eMedicine Specialties > Ophthalmology > Dermatologic Disorders

Dermatitis, Atopic

Author: R Scott Lowery, MD, Assistant Professor of Ophthalmology, Department of Pediatric Ophthalmology and Strabismus, University of Arkansas for Medical Center, Arkansas Children's Hospital
Contributor Information and Disclosures

Updated: Apr 10, 2009

Introduction

Background

Atopy is the hereditary predisposition to allergy or hypersensitivity. Symptoms may present as a dermatitis, hay fever, or asthma. According to Rapoza, Besnier first characterized atopic dermatitis, and many Europeans still use his name to describe the disease (prurigo Besnier).1 This disease was labeled eczema for many years in the United States until Coca and Cooke coined the term atopy as a skin hypersensitivity seen in patients with hereditary allergies. Wise and Sulzberger have been credited with the term atopic dermatitis to describe a group of diseases associated with atopic conditions that may be seen in all age groups.2

Pathophysiology

Atopic dermatitis is primarily caused by cellular immune deficiency and elevated immunoglobulin E (IgE). The pathogenesis can be traced to a genetically inherited, bone marrow–derived cell associated with chromosome 11q. Abnormal skin reactivity also plays a major role in the development of the disease. Irritants to the skin are believed to predispose an individual to develop dermatitis more often than simply exposure to an allergenic trigger. Nonetheless, patients frequently have a history of food or inhalant allergies or eventually develop them.3

Frequency

United States

An estimated 3-12% of the population will be affected at some time.

Race

The highest incidence is in urban areas and in cooler temperature zones, although no clear racial predisposition appears to exist.

Sex

According to Bezan, males appear to be affected more frequently by vernal and atopic conjunctivitis than females.4

Age

Children most commonly are affected, with 80% developing the disease before age 7 years. Less than 2% will have an onset after age 20 years. Most sources agree that persistence after age 20 years is uncommon. Only an estimated 10% of patients older than 20 years continue to be symptomatic.5

Clinical

History

  • The most common symptoms include pruritus, erythema, and skin lesions of the antecubital and/or popliteal skin, eyelids, corners of the mouth, neck, outer canthi, or behind the ears.
  • In infants, the eruption particularly involves the face, scalp, and extensor surfaces.
  • In older children and adults, the neck and antecubital or popliteal areas more commonly are involved.
  • Adult patients usually have a history of infantile disease that may require anecdotal history or contacting their caregivers from infancy.
  • Most patients have a familial occurrence of symptoms of atopy.

Physical

  • The most common physical findings are erythematous, exudative skin lesions of the antecubital and/or popliteal skin, eyelids, corners of the mouth, neck, outer canthi, or behind the ears.
    • Scaling, lichenification (thickening of the skin due to scratching and irritation), and pigmentary changes (eg, vitiligo, hyperpigmentation [often seen in patients with darker skin types]) are common in adolescents and adults.
    • In severe cases, generalized eruptions over the entire body may occur.
  • Possible physical findings on slit lamp examination include blepharitis, atopic keratoconjunctivitis (AKC), scarring of the palpebral conjunctiva, papillary conjunctival reaction, Trantas dots (limbal deposits of eosinophils), atopic cataracts, and keratoconus.
    • Unlike vernal conjunctivitis, the lower tarsus is involved more frequently.
    • Hyperemia, chemosis, and discharge are more common than papillary or cobblestone reaction.
  • Atopic cataracts develop in patients with long-standing atopic disease (10 or more years).
    • These patients usually are older children or young adults.
    • The incidence of atopic cataracts is estimated to be 10%, and they are most frequently bilateral.
    • These cataracts tend to evolve rapidly and may opacify within 6 months.
    • The cataracts often begin as a posterior subcapsular opacity and develop into an anterior cortex opacity that frequently resembles the shape of a shield or a bearskin rug.
  • Spontaneous retinal detachment is more common in patients with atopic disease than the general population.
  • In a few rare, advanced cases, symblepharon, entropion, and trichiasis may be seen.

Causes

  • Abnormal skin reactivity is a feature of the disease, and exposure to skin irritants, most frequently water and chemicals, may predispose patients to the development of atopic dermatitis.
  • Additionally, since many of these patients have allergic sensitivities to food or inhaled allergens, exposure to these may increase the chances of development of the dermatitis.
  • Skin irritants, thought to trigger this more frequently than other allergens, also may be more readily avoidable.
  • Psychological stress has been implicated as a possible contributor to disease development.
  • Recent studies have implicated loss-of-function mutations in the barrier protein filaggrin and diminished expression of certain antimicrobial peptides in atopic dermatitis skin, which may lead to further treatment research.

More on Dermatitis, Atopic

Overview: Dermatitis, Atopic
Differential Diagnoses & Workup: Dermatitis, Atopic
Treatment & Medication: Dermatitis, Atopic
Follow-up: Dermatitis, Atopic
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Rapoza PA, Chandler JW. Atopic dermatitis. In: Weingeist T, Gould D, eds. The Eye in Systemic Disease. Philadelphia: Lippincott; 1990:606-609.

