long-term use of medications to  treat the atopic dermatitis may cause  complications. Adults with atopic  dermatitis also have a predisposition  toward irritant contact dermatitis,  where the skin becomes red and  inflamed from contact with detergents, wool, friction  from clothing, or other potential irritants. It is more  likely to occur in occupations involving frequent hand  washing or exposure to chemicals. Some people develop  a rash around their nipples. These localized symptoms  are difficult to treat. Because adults may also develop  cataracts, the doctor may recommend regular eye exams.

#### Diagnosing Atopic Dermatitis

Each person experiences a unique combination of  symptoms, which may vary in severity over time.  The doctor will base a diagnosis on the symptoms the patient  experiences and may need to see the patient several times  to make an accurate diagnosis and to rule out other diseases  and conditions that might cause skin irritation. In some  cases, the family doctor or pediatrician may refer the patient  to a dermatologist (doctor specializing in skin disorders)  or allergist (allergy specialist) for further evaluation.

A medical history may help the doctor better understand  the nature of a patient’s symptoms, when they occur,  and their possible causes. The doctor  may ask about family history of allergic  disease; whether the patient also has  diseases such as hay fever or asthma;  and about exposure to irritants, sleep  disturbances, any foods that seem  to be related to skin flares, previous  treatments for skin-related symptoms,  and use of steroids or other medications.  A preliminary diagnosis of atopic  dermatitis can be made if the patient  has three or more features from each of  two categories: major features and minor  features. Some of these features are listed in the  box below.

Currently, there is no single test to diagnose atopic  dermatitis. However, there are some tests that can give the  doctor an indication of allergic sensitivity.

Pricking the skin with a needle that contains a small amount  of a suspected allergen may be helpful in identifying  factors that trigger flares of atopic dermatitis. Negative  results on skin tests may help rule out the possibility  that certain substances cause skin inflammation. Positive  skin prick test results are difficult to interpret in people  with atopic dermatitis because the skin is very sensitive  to many substances, and there can be many positive test  sites that are not meaningful to a person’s disease at the  time. Positive results simply indicate that the individual  has IgE (allergic) antibodies to the substance tested. IgE  (immunoglobulin E) controls the immune system’s allergic  response and is often high in atopic dermatitis.

##### Major and Minor Features of Atopic Dermatitis

**Major Features**
          - Intense itching
          - Characteristic rash in locations typical of the disease
          - Chronic or repeatedly occurring symptoms
          - Personal or family history of atopic disorders (eczema, hay fever, asthma).

**Some Minor Features**
          - Early age of onset
          - Dry skin that may also have patchy scales or rough bumps
          - High levels of immunoglobulin E (IgE), an antibody, in the blood
          - Numerous skin creases on the palms
          - Hand or foot involvement
          - Inflammation around the lips
          - Nipple eczema
          - Susceptibility to skin infection
          - Positive allergy skin tests. 

If the quantity of IgE antibodies to a food in the blood is  above a certain level, it is indicative of a food allergy. If  a food allergy is suspected, a person might be asked to  record everything eaten and note any reactions. Physician-supervised  food challenges (that is, the introduction of  a food) following a period of food elimination may be  necessary to determine if symptomatic food allergy is  present. Identifying the food allergen may be difficult  when a person is also being exposed to other possible  allergens at the same time or symptoms may be triggered  by other factors, such as infection, heat, and humidity.

#### Factors That Make Atopic Dermatitis Worse

Many factors or conditions can make symptoms of atopic dermatitis worse, further triggering the already overactive immune system, aggravating the itch-scratch cycle, and increasing damage to the skin. These factors can be broken down into two main categories: irritants and allergens. Emotional factors and some infections and illnesses can also influence atopic dermatitis.

