Atopic dermatitis in children

Atopic dermatitis in children (atopic eczema, atopic eczema/dermatitis syndrome) is a chronic allergic inflammatory skin disease accompanied by itching, age-related morphology of rashes and staging.

The disease typically begins in early childhood, may continue or recur in adulthood, and significantly impairs the quality of life of the patient and his family members.

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Epidemiology

Atopic dermatitis occurs in all countries, in both sexes and in different age groups. The incidence varies, according to various epidemiological studies, from 6.0 to 25.0 per 1000 population (Hanifin J., 2002). According to studies conducted in the early 60s, the prevalence of atopic dermatitis was no more than 3% (Ellis C. et al., 2003). By now, the prevalence of atopic dermatitis in the US pediatric population has reached 17.2%, in children in Europe - 15.6%, and in Japan - 24%, which reflects a steady increase in the incidence of atopic dermatitis over the past three decades.

The prevalence of atopic dermatitis symptoms ranged from 6.2% to 15.5% according to the results of the standardized epidemiological study ISAAC (International Study of Asthma and Allergy in Childhood).

In the structure of allergic diseases, atopic dermatitis in children is the earliest and most common manifestation of atopy and is detected in 80-85% of young children with allergies, and in recent years there has been a tendency towards a more severe clinical course of atopic dermatitis with a change in its pathomorphosis.

• In a significant proportion of children, the disease is chronic until puberty.
• Earlier manifestation (in 47% of cases, atopic dermatitis in children appears immediately after birth or in the first 2 months of life).
• A certain evolution of the symptoms of the disease with an expansion of the area of skin lesions, an increase in the frequency of severe forms and the number of patients with atopic dermatitis with a continuously recurring course, resistant to traditional treatment.

In addition, atopic dermatitis in children is the first manifestation of the “atopic march” and a significant risk factor for the development of bronchial asthma, since epicutaneous sensitization that develops with atopic dermatitis is accompanied not only by local inflammation of the skin, but also by a systemic immune response involving various parts of the respiratory tract.

Genetic studies have shown that atopic dermatitis develops in 82% of children if both parents suffer from allergies (it manifests itself mainly in the first year of the child's life); in 59% - if only one parent has atopic dermatitis, and the other has allergic respiratory disease, in 56% - if only one parent suffers from allergies, in 42% - if first-line relatives have manifestations of atopy.

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Causes of atopic dermatitis in a child

Atopic dermatitis in children in most cases develops in individuals with a hereditary predisposition and is often combined with other forms of allergic pathology, such as bronchial asthma, allergic rhinitis, allergic conjunctivitis, and food allergies.

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Symptoms of atopic dermatitis in a child

The stages of development, phases and periods of the disease, clinical forms depending on age are distinguished, and the prevalence, severity of the course and clinical and etiological variants of atopic dermatitis in children are also taken into account.

Prevalence of the skin process

Prevalence is estimated as a percentage, by the area of the affected surface (rule of nines). The process should be considered limited if the lesions do not exceed 5% of the surface and are localized in one of the areas (back of the hands, wrist joints, elbow bends or popliteal fossa, etc.). Outside the lesions, the skin is usually unchanged. Itching is moderate, in rare attacks.

A process is considered widespread when the affected areas occupy more than 5% but less than 15% of the surface, and skin rashes are localized in two or more areas (neck area with transition to the skin of the forearms, wrists and hands, etc.) and spread to adjacent areas of the limbs, chest and back. Outside the lesions, the skin is dry, has an earthy-gray tint, often with bran-like or fine-plate peeling. Itching is intense.

Diffuse atopic dermatitis in children is the most severe form of the disease, characterized by lesions of almost the entire surface of the skin (except for the palms and nasolabial triangle). The pathological process involves the skin of the abdomen, groin and gluteal folds. Itching can be so intense that it leads to scalping of the skin by the patient himself.

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Severity of the disease

There are three degrees of severity of atopic dermatitis in children: mild, moderate and severe.

Mild degree is characterized by slight hyperemia, exudation and peeling, single papulovesicular elements, mild itching of the skin, enlargement of the lymph nodes to the size of a pea. Frequency of exacerbations is 1-2 times a year. Duration of remissions is 6-8 months.

In children with moderate atopic dermatitis, multiple lesions with pronounced exudation, infiltration or lichenification; excoriations, hemorrhagic crusts are observed on the skin. Itching is moderate or severe. The lymph nodes are enlarged to the size of a hazelnut or bean. The frequency of exacerbations is 3-4 times a year. The duration of remissions is 2-3 months.

Severe course is accompanied by extensive lesions with pronounced exudation, persistent infiltration and lichenification, deep linear cracks and erosions. Itching is severe, "pulsating" or constant. Almost all groups of lymph nodes are enlarged to the size of a hazelnut or walnut. The frequency of exacerbations is 5 or more times a year. Remission is short-lived - from 1 to 1.5 months and, as a rule, incomplete. In extremely severe cases, the disease can proceed without remissions, with frequent exacerbations.

The severity of atopic dermatitis in children is assessed using the SCORAD system, which takes into account the prevalence of the skin process, the intensity of clinical manifestations and subjective symptoms.

Subjective symptoms can be reliably assessed in children over 7 years of age, provided that the parents and the patient understand the assessment principle.

Clinical and etiological variants of atopic dermatitis in children

Clinical and etiological variants of atopic dermatitis in children are distinguished based on the anamnesis, clinical course characteristics, and results of allergological examination. Identification of the causative allergen makes it possible to understand the patterns of disease development in a specific child and carry out appropriate elimination measures.

