Atopic dermatitis (AD) is usually diagnosed during childhood and have been associated with other allergies and asthma. Apart from genetic mutations in the filaggrin gene of individuals with AD, environmental and immunological factors are considered as etiological factors in its pathogenesis. Antihistamines are widely used in treating AD; corticosteroids should not be used in the first line, especially in children. In case antihistamines fail to provide benefits, immunomodulatory agents, such as systemic cyclosporine therapy may be considered. Topical emollients when used as adjuvants, for instance, those containing squalene, aloe vera extract, and vitamin E have shown to provide benefits in rehydrating the skin, reducing inflammation, and providing symptomatic relief in patients with AD. Long-term use of these ointments can reduce pruritus and the extent of AD lesions and improve the quality of life of AD patients.

Introduction

Atopic dermatitis (AD) or atopic eczema is a chronic, pruritic inflammatory skin condition, usually detected during infancy and childhood. The disease has a relapsing course and is often associated with elevated serum immunoglobulin (IgE) levels. Frequently, patients with AD reveal  a personal or family history of type-I allergies, allergic rhinitis, and asthma.1,2

AD is among the most common diseases that present during infancy and childhood. Its prevalence across countries ranges from 10-20%. Environmental factors have been implicated as the primary cause for AD. Factors contributing to its pathogenesis are genetic skin barrier defects and immune hyper-responsiveness. AD manifests as chronically inflamed skin lesions that may cause extensive pruritus or itching. Scratching of lesions may lead to exacerbation of dermatitis and make the skin vulnerable to secondary infections. Severe itchiness, on the other hand, can interfere with the sleep of these patients, causing morbidity. Even mild disease can negatively affect a child’s psychological well-being, self-confidence, and quality of life.

Earlier, evidence correlated atopic dermatitis to other atopic diseases and allergies. This has been explained via the hygiene hypothesis, which states that atopic diseases result from low microbial exposure during early childhood leading to inadequate or defective development of the immune system. Mutations in the epidermal gene filaggrin cause the development of AD and other allergies. Individuals with AD and mutated filaggrin gene present with severe AD that is usually accompanied by IgE sensitization. Such mutations cause a filaggrin deficiency that results in the reduction of the natural moisturizing factor and an elevated pH of the skin, which in turn, impair the barrier function of the skin. Owing to an inadequate barrier function, the body is rendered susceptible to sensitization from allergens.

Exposure to environmental allergens thus causes various allergic reactions in these patients.3

Here, we report a case of a 9-year-old boy with extensive eczematous rashes around the knees, arms, and abdomen. The lesions were associated with severe itchiness and disturbed the child’s sleep. The child had a history of seasonal flares of eczema during the winter months. Since the patient had elevated IgE levels and antihistamines and topical corticosteroid therapy had not been beneficial in the past, the boy was given systemic cyclosporine and was instructed to apply a topical moisturizing agent containing squalene, vitamin E, and aloe vera, which improved his lesions and prevented future flares.

Case Report

A 9-year-old boy complained of extensive eczematous rash around his knees, arms, and abdomen. His parents reported that the rash had first appeared behind the knees when the child was 4 years old. They also stated that the scratching in his lesions was worse at night and disturbed his sleep.

The patient had a history of chronic atopic dermatitis with recurrent skin infections. He usually suffered from seasonal flares of eczema during winters. The child was not allergic to any food. He had been on topical corticosteroids and antihistamine therapy, but these treatments had failed to attenuate his symptoms. Physical examination showed the presence of Dennie-Morgan lines and a ‘cobblestone’ appearance of his posterior pharynx. No abnormalities were detected in the lungs. Cardiac and abdominal examinations were unremarkable.

Skin examination demonstrated scattered scaly eczematous patches along the flexural areas of

his upper and lower extremities. Impetigo was noted on the left elbow.

Skin testing could not be carried out for this child due to the presence of eczematous lesions on

his arms. Laboratory testing to environmental allergens was performed, including common indoor and outdoor allergens. The total serum IgE level was markedly elevated at 4300 IU/ml, with

highly positive ImmunoCAP specific IgE levels to dust mite and insects along with certain tree

and grass pollens. The parents were counseled towards appropriate allergen avoidance and

integrative pest management (IPM) strategies as well as the need for immunotherapy.

The patient was started on cyclosporine and topical moisturizing lotion containing squalene,

vitamin E, and aloe vera. During the cyclosporine therapy, the patient was closely monitored for

alterations in blood pressure and renal function.

On follow-up after 6 months, the patient seemed to have responded well to the treatments. The

extent and severity of the lesions had reduced and pruritus improved considerably. Continued

application of the topical moisturizer aided in keeping his skin hydrated and eradicated itchiness

and sleep disturbances in the child.

Discussion

Patients with atopic dermatitis may present with variable manifestations. Also, the distribution and

severity of the lesions may not be similar in infants and children, as in adults. Thus, an individualized

approach is warranted. No specific biomarker can confirm the presence of atopy. The most commonly associated laboratory finding is an elevated total or allergen-specific serum IgE level.