Irritants are substances that directly affect the skin  and, when present in high enough concentrations with  long enough contact, cause the skin to become red and  itchy or to burn. Specific irritants affect people with  atopic dermatitis to different degrees. Over time, many  patients and their family members learn to identify  the irritants causing the most trouble. For example,  frequent wetting and drying of the skin may affect the  skin barrier function. Also, wool or synthetic fibers and  rough or poorly fitting clothing can rub the skin, trigger  inflammation, and cause the itch-scratch cycle to begin.  Soaps and detergents may have a drying effect and  worsen itching, and some perfumes and cosmetics may  irritate the skin. Exposure to certain substances, such  as solvents, dust, or sand, may also make the condition worse. Cigarette smoke may irritate the eyelids. Because  the effects of irritants vary from one person to another,  each person can best determine what substances or  circumstances cause the disease to flare.

Allergens are substances from foods, plants, animals, or  the air that inflame the skin because the immune system  overreacts to the substance. Inflammation occurs even  when the person is exposed to small amounts of the  substance for a limited time. Although it is known that  allergens in the air, such as dust mites, pollens, molds,  and dander from animal hair or skin, may worsen the  symptoms of atopic dermatitis in some people, scientists  aren’t certain whether inhaling these allergens or their  actual penetration of the skin causes the problems. When  people with atopic dermatitis come into contact with an  irritant or allergen they are sensitive to, inflammation producing  cells become active. These cells release  chemicals that cause itching and redness. As the person responds by scratching and rubbing the skin, further  damage occurs.

##### Common Irritants

          - Wool or synthetic fibers
          - Soaps and detergents
          - Some perfumes and cosmetics
          - Substances such as chlorine, mineral oil, or solvents
          - Dust or sand
          - Cigarette smoke. 

Children with atopic disease tend to have a higher  prevalence of food allergy than those in the general  population. An allergic reaction to food can cause  skin inflammation (generally an itchy red rash),  gastrointestinal symptoms (abdominal pain, vomiting,  diarrhea), and/or upper respiratory tract symptoms  (congestion, sneezing, and wheezing). The most common  allergenic (allergy-causing) foods are eggs, milk,  peanuts, wheat, soy, tree nuts, shellfish, and fish. A  recent analysis of a large number of studies on allergies  and breastfeeding indicated that breastfeeding an infant,  although preferable for many reasons, has little effect on  protecting the infant from developing atopic dermatitis.

  In addition to irritants and allergens, emotional factors,  skin infections, and temperature and climate play a role  in atopic dermatitis. Although the disease itself is not  caused by emotional factors, it can be made worse by  stress, anger, and frustration. Interpersonal problems or  major life changes, such as divorce, job changes, or the  death of a loved one, can also make the disease worse.

  Bathing without proper moisturizing afterward is a  common factor that triggers a flare of atopic dermatitis.  The low humidity of winter or the dry year-round climate  of some geographic areas can make the disease worse,  as can overheated indoor areas and long or hot baths and  showers. Alternately sweating and chilling can trigger a  flare in some people. Bacterial infections can also trigger  or increase the severity of atopic dermatitis. If a patient  experiences a sudden flare of illness, the doctor may  check for infection.

#### Treatment of Atopic Dermatitis

Treatment is more effective when a partnership  develops that includes the patient, family members,  and doctor. The doctor will suggest a treatment plan  based on the patient’s age, symptoms, and general  health. The patient or family member providing care  plays a large role in the success of the treatment plan by  carefully following the doctor’s instructions and paying  attention to what is or is not helpful. Most patients will  notice improvement with proper skin  care and lifestyle changes.

The doctor has two main goals in  treating atopic dermatitis: healing  the skin and preventing flares. These  may be assisted by developing skin  care routines and avoiding substances  that lead to skin irritation and trigger  the immune system and the itch-scratch  cycle. It is important for the  patient and family members to note  any changes in the skin’s condition  in response to treatment, and to be  persistent in identifying the treatment  that seems to work best.