Skin rashes in food allergies are associated with the use of products to which the child has increased sensitivity (cow's milk, cereals, eggs, etc.). Positive clinical dynamics usually occur in the first days after the elimination diet is prescribed.

In tick sensitization, the disease is characterized by a severe, continuously recurring course, year-round exacerbations, and increased skin itching at night. Improvement in the condition is observed when contact with house dust mites ceases: by changing residence, or by hospitalization. An elimination diet does not produce a pronounced effect.

In case of fungal sensitization, exacerbations of atopic dermatitis in children are associated with the intake of food products contaminated with fungal spores or products in the manufacturing process of which mold fungi are used. Exacerbations are also facilitated by dampness, the presence of mold in living quarters, and the prescription of antibiotics. Fungal sensitization is characterized by a severe course with exacerbations in autumn and winter.

Pollen sensitization causes exacerbations of the disease during the peak of flowering of trees, cereals or weeds; but it can also be observed when consuming food allergens that have common antigenic determinants with tree pollen (so-called cross-allergy). Seasonal exacerbations of atopic dermatitis are usually combined with classic manifestations of hay fever (laryngotracheitis, rhinoconjunctival syndrome, exacerbations of bronchial asthma), but can also occur in isolation.

In some cases, the development of atopic dermatitis in children is caused by epidermal sensitization. In such cases, the disease is exacerbated by the child's contact with pets or products made from animal wool and is often combined with allergic rhinitis.

It should be taken into account that "pure" variants of fungal, mite and pollen sensitization are rare. Usually we are talking about the predominant role of one or another type of allergen.

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Stages

The classification of atopic dermatitis was developed by a working group of pediatric specialists based on the SCORAD (scoring of atopic dermatitis) diagnostic system in accordance with ICD-10 and is presented in the National Scientific and Practical Program for Atopic Dermatitis in Children.

Working classification of atopic dermatitis in children

Stages of development, periods and phases of the disease	Clinical forms depending on age	Prevalence	Severity of the current	Clinical etiological variants
Initial stage. Stage of pronounced changes (period of exacerbation): acute phase; chronic phase. Remission stage: incomplete (subacute period); complete. Clinical recovery	Infant . Children. Teenage.	Limited . Widespread . Diffuse.	Light. Moderate. Heavy. Heavy.	With a predominance of: food, mite, fungal, pollen, allergies, etc.

The following stages of disease development are distinguished:

1. initial;
2. stage of pronounced changes;
3. remission stage;
4. stage of clinical recovery.

The initial stage usually develops in the first year of life. The most common early symptoms of skin lesions are hyperemia and swelling of the skin of the cheeks with slight peeling. At the same time, gneiss (seborrheic scales around the large fontanelle, eyebrows and behind the ears), "milk crust" (crusta lacteal, limited hyperemia of the cheeks with yellowish-brown crusts like baked milk), transient erythema on the cheeks and buttocks may be observed.

The stage of pronounced changes, or the period of exacerbation. During this period, the clinical forms of atopic dermatitis depend mainly on the age of the child. Almost always, the period of exacerbation goes through acute and chronic phases of development. The main symptom of the acute phase of the disease is microvesiculation followed by the appearance of crusts and peeling in a certain sequence: erythema -> papules -> vesicles -> erosions -> crusts -> peeling. The chronic phase of atopic dermatitis is indicated by the appearance of lichenification (dryness, thickening and intensification of the skin pattern), and the sequence of skin changes is as follows: papules -> peeling -> excoriations -> lichenification. However, in some patients, the typical alternation of clinical symptoms may be absent.

The remission period, or subacute stage, is characterized by the disappearance (complete remission) or reduction (incomplete remission) of clinical symptoms of the disease. Remission can last from several weeks and months to 5-7 years or more, and in severe cases the disease can proceed without remission and recur throughout life.

Clinical recovery is the absence of clinical symptoms of atopic dermatitis for 3-7 years (today there is no single point of view on this issue).

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Forms

Clinical symptoms of atopic dermatitis in children largely depend on the age of the patient, and therefore three forms of the disease are distinguished:

1. infantile, typical for children under 3 years of age;
2. children's - for children 3-12 years old;
3. adolescent, observed in adolescents aged 12-18 years.

The adult form is usually identified with diffuse neurodermatitis, although it can also be observed in children. Each age period has its own clinical and morphological features of skin changes.

Age	Characteristic elements	Characteristic localization
3-6 months	Erythematous elements on the cheeks in the form of a milk crust (crusta lacteal), serous papules and microvesicles, erosions in the form of a serous "well" (spongiosis). Later - peeling (parakeratosis)	Cheeks, forehead, extensor surfaces of the limbs, scalp, auricles
6-18 months	Edema, hyperemia, exudation	Mucous membranes: nose, eyes, vulva, foreskin, digestive tract, respiratory and urinary tract
1.5-3 years	Strophulus (confluent papules). Thickening of the skin and its dryness, strengthening of the normal pattern - lichenification (lichenification)	Flexor surfaces of the extremities (most often the elbows and popliteal fossa, less often the lateral surface of the neck, foot, wrist)
Over 3-5 years old	Formation of neurodermatitis, ichthyosis	Flexor surfaces of the limbs

Infant form

Characteristic signs of this form are hyperemia and swelling of the skin, microvesicles and micro-papules, pronounced exudation. The dynamics of skin changes is as follows: exudation -> serous "wells" -> crusts peeling -> cracks. Most often, foci are localized in the face (except for the nasolabial triangle), extensor (outer) surface of the upper and lower extremities, less often - in the elbow bends, popliteal fossa, wrists, buttocks, trunk. Skin itching can be very intense even in infants. Most patients have red or mixed dermographism.

