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 the rashes and staging.

Disease in typical cases begins in early childhood, can continue or recur in adulthood, significantly impairs the quality of life of the patient and his family members.

[1], [2], [3]

Epidemiology

Atopic dermatitis occurs in all countries, in people of 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 60's, the prevalence of atopic dermatitis was not more than 3% (Ellis C. Et al., 2003). To date, the prevalence of atopic dermatitis in the US children's population has reached 17.2%, in children in Europe - 15.6%, and in Japan - 24%, reflecting a steady increase in the frequency of atopic dermatitis in the last three decades.

The prevalence of symptoms of atopic dermatitis was 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 frequent manifestation of atopy and is detected in 80-85% of young children with allergies, and in recent years there has been a trend towards a more severe clinical course of atopic dermatitis with a change in its pathomorphism.

• In a significant part of children, the disease runs chronically until puberty.
• An earlier manifestation (in 47% of cases, atopic dermatitis in children manifests itself immediately after birth or in the first 2 months of life).
• A certain evolution of the symptoms of the disease with the expansion of the skin lesion area, 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, formed 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 (and it manifests itself primarily in the first year of life of the child); 59% - if only one parent has atopic dermatitis and the other has an allergic pathology of the respiratory tract, 56% - if only one parent has an allergy, 42% - if the relatives of the first line have atopic manifestations.

[4], [5], [6], [7], [8], [9], [10],

Causes of the atopic dermatitis in a child

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

[11],

Symptoms of the atopic dermatitis in a child

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

The prevalence of the skin process

The prevalence is estimated as a percentage of the area of the affected surface (rule of nine). The process should be considered limited if the foci do not exceed 5% of the surface and are localized in one of the regions (the rear of the hands, wrist joints, elbows or popliteal fossae, etc.). Outside the lesion, the skin is usually not changed. Itching is mild, with rare attacks. 

The process is considered to be 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 the transition to the skin of the forearms, wrist joints and brushes, etc.) and spread to adjacent parts of the limbs , chest and back. Outside the lesion, the skin is dry, has an earthy-gray hue, often with a pungent or finely flaked peeling. Itching is intense.

Diffuse atopic dermatitis in children is the most severe form of the disease, characterized by the defeat of almost the entire surface of the skin (with the exception of the palms and nasolabial triangle). In the pathological process, the skin of the abdomen, inguinal and gluteal folds are involved. Itching can be expressed so intensely that it leads to scalping of the skin by the patients themselves.

[12], [13], [14], [15], [16], [17], [18]

Severity of disease course

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

For an easy degree, insignificant hyperemia, exudation and flaking, single papule-vesicle elements, weak itching of skin integuments, an increase in the lymph nodes to the size of a pea are characteristic. The frequency of exacerbations is 1-2 times a year. The duration of remission is 6-8 months.

Atopic dermatitis in children of moderate severity, multiple lesions with marked exudation, infiltration or lichenification are observed on the skin; excoriation, hemorrhagic crusts. Itching is mild or severe. Lymph nodes are enlarged to the size of hazelnut or beans. The frequency of exacerbations is 3-4 times a year. The duration of remission is 2-3 months.

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

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

Subjective symptoms can be reliably estimated in children older than 7 years and provided that the parents and the patient understand the principle of evaluation.

Clinico-etiological variants of atopic dermatitis in children

Clinical etiological variants of atopic dermatitis in children are distinguished on the basis of anamnesis, clinical course features, and results of allergological examination. Revealing the cause-significant allergen makes it possible to understand the patterns of the disease in a particular child and to carry out appropriate elimination activities.

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

With tick sensitization, the disease is characterized by a severe continuously recurrent course, year-round exacerbations and increased skin itching at night. Improvement of the condition is observed when contact with mites of house dust ceases: change of place of residence, hospitalization. Elimination diet does not give a pronounced effect.

In fungal sensitization, exacerbations of atopic dermatitis in children are associated with the ingestion of food products contaminated with spores of fungi, or products in the process of manufacturing which use mold fungi. Aggravation is also promoted by dampness, the presence of mold in living quarters, the prescription of antibiotics. For fungal sensitization is characterized by a heavy current with exacerbations in autumn and winter.

