atopic dermatitis atopic dermatitis atopic dermatitis (ad), also known as atopic eczema, is a long-term type of inflammation of the skin (dermatitis). it results in itchy, red, swollen, and cracked skin. clear fluid may come from the affected areas, which can thicken over time. ad is sometimes simply called as eczema, a term that also refers to a larger group of skin conditions. atopic dermatitisother namesatopic eczema, infantile eczema, prurigo besnier, allergic eczema, neurodermatitisatopic dermatitis of the inside crease of the elbowspecialtydermatology, clinical immunology and allergysymptomsitchy, red, swollen, cracked skincomplicationsskin infections, hay fever, asthmausual onsetchildhoodcausesunknownrisk factorsfamily history, living in a city, dry climatediagnostic methodbased on symptoms after ruling out other possible causesdifferential diagnosiscontact dermatitis, psoriasis, seborrheic dermatitistreatmentavoiding things that worsen the condition, daily bathing followed by moisturising cream, steroid creams for flares humidifierfrequency~20% at some time atopic dermatitis affects about 20% of people at some point in their lives. it is more common in younger children. females are slightly more affected than males. many people outgrow the condition. while the condition may occur at any age, it typically starts in childhood, with changing severity over the years. in children under one year of age, the face and limbs and much of the body may be affected. as children get older, the areas on the insides of the knees and folds of the elbows and around the neck are most commonly affected. in adults, the hands and feet are commonly affected. scratching the affected areas worsens the eczema and increases the risk of skin infections. many people with atopic dermatitis develop hay fever or asthma. the cause is unknown but believed to involve genetics, immune system dysfunction, environmental exposures, and difficulties with the permeability of the skin. if one identical twin is affected, the other has an 85% chance of having the condition. those who live in cities and dry climates are more commonly affected. exposure to certain chemicals or frequent hand washing makes symptoms worse. while emotional stress may make the symptoms worse, it is not a cause. the disorder is not contagious. a diagnosis is typically based on the signs, symptoms and family history. treatment involves avoiding things that make the condition worse, enhancing the skin barrier through skin care and treating the underlying skin inflammation. moisturising creams are used to make the skin less dry and prevent ad flare-ups. anti-inflammatory corticosteroid creams are used to control flares-ups. creams based on calcineurin inhibitors (tacrolimus or pimecrolimus) may also be used to control flares if other measures are not effective. certain antihistamine pills might help with itchiness. things that commonly make it worse include house dust mite, stress and seasonal factors. phototherapy may be useful in some people. antibiotics (either by mouth or topically) are usually not helpful unless there is secondary bacterial infection or the person is unwell. dietary exclusion does not benefit most people and it is only needed if food allergies are suspected. more severe ad cases may need systemic medicines such as cyclosporin, methotrexate, dupilumab or baricitinib. other names of the condition include "infantile eczema", "flexural eczema", "prurigo besnier", "allergic eczema", and "neurodermatitis". signs and symptoms child with atopic dermatitis symptoms refer to the sensations that people with ad feel, whereas signs refers to a description of the visible changes that result from ad.the pattern of atopic eczema varies with age.the main symptom of ad is itching which can be intense. some people experience burning or soreness or pain. people with ad often have a generally dry skin that can look greyish in people with darker skin tones of colour. areas of ad are not well defined, and they are typically inflamed (red in a light coloured skin or purple or dark brown in people with dark skin of colour). surface changes include: scaling cracking (fissures) swelling (oedema) scratch marks (excoriation) bumpiness (papulation) oozing of clear fluid thickening of the skin (lichenification) where the ad has been present for a long time. eczema often starts on the cheeks and outer limbs and body in infants and frequently settles in the folds of the skin such as behind the knees, folds of the elbows, around the neck, wrists and under the buttock folds as the child grows. any part of the body can be affected by ad. ad commonly affects the eyelids, where an extra prominent crease can form under the eyelid due to skin swelling known as dennie-morgan infraorbital folds. cracks can form under the ears which can be painful (infra-auricular fissure). the inflammation from ad often leaves “footprints” known as postinflammatory pigmentation that can be lighter than the normal skin or darker. these marks are not scars and eventually go back to normal over a period of months providing the underlying ad is treated effectively. people with ad often have dry and scaly skin that spans the entire body, except perhaps the diaper area, and intensely itchy red, splotchy, raised lesions to form in the bends of the arms or legs, face, and neck. causes the cause of ad is not known, although some evidence indicates genetic, environmental, and immunologic factors. climate low humidity, and low temperature increase the prevalence and risk of flares in patients with atopic dermatitis. genetics many people with ad have a family history or a personal history of atopy. atopy is a term used to describe individuals who produce substantial amounts of ige. such individuals have an increased tendency to develop asthma, hay fever, eczema, urticaria and allergic rhinitis. up to 80% of people with atopic dermatitis have elevated total or allergen-specific ige levels. about 30% of people with atopic dermatitis have mutations in the gene for the production of filaggrin (flg), which increase the risk for early onset of atopic dermatitis and developing asthma. hygiene hypothesis according to the hygiene hypothesis, early childhood exposure to certain microorganisms (such as gut flora and helminth parasites) protects against allergic diseases by contributing to the development of the immune system. this exposure is limited in a modern "sanitary" environment, and the incorrectly developed immune system is prone to develop allergies to harmless substances. some support exists for this hypothesis with respect to ad. those exposed to dogs while growing up have a lower risk of atopic