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Children's uniform

Characterized by hyperemia/erythema and swelling of the skin, the appearance of lichenification areas; papules, plaques, erosions, excoriations, crusts, cracks (especially painful when located on the palms, fingers and soles) may be observed. The skin is dry with a large number of small and large lamellar (branzinoidea) scales. Skin changes are localized mainly on the flexor (inner) surfaces of the arms and legs, the back of the hands, the anterolateral surface of the neck, in the elbow folds and popliteal fossa. Hyperpigmentation of the eyelids (as a result of scratching) and a characteristic fold of skin under the lower eyelid (Denier-Morgan line) are often observed. Children are bothered by itching of varying intensity, leading to a vicious circle: itching -> scratching -> rash -> itching. Most children have white or mixed dermographism.

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Teenage form

Characterized by the presence of large, slightly shiny lichenoid papules, pronounced lichenification, multiple excoriations and hemorrhagic crusts in the lesions, which are localized on the face (around the eyes and in the mouth area), neck (in the form of a "décolleté"), elbow bends, around the wrists and on the back of the hands, under the knees. Severe itching, sleep disturbance, neurotic reactions are noted. As a rule, persistent white dermographism is determined.

It should be noted that, despite a certain age sequence (phase) of changes in the clinical and morphological picture, in each specific patient, individual features of a particular form of atopic dermatitis may vary and be observed in different combinations. This depends both on the constitutional characteristics of the individual and on the nature of the impact of trigger factors. 

Diagnostics of atopic dermatitis in a child

Diagnosis of atopic dermatitis in children is usually straightforward and is based on the clinical picture of the disease: typical localization and morphology of skin rashes, itching, persistent recurrent course. However, there is currently no single and universally recognized standardized system for diagnosing atopic dermatitis.

Based on the criteria of JM Hanifin and G. Rajka (1980), the Atopic Dermatitis Working Group (AAAI) developed an algorithm for diagnosing atopic dermatitis (USA, 1989), which identifies mandatory and additional criteria, according to which three or more mandatory and three or more additional signs are required to make a diagnosis. In our country, this algorithm has not found wide application.

In the Russian National Program for Atopic Dermatitis in Children, the following signs are recommended for diagnosis in clinical practice.

Algorithm for the diagnosis of atopic dermatitis in children [Working Group on Atopic Dermatitis (AAAI), USA, 1989]

Mandatory criteria

Additional criteria

Itching of the skin. Typical morphology and localization of skin rashes (in children, eczematous skin rashes localized on the face and extensor surfaces of the limbs; in adults, lichenification and excoriations on the flexor surfaces of the limbs). Chronic relapsing course. Atopy in the anamnesis or hereditary predisposition to atopy

Xerosis (dry skin). Palmar ichthyosis. Immediate reaction to skin testing with allergens. Localization of the skin process on the palms and feet. Cheilitis. Nipple eczema. Susceptibility to infectious skin lesions associated with cellular immunity disorders. Onset of the disease in early childhood. Erythroderma. Recurrent conjunctivitis. Denier-Morgan's line (additional fold under the lower eyelid). Keratoconus (conical protrusion of the cornea). Anterior subcapsular cataracts. Cracks behind the ears. High levels of IgE in the blood serum

Research methods for diagnosis

• Collection of allergy history.
• Physical examination.
• Specific allergological diagnostics.
• Complete blood count.

Collecting an allergological anamnesis has its own peculiarities and requires skill, patience, and tact from the doctor. Particular attention should be paid to:

• family predisposition to atopy, allergic reactions;
• on the mother’s diet during pregnancy and lactation, consumption of highly allergenic foods;
• the nature of the parents’ work (work in the food and perfume industries, with chemical reagents, etc.);
• on the timing of introducing new types of food into the child’s diet and their connection with skin rashes;
• on the nature of skin manifestations and their connection with taking medications, flowering trees (herbs), communication with animals, being surrounded by books, etc.;
• on the seasonality of exacerbations;
• for the presence of other allergic symptoms (itching of the eyelids, sneezing, lacrimation, coughing, asthma attacks, etc.);
• for concomitant diseases of the gastrointestinal tract, kidneys, ENT organs, and nervous system;
• reactions to preventive vaccinations;
• on living conditions (increased dryness or humidity of the room, clutter with upholstered furniture, books, presence of animals, birds, fish, flowers, etc.);
• on the effectiveness of the treatment;
• to improve the child's condition outside the home, during hospitalization, climate change, or change of residence.

A carefully collected anamnesis helps to establish a diagnosis, as well as to clarify the etiology of the disease: the most likely trigger allergen(s), relevant factors.

Physical examination

During the examination, the child's appearance, general condition and well-being are assessed; the nature, morphology and localization of skin rashes, and the area of the lesion are determined. Of great importance are the skin color and the degree of its moisture/dryness in certain areas, dermographism (red, white or mixed), tissue turgor, etc.

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Specific allergological diagnostics

To assess the allergological status and establish the causal role of a particular allergen in the development of the disease, the following are used:

• outside of an exacerbation - performing skin tests in vivo using scarification or prick testing (micro-prick within the epidermis);
• in case of exacerbation (as well as in case of severe or continuously relapsing course) - laboratory diagnostic methods for determining the content of total IgE and specific IgE in the blood serum (ELISA, RIST, RAST, etc.). Provocative tests with allergens in children are carried out
• only by allergists for special indications due to the risk of developing severe systemic reactions. The elimination-provocation diet is a routine method of diagnosing food allergies.

