Symptoms of atopic dermatitis in children

Atopic dermatitis in children is a pressing issue in modern medicine, affecting the interests of various medical specialties: pediatrics, dermatology, immunology, allergology, therapy, etc. This is due to the fact that, starting in early childhood, the disease becomes chronic and retains its clinical signs often throughout life, leading to disability and social maladjustment of patients. In 40-50% of children suffering from atopic dermatitis, bronchial asthma, hay fever, allergic rhinitis ("the march of atopy") subsequently develop.

The term "atopic dermatitis" usually emphasizes the immunological (allergic) concept of the pathogenesis of the disease, based on the concept of atopy as a genetically determined ability of the body to produce a high concentration of total IgE and specific IgE in response to environmental allergens. However, as is known, not only specific (immune) but also non-specific (non-immune) mechanisms are involved in the development of the disease.

In clinical practice, the term "atopic dermatitis" is often replaced by others, which creates a certain confusion and leads to the fact that patients do not receive timely and adequate medical care. Until now, there were a large number of designations for atopic dermatitis: "exudative diathesis", "exudative-catarrhal diathesis", "atopic eczema", "endogenous eczema", "infantile eczema", "diffuse neurodermatitis", etc. However, an increasing number of researchers and doctors around the world adhere to the term "atopic dermatitis" proposed in 1935 by L. Hill and M. Sulzberger, since it meets the general principles of identifying atopic disease (E. Besnier described the disease as an independent nosological form in 1882).

In the International Classification of Diseases, 10th revision (ICD-10, 1992), in subheading 691, the following chronic forms of allergic skin lesions are classified as atopic dermatitis: atopic eczema, atopic neurodermatitis, and diffuse neurodermatitis (prurigo Besnier). It should be emphasized that atopic eczema and atopic neurodermatitis are forms and stages of development of a single pathological process.

Usually, the manifestation of atopic dermatitis in children occurs in the first year of life. Atopic dermatitis in children goes through three stages in its development, which can be separated by periods of remission or directly transition from one to another.

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Symptoms of atopic dermatitis in children in the childhood stage

Symptoms of atopic dermatitis in children develop between the ages of 2 and 13. This form of the disease may follow the infantile stage without interruption and usually continues until adolescence. In this case, the skin exhibits less pronounced exudative lesions characteristic of the infantile stage, significant hyperemia, pronounced dryness and an emphasized pattern, thickening of folds and hyperkeratosis, and a folded nature of the lesions. The presence of these elements is defined as the erythematosquamous form of atopic dermatitis with lichenification. Later, lichenoid papules and lichenification lesions with typical localization in skin folds predominate on the skin surface. The rash is most often localized in the elbow, popliteal, gluteal folds, on the skin of the flexor surfaces of the elbow and wrist joints, the back of the neck, hands and feet. In this case, rashes in the form of lichenoid papules, abundant peeling, multiple scratches and cracks in the skin are observed - these manifestations are defined as the lichenoid form of atopic dermatitis.

This stage of atopic dermatitis is characterized by symptoms of atopic dermatitis in children, defined as "atopic face", manifested by hyperpigmentation of the eyelids with emphasized folds, peeling of the skin of the eyelids and scratching of the eyebrows. These patients have a very characteristic persistent and painful itching of the skin, especially pronounced at night.

Infantile stage of atopic dermatitis in children

It develops in children from the neonatal period to two years and is characterized by acute inflammation of the skin with rashes in the form of papules and microvesicles with pronounced exudation and oozing (exudative form). Symptoms of atopic dermatitis in children are expressed in rashes that are localized mainly on the face, less often on the shins and thighs. At the same time, against the background of hyperemia and exudation, infiltration and edema of individual areas of the skin, microvesicles with serous contents, a flaccid cap are detected, quickly opening with the formation of "eczematous wells". Eczematous papules and microvesicles are a manifestation of an acute inflammatory process and are non-cavity limited formations in the form of small nodules (up to 1 mm), slightly elevated above the skin level, rounded in shape, soft consistency, usually single, sometimes grouped and rapidly evolving. In addition, there is a pronounced itching and burning of the skin, soreness and a feeling of tension. The sick child scratches the skin, as a result of which the lesions become covered with serous-bloody crusts, and when a secondary infection is added - serous-bloody-purulent crusts. The lesions of the skin are located symmetrically.

With limited prevalence of the process, such rashes are localized more often on the face in the area of the cheeks, forehead and chin, with the exception of the nasolabial triangle, and symmetrically on the hands.

In the widespread, disseminated form of atopic dermatitis, lesions of the skin of the trunk and limbs (mainly their extensor surfaces) are observed.

Hyperemia, infiltration and mild peeling of the skin without exudation are characteristic of 30% of patients with atopic dermatitis, which are manifestations of the erythematosquamous form of the disease. Erythematous spots and papules typically first appear on the cheeks, forehead and scalp and are accompanied by itching. Erythema usually intensifies in the evening and is almost not detected in the morning.