However, this finding may not be consistent in nearly 20% of AD patients.2,4 In the case of infants

and children presenting with AD, the parents  should be inquired in detail of the complete family

history and drug history. Management of AD should be aimed at the provision of symptomatic

relief and prevention of an acute flare-up. In addition, reversal of xerotic skin changes is

important to promote the maintenance of the epidermal barrier mechanism, to reduce the risk of

secondary infections, and to improve the patient’s quality of life. Therefore, maintenance treatments

with topical moisturizers are important to sustain skin integrity and to ward off external allergens

that aggravate symptoms of AD.5

Antihistamines are used in the first line in the management of AD. Systemic steroids should

not be used for long-term treatment, especially in children. Systemic immunomodulatory

agents must be considered if antihistamines fail to provide satisfactory results, for instance,

cyclosporine. Caution must be practiced while selecting these drugs and patients should be

made aware of the side-effects. Those who are prescribed cyclosporine should be monitored for

fluctuations in blood pressure and renal function.

Topical moisturizers containing certain natural extracts like squalene, aloe vera, and vitamin E

have been used as adjuvants for maintenance therapy for the prevention of AD lesions and

to provide symptomatic relief. The use of these agents can attenuate skin symptoms of AD,

prevent exacerbation, and improve the severity and extent of the lesions.

Squalene acts as an antioxidant, moisturizer, and vehicle in topical lotions and ointments. Besides AD, emollients containing squalene are also used in treating seborrheic dermatitis, acne, and psoriasis.6 Vitamin E confers skin protection and has been widely used in skin moisturizers. It is a skin-protective nutraceutical which has antioxidant properties, prevents photo-damage, and reduces dryness of the skin and are hence beneficial when used over xerotic AD lesions.7 Researchers have found that topical agents containing aloe vera extracts modulate immunological responses in AD and are effective in the treatment of psoriasis and atopic dermatitis due to their anti-inflammatory properties.8

Conclusion

Atopic dermatitis is common among infants and children, and more so among those residing in

urban areas. A major contributing factor to the development of this condition is the exposure to

environmental allergens, for example, pollutants, dust, insects, and chemicals. The immunological

response to these allergens are heightened in individuals who have mutated filaggrin gene. They, therefore, experience a hypersensitivity response to common environmental allergens.

The primary concern of children with AD is itchiness that hampers their quality of life and impedes sleep. Furthermore, in many cases, scratching may be severe and the appearance of the lesions unpleasant, impacting a child’s self-confidence. Thus, the goal of the treatment should be to provide symptomatic relief and to reduce the extent of the lesions. Once the lesions are in control, steps must be taken to prevent flare-ups. Antihistamines are generally prescribed to reduce itchiness. However, in case these fail, immunomodulatory agents can be prescribed while closely monitoring the patient. Adjuvant therapies with moisturizing lotions or emollients containing squalene, aloe vera extract, and vitamin E provide excellent results in reducing the dryness and itchiness in the lesions locally and preventing future flare-ups. These topical agents aid in rehydrating the skin and benefit in restoring its physiology and function. Moreover, these topical agents repair the skin barrier function,

prevent progression of rashes, and improve the prognosis of AD.

Here, we describe a 9-year-old boy who had widespread eczematous rashes. The child experienced intense itchiness, especially during the night, which interfered with his sleep. He had been suffering from seasonal eczema flares during winters. The patient elicited scattered scaly eczematous patches over the flexural areas of his upper and lower extremities, along with impetigo on the left elbow. There was a marked elevation of the serum IgE level. He was successfully treated with systemic cyclosporine and a topical moisturizing agent with squalene, vitamin E, and aloe vera extract. Long-term application of the topical lotion reduced the severity of itching and the extent of the lesions. On continued application, the child had stopped scratching at night and hence, his sleep and quality of life improved.

References

1. Eichenfield LF, Tom WL, Chamlin SL, et al. GUIDELINES OF CARE FOR THE MANAGEMENT OF ATOPIC DERMATITIS: Part 1: Diagnosis and Assessment of

Atopic Dermatitis. Journal of the American Academy of Dermatology. 2014;70(2):338-351. doi:10.1016/j.jaad.2013.10.010.

2. Page S, Weston S, Loh R. RACGP - Atopic dermatitis in children. Racgp.org.au. https://www.racgp.org.

au/afp/2016/may/atopic-dermatitis-in-children/.Published 2016. Accessed January 22, 2019.

3. Simpson E. Comorbidity in Atopic Dermatitis. Curr Dermatol Rep. 2012;1(1):29-38. doi:10.1007/s13671-

011-0003-5

4. Kanchongkittiphon W, Gaffin JM, Phipatanakul W. Child with Atopic Dermatitis. Annals of allergy,

asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology.

2015;114(1):6-11. doi:10.1016/j.anai.2014.08.016.

5. Lebwohl MG, Del Rosso JQ, Abramovits W, Berman B, Cohen DE, Guttman-Yassky E, Mancini AJ, Schachner LA. Pathways to managing atopic dermatitis: consensus from the experts. The Journal of clinical

and aesthetic dermatology. 2013 Jul;6(7 Suppl):S2.

6. Wołosik KA, Knaś MA, Zalewska AN, Niczyporuk MA, Przystupa AW. The importance and perspective of plant-based squalene in cosmetology. Journal of cosmetic science. 2013;64(1):59-66.
7. Nwanodi O. Skin Protective Nutraceuticals: The Current Evidence in Brief. Healthcare. 2018;6(2):40.

doi:10.3390/healthcare6020040

8. Fowler JJ, Woolery-Lloyd H, Waldorf H, Saini R. Innovations in natural ingredients and their use in skin care. Journal of drugs in dermatology: JDD. 2010 Jun;9(6 Suppl):S72-81.