To identify concomitant pathology, a set of laboratory, functional and instrumental studies is carried out, the choice of which is determined individually for each patient.

Laboratory and instrumental studies

Clinical blood test (a non-specific sign may be the presence of eosinophilia. In the case of a skin infectious process, neutrophilic leukocytosis is possible).

Determination of the concentration of total IgE in the blood serum (a low level of total IgE does not indicate the absence of atopy and is not a criterion for excluding the diagnosis of atopic dermatitis).

Skin tests with allergens (prick tests, scarification skin tests) are performed by an allergist and reveal IgE-mediated allergic reactions. They are performed in the absence of acute manifestations of atopic dermatitis in the patient. Taking antihistamines, tricyclic antidepressants and neuroleptics reduces the sensitivity of skin receptors and can lead to false negative results, so these drugs must be discontinued 72 hours and 5 days, respectively, before the expected date of the study.

The administration of an elimination diet and a provocative test with food allergens is usually carried out only by specialist doctors (allergists) in specialized departments or offices to identify food allergies, especially to cereals and cow's milk.

In vitro diagnostics are also carried out upon referral from an allergist and include the determination of allergen-specific antibodies to IgE in the blood serum, which is preferable for patients:

• with widespread skin manifestations of atopic dermatitis;
• if it is impossible to stop taking antihistamines, tricyclic antidepressants, neuroleptics;
• with questionable skin test results or in the absence of correlation between clinical manifestations and skin test results;
• with a high risk of developing anaphylactic reactions to a specific allergen when performing skin testing;
• for infants;
• in the absence of allergens for skin testing, and in the presence of allergens for in vitro diagnostics.

Diagnostic criteria for atopic dermatitis

Main criteria

• Itchy skin.
• Typical morphology of rashes and their localization:
• children in the first years of life - erythema, papules, microvesicles localized on the face and extensor surfaces of the extremities;
• older children - papules, lichenification of symmetrical areas of the flexor surfaces of the extremities.
• Early manifestation of the first symptoms.
• Chronic relapsing course.
• Hereditary burden of atopy.

Additional criteria (help to suspect atopic dermatitis, but are non-specific).

• Xerosis (dry skin).
• Immediate hypersensitivity reactions when tested with allergens.
• Palmar hyperlinearity and intensification of the pattern (“atopic” palms).
• Persistent white dermographism.
• Nipple eczema.
• Recurrent conjunctivitis.
• Longitudinal suborbital fold (Denny-Morgan line).
• Periorbital hyperpigmentation.
• Keratoconus (a conical protrusion of the cornea in its center).

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Differential diagnosis

Differential diagnosis of atopic dermatitis in children is carried out with diseases in which phenotypically similar skin changes occur:

• seborrheic dermatitis;
• contact dermatitis;
• scabies;
• microbial eczema;
• pink lichen;
• immunodeficiency diseases;
• hereditary disorders of tryptophan metabolism.

In seborrheic dermatitis, there is no hereditary predisposition to atopy, and no connection with the action of certain allergens can be traced. Skin changes are localized on the scalp, where, against the background of hyperemia and infiltration, accumulations of greasy, sebaceous scales appear, covering the head in the form of crusts; the same elements can be located on the eyebrows, behind the ears. In the natural folds of the skin of the trunk and limbs, hyperemia is observed with the presence of spotted papular elements covered with scales on the periphery. Itching is moderate or absent.

Contact dermatitis is associated with local skin reactions to various irritants. At the sites of contact with the relevant agents, erythema, severe connective tissue edema, urticarial or vesicular (rarely bullous) rashes occur. Skin changes are limited to those areas of the skin where contact occurred (e.g., "diaper" dermatitis).

Scabies is a contagious disease from the group of dermato-zoonoses (caused by the scabies mite Sarcoptes scabiei), which accounts for the greatest number of diagnostic errors. Scabies is characterized by paired vesicular and papular elements, scabies "passages", excoriations, erosions, serous-hemorrhagic crusts. As a result of scratching, linear rashes appear in the form of elongated and slightly protruding whitish-pink ridges with blisters or crusts at one end. The rashes are usually localized in the interdigital folds, on the flexor surfaces of the limbs, in the groin and abdominal area, palms and soles. In young children, the rashes are often located on the back and in the armpits.

Microbial (nummular) eczema is more often observed in older children and is caused by sensitization to microbial antigens (usually streptococcal or staphylococcal). Characteristic foci of erythema with clearly defined borders with scalloped edges, of a deep red color, are formed on the skin. Subsequently, abundant weeping develops in the foci with the formation of crusts on the surface. Serous "wells" and erosions are absent. The lesions are located asymmetrically on the anterior surface of the shins, the dorsum of the feet, in the navel area. Itching is moderate, a burning sensation and pain in the areas of the rash are possible. It is important to take into account the data on the presence of foci of chronic infection.

Pink lichen belongs to the group of infectious erythema and usually occurs against the background of acute respiratory infections, rarely occurs in young children. Skin changes are characterized by round pink spots 0.5-2 cm in diameter, located along the Langer "tension" lines on the trunk and limbs. In the center of the spots, dry folded scales are determined, framed by a red border along the periphery. Skin itching is expressed significantly. Pink lichen occurs cyclically, with exacerbations in spring and autumn.

Wiskott-Aldrich syndrome occurs in early childhood and is characterized by a triad of symptoms: thrombocytopenia, atopic dermatitis, recurrent gastrointestinal and respiratory infections. The disease is based on primary combined immune deficiency with predominant damage to the humoral component of immunity, a decrease in the B-lymphocyte population (CD19+).