  2. Shen CP, Xing H, Ma L. [Research advances in atopic dermatitis]. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. Feb 2009;31(1):103-6. [Medline].

  3. Jung T, Stingl G. Atopic dermatitis: therapeutic concepts evolving from new pathophysiologic insights. J Allergy Clin Immunol. Dec 2008;122(6):1074-81. [Medline].

  4. Bezan DJ. Eye itch. In: Bezan DJ, Larussa FP, Nishimoto JH, et al, eds. Differential Diagnosis in Primary Eye Care. Boston: Butterworth-Heinemann; 1999:67-71.

  5. Brenninkmeijer EE, Legierse CM, Sillevis Smitt JH, Last BF, Grootenhuis MA, Bos JD. The course of life of patients with childhood atopic dermatitis. Pediatr Dermatol. Jan-Feb 2009;26(1):14-22. [Medline].

  6. Anderson PC, Dinulos JG. Atopic dermatitis and alternative management strategies. Curr Opin Pediatr. Feb 2009;21(1):131-8. [Medline].

  7. Ricci G, Dondi A, Patrizi A, Masi M. Systemic therapy of atopic dermatitis in children. Drugs. 2009;69(3):297-306. [Medline].

  8. Kaujalgi R, Handa S, Jain A, Kanwar AJ. Ocular abnormalities in atopic dermatitis in Indian patients. Indian J Dermatol Venereol Leprol. Mar-Apr 2009;75(2):148-51. [Medline].

  9. Clark RAF, Kristal L. Atopic dermatitis. In: Sams J, Lynch PJ, eds. Principles and Practice of Dermatology. 2nd ed. New York: Churchill Livingstone Inc; 1996:403-418.

  10. Friedlander MH. Diseases affecting the eye and the skin. In: Allergy and Immunology of the Eye. 2nd ed. 1993:75-106.

  11. Friedlander MH. Atopic dermatitis. In: Current Ocular Therapy. 5th ed. Philadelphia: WB Saunders Co; 2000:143-144.

  12. Furue M, Terao H, Moroi Y, et al. Dosage and adverse effects of topical tacrolimus and steroids in daily management of atopic dermatitis. J Dermatol. Apr 2004;31(4):277-83. [Medline].

  13. Guin JD. Eyelid dermatitis: experience in 203 cases. J Am Acad Dermatol. Nov 2002;47(5):755-65. [Medline].

  14. Hanifin JM. Atopic dermatitis: broadening the perspective. J Am Acad Dermatol. Jul 2004;51(1 Suppl):S23-4. [Medline].

  15. Kanski JJ. Disorders of the conjunctiva. In: Clinical Ophthalmology. 4th ed. Boston: Butterworth-Heinemann; 1999:69-71.

  16. Liesegang TJ. Atopic keratoconjunctivitis. In: Pepose JS, Holland GN, Wilhelmus KR, eds. Ocular Infection and Immunity. St. Louis: Mosby; 1996:376-390.

  17. Roy FH. Ocular Differential Diagnosis. 7th ed. Philadelphia: Williams & Wilkins; 2002.

  18. Shelley WB, Shelley EB. Atopic dermatitis. In: Advanced Dermatologic Diagnosis. Philadelphia: WB Saunders Co; 1992:285-291.

  19. Uchio E, Miyakawa K, Ikezawa Z, Ohno S. Systemic and local immunological features of atopic dermatitis patients with ocular complications. Br J Ophthalmol. Jan 1998;82(1):82-7. [Medline].

  20. Weisbecker CA, Fraunfelder FT, Rhee D. Physicians' Desk Reference for Ophthalmology. 28th ed. Oradell, NJ: Medical Economics Co; 2000.

  21. Zimmerman TJ, Kulkarni PS, Meredith TA. Steroids in ocular therapy, antibiotics and antifungals, antiallergic therapies. In: Zimmerman TJ, Kooner KS, Shariv M, Fechtner RD, eds. Textbook of Ocular Pharmacology. Philadelphia: Lippincott-Raven; 1997:61-74, 363-385, 609-633,683-701, 801-804.

[ CLOSE WINDOW ]

Keywords

atopic dermatitis, atopic eczema, Besnier prurigo, prurigo Besnier, Besnier's prurigo, atopy

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

R Scott Lowery, MD, Assistant Professor of Ophthalmology, Department of Pediatric Ophthalmology and Strabismus, University of Arkansas for Medical Center, Arkansas Children's Hospital
R Scott Lowery, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.

Medical Editor

Jack L Wilson, PhD, Distinguished Professor, Department of Anatomy and Neurobiology, University of Tennessee at Memphis
Jack L Wilson, PhD is a member of the following medical societies: American Association of Anatomists, American Association of Clinical Anatomists, and American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.