Adolescent stage of atopic dermatitis in children

Symptoms of atopic dermatitis in children are observed at the age of over 13 years and are characterized by pronounced lichenification, dryness and flaking, predominantly lesions of the skin of the face and upper body and a continuously relapsing course. This stage begins during puberty and often continues into adulthood. The lesions predominantly affect the flexor surfaces in the area of natural folds, face and neck, shoulders and back, dorsum of the hands, feet, fingers and toes. The rash is represented by dry flaky erythematous papules and plaques with the formation of large lichenified plaques in chronic lesions of the skin. Lesions of the skin of the face and upper body are observed significantly more often than in the previous age group.

In adolescents and adults, a pruriginous form of atopic dermatitis may be observed, which is characterized by severe itching and multiple follicular papules of dense consistency, spherical shape with numerous scattered excoriations on the surface. These rashes are combined with pronounced lichenification with a typical localization for this age on the flexor surfaces of the extremities.

Depending on the prevalence of the inflammatory process on the skin, the following symptoms of atopic dermatitis in children are distinguished:

• limited atopic dermatitis (localized mainly on the face, the area of skin damage is no more than 5-10%);
• widespread atopic dermatitis (affected area 10-50%);
• diffuse atopic dermatitis (extensive skin lesions - more than 50%).

According to the stages of atopic dermatitis, the following are distinguished:

• acute stage (itching of the skin, papules, microvesicles against the background of erythema, multiple scratches and erosions, release of serous exudate);
• subacute stage (erythema, peeling, scratching, including against the background of skin thickening);
• chronic stage (thickened plaques, fibrous papules, accentuated skin pattern - lichenification).

Assessment of the severity of clinical symptoms of atopic dermatitis in children

Assessment of the severity of atopic dermatitis by the severity of clinical manifestations

	Mild flow	Moderately severe course	Severe course
Severity of inflammatory changes on the skin	Limited areas of skin lesions, mild erythema or lichenification, mild itching of the skin, rare exacerbations - 1-2 times a year	Widespread nature of skin lesions with moderate exudation, hyperemia and/or lichenification, moderate itching, more frequent exacerbations - 3-4 times a year with short remissions	Diffuse nature of skin lesions with pronounced exudation, hyperemia and/or lichenification, constant severe itching and almost continuous recurring course
Itching of the skin	Weak	Moderate or strong	Strong, bipulsating, constant
Enlarged lymph nodes	Up to the size of a pea	Up to the size of a hazelnut	Up to the size of a bean or an increase in all groups of lymph nodes to the size of a “hazelnut”
Frequency of exacerbations	1-2 times a year	3-4 times a year	5 or more times a year
Duration of remission periods	6-8 months	2-3 months	1-1.5 months
Characteristics of remission periods	There are no symptoms of the disease	Incomplete clinical and laboratory remission	The presence of persistent infiltration, lichenification, incomplete clinical and laboratory remission
Eosinophilia	5-7%	7-10%	More than 10%
Total IgE level, IU/L	150% 0	250-500	More than 500

There are several scales for assessing the severity of clinical symptoms of atopic dermatitis in children: SCORAD (Scoring Atopic Dermatitis), EASY (Eczema Area and Severity Index), S ASS AD (Six Area Six Sign Atopic Dermatitis Severity Score). Despite the fact that none of the above scales has become widespread in our country, we provide a detailed description of the SCORAD scale, since it is used by specialists to assess the effectiveness of treatment and the dynamics of clinical manifestations of atopic dermatitis.

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Parameter A

The prevalence of a skin process is the area of affected skin (%), which is calculated using the "nine" rule. The "palm" rule can also be used for assessment (the area of the palmar surface of the hand is taken to be equal to 1% of the entire skin surface).

Parameter B

To determine the intensity of clinical symptoms of atopic dermatitis in children, the severity of 6 signs is calculated (erythema, edema/papules, crusts/oozing, excoriations, lichenification, dry skin). Each sign is assessed from 0 to 3 points (0 - absent, 1 - weakly expressed, 2 - moderately expressed, 3 - sharply expressed; fractional values are not allowed). Symptoms are assessed on the skin area where they are most pronounced. The total score can be from 0 (no skin lesions) to 18 (maximum intensity of all 6 symptoms). The same area of affected skin can be used to assess the severity of any number of symptoms.

Parameter C

Subjective symptoms of atopic dermatitis in children (itching of the skin and sleep disturbances) are assessed only in children over 7 years of age. The patient or his parents are asked to indicate a point within a 10-centimeter ruler that, in their opinion, corresponds to the degree of itching and sleep disturbances, averaged over the past 3 days. The sum of points of subjective symptoms can vary from 0 to 20.

The overall score is calculated using the formula A/5 + 7B/2 + C.

The total score on the SCORAD scale can range from 0 (clinical symptoms of atopic dermatitis in children, no skin lesions) to 103 (maximally pronounced manifestations of atopic dermatitis).