Pollen sensitization causes exacerbation of the disease in the midst of flowering trees, grasses or weeds; but can also be observed when eating food allergens having common antigenic determinants with pollen of trees (so-called cross-allergy). Seasonal exacerbations of atopic dermatitis are usually combined with classical manifestations of pollinosis (laryngotracheitis, rhinoconjunctival syndrome, exacerbations of bronchial asthma), but can also proceed in isolation.

In some cases, the development of atopic dermatitis in children is due to epidermal sensitization. In such cases, the disease worsens when the child comes into contact with domestic animals or animal wool products and is often combined with allergic rhinitis.

It should be borne in mind that "pure" variants of fungal, tick-borne and pollen sensitization are rare. Usually it is a question of the predominant role of one or another type of allergen.

[19]

Stages

The classification of atopic dermatitis was developed by a working group of pediatric specialists on the basis of the diagnostic system SCORAD (scoring of atopic dermatitis) in accordance with ICD-10 and is presented in the National Scientific and Practical Program on 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	Gravity of the current	Clinical etiological variants
Initial stage. Stage of pronounced changes (period of exacerbation): acute phase; chronic phase. Stage of remission: incomplete (subacute period); complete. Clinical recovery	Infant . Children's. Teenager	Limited . Spread out. Diffuse	Lung. Medium heavy. Heavy	With the predominance of: food, tick-borne, fungal, pollen, allergies, etc.

Distinguish the following stages of the disease:

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

The initial stage develops, as a rule, in the first year of life. The most common early symptoms of skin lesions are flushing and swelling of the cheeks with light peeling. At the same time, gneiss (seborrheic scales around the large fontanel, eyebrows and behind the ears), "dairy scab" (crusta lacteal, limited hyperemia of the cheeks with yellowish brown crusts like melted milk), transitory (transitory) erythema on the cheeks and buttocks can be observed.

Stage of pronounced changes, or 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 is an acute and chronic phase of development. The main symptom of the acute phase of the disease is microveiculation with the subsequent appearance of crusts and peeling in a certain sequence: erythema -> papules -> vesicles -> erosions -> crusts -> peeling. The appearance of lichenization (dryness, thickening and strengthening of the skin pattern) indicates the chronic phase of atopic dermatitis, and the sequence of skin changes looks as follows: papules -> peeling -> excoriation -> lichenization. However, in some patients the typical alternation of clinical symptoms may be absent.

The remission period, or subacute stage, is characterized by disappearance (complete remission) or a decrease (incomplete remission) of the 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).

[20], [21], [22], [23],

Forms

Clinical symptoms of atopic dermatitis in children largely depend on the age of patients, in connection with which there are three forms of the disease:

1. infantile, characteristic for children under 3 years;
2. children's - for children 3-12 years;
3. adolescent, observed in adolescents 12-18 years.

The adult form is usually identified with diffuse neurodermatitis, although it can 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 cheeks in the form of a dairy scrotal (crusta lacteal), serous papules and microvesicles, erosion in the form of a serous "well" (spongiosis). In the future - peeling (parakeratosis)	Cheeks, forehead, extensor surfaces of the limbs, scalp, ears
6-18 months	Edema, hyperemia, exudation	Mucous membranes: nose, eye, vulva, foreskin, digestive tract, respiratory and urinary tract
1,5-3 years	Strofululus (draining papules). Sealing of the skin and its dryness, strengthening of normal pattern - lichenization (lichenification)	Bending surfaces of extremities (more often elbows folds and popliteal fossae, less often - lateral surface of the neck, feet, wrists)
Older than 3-5 years	Formation of the neurodermatitis, ichthyosis	Bending surfaces of extremities

Infant form

Characteristic features of this form are hyperemia and puffiness of the skin, microvesicles and micro-papules, pronounced exudation. The dynamics of skin changes is as follows: exudation -> serous "wells" -> peelings peeling -> cracks. Most of the foci are located in the face (except the nasolabial triangle), extensor (external) surface of the upper and lower extremities, less often - in the area of the elbows, popliteal pits, wrists, buttocks, trunk. Itching of the skin even in infants can be very intense. Most patients have red or mixed dermographism.

