Does it run in families?
AD is a familial disease, though the exact way it passes from parents to children is unclear. If one parent has AD, or any of the other atopic diseases (asthma, hay fever), the chances are about 50% that the child will have one or more of the diseases. If both parents are atopic, chances are even greater that their child will have it. However, the connection is not an absolute one: As many as 30% of affected patients have no family members with any of these allergic disorders.

What causes atopic dermatitis?
AD is not contagious. People with AD cannot "give" it to someone else.

AD inflammation results from too many reactive inflammatory cells in the skin. Research is seeking the reason why these cells over-react. Patients with AD (or asthma or hay fever) are born with these over-reactive cells. When something triggers them, they don’t turn off as they should. We try to control AD by preventing the trigger factors that turn on inflamed skin, or by "damping the flames" with anti-inflammatory therapies.

What are the trigger factors?
Trigger factors may be different for different people. Most children get worse when they get a cold or other infection. Most have worse problems in the winter; but others simply can’t stand the sweating during hot, humid summer weather. Let’s look at the trigger factors that seem to affect every child with AD.

Dry skin. The skin’s main function is to provide a barrier against dirt, germs and chemicals from the outside. We don’t notice this barrier unless it gets dry, and then it’s scaly, rough and tight. Dry skin is brittle — moist skin is soft and flexible. People with AD have a defect in their skin and it won’t stay moist. It is especially bad in winter when the heat is on in the house and the humidity drops. Other things that dry the skin are too much bathing without proper moisturizing. The challenge: Prevent skin dryness.

Irritants. Irritants are any of the substances outside the body that can cause burning, redness, itching or dryness of the skin. The challenge: Avoid irritating substances.

Stress. Emotional stress comes from many situations. People with AD often react to stress by having red flushing and itching. Special problems for children with AD include frustration, anger or fear, such as when getting the "silent treatment" from a parent. And, of course, AD itself, and its treatments, are a source of stress! The challenge: Recognize stress and reduce it.

Heat and sweating. Most people with atopic dermatitis notice that when they get hot, they itch. They have a type of prickly heat that doesn’t occur just in humid summertime but any time they sweat. It can happen from exercise, from too many warm bedclothes or rapid changes in temperature from cold to warm.

Infections. Bacterial "staph" infections are the most common, especially on arms and legs. Such infections might be suspected if areas are weeping or crusted or if small "pus-bumps" are seen. Herpes infections (such as fever blisters or cold sores) and fungus (ringworm or athlete’s foot) can also trigger AD. If some lesions look different, ask your doctor. If they turn out to be infected, they can be treated with antibiotics. Recognize and treat pustules or crusted lesions.

Allergens. Allergens are materials such as pollen, pet dander, foods, or dust, that cause allergic responses. Allergic diseases such as asthma and hay fever, which flare quickly, are easy to tie to allergens. Itching and hives appear soon after exposure to these airborne allergens and last only briefly. The slower, continuing, chronic eczema of AD may be more difficult to tie to specific allergens. In general, food allergies trigger AD only in children, mainly those with severe disease. Pollens, dust mites and pets can seldom be shown to trigger eczema. Scratch tests are only brief reactions and do not diagnose allergen-triggered eczema. Patch tests can diagnose eczema responses in some cases such as allergies to skin care products.

Are there other trigger factors?
Children with AD will be helped by reducing the major trigger factors described above. But individuals may be subject to other trigger factors, and it is important to be alert for these, too. They may be less common, but can be very damaging for a given child.

How can you avoid trigger factors?

