Correct and safe treatment of atopic dermatitis in adults

Of all known skin diseases, atopic dermatitis is the most insidious. It is quite difficult to identify it, make an accurate diagnosis and treat it. The signs of atopic dermatitis, as a rule, do not differ from the symptoms characteristic of other skin pathologies, but they have some features. Often people do not even realize that they are sick; they try to cure skin irritation with ordinary cosmetics and folk remedies. Sometimes the symptoms go away, but after some time atopic dermatitis appears again with a number of complications. To avoid this, it is necessary to recognize dermatitis in time and understand the causes and mechanism of its development.

Causes of development of atypical dermatitis

Atopic dermatitis is an inflammatory, chronically relapsing pathology of the skin, accompanied by constant itching, as well as eczematous and lichenoid rashes. The disease is also called allergic eczema, as it very often occurs at the same time as:

• bronchial asthma;
• food allergies;
• allergic rhinitis;
• conjunctivitis;
• ichthyosis. [12]

Atopic dermatitis most often develops in childhood - the prevalence among children reaches 15-30%; in 9 out of 10 cases it develops in the first year of life. The incidence in adults is 2-10%. Women suffer from it more often than men. Most cases occur in cities with high levels of pollution and cold climates. [3]

This is an immune-dependent pathology. The reasons for its development are associated with mutations in genes that are responsible for the synthesis of filaggrin, a structural skin protein involved in the formation of the stratum corneum, which, in turn, is responsible for the barrier functions of the skin. Like a brick wall, the stratum corneum of the epidermis retains water and does not allow a large number of allergens and microorganisms to enter the body. In patients with dermatitis, the synthesis of filaggrin is impaired, and the connections between the cells of the stratum corneum are damaged. Because of this, the skin retains moisture worse and is more sensitive to any external influences. The mechanism is as follows: the pathogen enters the body through damaged skin, and the immune system produces immunoglobulins. Against the background of these processes, symptoms of atopic dermatitis arise. [4]

Auxiliary basic therapy of atopic dermatitis in children

In 2002, an international expert group on atopic dermatitis (AD) came to the following conclusion: “AD in childhood and adulthood appears to be a single disease, although in the future genetic subtypes with different expression patterns may be identified” [1 ]. Experts emphasize a characteristic feature of the course of AD: since in such patients the barrier function of the skin is impaired and itching occurs, therapy takes a symptomatic focus - moisturizing the skin and relieving itching. Today there is no doubt that external therapy is pathogenetically substantiated and absolutely necessary for every patient suffering from AD. However, recommendations for external therapy, including skin care and the correct use of local drugs, have not yet received adequate support from practicing doctors, and therefore from patients. Moreover, modern knowledge and achievements in the treatment of AD are sometimes of little use in practice and are reduced mainly to the prescription of topical corticosteroids (TCS) and/or symptomatic drugs in the form of various dermatological prescriptions.

In a recently published review, one of the leading scientists, Prof. D. Leung called moisturizing and softening the skin the “key” point of AD therapy [2]. What explains the fundamental importance of external therapy for blood pressure? First of all, the need to restore and maintain the integrity of the skin barrier, the violation of which is one of the cardinal signs of AD, entailing increased transepidermal water loss, as well as the development of increased sensitivity of the skin to various irritants and colonization of the skin by Staphylococcus aureus [2, 3].

Auxiliary basic therapy

In the adopted consensus document on AD, skin hydration and the use of moisturizers are classified as adjuvant basic therapy, the use of which is an absolutely necessary element in the treatment of atopic dermatitis [1]. Experts emphasize the importance of individual, adequate selection of the necessary skin care products, depending on personal preferences, the patient’s age and type of blood pressure. These can be agents with different mechanisms of action - occlusive, moisturizing, emollient, as well as stimulators of protein recovery [1].

An important aspect of auxiliary basic therapy should be especially noted, which is that due to a violation of the barrier function of the skin and its dryness, moisturizers/emollients are used even during periods when there are no symptoms of the disease [1, 8–10].

It is known that in patients with AD, the same inflammatory cells that infiltrate atopic areas are found in the skin that is not involved in the pathological process; As for the manifestations of skin hyperreactivity, they also do not differ in any way in different places [10, 11]. It has also been shown that dry skin, accompanied by transepidermal water loss, leads to increased systemic absorption of TCS [12].

In addition, atopic skin, due to its hyperreactivity, has the following characteristic feature: its condition changes depending on fluctuations in air temperature, stressful situations, after eating certain foods or for other reasons [1, 6, 13]. Undoubtedly, external treatments also affect the condition of the skin. And such changes in the skin after the application of drugs, such as burning, increased itching, hyperemia, can be associated by patients or doctors with the use of a particular drug, which often entails its withdrawal. In fact, the cause of such skin manifestations may be the above-mentioned exogenous factors, and doctors should remember this when observing the patient over time, and, if necessary, test him for drug tolerance. We should not forget about the possibility of developing allergic contact dermatitis even to the main anti-inflammatory drugs for treating AD - topical corticosteroids and/or topical calcineurin inhibitors [14–17].