***Medications:***New medications  known as immunomodulators have  been developed that help control  inflammation and reduce immune  system reactions when applied to the  skin. They can be used in patients older than 2 years of  age and have few side effects (burning or itching the first  few days of application). They not only reduce flares, but  also maintain skin texture and reduce the need for long-term  use of corticosteroids.

Corticosteroid creams and ointments have been used  for many years to treat atopic dermatitis and other  autoimmune diseases affecting the skin. Sometimes  over-the-counter preparations  are used, but in many cases the  doctor will prescribe a stronger  corticosteroid cream or ointment.  When prescribing a medication,  the doctor will take into account  the patient’s age, location of the  skin to be treated, severity of the  symptoms, and type of preparation  (cream or ointment) that will  be most effective. Sometimes  the base used in certain brands  of corticosteroid creams and  ointments irritates the skin of a  particular patient. Side effects of  repeated or long-term use of topical  corticosteroids can include thinning  of the skin, infections, growth  suppression (in children), and  stretch marks on the skin.

  When topical corticosteroids are not  effective, the doctor may prescribe  a systemic corticosteroid, which is  taken by mouth or injected instead  of being applied directly to the  skin. Typically, these medications are used only in  resistant cases and only given for short periods of time.  The side effects of systemic corticosteroids can include  skin damage, thinned or weakened bones, high blood  pressure, high blood sugar, infections, and cataracts.

It can be dangerous to suddenly stop taking corticosteroids,  so it is very important that the doctor and patient work  together in changing the corticosteroid dose.

  Antibiotics to treat skin infections may be applied  directly to the skin in an ointment, but are usually  more effective when taken by mouth. If viral or fungal  infections are present, the doctor may also prescribe  specific medications to treat those infections.

  Certain antihistamines that cause drowsiness can reduce  nighttime scratching and allow more restful sleep when  taken at bedtime. This effect can be particularly helpful  for patients whose nighttime scratching makes the  disease worse.

  In adults, drugs that suppress the immune system may be  prescribed to treat severe cases of atopic dermatitis that  have failed to respond to other forms of therapy. These  drugs block the production of some immune cells and  curb the action of others. The side effects of drugs like  these can include high blood pressure, nausea, vomiting,  kidney problems, headaches, tingling or numbness, and a  possible increased risk of cancer and infections. There is  also a risk of relapse after the drug is stopped. Because  of their toxic side effects, systemic corticosteroids  and immunosuppressive drugs are used only in severe  cases and then for as short a period of time as possible.  Patients requiring systemic corticosteroids should be  referred to dermatologists or allergists specializing in the  care of atopic dermatitis to help identify trigger factors  and alternative therapies.

  In rare cases, when home-based treatments have been  unsuccessful, a patient may need a few days in the  hospital for intense treatment.

***Phototherapy:*** Use of ultraviolet A or B light waves,  alone or combined, can be an effective treatment for mild  to moderate dermatitis in older children (over 12 years  old) and adults. A combination of ultraviolet light therapy  and a drug called psoralen can also be used in cases that  are resistant to ultraviolet light alone. Possible long-term  side effects of this treatment include premature skin aging  and skin cancer. If the doctor thinks that phototherapy  may be useful to treat the symptoms of atopic dermatitis, he or she will use the minimum exposure necessary and  monitor the skin carefully.

##### Treating Atopic Dermatitis in Infants and Children

          - Give lukewarm baths.
          - Apply lubricant immediately following the bath.
          - Keep child’s fingernails filed short.
          - Select soft cotton fabrics when choosing clothing.
          - Consider using sedating antihistamines to promote sleep and reduce scratching at night.
          - Keep the child cool; avoid situations where overheating occurs.
          - Learn to recognize skin infections and seek treatment promptly. 
          - Attempt to distract the child with activities to keep him or her from scratching.
          - Identify and remove irritants and allergens. 

***Skin care:*** Healing the skin and keeping it healthy are  important to prevent further damage and enhance quality  of life. Developing and sticking with a daily skin care  routine is critical to preventing flares.

