Atopic Dermatitis: Uncontrollable Scratching

Over the years, I have had elementary school children sent to me with a red, raised itchy rash on the inside creases of their elbows and behind their knees. Sometimes, the rash is also noted on the back of the neck, in the armpits, and along the jawline. Frequently, the student is also known to have asthma, with an inhaler or nebulizer used at school. Often, the teacher is concerned about something contagious, such as chickenpox or scabies.

These signs and symptoms usually result in a diagnosis of atopic dermatitis. This is a noncontagious skin condition that starts in infancy and is most notable by about the age of 3 months. It is a form of excema. The child will show bright red, raised and bumpy skin on the cheeks and chin. Soon, the red patches appear in the creases of the elbows and behind the knees. The child will rub the itchy areas until the skin is raw and weepy. Some respiratory problems might be noticed at this time, such as coughing or runny nose.

As the child develops into a toddler and preschooler, it is obvious that something occurs with the skin in a course that has flare-ups and total remission. I have dealt with this condition affecting my own child for 14 years. With my child, the flare-ups would occur on the first warm day of spring. Instantly, her cheeks would become swollen with reddened hives, she would begin scratching her arms in the elbow creases, her legs behind the knees, and the skin folds under her eyes would become visible. She would scratch until the skin was scraped raw, and the areas would become weepy. Attempts to cover the itching skin was futile; the area was too great and any covering would stick to the weepy skin. Asthma symptoms would then start, with coughing and wheezing evolving into need for a nebulizer. Interestingly, by the fall and winter, the skin condition that had once defined our summers was a distant memory.

By the time the child is school-aged, the itch-scratch cycle is evident if not predictable. The rash location is very predictable: behind the knees, in the creases of the elbows, the armpits, behind the ears, at the neck and the jawbone. Scratching is uncontrollable, especially while the child is sleeping. The skin in the creases becomes thick and leather-like. Asthma or other breathing problems usually accompany the rash.

Criteria used to diagnose atopic dermatitis include: itching skin in a cycle that is preceded by some type of irritation (for my child, we believe it is warm weather and sweating); remissions; early onset, such as in infancy; changes in the skin as time passes (such as leathery or discolored skin).

Treatment is designed to combat three problems:
1. Avoiding the irritant if it can be identified
2. Preventing the itch-scratch cycle
3. Treating the rash if it develops

Avoiding the irritant is easier once you are able to identify the problem. For my child, we believe it is triggered by heat. Therefore, we attempt to keep her indoors on hot days and have air conditioning to keep her cool at night. Air conditioning helps in two ways: it improves the asthma symptoms and keeps night time scratching to a minimum.

Preventing the itch-scratch cycle starts with keeping other irritants to a minimum by using mild soap only, such as unscented Dove; unscented laundry detergent; and mild shampoo. Use an unscented moisturizer such as Cetaphil to keep the skin from becoming dry and leathery. Have the child wear cotton gloves to bed to prevent nighttime scratching ( a pair of cotton socks on the hands at night works well also). The doctor may prescribe an antihistamine at night to keep the itching under control.

Treating the rash will depend on the prescribing physician. A steroid cream is often effective, and the physician will recommend using it only during flare-ups to avoid side effects from long term use.

Research shows that this condition may be hereditary, and usually lessens in intensity by puberty and early adulthood. In the meantime, vigilance in watching for triggers, preventing the itch-scratch cycle, treatment during flare-ups; and remaining aware of respiratory complications should help the child remain more comfortable until the condition lessens with age.