Regular use of emollients/moisturizers is extremely important for the skin. This has been confirmed by a number of randomized studies.

It should be noted that the terms “emollients” and “moisturizers” are not equivalent concepts [18]. As is known, dry skin is associated with a violation of its barrier function, which occurs not only in AD, but also in ichthyosis and contact dermatitis. However, xerosis (dryness) and impaired skin barrier function are characterized by various biochemical, physicochemical and morphological changes. The study of the features of these processes underlies the development of a new direction in the treatment of skin diseases - the pharmaceutical and cosmetic industry.

It has been proven that the effectiveness of moisturizers depends on their dose (moisturizers should be used regularly in sufficient quantities), skin pH, and patient compliance [18–21]. After application, the ingredients included in moisturizers (emulsifiers, antioxidants, preservatives) remain on the surface of the skin, are absorbed and subsequently metabolized, or disappear from the skin. In addition to the moisturizing effect, these products also have other properties. Thus, emulsifiers affect the barrier function of the skin, and ceramide-containing lipid components reduce transepidermal water loss through the skin. In general, moisturizers make atopic skin less sensitive to irritants and contact allergens [18].

Recently, to reduce dry skin in patients in whom the use of emollients and moisturizers has proven ineffective, a new line of drugs that can affect the extracellular membrane of the epidermis has been developed - the so-called ceramide-dominant emollients [19, 20]

The fact that emollients/moisturizers have pharmacological properties has been confirmed experimentally. Thus, in experiments on mice it was shown that the application of white paraffin or cream with ketomacrogol leads to an increase in antimitotic processes in the skin [22]. Emollients containing white paraffin also have a vasoconstrictor and atrophogenic effect on the skin (of course, to a lesser extent than TCS) [23]. Another study confirmed the anti-cyclooxygenase capacity of emollients, suggesting their anti-inflammatory effect [4].

However, even before prescribing emollients/moisturizers to a patient with AD, it is necessary to teach him to follow certain skin care rules.

AD requires special skin care in any phase of the disease (exacerbation, remission). As mentioned above, even in the absence of clinical symptoms of AD, it is necessary to continue to carry out general skin care, the important components of which are skin hydration and regular use of moisturizers.

General skin care rules must be followed. Regardless of age, patients with AD need daily 15–20-minute water procedures (shower, bath), which clean and moisturize the skin, prevent infection, and improve the penetration of drugs into the skin [2, 24, 25]. Bathing water should be cool and dechlorinated. The latter is achieved by leaving it in a bath for 1–2 hours, followed by warming or adding boiling water. You can also use water that has been purified using special filters.

Often the appearance of dry skin and exacerbation of blood pressure are associated with swimming in pools with chemically treated water, as well as other water procedures. It has been proven that the skin of patients with AD is more sensitive to the effects of residual chlorine contained in tap water compared to the skin of healthy individuals [26]. In addition, exposure to residual chlorine itself may play a provoking role in the development and exacerbation of AD. When visiting swimming pools, some patients note a deterioration in their skin condition, although others, on the contrary, may benefit from swimming [3]. In any case, immediately after swimming in pools, patients with AD are advised to use mild cleansers to remove chlorine or bromine, followed by a moisturizer.

When swimming:

• Do not use washcloths or rub the skin;
• It is advisable to use high-quality detergents with a neutral pH of 5.5 (exclude soap!);
• after bathing, pat the skin dry (do not wipe dry!) ​​with a towel;
• To prevent the effect of evaporation, emollient/moisturizing skin care products are applied to still damp skin, especially to areas of extreme dryness.

Moisturizers

Most studies support the effectiveness of daily moisturizing therapy in patients with AD [4, 24, 25]. The combined use of such drugs with anti-inflammatory drugs (TCS, topical calcineurin inhibitors) is especially important.

In children and adults with mild to moderate AD, J. Hanifin et al. conducted a comparative study of the effectiveness of topical application of a moisturizing cream, used 3 times a day, in combination with TCS - 2 times a day (group 1), and monotherapy with a hormonal drug (group 2) [21]. After 3 weeks of treatment, significant clinical improvement was achieved in the 1st group of patients compared to the 2nd group. In addition, more than 95% of all study participants expressed a desire to receive combination therapy.

In another study, an emollient cream was added to hydrocortisone 2.5% cream administered once daily; This treatment regimen was compared in terms of effectiveness with the double use of TCS alone [27]. The emollient has been shown to reduce the need for TCS, and its regular use helps prevent exacerbations of blood pressure. However, in 2/3 of children over 1 year of age, monotherapy with emollients did not help prevent exacerbations of blood pressure.

The effectiveness of auxiliary drugs was clinically and morphologically confirmed in a study by S. Chamlin et al., who added an emollient with a predominance of ceramides to the standard therapy of a group of children with “persistent resistant blood pressure” [28]. By the end of 6–12 weeks, all patients showed clinical improvement in blood pressure symptoms. In addition, extracellular laminar membranes were found in the ultrastructure of the stratum corneum, which were almost completely absent initially.