  A lukewarm bath helps to cleanse and moisturize the  skin without drying it excessively. Because soaps can be  drying to the skin, the doctor may recommend use of  a mild bar soap or nonsoap cleanser. Bath oils are not  usually helpful.

  After bathing, a person should air-dry the skin, or pat  it dry gently (avoiding rubbing or brisk drying), and  then apply a lubricant to seal in the water that has been  absorbed into the skin during bathing. A lubricant  increases the rate of healing and establishes a barrier  against further drying and irritation. Lotions that have a  high water or alcohol content evaporate more quickly, and  alcohol may cause stinging. Therefore, they generally are  not the best choice. Creams and ointments work better at  healing the skin.

  Another key to protecting and restoring the skin is taking  steps to avoid repeated skin infections. Signs of skin  infection include tiny pustules (pus-filled bumps), oozing  cracks or sores, or crusty yellow blisters. If symptoms of  a skin infection develop, the doctor should be consulted  and treatment should begin as soon as possible.

***Protection from allergen exposure:*** The doctor may  suggest reducing exposure to a suspected allergen. For  example, the presence of the house dust mite can be  limited by encasing mattresses and pillows in special  dust-proof covers, frequently washing bedding in hot water, and removing carpeting. However, there is no way  to completely rid the environment of airborne allergens.

Changing the diet may not always relieve symptoms of  atopic dermatitis. A change may be helpful, however,  when the medical history, laboratory studies, and specific  symptoms strongly suggest a food allergy. It is up to the  patient and his or her family and physician to decide  whether the dietary restrictions are appropriate. Unless  properly monitored by a physician or dietitian, diets with  many restrictions can contribute to serious nutritional  problems, especially in children.

#### Atopic Dermatitis and Quality of Life

Despite the symptoms caused by atopic dermatitis, it  is possible for people with the disorder to maintain a  good quality of life. The keys to quality of life lie in being  well-informed; awareness of symptoms and their possible  cause; and developing a partnership involving the patient  or caregiving family member, medical doctor, and other  health professionals. Good communication is essential.  (See “Tips for Working With Your Doctor.”)

  When a child has atopic dermatitis, the entire family  may be affected. It is helpful if families have additional  support to help them cope with the stress and frustration  associated with the disease. A child may be fussy and  difficult and unable to keep from scratching and rubbing  the skin. Distracting the child and providing activities  that keep the hands busy are helpful but require much  effort on the part of the parents or caregivers. Another  issue families face is the social and emotional stress  associated with changes in appearance caused by atopic  dermatitis. The child may face difficulty in school or with  social relationships and may need additional support and  encouragement from family members.

Adults with atopic dermatitis can enhance their  quality of life by caring regularly for their skin and  being mindful of the effects of the disease and how  to treat them. Adults should develop a skin care  regimen as part of their daily routine, which can be  adapted as circumstances and skin conditions change.  Stress management and relaxation techniques may  help decrease the likelihood of flares. Developing a  network of support that includes family, friends, health  professionals, and support groups or organizations can  be beneficial. Chronic anxiety and depression may be  relieved by short-term psychological therapy.

  Recognizing the situations when scratching is most  likely to occur may also help. For example, many  patients find that they scratch more when they are idle,  and they do better when engaged in activities that keep  the hands occupied. Counseling also may be helpful to  identify or change career goals if a job involves contact  with irritants or involves frequent hand washing, such as  work in a kitchen or auto machine shop.

#### Atopic Dermatitis and Vaccination Against Smallpox

Although scientists are working to develop safer  vaccines, individuals diagnosed with atopic  dermatitis (or eczema) should not receive the current  smallpox vaccine. According to the Centers for Disease  Control and Prevention (CDC), a U.S. Government  organization, individuals who have ever been diagnosed  with atopic dermatitis, even if the condition is mild or  not presently active, are more likely to develop a serious  complication if they are exposed to the virus from the  smallpox vaccine.