Hyperimmunoglobulinemia E (Job's syndrome) is a clinical syndrome characterized by high levels of total IgE, atopic dermatitis, and recurrent infections. The disease debuts at an early age, when rashes appear that are identical to atopic dermatitis in localization and morphological features. With age, the evolution of skin changes is similar to that in atopic dermatitis, with the exception of lesions in the joint area. Subcutaneous abscesses, purulent otitis, pneumonia, candidiasis of the skin and mucous membranes often develop. High levels of total IgE are noted in the blood. Expression of T-lymphocytes (CD3+) and decreased production of B-lymphocytes (CD19+), an increase in the CD3+/CD19+ ratio are characteristic. Leukocytosis, an increase in ESR, and a decrease in the phagocytic index are found in the blood.

Hereditary disorders of tryptophan metabolism are represented by a group of diseases caused by genetic defects of enzymes involved in its metabolism. The diseases debut in early childhood and are accompanied by skin changes similar to atopic dermatitis in morphology and localization, sometimes seborrhea is observed. Age dynamics of clinical manifestations also proceeds similarly to atopic dermatitis. Itching of varying severity. Skin rashes are aggravated by the sun (photodermatosis). Neurological disorders (cerebellar ataxia, decreased intelligence, etc.), reactive pancreatitis, and intestinal malabsorption syndrome often develop. Eosinophilia, high levels of total IgE, imbalance in the total population of T-lymphocytes (CD3+) and cytotoxic T-lymphocytes (CD8+), and a decrease in the CD3+/CD8+ ratio are noted in the blood. For differential diagnosis, chromatography of amino acids in urine and blood is performed, and the level of kynurenic and xanthurenic acids is determined.

Although diagnostics and diagnosis of atopic dermatitis in children is not difficult, about 1/3 of children have pseudo-allergic reactions under the guise of the disease. In such cases, sometimes only time can put a final point in the diagnosis.

Pseudoallergic reactions are reactions in the development of which mediators of true allergic reactions (histamine, leukotrienes, complement activation products, etc.) participate, but the immune phase is absent. The occurrence of these reactions can be caused by:

• massive release of histamine and other biologically active substances that induce the release of preformed mediators from mast cells and basophils, which include medicinal substances (polyamines, dextran, antibiotics, enzyme preparations, etc.), products with high sensitizing potential, etc.;
• deficiency of the first component of complement and non-immunological activation of complement via the alternative properdin pathway (pathway C), which is activated by bacterial lipo- and polysaccharides and is the most important mechanism of anti-infective defense. This pathway can also be "triggered" by drugs, some endogenously formed enzymes (trypsin, plasmin, kallikrein);
• a disorder of polyunsaturated fatty acid (PUFA) metabolism, most often arachidonic acid. Analgesics (acetylsalicylic acid and its derivatives) can inhibit cyclooxygenase activity and shift the balance of PUFA metabolism towards the expression of leukotrienes, which is clinically manifested by edema, bronchospasm, skin rashes such as urticaria, etc.;
• disruption of the processes of inactivation and elimination of mediators from the body: in case of disruption of the function of the hepatobiliary system, gastrointestinal tract, kidneys, nervous system, in metabolic diseases (the so-called pathology of cell membranes).

Treatment of atopic dermatitis in a child

Complex treatment of atopic dermatitis in children should be aimed at suppressing allergic inflammation in the skin, reducing the impact of triggers and include diet therapy, environmental control measures, the use of systemic and local drugs, rehabilitation, non-drug methods, psychological assistance. The success of treatment is also determined by the elimination of concomitant diseases.

Monitoring environmental conditions

The nature of the measures taken largely depends on the detection of hypersensitivity to certain aeroallergens (house dust, epidermal allergens, mold fungi, plant pollen, etc.). It is necessary to completely eliminate or reduce contact with the listed agents (wet regular cleaning of premises, a minimum amount of upholstered furniture and books in the child's environment, special bed linen and its frequent change, no TV or computer in the room where the patient is located, etc.).

It is also important to provide for the elimination of non-specific factors that can provoke an exacerbation of the disease or maintain its chronic course (stress, intense physical activity, infectious diseases).

Drug treatment

Drug treatment of atopic dermatitis in children depends on the etiology, form, stage (period) of the disease, area of skin lesion, age of the child, degree of involvement of other organs and systems in the pathological process (comorbidities). Treatment requires high professional training from the doctor, close mutual understanding with the parents of small children (and then with the patients themselves, as they grow up), great patience, ability to compromise and communicate with doctors of other specialties, to be literally a "family doctor". There are drugs of systemic (general) action and means for external treatment.

Systemic pharmacological agents are used in combination or as monotherapy and include the following groups of drugs:

• antihistamines;
• membrane stabilizing;
• improving or restoring gastrointestinal function;
• vitamins;
• regulatory functions of the nervous system;
• immunotropic;
• antibiotics.

The use of antihistamines (AHP) is one of the effective and recognized directions in the treatment of atopic dermatitis in children, which is due to the important role of histamine in the mechanisms of disease development. AHP is prescribed for exacerbation of the disease and severe itching of the skin.

A distinctive feature of first-generation antihistamines is their easy penetration through the blood-brain barrier and a pronounced sedative effect, so they are used in the acute period, but it is inappropriate to prescribe them to schoolchildren.

Second-generation antihistamines do not penetrate the blood-brain barrier and have a weak sedative effect. Compared to first-generation drugs, they have a more pronounced affinity for H2 receptors, which ensures a rapid onset of action and a long-term therapeutic effect. In addition, they inhibit the early and late phases of an allergic reaction, reduce platelet aggregation and the release of leukotrienes, providing a combined antiallergic and anti-inflammatory effect.