Another study using a ceramide-dominant emollient (atopalm multilayer emulsion in combination with TCS) found a decrease in skin atrophy and a decrease in skin pH compared with hormonal drug alone [20].

Even earlier, R. Marks reported that in adult patients with hand dermatitis who used moisturizers for more than 1 month, clinical improvement (as assessed by the severity of blood pressure using the SCORАD index) was comparable to that observed in the group of patients who used highly active TCS - 0.025% betamethasone valerate [23].

A very interesting study was conducted by R. Ainley-Walker et al., who studied the effectiveness of various external agents by applying them to two symmetrical areas of the affected skin [13]. The study included 82 patients (66 of them children) who used medium- and high-potency TCS, as well as emollients. The following features of external therapy were identified: for example, when comparing the effectiveness of light class TCS and an emollient, TCS was effective in 10 cases out of 17, in five cases the clinical effectiveness of the drugs was the same, and in two cases the emollient was considered even more effective than a topical corticosteroid . In another comparison group, in three patients, the emollient in terms of therapeutic effectiveness was almost no different from TCS of average activity.

However, these conclusions still need to be confirmed in randomized clinical trials [2, 3, 22].

What medications are advisable to use in patients with AD?

For skin care, there are various products from the medical and cosmetic series such as “Mustela StelAtopia” (MUSTELA), “Aven” (AVENE), “A-DERMA”, “Topicrem” (NIGY CHARLIEU), “Vichy” ( VICHY), “Uriage” (URIAGE), “Bioderma” (BIODERMA), etc. [29, 30].

When using skin care products, you should take into account the age of the patient (it is known, for example, that the skin of children has a more neutral pH, is more permeable, they have a higher intensity of skin respiration, etc.), the composition of the drugs and indications for their use.

Let's conduct a comparative analysis of some products intended for skin care with AD, taking into account such important parameters as: completeness of the series; age from which the product can be used; the ability of the drug to create a protective film on the skin, as well as inhibit the growth of microorganisms; intensity of skin hydration; the ability to restore the lipid layer in the skin; anti-inflammatory effect; active component of the drug, etc.

Complete series: Hygiene / Skin cleansing / Care for blood pressure - Mustela StelAtopia, Aven laboratory, A-Derma line of Ducray laboratories, Vichy laboratory.

Softening/moisturizing: Topicrem, Lipikar-Balm, Lipikar emulsion; Lipidiosis 1, 2, 3; Nutrilozh 1, 2; Topicrem; Mustela StelAtopia cream-emulsion, soothing cream A-Derma.

Phases of the disease:

• exacerbation - cream Atoderm R.O. zinc, Mustela StelAtopia Bath Oil, Lipikar Bath Oil, Trixera line of Aven laboratory, Egzomega line of A-Derma gamma;
• remission - Topicrem, Mustela StelAtopia cream-emulsion, Atoderm cream, Uriage Cu-Zn-gel, Aven Trixera, A-Derma Egzomega, Iktian cream from Ducray laboratories.

Age from which the drug can be used:

• 0 - adult patients with AD - Uriage Cu-Zn-gel, Uriage Cu-Zn-cream; Topicrem, Atoderm, Aven, A-Derma;
• 0–15 years - Topicrem, Mustela StelAtopia, Aven, A-Derma;
• after 2 years and adults - Lipikar, Aven, A-Derma.

The creation of a protective film is characteristic of many products, with the exception of Atoderm mousse and Uriage Cu-Zn gel.

Skin moisturizing is characteristic of many products, with the exception of Pruured cream and Uriage Cu-Zn cream.

Restoration of lipids in the skin is characteristic of many products, with the exception of Atoderm R.O. Zn cream, Atoderm mousse, Uriage Cu-Zn cream.

Anti-inflammatory action is characteristic of many products, with the exception of Topicrem.

Suppression of the growth of microorganisms is typical only for Mustela StelAtopia (all types), Atoderm R.O. Zn cream, Dermalibur cream of the A-Derma line, Sicalfat cream of the Avene line.

The main active component of the products:

• vegetable oil - in Mustela StelAtopia;
• mineral oil, shea butter in small quantities - in Lipikara;
• 2% urea and glycerin - 9.5% - in Topicrem;
• Aven thermal water in the Aven line;
• colloidal oat extract Realba in A-Derm;
• β-sitosterol in Atoderm R.O. zinc.

The Mustela StelAtopia cosmetic line is designed to care for atopic skin using sunflower oil distillate, obtained using a unique method through molecular distillation, which occurs under extreme vacuum (103 mm Hg) and temperature leading to the evaporation of organic components with high molecular weight - vitamins, steroids, polymers, fatty compounds, etc. The active ingredients of the drug include: 90% - essential lipids (linoleic and oleic triglycerides), 5% - phytosterols, 1% - a-tocopherol (90% natural vitamin E) , ceramides, softening components. The patented sunflower oil distillate has a chemical structure that is capable of being involved in lipid metabolism. As is known, dry skin in AD leads to changes in the epidermal barrier and is associated with a violation of the lipid content in it, so it is very important to use drugs that can affect the lipid balance of the skin.