[24], [25]

Children's uniform

It is characterized by hyperemia / erythema and edema of the skin, the appearance of lichenification areas; can be observed papules, plaques, erosion, excoriation, crusts, cracks (especially painful when placed on the palms, fingers and soles). The skin is dry with a lot of small- and large-plate (scabby) scales. Skin changes are localized mainly on the flexural (internal) surfaces of the hands and feet, the rear of the hands, the anterolateral surface of the neck, in the elbows and popliteal pits. Often observed hyperpigmentation of the eyelids (as a result of combing) and a characteristic fold of the skin under the lower eyelid (the Denier-Morgan line). Children are concerned about the itching of varying intensity, leading to a vicious cycle: itching -> calculus -> rash -> itching. Most children have white or mixed dermographism.

[26], [27], [28], [29]

Teenager's uniform

Characterized by the presence of large slightly shiny lichenoid papules, pronounced lichenification, a lot of excoriations and hemorrhagic crusts in lesions that are located on the face (around the eyes and in the mouth), neck (in the form of "decollete"), elbows, around the wrists and on the back the surface of the hands, under the knees. There are severe itching, sleep disturbance, neurotic reactions. As a rule, stable white dermographism is determined.

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

Diagnostics of the atopic dermatitis in a child

Diagnosis of atopic dermatitis in children usually does not cause difficulties and is based on the clinical picture of the disease: typical localization and morphology of skin rashes, itching, persistent recurrent course. However, at present there is 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), where mandatory and additional criteria are singled out, according to which three and more binding and three or more additional features. In our country this algorithm has not found wide application.

In the Russian national program on atopic dermatitis in children, it is recommended to take into account the following signs for diagnosis in clinical practice.

Algorithm for diagnosing atopic dermatitis in children [Atopic Dermatitis Working Group (AAAI), USA, 1989]

Required 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 - lichenization and excoriation on the flexor surfaces of the limbs). Chronic recurrent course. Atopy in history or hereditary predisposition to atopy

Xerosis (dry skin). Palmar ichthyosis. Reaction of immediate type in skin testing with allergens. Localization of the skin process on the palms and feet. Heilit. Eczema of the nipples. Susceptibility to infectious skin lesions associated with impaired cellular immunity. The onset of the disease in early childhood. Erythroderma. Recurrent conjunctivitis. The Denier-Morgan line (an additional fold below the lower eyelid). Keratoconus (conical protrusion of the cornea). Anterior subcapsular cataracts. Cracks behind the ears. High IgE level in serum

Research methods for diagnosis

• Collecting allergological anamnesis.
• Physical examination.
• Specific allergological diagnosis.
• General blood analysis.

Collecting an allergic medical history has its own characteristics and requires a doctor's skill, patience, tact. Particular attention should be paid to:

• on family predisposition to atopy, allergic reactions;
• on the nature of the mother's nutrition during pregnancy and lactation, the use of highly allergenic foods;
• on the nature of the work of parents (work in the food, perfume industry, chemical reagents, etc.);
• on the timing of the introduction into the diet of the child of new types of food and their relationship to skin rashes;
• on the nature of skin manifestations and their relationship with taking medication, blossoming trees (herbs), communicating with animals, finding themselves surrounded by books, etc .;
• on seasonality of exacerbations;
• on the presence of other allergic symptoms (itchy eyelids, sneezing, tears, coughing, attacks of suffocation, etc.);
• on concomitant diseases of the digestive tract, kidneys, ENT organs, nervous system;
• on reactions to preventive vaccinations;
• for living conditions (increased dryness or humidity of the room, cluttering with soft furniture, books, the presence of animals, birds, fish, flowers, etc.);
• on the effectiveness of the treatment;
• to improve the state of the child outside the home, with hospitalization, climate change, change of residence.

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

Physical examination

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

[30], [31], [32], [33]

Specific allergological diagnosis

To assess the allergic status and establish the causative role of an allergen in the development of the disease apply:

• Outside exacerbation - the in vivo skin test is performed by scarification or prick-test (micro-incision within the epidermis);
• with exacerbation (as well as with severe or continuously recurrent flow) - laboratory diagnostic methods to determine the total IgE and specific IgE in the blood serum (ELISA, RIST, RAST, etc.). Provocative tests with allergens in children are conducted
• only allergists for special indications because of the danger of developing severe systemic reactions. Elimination-provocative diet is an everyday method of diagnosing food allergy.

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

Laboratory and instrumental research

Clinical analysis of blood (a nonspecific sign may be the presence of eosinophilia. In case of a skin infection, neutrophilic leukocytosis is possible).