Third generation drugs include Telfast, which is approved for use only in children over 12 years of age.

Membrane stabilizers - ketotifen, cetirizine, loratadine, cromoglycic acid (sodium cromoglycate) - represent a group of drugs that have a complex inhibitory effect on the mechanisms of development of allergic inflammation, and are prescribed in the acute and subacute periods of the disease.

Ketotifen, cetirizine, loratadine have antagonism to H2-histamine receptors, suppress the activation of mast cells in vitro, inhibit the process of allergy mediators release from mast cells and basophils, inhibit the development of allergic inflammation and have other effects that suppress allergic reactions. The clinical effect of these drugs begins to develop after 2-4 weeks, so the minimum course of treatment is 3-4 months.

Oral antihistamines

Name of the drug		Release form	Doses and frequency of administration
INN	Trading
Mebhydrolin	Diazolin	Tablets 0.05 and 0.1 g	Up to 2 years: 50-150 mg/day; 2-5 years: 50-100 mg/day, 5-10 years: 100-200 mg/day
Cyproheptadine	Peritol	Tablets 0.004 g Syrup (1 ml = 0.4 mg)	From 6 months to 2 years (for special indications!): 0.4 mg/(kg x day); from 2 to 6 years: up to 6 mg/day; from 6 to 14 years: up to 12 mg/day; 3 times a day
Chloropyramine	Suprastin	Tablets 0.025 g	Up to 1 year: 6.25 mg (1/4 tablet), from 1 to 6 years: 8.3 mg (1/3 tablet), from 6 to 14 years: 12.5 mg (1/2 tablet); 2-3 times a day
Clemastine	Tavegil	Tablets 0.001 g	From 6 to 12 years: 0.5-1.0 mg; children > 12 years: 1.0; 2 times a day
Dimethindene	Fenistil	Drops (1 ml = 20 drops = = 1 mg) Capsules 0.004 g	From 1 month to 1 year: 3-10 drops; 1-3 years: 10-15 drops; 4-11 years: 15-20 drops; 3 times a day. Children >12 years: 1 capsule per day
Hifenadine	Fenkarol	Tablets 0.01 and 0.025 g	Up to 3 years: 5 mg; 3-7 years: 10-15 mg; children >7 years: 15-25 mg; 2-3 times a day
Ketotifen	Zaditen Ketof Astafen	Tablets 0.001 g Syrup (1 ml = 0.2 mg)	From 1 year to 3 years: 0.0005 g, children >3 years: 0.001 g; 2 times a day
Cetirizine	Zyrtec	Tablets 0.01 g Drops (1 ml = 20 drops = 10 mg)	Children >2 years: 0.25 mg/kg, 1-2 times daily
Loratadine	Claritin	Tablets 0.01 g Syrup (5 ml = 0.005 g)	Over 2 years and body weight less than 30 kg: 5 mg; children weighing over 30 kg: 10 mg once a day
Fexofenadine	Telfast	Tablets 0.120 and 0.180 g	Children over 12 years old: 0.120-0.180 g once a day

Cromoglycic acid (sodium cromoglycate, nalcrom) prevents the development of the early phase of an allergic response by blocking the release of biologically active substances from mast cells and basophils. Nalcrom has a direct and specific effect on lymphocytes, enterocytes and eosinophils of the gastrointestinal mucosa, preventing the development of allergic reactions at this level. Nalcrom is prescribed in combination with antihistamines. The duration of the course is usually from 1.5 to 6 months, which ensures the achievement of stable remission and prevents the development of relapses of the disease.

Medicines that improve or restore the functions of the digestive organs are prescribed in the acute and subacute periods of atopic dermatitis, taking into account the identified changes in the gastrointestinal tract. To improve the processes of digestion and breakdown of food substances, correct functional disorders of the gastrointestinal tract, enzymes are used: festal, enzistal, digestal, pancreatin (mezim-forte, pancreatin, pancitrate), panzinorm, etc., as well as choleretic agents: corn silk extract, allochol, rosehip extract (holosas), hepabene, etc., the course of treatment is 10-14 days. For dysbacteriosis, eu-, pre- or probiotics are prescribed: baktisubtil, biosporin, enterol, bifidobacteria bifidum (bifidumbacterin) and intestinal bacteria (colibacterin), linex, bificol, hilak-forte, bifiform, etc., usually the course of treatment with these drugs is 2-3 weeks.

Vitamins increase the effectiveness of treatment of atopic dermatitis in children. Calcium pantothenate (vitamin B15) and pyridoxine (vitamin B6) accelerate the processes of reparation in the skin, restoration of the functional state of the adrenal cortex and liver. (Beta-Carotene increases the resistance of membranes to the action of toxic substances and their metabolites, stimulates the immune system, regulates lipid peroxidation.

Up to 80% of patients need medications that regulate the functional state of the nervous system, but they should be prescribed by a neurologist or psychologist. Sedatives and hypnotics, tranquilizers, neuroleptics, nootropics, medications that improve cerebrospinal fluid and hemodynamics are used: vinpocetine (cavinton), actovegin, piracetam (nootropil, piracetam), vasobral, cerebrolysin, cinnarizine, pyritinol (encephabol), etc.

Immunomodulatory treatment is indicated only in cases where atopic dermatitis in children occurs in combination with clinical signs of immune deficiency. Uncomplicated atopic dermatitis does not require the use of immunomodulators.

Systemic antibacterial treatment is used for atopic dermatitis complicated by pyoderma. Before prescribing drugs, it is advisable to determine the sensitivity of microflora to antibiotics. In empirical treatment, preference is given to the use of macrolides, cephalosporins of the first and second generations, lincomycin, aminoglycosides.