Mustela Stelatopia Cleansing cream is a soap-free product that contains sunflower concentrate, glycerin, castor oil, glycine. Use for daily washing in the bath or shower, rinse with water. Protects and softens the skin.

Mustela StelAtopia Bath oil contains 90% emollients, including sunflower oleodistillate, bisabolol, phospholipids. Ideal for dry atopic skin: the fat base makes the skin soft; relieves inflammation, relieves itching. Add 2-3 capfuls to the water per bath. After washing, do not rinse off; pat the skin dry with a towel.

Mustela StelAtopia Cream emulsion contains sunflower concentrate, essential fatty acids, ceramides, sitosterol, sucrose derivatives, and emollient components. Restores key skin lipids, relieves inflammation. Apply to clean, dry skin of the face and body 2-3 times a day.

Thus, in children with blood pressure the following is used:

• during exacerbation of blood pressure - Mustela StelAtopia Bath Oil + Mustela StelAtopia Cream-emulsion;
• during the period of remission of blood pressure - Mustela StelAtopia Cleansing cream + Mustela StelAtopia Cream-emulsion.

There are also other effective skin care products for AD patients.

Atoderm mousse, super-nourishing soap Atoderm is a soap-free cleanser used for daily hygiene of dry and atopic skin. Moisturizes, soothes, softens the skin.

Atoderm R.O. zinc cream is a soothing, antipruritic and moisturizing cream for dry, irritated skin during periods of exacerbation of blood pressure.

Atoderm cream is a compensating, protective and moisturizing cream for skin care outside of exacerbation.

The Egzomega line of the A-Derma dermocosmetic laboratory is specially designed for the care of atopic skin. The main active components of the line are Realba oat extract and a complex of essential Omega 6 fatty acids. The anti-inflammatory and softening properties of Realba oats reduce irritation and itching, and Omega 6 essential fatty acids quickly penetrate deep into the membrane phospholipids and intercellular cement of the stratum corneum, restoring its homogeneity and tightness, block inflammation and suppress the synthesis of prostaglandins and leukotrienes.

The Egzomega line consists of three products.

• Cleansing foaming shower oil can be used simultaneously as a face and body gel, as well as a cleansing softening bath by dissolving 2 caps of product in water;
• Egzomega cream and Egzomega milk are used daily in comprehensive dermatological care for atopic skin of infants, children and adults. The liquid texture of the milk makes it easy to apply to large areas of the skin.

Lipikar Sindet is a liquid cleanser with pH = 5.5. Contains: shea butter - 1% (reduces skin dryness by restoring the hydrolipid film on the surface of the epidermis); glycerin - 2% (provides rapid hydration of the upper layers of the epidermis); emollient components - 8% (soothe irritated skin); anti-lime components - 0.3% (neutralizes lime water).

Lipikar oil is a soothing lipid-replenishing bath product. Dissolve in water or apply directly to skin in the shower. Coming into contact with water, Lipikar oil restores the damaged hydrolipidic film of extremely dry skin, protecting it from the dehydrating and irritating effects of salts contained in tap water. Lipikar contains shea butter (5%) and active components of the epidermis: fatty acids, similar in structure to those that are absent or significantly reduced in people with dry skin; sterols that relieve skin irritation and have a healing effect.

Lipikar-balm is the first lipid-replenishing balm for the face and body that does not cause clogging of pores, and the first “oil-in-water” emulsion containing oleosomes. Oleosomes are microdroplets of oil containing lipophilic active components that have a high affinity for the surface layers of the epidermis (due to the latter, a pronounced and long-lasting moisturizing effect of the drug on the skin is achieved). In addition to oleosomes, Lipikar includes: shea butter - 20% (provides natural replenishment of skin lipids, has a wound-healing and softening effect); glycerin - 10% (moisturizing component); rapeseed oil - 5% (has a softening effect); thermal water LA ROCHE-POSAY (soothes and softens the skin, has a wound-healing effect).

Lipikar emulsion is a moisturizing softening emulsion for face and body. Contains: α-bisabolol (intensively moisturizes and softens the skin); allantoin (prevents the occurrence of lichenification); shea butter (restores the hydrolipidic film on the surface of the epidermis); thermal water LA ROCHE-POSAY (soothes and softens the skin, has a wound-healing effect).

Ceralip is a restorative lip cream. Contains: shea butter (replenishes the lack of fatty acids on the surface of the skin of the lips); wax (provides additional protection for the skin of the lips from external influences of adverse factors); does not contain preservatives and is odorless.

A series of pharmaceutical cosmetics from the VICHY laboratory for the care of atopic skin includes: Lipidioz 1 milk, Lipidioz 2 cream, Lipidioz hand cream, Nutrilozhi 1 and Nutrilozhi 2 face cream, Lipidioz stick for lips.

