Complications of atopic dermatitis

Psychosocial effects of atopic dermatitis

Any chronic illness can have a major impact on the sufferer's life, and this is particularly so for childhood eczema, as well as on the lives of their families. Most people with eczema continue to lead normal lives but for a few, eczema can be a source of major psychosocial distress.

Young children often suffer sleep disturbances which are difficult for parents and may cause behavioural problems in the child. Older children may become shy and withdrawn due to the embarrassment of a visible skin condition. Activities such as sport, school camps and swimming may have to be restricted, which further alienates the child. Long absences from school may result from both eczema itself and from the social avoidance that develops in some children.

Adults may also suffer shyness and withdrawal due to the appearance of eczema. Work may be difficult and some people with bad eczema will have to change jobs to cope with their eczema.

Retarded growth due to atopic dermatitis

Severe eczema may slow the growth rate in children. This is most often due to eczema rather than its treatment. Corticosteroids, particularly oral corticosteroids, can also cause short term growth retardation, so use of these drugs should be closely monitored.

Bacterial infections in atopic dermatitis

Bacterial skin infection is extremely common in atopic dermatitis. This is usually with staphylococcal or streptococcal bacteria (see staphylococcal skin infections and streptococcal skin infections). Infection is in part due to breaks in the skin from very dry, split skin and from scratching the itchy areas. People with atopic dermatitis also seem to have a reduced ability to fight against these common bacteria on the skin. As a result, people with atopic dermatitis frequently also suffer from boils, folliculitis and impetigo. This begins a vicious cycle, as infection causes eczema to worsen and become more resistant to the usual treatment with emollients and topical steroids. Antibiotics are often required to eliminate the infection before eczema can be brought under control.

Rarely, bacterial infection can be especially severe, involving much of the skin surface. This can cause blood poisoning (septicaemia) and require hospital admission. Infants are particularly at risk of severe skin infections.

Infected dermatitis

Infected dermatitis

Infected dermatitis

Viral infections in atopic dermatitis

Viral infections, in particular herpes simplex virus (the virus that causes cold sores and genital herpes), is more common in patients with atopic dermatitis. A herpes simplex infection can spread rapidly in the presence of eczema and cause a severe infection, which is known as eczema herpeticum. This may present as a generalised illness with fever, malaise and a widespread crusted, blistering rash. It can also be more localised, often confined to areas with active eczema. A history of a recent cold sore in the affected individual or a close contact is useful in making the diagnosis before swab results become available. Because of the severity of the condition, treatment with oral antiviral agents such as aciclovir or valaciclovir is often started before any swab results are available.

Eczema coxsackium is an atypical form of hand foot and mouth disease presenting as blisters on areas of active atopic eczema. 

Eczema herpeticum

Eczema herpeticum

Eczema herpeticum

Molluscum contagiosum is another common viral skin infection, most often affecting children. It may be more common in people with atopic dermatitis. Molluscum infection often causes an increase in eczema symptoms, usually worst around the areas affected with molluscum. Molluscum lesions often resolve more slowly in people with atopic dermatitis and eczema may continue to be more active until the molluscum finally disappears. Resolution can be hastened by mild traumatising of one or two molluscum lesions at a time to generate an inflammatory response. This can be done by quick pinching with clean tweezers of one or two lesions each night for a few nights. This is usually better tolerated if done while the child is asleep.

Molluscum contagiosum

Molluscum contagiosum

Molluscum contagiosum

Erythrodermic atopic dermatitis

Erythroderma is a generalised redness of the skin. It is a very severe skin condition that can be fatal. It is caused by a number of conditions including eczema, psoriasis, other inflammatory skin conditions, drugs and malignancies.

Erythrodermic eczema usually occurs in patients with worsening or unstable eczema. Treatment of erythroderma is similar despite the many underlying causes. Inpatient hospital treatment is usually required to cool the skin and support the hydration and temperature control of the affected individual. Skin infection is also common in the setting of erythrodermic eczema and intravenous antibiotics are commonly given for a period of time. Treatment for erythrodermic eczema may include:

• Hospitalisation for supportive care including intravenous fluids and temperature regulation
• Bland emollients and cooling wet dressings
• Bed rest
• Topical steroids
• Antibiotics
• Treatment of complications (for example diuretics for swelling, nutritional support for weight loss)
• Treatment with wet wraps, emollients and topical steroids, and bed rest results in rapid improvement in the majority of affected individuals. Early treatment leads to a better outcome.

Complications of erythroderma include:

• Dehydration
• Heart failure
• Infection
• Hypothermia
• Protein loss and malnutrition
• Oedema (swelling)
• Death.

Wet wraps

Detail of wet wraps

Eye abnormalities associated with atopic dermatitis

Many eye changes may be seen in association with atopic dermatitis.

A Dennie-Morgan fold is a fold of skin under the lower eyelid. Due to chronic eyelid dermatitis, it is often seen in atopic dermatitis but may also be seen independent of atopic dermatitis and is of no significance to the overall health of the person.

Conjunctival irritation is also common. It may be due to an allergic reaction, as in hayfever, or an irritant response.

Keratoconus (conical-shaped eyeball) is a rare condition which is occasionally associated with atopic dermatitis. It is due to degeneration and weakening of the cornea (the front of the eye) which results in pushing of the front of the eye outwards due to the normal pressure within the eyeball. It can result in marked visual disturbances and can be partially corrected by contact lenses. The onset of keratoconus is after childhood and progression is usually self-limited.

Cataracts can also occur in association with severe atopic dermatitis, usually around 15–25 years of age. They are almost always bilateral and may have a characteristic appearance on eye examination which helps distinguish them from other causes of cataract.

Retinal detachment is when part of the inner eye lining breaks away from the underlying structures. This is a very rare complication seen in association with atopic dermatitis.