##### Tips for Working With Your Doctor

          - Provide complete, accurate medical information.
          - Make a list of your questions and concerns in advance.
          - Be honest and share your point of view with the doctor.
          - Ask for clarification or further explanation if you need it.
          - Talk to other members of the health care team, such as nurses, therapists, or pharmacists.
          - Don’t hesitate to discuss sensitive subjects with your doctor.
          - Discuss changes to medical treatment or medications with your doctor.

People with atopic dermatitis should exercise caution  when coming into close physical contact with a person  who has been recently vaccinated, and make certain  the vaccinated person has covered the vaccination site  or taken other precautions until the scab falls off (about  3 weeks). Those who have had physical contact with a  vaccinated person’s unhealed vaccination site or to their  bedding or other items that might have touched that site  should notify their doctor, particularly if they develop a  new or unusual rash.

  During a smallpox outbreak, these vaccination  recommendations may change. People with atopic  dermatitis who have been exposed to smallpox should  consult their doctor about vaccination.

Additional information about atopic dermatitis and  smallpox vaccination is available from CDC. (See  “For More Information” section of this booklet.)

#### Current Research

Researchers supported by the National Institute of  Arthritis and Musculoskeletal and Skin Diseases  and other institutes of the National Institutes of Health  are gaining a better understanding of what causes  atopic dermatitis and how it can be managed, treated,  and, ultimately, prevented. Some promising avenues of  research are described below.

***Genetics:*** Although atopic dermatitis runs in families,  the role of genetics (inheritance) remains unclear. It does  appear that more than one gene is involved in the disease.

Research has helped shed light on the way atopic  dermatitis is inherited. Studies show that children are  at increased risk for developing the disorder if there is  a family history of other atopic disease, such as hay  fever or asthma. The risk is significantly higher if both  parents have an atopic disease. In addition, studies of  identical twins (who have the same genes) show that a  person whose identical twin has atopic dermatitis is seven  times more likely to have atopic dermatitis than someone  in the general population. A person whose fraternal  (nonidentical) twin has atopic dermatitis is three times  more likely to have atopic dermatitis than someone in the  general population. These findings suggest that genes play  an important role in determining who gets the disease.

 Also, scientists have discovered mutations in a certain  gene that plays a role in the production of a protein called  filaggrin. The filaggrin protein is normally found in the  outermost layer of the skin and functions as a component  of the skin barrier. The gene mutation disrupts filaggrin’s  ability to maintain a normal skin barrier and appears to  be a genetic factor that predisposes people to develop  atopic dermatitis and other diseases in which the skin  barrier is compromised.

***Biochemical abnormalities:*** Scientists suspect that  changes in the skin’s protective barrier make people with  atopic dermatitis more sensitive to irritants. Such people  have lower levels of fatty acids (substances that provide  moisture and elasticity) in their skin, which causes dryness  and reduces the skin’s ability to control inflammation.  Researchers continue to search for treatments that help  keep the skin intact and prevent flares.

Other research points to a possible defect in a type of  white blood cell called a monocyte. In people with  atopic dermatitis, monocytes appear to play a role in the  decreased production of an immune system hormone  called interferon gamma (IFN-γ), which helps regulate allergic reactions. This defect may cause exaggerated  immune and inflammatory responses in the blood and  tissues of people with atopic dermatitis.

##### Controlling Atopic Dermatitis

          - Prevent scratching or rubbing whenever possible.
          - Protect skin from excessive moisture, irritants, and rough clothing.
          - Maintain a cool, stable temperature and consistent humidity levels.
          - Limit exposure to dust, cigarette smoke, pollens, and animal dander.
          - Recognize and limit emotional stress.

***Faulty regulation of immunoglobulin E (IgE):*** As  already described in the section on diagnosis, IgE is  a type of antibody that controls the immune system’s  allergic response. An antibody is a special protein  produced by the immune system that  recognizes and helps fight and destroy  viruses, bacteria, and other foreign  substances that invade the body.  Normally, IgE is present in very  small amounts, but levels are high  in about 80 percent of people with  atopic dermatitis.