dermatitis. also, epidemiological studies support a protective role for helminths against ad. likewise, children with poor hygiene are at a lower risk for developing ad, as are children who drink unpasteurized milk. allergens in a small percentage of cases, atopic dermatitis is caused by sensitization to foods such as milk, but there is growing consensus that food allergy most likely arises as a result of skin barrier dysfunction resulting from ad, rather than food allergy causing the skin problems. atopic dermatitis sometimes appears associated with coeliac disease and non-coeliac gluten sensitivity. because a gluten-free diet (gfd) improves symptoms in these cases, gluten seems to be the cause of ad in these cases. a diet high in fruits seems to have a protective effect against ad, whereas the opposite seems true for heavily processed foods. exposure to allergens, either from food or the environment, can exacerbate existing atopic dermatitis. exposure to dust mites, for example, is believed to contribute to the risk of developing ad. role of staphylococcus aureus colonization of the skin by the bacterium s. aureus is extremely prevalent in those with atopic dermatitis. abnormalities in the skin barrier of persons with ad are exploited by s. aureus to trigger cytokine expression, thus aggravating the condition. there is insufficient evidence for the effectiveness of anti-staphylococcal treatments for treating s. aureus in infected or uninfected eczema. hard water the prevalence of atopic dermatitis in children may be linked to the level of calcium carbonate or "hardness" of household drinking water. living in areas with hard water may also play a part in the development of ad in early life. however, when ad is already established, using water softeners at home does not reduce the severity of the symptoms. pathophysiology excessive type 2 inflammation underlies the pathophysiology of atopic dermatitis. disruption of the epidermal barrier is thought to play an integral role in the pathogenesis of ad. disruptions of the epidermal barrier allows allergens to penetrate the epidermis to deeper layers of the skin. this leads to activation of epidermal inflammatory dendritic and innate lymphoid cells which subsequently attracts th2 cd4+ helper t cells to the skin. this dysregulated th2 inflammatory response is thought to lead to the eczematous lesions. the th2 helper t cells become activated, leading to the release of inflammatory cytokines including il-4, il-13 and il-31 which activate downstream janus kinase (jak) pathways. the active jak pathways lead to inflammation and downstream activation of plasma cells and b lymphocytes which release antigen specific ige contributing to further inflammation. other cd4+ helper t-cell pathways thought to be involved in atopic dermatitis inflammation include the th1, th17, and th22 pathways. some specific cd4+ helper t-cell inflammatory pathways are more commonly activated in specific ethnic groups with ad (for example, the th-2 and th-17 pathways are commonly activated in asian people) possibly explaining the differences in phenotypic presentation of atopic dermatitis in specific populations. mutations in the filaggrin gene, flg, also cause impairment in the skin barrier that contributes to the pathogenesis of ad. filaggrin is produced by epidermal skin cells (keratinocytes) in the horny layer of the epidermis. filaggrin stimulates skin cells to release moisturizing factors and lipid matrix material, which cause adhesion of adjacent keratinocytes and contributes to the skin barrier. a loss-of-function mutation of filaggrin causes loss of this lipid matrix and external moisturizing factors, subsequently leading to disruption of the skin barrier. the disrupted skin barrier leads to transdermal water loss (leading to the xerosis or dry skin commonly seen in ad) and antigen and allergen penetration of the epidermal layer. filaggrin mutations are also associated with a decrease in natural antimicrobial peptides found on the skin; subsequently leading to disruption of skin flora and bacterial overgrowth (commonly staphylococcus aureus overgrowth or colonization). atopic dermatitis is also associated with the release of pruritogens (molecules that stimulate pruritus or itching) in the skin. keratinocytes, mast cells, eosinophils and t-cells release pruritogens in the skin; leading to activation of aδ fibers and group c nerve fibers in the epidermis and dermis contributing to sensations of pruritus and pain. the pruritogens include the th2 cytokines il-4, il-13, il-31, histamine, and various neuropeptides. mechanical stimulation from scratching lesions can also lead to the release of pruritogens contributing to the itch-scratch cycle whereby there is increased pruritus or itch after scratching a lesion. chronic scratching of lesions can cause thickening or lichenification of the skin or prurigo nodularis (generalized nodules that are severely itchy). diagnosis ad is typically diagnosed clinically, meaning it is based on signs and symptoms alone, without special testing. several different criteria developed for research have also been validated to aid in diagnosis. of these, the uk diagnostic criteria, based on the work of hanifin and rajka, has been the most widely validated. uk diagnostic criteria people must have itchy skin, or evidence of rubbing or scratching, plus three or more of: skin creases are involved - flexural dermatitis of fronts of ankles, antecubital fossae, popliteal fossae, skin around eyes, or neck, (or cheeks for children under 10) history of asthma or allergic rhinitis (or family history of these conditions if patient is a child ≤4 years old) symptoms began before age 2 (can only be applied to patients ≥4 years old) history of dry skin (within the past year) dermatitis is visible on flexural surfaces (patients ≥age 4) or on the cheeks, forehead, and extensor surfaces (patients<age 4) other diseases that must be excluded before making a diagnosis include contact dermatitis, psoriasis, and seborrheic dermatitis. treatments no cure for ad is known, although treatments may reduce the severity and frequency of flares. the most commonly used topical treatments for ad are topical corticosteroids (to get control of flare-ups) and moisturisers (emollients) to help keep control. moisturisers daily basic care is intended to stabilize the barrier function of the skin to mitigate its sensitivity to irritation and penetration of allergens. affected persons often report that improvement of skin hydration parallels with improvement in ad symptoms. moisturisers (or emollients) can improve skin comfort and may reduce disease flares. they can be used as leave-on