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

Skin tests with allergens (prik test scarification skin tests) are conducted by an allergist, identify IgE-mediated allergic reactions. They are carried out in the absence of acute manifestations of atopic dermatitis in the patient. Taking antihistamines, tricyclic antidepressants and antipsychotics reduces the sensitivity of skin receptors and can lead to false negative results, so these drugs must be canceled for 72 hours and 5 days, respectively, before the expected study period.

The purpose 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 cereals and cow's milk.

Diagnosis in vitro is also conducted in the direction of an allergist and includes the detection of allergen-specific antibodies to IgE in serum, which is preferred for patients:

• with widespread skin manifestations of atopic dermatitis;
• if it is impossible to cancel the antihistamines taken. Tricyclic antidepressants, neuroleptics;
• with doubtful results of skin tests or in the absence of correlation of clinical manifestations and results of skin tests;
• with a high risk of developing anaphylactic reactions to a certain allergen during skin testing;
• for infants;
• in the absence of allergens for skin testing, if any, for in vitro diagnostics .

Diagnostic criteria of atopic dermatitis

Main criteria

• Itching of the skin.
• A typical morphology of the rashes and their localization:
• children of the first years of life - erythema, papules, microvesicles with localization on the face and extensor surfaces of the limbs;
• children of older age - papules, lichenification of symmetrical segments of flexor surfaces of extremities.
• Early manifestation of the first symptoms.
• Chronic recurrent course.
• Hereditary burdens on atopy.

Additional criteria (help to suspect atopic dermatitis, but are nonspecific).

• Xerosis (dry skin).
• Immediate-type hypersensitivity reactions when tested with allergens.
• Palmar hyperlaneity and reinforcement of the drawing ("atopic" palms).
• Persistent white dermographism.
• Eczema of the nipples.
• Recurrent conjunctivitis.
• Longitudinal suborbital fold (Denny-Morgan line).
• Periorbital hyperpigmentation.
• Keratoconus (conical protrusion of the cornea at its center).

[34], [35], [36]

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.

With seborrheic dermatitis there is no hereditary predisposition to atopy, nor is there a link with the action of certain allergens. Skin changes are localized on the scalp, where on the background of hyperemia and infiltration there are accumulations of fatty sebaceous scales 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 extremities, there is hyperemia with the presence of spottypopular elements covered with scales on the periphery. Itching is mild or absent.

Contact dermatitis is associated with local skin reactions to various stimuli. In places of contact with agents, there are erythema, pronounced edema of connective tissue, urticarous or vesicular (rarely bullous) rashes. Skin changes are limited to those areas of skin where contact has occurred (for example, "diaper" dermatitis).

Scabies is a contagious disease from the dermato-zoonotic group (caused by the scabies Sarcoptes scabieï), which accounts for the greatest number of diagnostic errors. When scabies identify paired vesicular and papular elements, scabies "moves", excoriation, erosion, serous-hemorrhagic crusts. Due to the calculations, linear eruptions occur in the form of elongated and slightly protruding whitish-pink rolls with bubbles or crusts at one end. Eruptions are usually localized in the interdigital folds, on the flexor surfaces of the extremities, in the groin and abdominal areas, palms and soles. In infants, rashes are often located on the back and in the armpits.

Microbial (numular) eczema is more often observed in older children and is caused by sensitization to microbial antigens (more often streptococcal or staphylococcal). On the skin, characteristic foci of erythema with clearly defined borders with scalloped edges, rich red color are formed. Subsequently, abundant wetness develops in the foci, with the formation of crusts on the surface. There are no serous "wells" and erosion. The lesions are located asymmetrically on the front surface of the shins, the back of the feet, in the navel. Itching is mild, there may be a burning sensation and pain in the rash. 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 arises against the background of ARI, it is rare in young children. Skin changes are characterized by round spots of pink color with a diameter of 0.5-2 cm, located along the lines of "tension" of the Langer on the trunk and extremities. In the center of the spots, dry folded scales are defined, framed by a red border around the periphery. The itching of the skin is expressed significantly. Pink lichen flows cyclically, with exacerbations in the spring and autumn.