Systemic glucocorticoids (GC) are used extremely rarely and only in particularly severe cases of the disease, in a hospital setting: in a short course (5-7 days) at a dose of 0.8-1.0 mg/kg/day).

One should not forget about the treatment of concomitant pathology: sanitation of foci of chronic infection (oral cavity, ENT organs, intestines, biliary tract, genitourinary system), treatment of parasitic infections (giardiasis, helicobacteriosis, toxocariasis, enterobiasis), etc.

External use products. The leading place is occupied by external treatment, the goals of which are:

• suppression of signs of skin inflammation and associated main symptoms of atopic dermatitis in children;
• elimination of dry skin;
• prevention and elimination of skin infections;
• restoration of damaged epithelium;
• improving the skin's barrier functions.

Depending on the phase of atopic dermatitis in children, anti-inflammatory, keratolytic, keratoplastic, antibacterial drugs and skin care products are used.

Anti-inflammatory drugs (AIDs) for external use are divided into 2 large groups: non-hormonal and containing glucocorticoids.

Non-hormonal PVAs have long been widely used in the treatment of atopic dermatitis in children: these are preparations containing tar, naphthalene oil, zinc oxide, papaverine, retinol, ASD fraction (Dorogov's antiseptic stimulator, fraction 3). They are indicated for mild and moderate forms of the disease in children, starting from the first months of life; they are well tolerated, can be used for a long time, and do not cause side effects. Vitamin F 99 cream and pimecrolimus (elidel) are also used. With minimal clinical manifestations of atopic dermatitis in children, local antihistamines are prescribed [dimethindene (fenistil), 0.1% gel].

Topical glucocorticoids are effective in treating both acute and chronic manifestations of atopic dermatitis in children, but are never prescribed for prophylaxis.

The anti-inflammatory effect of GC is associated with the immunoregulatory effect on cells responsible for the development and maintenance of allergic inflammation of the skin (Langerhans cells, lymphocytes, eosinophils, macrophages, mast cells, etc.), as well as with the vasoconstrictor effect on the blood vessels of the skin, reducing swelling.

Mechanisms of anti-inflammatory activity of topical glucocorticoid drugs:

• activation of histaminase and the associated decrease in the level of histamine in the inflammation site;
• decreased sensitivity of nerve endings to histamine;
• increased production of lipocortin protein, which inhibits the activity of phospholipase A, which reduces the synthesis of mediators of allergic inflammation (leukotrienes, prostaglandins) from cell membranes;
• decreased activity of hyaluronidase and lysosomal enzymes, which reduces the permeability of the vascular wall and the severity of edema.

The potential activity of topical GC depends on the structure of their molecule and the strength of binding to glucocorticoid receptors that transport it into the cell. This allows us to classify a particular local GC into the class of weak (hydrocortisone), medium [betamethasone (Betnovate), bismuth subgallate (Dermatol), etc.], strong [methylprednisolone aceponate (Advantan), betamethasone in the form of dipropionate (Beloderm), Lokoid, mometasone (Elocom), triamcinolone (Fluorocort), betamethasone (Celestoderm), etc.], very strong [clobetasol (Dermovate)] preparations.

In pediatric practice, the latest generation of external GCs are used: methylprednisolone aceponate (Advantan), mometasone (Elocom), hydrocortisone (locoid-hydrocortisone 17-butyrate).

These topical GCs are highly effective and safe, have minimal side effects and can be used once a day, including in young children. A course of treatment with these drugs can last from 14 to 21 days, although in most cases it is limited to 3-5 days.

To eliminate dry skin - one of the most common symptoms of atopic dermatitis in children - it is necessary to follow a number of simple rules: ensure sufficient humidity in the room where the child is, observe hygiene rules. For example, it is not justified to prohibit bathing children, especially during an exacerbation of the disease.

In case of skin infection with staphylococci and streptococci, external agents containing antibiotics are prescribed: erythromycin, lincomycin (3-5% paste), fucorcin, brilliant green (1-2% alcohol solution) and methylthionium chloride (5% aqueous solution of methylene blue), ready-made forms of external antibiotics. The frequency of their use is usually 1-2 times a day. In case of severe pyoderma, systemic antibiotics are additionally prescribed.

For fungal infections, external antifungal drugs are used: creams isoconazole (Travogen), ketoconazole (Nizoral), natamycin (Pimafucin), clotrimazole, etc.

When a bacterial and fungal infection is combined, combination drugs containing antimicrobial components and GC are used: Triderm, Celestoderm-B with Garamycin, etc.

To improve microcirculation and metabolism in the affected areas, ointments containing actovegin or sodium heparin are used, as well as applications of ozokirite, liquid paraffin, clay, and sapropel.

For deep cracks and ulcerative skin lesions, agents are prescribed that improve skin regeneration and restore damaged epithelium: dexpanthenol (bepanten), solcoseryl, ointments with vitamin A.

Physiotherapy

Physiotherapy in the acute period includes such methods as electrosleep, dry carbon baths, alternating magnetic field, and in the period of remission - balneotherapy and mud therapy.

Rehabilitation and psychological assistance

Rehabilitation measures significantly increase the effectiveness of staged treatment of patients with atopic dermatitis. The healing properties of radon, sulfur and sulfide waters have long been used for spa treatment (Belokurikha, Yeysk, Matsesta, Pyatigorsk, Priebrusye, Goryachiy Klyuch, etc.). Specialized sanatoriums for children with atopic dermatitis operate successfully: "Lake Shira" (Krasnoyarsk Territory), "Krasnousolsky" (Bashkortostan), "Lake Savatikova" (Republic of Tuva), "Ust-Kachka" (Perm Region), "Mayan" (Sverdlovsk Region), "Tutalsky" (Kemerovo Region), "Lenin Rocks" (Pyatigorsk), etc.