1. Keep the skin barrier intact. MOISTURIZE!
2. Wear soft clothes that "breathe." Avoid fabrics of wool, nylon, or stiff material.
3. If sweating causes itch, find ways to keep cooler:
• Reduce exertion, especially during times of flare.
• Layer clothing and adjust to temperature changes.
• Don’t overheat rooms, especially the bedroom.
• Use light bedclothes.
4. When itching from sweating, dust, pollen or other exposures, take a cooling shower or tub bath.
5. Learn to recognize signs of infection and treat early.
6. If you suspect food allergy, be systematic. Likely offenders are eggs, milk, peanuts, soy, wheat and seafood, but any food can do it. Can you exclude the most likely offender for a week? Substitute hydrolysate (e.g. Alimentum® or Nutramagen®) for cow milk formula. Keep a food diary. When the skin clears up, try the food. Watch for signs of itching or redness over the next two hours. Do not try a suspect food if it causes hives or face swelling. Don’t exclude multiple food groups at the same time — it’s rare to have more than one or two food allergies, and your child can get malnourished with prolonged avoidance of many foods.
7. With allergy-prone kids, furry animals are a risk. If you must have pets, keep them outside or at least off beds, rugs and furniture where the child plays. Dust mites collect in bedroom carpets and bedding. Simple control measures include coverings for pillows and mattresses, removing bedroom carpets and frequent washing of bedclothes in hot water.
8. Think about stress-causing events and ways to cope with them. Review problems with your doctor or a mental health professional. Try to make AD treatments part of a daily, family routine. Encourage children with AD to do what they can on their own.

What kinds of medicines help?
Moisturizers.   Ointments such as petroleum jelly (such as Vaseline®) are best unless they're too thick and cause discomfort.   Creams may be fine for moderately dry skin or in hot, humid weather.  Apply them to wet skin, immediately after bathing.  Lotions and oils are not rich enough and often have a net drying effect on AD skin.

Corticosteroids.   Often called topical ("applied to the skin") steroids, these are cortisone-like medications used in creams or ointments which your doctor may prescribe (e.g. Hydrocortisone, Mometasone, Desonide, Triamcinolone).  They are not the same as the dangerous "steroids" some athletes misuse.  Corticosteroid medicines are very helpful.  Often they are the only treatment that can calm the inflamed skin.   Use of steroid ointments and creams requires good judgment and careful supervision. They come in many strengths from mild to super-potent.   Hydrocortisone is quite safe.  The more potent ones can cause thinned skin, stretch marks and other problems if used too many days in the same areas of the body.   Parents should monitor the child's use.  Ask the doctor about potency and side effects of prescribed corticosteroid medicines.

Antibiotics. Oral or topical antibiotics reduce the surface bacterial infections that may accompany flares of AD.

Antihistamines. Often prescribed to reduce itching, these medicines may cause drowsiness but seem to help some children.

Tar preparations. Tar creams or bath emulsions can be helpful for mild inflammation.

When will my child outgrow atopic dermatitis?
For any given child, it is difficult to predict. The majority of babies with AD will lose most of the problem by adolescence, often before grade school. A small number will have severe AD into adulthood. Many have remissions that last for years. The dry skin tendency will remain. Most people learn to use moisturizers to keep their dermatitis controlled. Occasional episodes of AD may occur during times of stress or with jobs that expose the skin to irritants and wet work.

Will AD affect my child’s career choice?
Someone who has had eczema should avoid jobs that can injure the skin. Military service automatically excludes people with AD or asthma. Wet work in restaurants or hospitals is especially damaging to hands predisposed by AD to drying and cracking. Generally, it’s better to pick "clean" indoor work such as with computers, papers or books, given the choice.

Acknowledgments
The National Eczema Association for Science and Education acknowledges the help of Drs. John Crossen, Jon Hanifin, Amy Paller, Hugh Sampson, and Mary Spraker in preparing the information for this brochure.

This patient education pamphlet was developed under the direction of the National Eczema Association for Science and Education. The information in this pamphlet sets forth current information and opinions from recognized authorities, but it does not dictate an exclusive treatment course and is not intended as medical advice. Persons with questions about a medical condition should consult a physician regarding health matters and for further important information concerning use of prescription drugs.

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