Wiskott-Aldrich syndrome occurs at an early age and is characterized by a triad of symptoms: thrombocytopenia, atopic dermatitis, recurrent gastrointestinal and respiratory infections. At the heart of the disease is the primary combined immune deficiency with a predominant lesion of the humoral link of immunity, a decrease in the population of B-lymphocytes (CD19 +).

Hyperimmunoglobulinemia E (Joba syndrome) is a clinical syndrome characterized by a high level of total IgE, atopic dermatitis, and recurrent infections. The debut of the disease occurs at an early age, when rashes appear that are identical to atopic dermatitis by localization and morphological features. With age, the evolution of skin changes is similar to that of atopic dermatitis, with the exception of lesions in the joint region. Often develop subcutaneous abscesses, purulent otitis media, pneumonia, candidiasis of the skin and mucous membranes. In the blood there is a high level of total IgE. Characteristic expression of T-lymphocytes (CD3 +) and a decrease in the production of B-lymphocytes (CD19 +), an increase in the ratio of CD3 + / CD19 +. In the blood there is leukocytosis, an increase in ESR, a decrease in the phagocytic index.

Hereditary disorders of tryptophan metabolism are represented by a group of diseases that are caused by genetic defects of enzymes involved in its metabolism. Diseases debut in early childhood and are accompanied by skin changes that are similar to atopic dermatitis in morphology and localization, sometimes there is seborrhea. The age-related dynamics of clinical manifestations also proceed similar to atopic dermatitis. Itching of varying severity. Skin eruptions are exacerbated in the sun (photodermatosis). Often develop neurological disorders (cerebellar ataxia, decreased intelligence, etc.), reactive pancreatitis, a syndrome of intestinal absorption. Eosinophilia, a high level of total IgE, an imbalance in the general population of T-lymphocytes (CD3 +) and cytotoxic T-lymphocytes (CD8 +), a decrease in the CD3 + / CD8 + ratio are noted in the blood. For differential diagnosis, the chromatography of the amino acids of urine and blood is carried out, the determination of the level of kinurenic and xanthurenic acids.

Although the diagnosis and diagnosis of atopic dermatitis in children does not cause difficulties, about 1/3 of children under the guise of the disease are pseudo-allergic reactions. In such cases, sometimes only time can put the final point in the diagnosis.

Pseudoallergic refers to reactions in the development of which mediators of true allergic reactions (histamine, leukotrienes, complement activation products, etc.) participate, but there is no immune phase. The occurrence of these reactions may be due to:

• massive release of histamine and other biologically active substances inducing the liberation (release) of preformed mediators from mast cells and basophils, which include drugs (polyamines, dextran, antibiotics, enzyme preparations, etc.), products with a high sensitizing potential, etc .;
• deficiency of the first complement component and non-immunological activation of complement on the alternative promperin pathway (path C), which is activated by bacterial lipo and polysaccharides and is the most important mechanism of anti-infective protection. This pathway can also be "triggered" by drugs, some endogenously forming enzymes (trypsin, plasmin, kallikrein);
• a violation of the metabolism of polyunsaturated fatty acids (PUFA), more often - arachidonic. Analgesics (acetylsalicylic acid and its derivatives) can inhibit the activity of cyclooxygenase and shift the metabolism balance of PUFA towards leukotrienes expression, which is clinically manifested by edema, bronchospasm, skin rashes like hives, etc .;
• violation of the processes of inactivation and elimination of mediators from the body: if the hepatobiliary system, the digestive tract, the kidneys, the nervous system, in metabolic diseases (so-called pathology of cell membranes) are violated.

Treatment of the 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 care. The success of treatment is also determined by the elimination of concomitant diseases.

Monitoring of environmental conditions

The nature of the activities carried out depends to a large extent on the detection of hypersensitivity to any aeroallergens (house dust, epidermal allergens, mold fungi, pollen of plants, etc.). It is necessary to carry out complete elimination or reduction of contact with the listed agents (wet regular cleaning of premises, minimal amount of upholstered furniture and books in the environment of the child, special bed linen and frequent shifts, lack of TV and computer in the room where the patient is, etc.).

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

Medication

Medical treatment of atopic dermatitis in children depends on the etiology, form, stage (period) of the disease, skin lesion area, child's age, degree of involvement in the pathological process of other organs and systems (concomitant diseases). Treatment requires a doctor of high professional training, close understanding with the parents of small children (and then with the patients themselves, as they grow up), great patience, the ability to make compromises and contacts with physicians of other specialties, to be literally a "family doctor" . Distinguish preparations of systemic (general) action and means for external treatment.