Lipidiosis 1 is a moisturizing milk for dry body skin. Contains: active hydrofixatives (urea + ammonium lactate), glycerin, shea butter, VICHY thermal water. Hydrofixators retain moisture in the skin and limit the disorganization of lipid plates, which helps to moisturize the skin for 24 hours. The use of Lipidioz 1 ensures the disappearance of the feeling of skin tightness and cracks.

Lipidiosis 2 is a liquid cream for very dry skin of the torso. Contains: glycerin, mineral oil, olive oil, avocado oil, currant seed oil, shea butter, VICHY thermal water. The supply of prestructured lipids allows you to restore gaps in the intercellular cement and optimally increase the protective function of the skin. As a result of using the cream, flaking and itching of the skin are eliminated, cracks heal, and the skin becomes smooth and soft.

Lipidiosis is a restorative product for the care of dry and cracked lip skin. The unique composition of the drug allows you to protect the red border of the lips from ultraviolet rays, promotes the healing of cracks, nourishes and softens the skin of the lips.

Nutrilozhi 1 is a cream for dry facial skin based on a patented sphingolipid, created using oleosome technology. Sphingolipid is an exogenous precursor of lipids that restores the disrupted natural process of reproduction of the skin's own lipids and the barrier function of the epidermis. The oleosome is the newest galenic transport form for the transfer of lipophilic active components, providing protection, deep penetration and prolonged action of lipophilic components (sphingolipids). In addition, Nutrilozhi 1 contains: patented sphingolipid - N-(2-hydroxyhexadecanoyl sphinganine), ceramides, tocopherol, cholesterol, glycerin, disodium EDTA, apricot oil, VICHY thermal water. Thanks to oleosomal technology, sphingolipid penetrates into the deep layers of the skin and restores the skin's ability to produce its own lipids. Apricot oil, glycerin, essential fatty acids soften and nourish the skin. Thermal water has a soothing effect on the skin and enhances its natural protective properties. Nutrilozhi 1 cream restores the barrier properties of the epidermis by increasing the skin's level of its own ceramides, softens and nourishes the skin, making it smooth and soft.

Nutrilozhi 2 is a cream for very dry facial skin based on a patented sphingolipid, created using oleosome technology. The composition and mechanism of action of Nutrilodge 2 and Nutrilodge 1 are similar. Additionally contains: beeswax, petroleum jelly, karite oil, thanks to which the nourishing and softening effect on the skin is enhanced.

Another French company, Laboratoires Nygy-Charlieu, has specially developed and produces a hypoallergenic, highly effective moisturizing emulsion Topicrem.

Topicrem is a water-oil emulsion based on glycerin (long-term moisturizes the skin), urea 2% (keratolytic agent), which can be used for dry and flaky skin, including in newborns. Topicrem quickly restores the water-fat balance on the surface of the skin, effectively softens and eliminates the feeling of tightness that occurs with severe dry skin [29, 30].

To eliminate dry skin, they also use Bepanten, F-99, Drapolen, Children's creams, Rosa, Glutamol cream (Infarma CJSC), which contains the substance glutamol isolated from sea mollusks, vitamins A, E, petroleum jelly, glycerin, emulsifiers, etc. ... [25, 29, 30]. For the same purpose, Unna cream continues to be widely used. External therapy also includes such dermatological and symptomatic agents as anti-inflammatory drugs in the form of zinc, naphthalan, tar; ointments or gels containing antihistamines (Fenistil-gel, Psilo-balm).

In the practice of treating AD, phytocreams are also often used; products created according to recipes from Chinese doctors are especially popular [33].

An extremely important and interesting study was recently conducted by N. Ramsay et al. among children with AD whose parents reported the use of phytocreams with a positive effect [34]. It was proposed to conduct a chemical analysis of the cream, which was used by 19 patients. Determination of hydrocortisone, clobetasone butyrate, betamethasone valerate and clobetasol propionate in the composition of the product was carried out by high-performance liquid chromatography. 24 samples of the cream were examined. Seven samples contained propionate in clobetasol (in particular, 20% dermovate), 13 out of 17 samples of cream from unknown manufacturers also contained various TCS. None of the parents suspected that the cream they were using contained a corticosteroid, including strong and very strong ones. In this regard, it should be noted that this fact requires the immediate adoption of measures in the field of licensing herbal creams and improving the system of informing the population about the possible dangers posed by non-traditional methods of treatment.

Abroad, particularly in the UK, the use of compresses with emollients and/or TCS is widely practiced - occlusive circular dressings that are applied over the drug [35, 36].

From the standpoint of evidence-based medicine, the effectiveness of using emollients/moisturizers for AD is understandable, while the effectiveness of using compresses and other types of dressings in patients with AD has not been established [37].

Sometimes, when using emollients and moisturizers, patients experience minor side effects, mainly burning [32].

Typically, emollients and moisturizers are used several times in the morning and throughout the day, and always after a bath and shower, while topical steroids are prescribed mainly at night.