The child's environment plays a huge role in creating the right psychological climate, restoring the emotional state, cortical neurodynamics, and correcting vegetative disorders, so psychological assistance should concern both the child and his parents.

Prevention

Primary prevention consists of preventing the child's sensitization, especially in families with a hereditary predisposition to atopy. It is carried out before and during pregnancy, during lactation and concerns dietary restrictions, caution in the use of drugs, reducing contacts with inhaled allergens, etc.

Secondary prevention is the prevention of manifestation of atopic dermatitis and its exacerbations in a sensitized child. The higher the risk of atopy development in a particular child, the more categorical the elimination measures should be: exclusion of products with a high sensitizing potential, reduction of the level of exposure to aeroallergens, exclusion of contacts with pets, etc.

It should be emphasized that atopic dermatitis in children is not a contraindication to vaccination. Vaccination may be postponed for the period of acute manifestations and in case of pyogenic complications. In other cases, vaccination is carried out in full, necessarily against the background of accompanying treatment, depending on the form, severity and clinical picture of the disease.

The key to success in preventing exacerbations of the disease and treating children suffering from atopic dermatitis is continuity in the activities of various specialists - pediatricians, allergists, dermatologists, immunologists. However, without the help of parents of sick children, their understanding of the problem, it is impossible to achieve good results in controlling the disease. For the training of patients with atopic dermatitis and their family members, there are special programs implemented in family counseling departments.

The main areas of the educational program for patients with atopic dermatitis and their family members:

• informing the patient and his relatives about the disease and possible factors that support the chronic course of atopic dermatitis in children (carried out after examining the patient);
• nutritional correction: balanced, complete nutrition with an established and controlled regime;
• recommendations for detoxification (enterosorbents, rice sorption, regulation of intestinal activity, etc.);
• correction of identified neurovertebral dysfunctions (massage, manual therapy, exercise therapy, etc.);
• skin care tips with a list of topical preparations and indications for their use;
• differentiated psychological assistance to the family. The complex use of preventive, therapeutic and rehabilitation measures allows to reduce the incidence of atopic dermatitis and improve the quality of life of sick children.

Primary prevention

Prevention of atopic dermatitis in children should be carried out before the birth of the child in the antenatal period (antenatal prevention) and continued after the birth of the child (postnatal prevention).

[ 36 ], [ 37 ], [ 38 ], [ 39 ], [ 40 ]

Antenatal prophylaxis

High antigen loads (toxicosis of pregnancy, irrational use of medications, exposure to professional allergens, one-sided carbohydrate diet, abuse of products with obligate food allergens, etc.) significantly increase the risk of developing atopic dermatitis. Elimination of these factors is an important stage in the prevention of atopic dermatitis. Pregnant women with a burdened heredity for allergies and especially if they have one should exclude or limit as much as possible contacts with any (food, household, professional) allergens.

[ 41 ], [ 42 ], [ 43 ], [ 44 ], [ 45 ]

Postnatal prevention

In the early postnatal period, it is necessary to limit newborns from excessive intake of medications and early artificial feeding, which lead to stimulation of IgE synthesis. An individual diet is necessary not only for the child, but also for the breastfeeding mother. A newborn with risk factors for the development of atopic dermatitis requires proper skin care, normalization of the gastrointestinal tract (GIT), organization of rational nutrition with an explanation of the need for breastfeeding, rational introduction of complementary foods, as well as compliance with recommendations for a hypoallergenic regimen.

Of no small importance in the prevention of atopic dermatitis in children is compliance with such factors as:

• avoid smoking during pregnancy and in the house where the child is;
• avoiding contact between pregnant women and young children and pets;
• reducing children's exposure to household chemicals;
• prevention of acute respiratory viral and other infectious diseases.

Primary prevention of atopic dermatitis in children is possible provided there is close continuity in the work of a pediatrician, obstetrician-gynecologist, allergist and dermatologist.

Secondary prevention

A mother's adherence to a hypoallergenic diet while breastfeeding a child suffering from atopic dermatitis can reduce the severity of the disease. The mother's intake of Lactobacillus sp. during pregnancy and lactation, as well as enrichment of the child's diet with them in the first six months of life, reduces the risk of early development of atopic diseases in predisposed children. If exclusive breastfeeding is not possible in the first months of life, the use of hypoallergenic mixtures (hydrolysates - complete or partial) is recommended for predisposed children.

Tertiary prevention

It consists in preventing the recurrence of existing symptoms of atopic dermatitis and timely therapy of developed exacerbations. Data concerning the effect of elimination measures (use of special bedding and mattress covers, vacuum cleaners for cleaning, acaricides) on the course of atopic dermatitis are contradictory, however, 2 studies confirmed a significant reduction in the severity of atopic dermatitis symptoms in children with sensitization to house dust mites with a decrease in the concentration of mites in the environment.

Forecast

According to various data, complete clinical recovery occurs in 17-30% of patients. In most patients, the disease continues throughout life. Unfavorable prognostic factors: atopic diseases (especially bronchial asthma) in the mother or both parents, the onset of persistent skin rashes before the age of 3 months, a combination of atopic dermatitis with vulgar ichthyosis, a combination of atopic dermatitis with persistent infection (parasitic, viral, bacterial, etc.), unfavorable psychological environment in the family (children's group), lack of faith in recovery.

[ 46 ], [ 47 ]