Pharmacological agents of systemic action are used in combination or in the form of monotherapy and include the following groups of drugs:

• antihistamines;
• membrane stabilizing;
• improving or restoring the function of the digestive tract;
• vitamins;
• regulating functions of the nervous system;
• immunotropic;
• antibiotics.

The use of antihistamines (AGP) is one of the most 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 the development of the disease. AHP is prescribed for exacerbation of the disease and severe itching of the skin.

A distinctive feature of AGP I generation is their easy penetration through the blood-brain barrier and pronounced sedative effect, therefore they are used in acute period, but it is inappropriate to assign them to schoolchildren.

AHP II generation does not penetrate the blood-brain barrier and has a weak sedative effect. They have, in comparison with the preparations of the first generation, more pronounced affinity for H2-receptors, which provides a rapid onset of action and a prolonged therapeutic effect. In addition, they inhibit the early and late phase of the allergic reaction, reduce platelet aggregation and release of leukotrienes, providing a combined anti-allergic and anti-inflammatory effect.

To preparations of the third generation carry telphast, which is allowed to use only in children over 12 years old.

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 acute and subacute periods of the disease.

Ketotifen, cetirizine, loratadine have antagonism to H2-histamine receptors, inhibit the activation of mast cells in vitro, inhibit the process of releasing mediators of allergy 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 in 2-4 weeks, so the minimum course of treatment is 3-4 months.

Antihistamines for oral administration

Name of the drug		Form of issue	Doses and multiplicity of prescription
INN	Trading
Mebrogroline	Diazoline	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 / (kilogram); 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 (U4 tablets), 1 to 6 years: 8.3 mg (1/3 tablet), 6 to 14 years: 12.5 mg (1/2 tablet); 2-3 times a day
Clemastine	Tavegil	Tablets 0.001 grams	From 6 to 12 years: 0.5-1.0 mg; children> 12 years: 1.0; 2 times a day
Dimethinden	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. For 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 each; children> 7 years of age: 15-25 mg each; 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	Zirtek	Tablets 0.01 g Drops (1 ml = 20 drops = 10 mg)	Children> 2 years: 0.25 mg / kg, 1-2 times a day
Loratadin	Claritin	Tablets 0.01 g Syrup (5 ml = 0.005 g)	Older than 2 years old and weighing 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: 0.120-0.180 g once a day

Cromoglycic acid (sodium cromoglycate, nalcrom) prevents the development of an early phase of an allergic response, blocking the release of biologically active substances from mast cells and basophils. Nalcrome directly influences specifically lymphocytes, enterocytes and eosinophils of the gastrointestinal mucosa, preventing the development of allergic reactions at this level. Nakrrom is prescribed in combination with AGP. The duration of the course is usually from 1.5 to 6 months, which ensures the achievement of persistent remission and prevents the development of relapses of the disease.

Preparations that improve or restore the functions of the digestive organs are prescribed in acute and subacute periods of atopic dermatitis, taking into account the revealed changes on the part of the gastrointestinal tract. To improve digestion and cleavage of food substances, correction of functional disorders of the gastrointestinal tract use enzymes: festal, enzyme, digestal, pancreatin (mezim-forte, pancreatin, pancreatin), panzinorm and others, as well as cholagogue: corn sturge extract, allochol, hips extract (holosas), hepabene, etc., the course of treatment 10-14 days. In dysbacteriosis, eukaryn, pre- or probiotics are prescribed: bactisubtil, biosporin, enterol, bifidobacteria bifidum (bifidumbacterin) and intestinal sticks (colibacterin), linex, bifikol, 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 repair process in the skin, restore 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.

In drugs that regulate the functional state of the nervous system, up to 80% of patients need it, however they should be prescribed by a psychoneurologist or psychologist. Used sedatives and hypnotics, tranquilizers, neuroleptics, nootropics, drugs that improve the liquor and hemodynamics: vinpocetine (cavinton), actovegin, pyracetam (nootropil, piracetam), vasobral, cerebrolysin, cinnarizine, pyrithinol (encephabol), etc.