Since AD ​​is characterized by a change in the balance between water and lipids on the skin surface, which leads to the development of clinical symptoms such as dryness and itching of the skin, the need for auxiliary basic therapy is absolutely obvious.

Modern research has proven the important role of skin hydration and the administration of moisturizers in the acute and chronic phases of AD. The literature even describes cases where moisturizers and TCS were equally effective in patients with AD. In general, skin hydration and moisturizers significantly increase the effectiveness of complex therapy for AD and the quality of life of such patients. In addition, moisturizing preparations have a kind of preventive effect even before the appearance of pronounced symptoms of exacerbation of the disease and can significantly reduce the amount of drug therapy [13, 18, 21].

At the same time, auxiliary basic therapy does not replace drugs with anti-inflammatory effects (TCS, topical calcineurin inhibitors).

Modern practice shows that the importance of using moisturizers in the treatment of AD is greatly underestimated throughout the world. Perhaps the main reason for this is a lack of information among doctors themselves, or low compliance on the part of patients. Thus, a recent survey showed that of 77% of children suffering from AD, to whom specialists prescribed emollient ointments, only 21% used them immediately after water procedures [32].

The task of the treating physician and nursing staff is to educate patients with AD and their caregivers about the importance of regular hydration and cleansing of the skin, followed by the application of a moisturizer. Only after this the patient is recommended to use anti-inflammatory drugs (TCS, topical calcineurin inhibitors).

For questions regarding literature, please contact the editor.

D. Sh. Macharadze , Doctor of Medical Sciences Children's City Clinic No. 102, Moscow

Factors provoking the disease

A genetic mutation does not cause atopic dermatitis on its own. The disease develops under the influence of provoking factors. Most often these are atopenes - allergens to which the immune system produces antibodies. These include:

• food allergens - cow's milk, wheat, crayfish, crab, soy, chocolate, citrus fruits;
• pollen atopenes – wormwood, ragweed;
• dust pathogens - animal hair, dust, bed mites, molds. [5]

Some foods (smoked meats, sweets, hot spices, alcoholic drinks), medications (antibiotics, vitamins, sulfonamides) and cosmetics (perfumes, decorative cosmetics) can also lead to the development of atopic dermatitis in children and adults.

Factors due to which a person can develop dermatitis are divided into external and internal. Some of the external factors have already been mentioned, but they also include:

• climatic conditions;
• evaporation of solvents such as turpentine and acetone;
• harmful working conditions;
• environmental pollution with smoke and toxic fumes of aggressive substances. [5]

Internal factors are associated with other diseases of the gastrointestinal tract and endocrine system, as well as viral infections.

Many scientists believe that severe emotional stress and hormonal changes are also risk factors for developing atopic dermatitis. [6]

What is the cause of atopic dermatitis on the face?

The appearance of rashes on the face is one of the manifestations of atopy. The term itself is interpreted as a person’s high sensitivity to certain external stimuli. The mechanisms of atopic dermatitis are still being studied.

A significant role in the occurrence of atopic dermatitis on the skin of the face is played by such a factor as hereditary predisposition. If the disease is diagnosed in one or both parents, then the likelihood of a similar problem in the child increases to 30-80%.

Atopic manifestations on the skin of the face can also occur for other reasons. Provoking factors for exacerbation of atopic dermatitis include:

• regular skin contact with aggressive chemical compounds (they can be contained in care products and decorative cosmetics);
• exposure to household chemicals (for example, aggressive components of washing powders, cleaning products and detergents);
• consumption of foods that are potentially allergens (these include honey, nuts, some fruits and berries, etc.);
• taking certain medications;
• adverse environmental impacts (living in places with poor ecology, in industrial areas, near waste sites, etc.);
• stress associated with increased physical and mental stress.

An important role in the occurrence of atopic dermatitis on the face is played by disruption of the skin microbiome. Recent research in this area suggests that cutaneous manifestations of atopy may be exacerbated in response to increased activity of fungi of the genus Malassezia spp.

Colonies of Malassezia spp. for most healthy people there is no danger. But in patients prone to atopic dermatitis, sensitivity to these fungi increases. As a result of the interaction of lipophilic yeast with the human immune system, the production of specific IgE is activated. Therefore, in people with atopic skin, in addition to rashes, other manifestations of allergies are possible. A similar increased response was found to the bacteria Staphylococcus aureus (Staphylococcus aureus).

Symptoms of atopic dermatitis

Depending on the age of patients with dermatitis, the symptoms of the disease can be very different. There are three phases of atopic dermatitis:

• infant - from 7-8 weeks to 1.5-2 years;
• children's - from 2 to 12-13 years;
• adults - from the onset of puberty and older. [6, 7]

Beginning in infancy, atopic dermatitis lasts until puberty, and even until the end of life, often with remissions of varying duration. As a rule, symptoms are most pronounced in infancy and early childhood. In infants, the symptoms of atopic dermatitis include dry, scaly and itchy plaques that appear on the head, forehead and cheeks, and the outer elbows and knees. In children over 2 years of age, the manifestations are more extensive - rash and redness, dryness and flaking of the skin, as well as constant itching of the affected skin, which becomes rougher and thicker. In this case, atopic dermatitis affects the elbow and knee folds, wrists, ankles, neck, and buttock folds. An exacerbation of the disease is observed at the ages of 7-8 years and 12-14 years. [8]

As for symptoms in adulthood, we are talking specifically about episodic exacerbations of atopic dermatitis after many years of remission. They are characterized by:

• inflammation that starts from the elbow or knee folds, the back of the neck and spreads to the arms;
• pronounced dry skin with very severe peeling;
• incessant itching. [8]

What it is?