 In allergic diseases, IgE antibodies  are produced in response to different  allergens. When an allergen comes into  contact with IgE on specialized immune  cells, the cells release various chemicals,  including histamine. These chemicals  cause the symptoms of an allergic  reaction, such as wheezing, sneezing,  runny eyes, and itching. The release of  histamine and other chemicals alone  cannot explain the typical long-term  symptoms of the disease. Research is underway to identify  factors that may explain why too much IgE is produced  and how it plays a role in the disease.

***Immune system imbalance:*** Researchers also think that an imbalance in the immune system may contribute to the development of atopic dermatitis. It appears that the part of the immune system responsible for stimulating IgE is overactive, and the part that handles skin viral and fungal infections is underactive. Indeed, the skin of people with atopic dermatitis shows increased susceptibility to skin infections. This imbalance appears to result in the skin’s inability to prevent inflammation, even in areas of skin that appear normal. In one project, scientists are studying the role of the infectious bacterium *Staphylococcus aureus (S. aureus)* in atopic dermatitis.

Researchers believe that one type of immune cell in the skin, called a Langerhans cell, may be involved in atopic dermatitis. Langerhans cells pick up viruses, bacteria, allergens, and other foreign substances that invade the body and deliver them to other cells in the immune defense system. Langerhans cells appear to be hyperactive in the skin of people with atopic diseases. Certain Langerhans cells are particularly potent at activating white blood cells called T cells in atopic skin, which produce proteins that promote allergic response. This function results in an exaggerated response of the skin to tiny amounts of allergens. 

Scientists have also developed mouse models to study step-by-step changes in the immune system in atopic dermatitis, which may eventually lead to a treatment that effectively targets the immune system.

***Drug research:*** Some researchers are focusing on new treatments for atopic dermatitis, including biologic agents, fatty acid supplements, and phototherapy. For example, they are studying how ultraviolet light affects the skin’s immune system in healthy and diseased skin. They are also investigating biologic response modifiers, or biologics, which are a new family of genetically engineered drugs that block specific molecular pathways of the immune system that are involved in the inflammatory process. A clinical trial is underway to test a drug to see if it can help control the itching associated with atopic dermatitis. 

Researchers also continue to look for drugs that suppress the immune system. Also, anti-inflammatory drugs have been developed that affect multiple cells and cell functions, and may prove to be an effective alternative to corticosteroids in the treatment of atopic dermatitis.

***Other research:*** Several experimental treatments are being  evaluated that attempt to replace substances that are deficient  in people with atopic dermatitis. Evening primrose oil is  a substance rich in gamma-linolenic  acid, one of the fatty acids that is  decreased in the skin of people with  atopic dermatitis. Studies to date using  evening primrose oil have yielded  contradictory results. In addition,  dietary fatty acid supplements have not  proven highly effective. There is also a  great deal of interest in the use of herbs  and plant extracts to treat the disease.  Studies to date show some benefit, but  not without concerns about toxicity and  the risks involved in suppressing  the immune system without close  medical supervision.

#### Hope for the Future

Although the symptoms of atopic  dermatitis can be difficult and  uncomfortable, the disease can  be successfully managed. People  with atopic dermatitis can lead healthy, productive lives.  As scientists learn more about atopic dermatitis and  what causes it, they continue to move closer to effective  treatments, and perhaps, ultimately, a cure.