Immunomodulatory treatment is indicated only in cases where atopic dermatitis in children occurs in combination with clinical signs of immune deficiency. Uncomplicated course of atopic dermatitis does not require the appointment 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 I and II generation, lincomycin, aminoglycosides.

Systemic glucocorticoids (HA) are used extremely rarely and only in cases of especially severe disease, in a hospital: a short course (5-7 days) at a dose of 0.8-1.0 mg / kghsut).

Do not forget about the treatment of concomitant pathology: sanation of foci of chronic infection (oral cavity, ENT organs, intestines, bile ducts, genitourinary system), treatment of parasitic infections (giardiasis, helicobacteriosis, toxocarosis, enterobiosis), etc.

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

• suppression of signs of skin inflammation and associated with it the main symptoms of atopic dermatitis in children;
• elimination of dry skin;
• prevention and elimination of skin infection;
• restoration of damaged epithelium;
• improvement of skin barrier functions.

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

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

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

External glucocorticoid drugs 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 HA is associated with immunoregulatory effects on cells responsible for the development and maintenance of allergic skin inflammation (Langerhans cells, lymphocytes, eosinophils, macrophages, mast cells, etc.), as well as with a vasoconstrictor effect on the skin vessels, reducing edema.

Mechanisms of anti-inflammatory activity of external glucocorticoid drugs:

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

The potential activity of topical HA depends on the structure of their molecule and the binding strength to the glucocorticoid receptors that transport it into the cell. This makes it possible to classify this or that local HA as a class of weak (hydrocortisone), medium [betamethasone (Betnoveit), bismuth subgallate (dermatol), etc.], strong [methylprednisolone aceponate (advantan), betamethasone in the form of dipropionate (Beloderm), lokoid, mometasone (elokom), triamcinolone (fluorocort), betamethasone (celestoderm), etc.], very strong [clobetasol (dermovate)] preparations.

In pediatric practice, the latest generation drugs are used from external HA: methylprednisolone aceponate (advantan), mometasone (elocom), hydrocortisone (lokoid-hydrocortisone 17-butyrate).

These topical HA have high efficacy and safety, a minimum of side effects and the possibility of application once a day, including in young children. Course 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 observe a number of simple rules: to ensure sufficient humidity in the room where the child is, to observe the rules of hygiene. For example, the ban on bathing children is not justified, especially when the disease worsens.

When the skin is infected with staphylo- and streptococci, external agents containing antibiotics are prescribed: erythromycin, lincomycin (3-5% paste), fucocin, brilliant green (1-2% alcohol solution) and methylthionium chloride (5% aqueous methylene blue), ready forms of external antibiotics. Multiplicity of their application is usually 1-2 times a day. With pronounced pyoderma, systemic antibiotics are additionally prescribed.

In fungal infections, external antifungal agents are used: creams isoconazole (travogen), ketoconazole (nizoral), natamycin (pimafucin), clotrimazole, and others.

When combined with a bacterial and fungal infection, combined preparations containing antimicrobial components and HA are used: triderm, Cestoderm-B with garyamicin, etc.

To improve microcirculation and metabolism in lesions use ointments containing actovegin or heparin sodium, as well as applications of ozocerite, paraffin liquid, clay, sapropel.

With deep cracks and ulcerative skin lesions, agents are prescribed that improve the regeneration of the skin and restore the damaged epithelium: dexpanthenol (beponen), 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 help

Rehabilitation measures significantly increase the effectiveness of step-wise treatment of patients with atopic dermatitis. Sanatorium and spa treatment has long used the healing properties of radon, sulfur and sulphide waters (Belokurikha, Yeysk, Matsesta, Pyatigorsk, Priebrusye, Goryachy Klyuch, etc.). Specialized sanatoriums for children with atopic dermatitis are successfully functioning: Lake Shira (Krasnoyarsk Territory), Krasnousolsky (Bashkortostan), Lake Savatikova (Tuva Republic), Ust-Kachka (Perm Oblast), Mayan ( Sverdlovsk Region), Tutalsky (Kemerovo Region), Leninskie Rocks (Pyatigorsk), and others.

The environment of the child has a huge role in creating the right psychological climate, restoring the emotional state, cortical neurodynamics, correction of vegetative disorders, so psychological care should concern both the child and his parents.