Atopic dermatitis (AD) is an allergic skin disease that usually occurs in early childhood in people with a hereditary predisposition to atopic diseases, has a chronic relapsing course, age-related features of the localization and morphology of inflammation, characterized by skin itching and caused by hypersensitivity to both allergens and non-specific irritants.
The problem of AD is becoming increasingly important in modern medicine. The increase in incidence in the last 10 years, the chronic course of the disease with frequent relapses, and the insufficient effectiveness of existing methods of treatment and prevention make this disease one of the most pressing medical problems.

Atopic dermatitis is largely classified as a childhood disease, since its symptoms manifest in childhood.

The manifestation of AD symptoms in children is observed at the age of:

• 6 months in 50-60% of cases;
• up to 1 year in 75% of cases;
• up to 7 years - in 80-85% of cases (according to various authors).

Among the adult population in developed countries, AD occurs in 0.2-2% (5.9% in Russia). Over the past decades, there has been a significant increase in AD, its course becomes more complicated, and its outcome is aggravated.

AD is often combined with other allergic diseases:

• in 40% - with bronchial asthma;
• in 25% of cases – with allergic rhinitis;
• in 8% of cases – with hay fever.

Risk factors for developing atopic dermatitis

internal non-immunological, immunological

• heredity burdened with allergies;
• high intrauterine sensitization of the fetus associated with the pathology of pregnancy and childbirth;
• early artificial feeding;
• pathology of the gastrointestinal tract;
• intestinal dysbiosis from birth;
• frequent ARVI;
• the presence of foci of chronic infection;
• factors causing dry skin (impaired sweating, lack of interstitial fluid), changes in skin lipids, decreased itching threshold;

external

• exposure to reactive chemical compounds, food antigens, microorganisms, stressful situations, climatic conditions.

Trigger factors (provoking factors)

• Food product (usually cow's milk protein, egg, cereals, soy fish)
• Inhalation allergens (house dust, house dust mites, plant pollen). Microorganisms (St. aureus, V. Herpes, Malasseria furfur, especially Malasseria spp. and other mold fungi.)

Irritants

• Sex hormones
• Stress
• Climatic factors

The development of sensitization to these allergens occurs when they enter through the respiratory tract, gastrointestinal tract, or contact route (through the skin) and leads to the appearance of respiratory manifestations of atopy, such as allergic rhinitis and bronchial asthma. In more than 80% of patients, AD is associated with allergic rhinitis and in 30%-40% with bronchial asthma. In older children, food sensitization transforms into sensitization to aeroallergens:

Skin changes in AD are that with allergic inflammation, the skin of patients has a number of features and is characterized by:

• nonspecific hyperactivity to various stimuli and antigens;
• increased dryness;
• disorders of ceramide biosynthesis;
• increased physiological desquamation of the epithelium;
• thickening of the stratum corneum with the development of hyperkeratosis and pronounced peeling.
• Intense itching and scratching of the skin in combination with its hyperreactivity and a lower sensitivity threshold for itching determine the presence of a vicious circle: dry skin, itchy skin, inflammation.

Classification of AD

• Exogenous (allergic) AD associated with respiratory allergies and sensitization to aeroallergens. The risk of developing respiratory allergies in patients suffering from AD, according to various authors, ranges from 30 to 80%. 60% of AD patients have a latent tendency to develop bronchial asthma, and 30-40% develop it;
• Endogenous (non-allergic) AD, not associated with respiratory allergies and sensitization to any allergens.

Stages of the disease:

Age period:

• I age period – infant (up to 2 years)
• II age period – children (from 2 to 13 years)
• III age period – adolescence and adulthood (over 13 years old)

Stages of the disease:

• Exacerbation stage Phase of pronounced clinical manifestations
• Phase of moderate clinical manifestations

Complications

• pyoderma;
• viral infection;
• fungal infection

Severity of the process

• mild course
• moderate severity
• severe course

Symptoms that require you to contact an allergist-immunologist

Main clinical signs of atopic dermatitis

• itchy skin;
• typical morphology and location of the rash according to the age period;
• tendency towards a chronic relapsing course;
• personal or family history of atopic disease;
• seasonality of exacerbation (deterioration in the cold season and improvement in summer);
• exacerbation of the process under the influence of provoking factors (allergens, irritants, foods, emotional stress); - connection between exacerbations and exposure to allergens;
• dry skin;
• white dermographism;
• tendency to skin infections;
• cheilitis (seed);
• Denny-Morgan sign (additional fold of the lower eyelid);
• hyperpigmentation of the periorbital area (around the eyes);
• increased levels of total and allergen-specific IgE in serum;
• peripheral blood eosinophilia.