#### For More Information

        -    National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) Information ClearinghouseNational Institutes of Health  1 AMS Circle   Bethesda,  MD 20892-3675         Phone: 301-495-4484         Toll Free: 877-22-NIAMS (226-4267)         TTY: 301-565-2966         Fax: 301-718-6366        Email: [email protected]         Website: http://www.niams.nih.gov   
        -    Centers for Disease Control and Prevention (CDCP)  1600 Clifton Road, N.E.   Atlanta,  GA 3033330333         Phone: 404-639-3311/404-639-3543         Toll Free: 800-311-3435        Email: [email protected]         Website: http://www.cdc.gov   
        -    American Academy of Dermatology (AAD)  P.O. Box 4014  Schaumberg,  IL 60618-4014         Phone: 847-330-0230         Toll Free: 866-503-SKIN (7546)         Fax: 847-240-1859         Website: http://www.aad.org   
        -    American Academy of Allergy, Asthma, and Immunology  611 East Wells Street  Milwaukee,  WI 53202         Phone: (414) 272-6071         Toll Free: (800) 822-2762        Email: [email protected]         Website: http://www.aaaai.org   
        -      National Eczema Association for Science And Education (NEASE)  4460 Redwood Highway, Suite 16-D  San Rafael,  CA 94903-1953         Phone: 415-499-3474          Toll Free: 800-818-7546         Fax: 415-472-5345        Email: [email protected]         Website: http://www.nationaleczema.org 
        -    Inflammatory Skin Disease Institute  P.O. Box 1074  Newport News,  VA 23601         Phone: (757) 223-0795         Toll Free: (800) 484-6800, Ext. 6321         Fax: 757) 595-1842         Website: http://www.isdionline.org   
        -    Food Allergy and Anaphylaxis Network (FAAN)  10400 Eaton Place  Fairfax,  VA 22030         Phone: (703) 691-3179         Toll Free: (800) 929-4040         Fax: (703) 691-2713        Email: [email protected]         Website: http://www.foodallergy.org   

#### Acknowledgments

NIAMS gratefully acknowledges the assistance of the following people in the preparation and review of this publication: Joanne Cono, M.D., Sc.M., Centers for Disease Control and Prevention, Atlanta; Kevin Cooper, M.D., Case Western Reserve University, University Hospitals of Cleveland; Jon Hanifin, M.D., Oregon Health & Science University, Portland, Oregon; Donald Leung, M.D., Ph.D., National Jewish Medical and Research Center, Denver; Alan Moshell, M.D., NIAMS, NIH; Amy Paller, M.D., Children’s Hospital of Chicago; Hugh Sampson, M.D., Mount Sinai School of Medicine, New York; Maria Turner, M.D., National Cancer Institute, NIH; and LaDonna Williams, Inflammatory Skin Disease Institute, Newport News, Virginia.

The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the U.S. Department of Health and Human Services’ National Institutes of Health (NIH), is to support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases; the training of basic and clinical scientists to carry out this research; and the dissemination of information on research progress in these diseases. The National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse is a public service sponsored by NIAMS that provides health information and information sources. Additional information can be found on the NIAMS Web site at www.niams.nih.gov.

#### For Your Information

This booklet contains information about medications used to treat the health condition discussed here. When this booklet was printed, we included the most up-to-date (accurate) information available. Occasionally, new information on medication is released.

For updates and for any questions about any medications you are taking, please contact
        -    U.S. Food and Drug Administration         Toll Free: 888–INFO–FDA (888–463–6332)         Website: http://www.fda.gov/ 

For updates and questions about statistics, please contact
        -    Centers for Disease Control and Prevention's National Center for Health Statistics  3311 Toledo Rd.   Hyattsville,  MD 20782         Toll Free: 800-232-4636         Website: http://www.cdc.gov/nchs 

This booklet is not copyrighted. Readers are encouraged to duplicate and distribute as many copies as needed.

Additional copies of this booklet are available from:
        -    National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) Information ClearinghouseNational Institutes of Health  1 AMS Circle   Bethesda,  MD 20892-3675         Phone: 301-495-4484         Toll Free: 877-22-NIAMS (226-4267)         TTY: 301-565-2966         Fax: 301-718-6366        Email: [email protected]         Website: http://www.niams.nih.gov 

NIH Publication No. 09-4272

   

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