Prevention

Primary prevention consists in preventing the sensitization of the child, especially in families with hereditary predisposition to atopy. It is performed before and during pregnancy, with lactation and concerns dietary restrictions, caution in the use of medicines, reducing contact with inhalant allergens, etc.

Secondary prevention - 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 cautious the elimination measures should be: the exclusion of products with a high sensitizing potential, a decrease in the level of exposure to air allergens, the exclusion of contacts with domestic animals,

It should be emphasized that atopic dermatitis in children is not a contraindication to vaccine prophylaxis. Postponement of vaccination is possible for a period of acute manifestations and with pyogenic complications. In other cases, the vaccination is carried out in full, necessarily against the backdrop of accompanying treatment, depending on the form, severity and clinical picture of the disease.

The key to success in the prevention of exacerbations of the disease and the treatment of children suffering from atopic dermatitis is continuity in the work 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. To teach patients with atopic dermatitis and their families, there are special programs implemented in the family counseling offices.

The main directions of the training program for patients with atopic dermatitis and their families:

• informing the patient and his relatives about the disease and possible factors that support the chronic course of atopic dermatitis in children (performed after the examination of the patient);
• correction of nutrition: a balanced full-fledged nutrition with an established and controlled regime;
• recommendations on detoxification (enterosorbents, rice sorption, regulation of intestinal activity, etc.);
• correction of the revealed nejervertebralnyh dysfunctions (massages, manual therapy, exercise therapy, etc.);
• advice on skin care with a listing of drugs for external use and indications for their use;
• differentiated psychological help to the family. The complex use of preventive, curative and rehabilitation measures allows reducing the incidence of atopic dermatitis and improving 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 continue after the birth of the child (postnatal prophylaxis).

[37], [38], [39], [40], [41],

Antenatal prophylaxis

Significantly increase the risk of forming atopic dermatitis high antigenic loads (toxicosis of pregnant women, irrational intake of medications, exposure to professional allergens, unilateral carbohydrate nutrition, abuse of products with obligate food allergens, etc.). Elimination of these factors is an important stage in the prevention of atopic dermatitis. Pregnant women with hereditary inheritance for allergies, and especially if they are present, should exclude or limit contact with any (food, domestic, professional) allergens as much as possible.

[42], [43], [44], [45], [46]

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 needs proper skin care, normalization of the gastrointestinal tract (GIT), the organization of a rational diet with an explanation of the need for breastfeeding, the rational introduction of complementary foods, as well as compliance with recommendations for hypoallergenic treatment.

Important in the prevention of atopic dermatitis in children is compliance with such factors as:

• The exclusion of smoking during pregnancy and in the home where the child is;
• the exclusion of contact between a pregnant and an early child with domestic animals;
• reducing the contact of children with chemicals in everyday life;
• prevention of acute respiratory viral and other infectious diseases.

Primary prophylaxis of atopic dermatitis in children is possible on condition of close continuity in the work of pediatrician, obstetrician-gynecologist, allergist and dermatologist.

Secondary prevention

Observance of a hypoallergenic diet by a mother during breast-feeding of a child suffering from atopic dermatitis can reduce the severity of the course of the disease. Adoption of mothers during pregnancy and lactation Lactobacillus sp., As well as enriching them with the baby's first half life reduces the risk of early development of atopic diseases in predisposed children. With the impossibility of exclusive breastfeeding in the first months of life, predisposing children are recommended to use hypoallergenic mixtures (hydrolysates - full or partial).

Tertiary prevention

It consists in preventing the recurrence of the already existing symptoms of atopic dermatitis and timely treatment of the exacerbations that have developed. Data on the effect of elimination measures (use of special bedding and covers for mattresses, vacuum vacuum cleaners for cleaning, acaricides) on the course of atopic dermatitis are controversial, but two studies have confirmed a significant reduction in the severity of atopic dermatitis symptoms in children with sensitization to house dust mites reducing 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 lasts a lifetime. Adverse factors of the prognosis: atopic diseases (especially bronchial asthma) in the mother or both parents, the onset of persistent skin rashes at the age of up to 3 months, the combination of atopic dermatitis with vulgar ichthyosis, the combination of atopic dermatitis with persistent infection (parasitic, viral, bacterial, etc.) , an unfavorable psychological situation in the family (children's team), lack of faith in recovery.

[47], [48], [49]