Age characteristics and localization of skin lesions

The doctor evaluates

• the nature of the rashes and their correspondence to the age period
• presence or absence of scratching (intensity of skin itching)
• additionally, if any, symptoms of allergic rhinitis, allergic conjunctivitis, bronchial asthma

After which laboratory tests are prescribed to confirm the diagnosis.

Laboratory and instrumental studies

• Clinical blood test
• Determination of the concentration of total IgE in blood serum
• Skin tests with allergens to detect an IgE-mediated reaction
• Provocative test with food allergens
• determination of allergen-specific IgE-AT in blood serum

In addition, a general clinical examination is carried out, for example, 80-90% of patients have concomitant pathology of the digestive system. It has long been noticed that if there are several sources of the inflammatory process in the body, they “warm up” and increase the severity of each other. Therefore, after treating the concomitant pathology, the inflammatory process on the skin subsides and we need much less time and the amount of drugs used to stop it completely.

In light of all of the above, it is quite logical to additionally assign such studies:

• clinical and biochemical blood test
• general urine analysis
• coproocystoscopy
• bacteriological examination of feces
• esophagogastoduodenoscopy
• detection of Helicobacter pylori using a breath test
• Ultrasound of the abdominal organs
• X-ray examination of the chest and paranasal sinuses
• FVD assessment
• immunological examination (all immunoglobulins, possible selective deficiency of IgA, which often accompanies AD)

Specialist consultations:

• dermatologist - to establish a diagnosis, carry out differential diagnosis with other skin diseases, select and correct local therapy, and educate the patient.
• repeat consultation - in case of poor response to local glucocorticosteroid therapy or secondary infection.
• nutritionist – to create and correct an individual diet
• ENT – identification and sanitation of foci of chronic infection, early detection of AR symptoms
• neuropsychiatrist - for severe itching, behavioral disorders, psychotherapeutic treatment, training in relaxation techniques, stress relief and behavior modification.

Diagnosis of skin pathology

At the moment, there is no specific laboratory test that can detect atopic dermatitis. The diagnosis is made based on the symptoms present and an assessment of the severity of the disease. The severity of atopic dermatitis is determined using the SCORAD scale, which includes a number of objective and subjective criteria. The first includes the strength and prevalence of lesions, the subjective - the intensity of itching during the day and night. [9]

To establish atopic dermatitis, it is necessary to identify specific IgE antibodies to allergens. For this purpose, cutaneous patch tests are performed, but only if the patient has delayed-type hypersensitivity.

Atopic dermatitis is often confused with other diseases. To avoid mistakes, differential diagnosis is carried out using laboratory tests:

• detection of platelet pathology;
• determination of immune status;
• microscopy of scales. [9]

Sometimes, to distinguish atopic dermatitis from other pathologies, the localization of the rash is sufficient. So vulgar psoriasis affects the extensor surfaces, while the manifestations of atopic dermatitis are localized in the flexor areas.

What complications can there be?

If atopic dermatitis is not properly treated, the disease will develop and lead to complications. Like manifestations, the severity and severity of complications are directly related to the age of the patient. The infantile phase is characterized by complications of atopic dermatitis such as candidiasis and Kaposi's eczema herpetiformis. In childhood, staphylococcal impetigo, molluscum contagiosum and chronic papillomavirus infection are observed. Complications in the adult phase are represented by dermatophytosis and keratomycosis. [10]

Without treatment, atopic dermatitis can significantly reduce the quality of life of the patient and his family. Discomfort is primarily associated with a person’s appearance - with dermatitis, noticeable itchy spots appear on the body, which cause anxiety among others. And although atopic dermatitis cannot be contracted, people are wary of patients and do not want to come into contact with them. Patients experience a continuous desire to scratch the inflammation, so their posture and facial expression look tense and repulsive. Therefore, when it comes to dermatitis, one cannot fail to mention the neurotic and psychological syndromes that this disease entails.

Treatment with Akriderm drugs

Akriderm preparations are products for the local treatment of manifestations of atopic dermatitis with a wide spectrum of action. Thanks to the combined composition, including a glucocorticosteroid, an antibiotic and an antifungal component, the products have several effects at once:

• anti-inflammatory;
• antiallergic;
• vasoconstrictor;
• antipruritic. [12]

Since atopic dermatitis can occur in both acute and chronic forms, Akriderm preparations are available in the form of ointments and creams. This allows you to choose the most appropriate remedy based on the course of the disease, the severity of manifestations and the presence of secondary infection. Active substances penetrate deeply into the source of inflammation, fighting not only pathogens that provoke atopic dermatitis. Treatment is also aimed at combating attached microorganisms. Thus, Akriderm preparations have a bacterial and antifungal effect. [13]

A well-thought-out formulation of the drugs makes it possible to use them in the treatment of atopic dermatitis in children over 2 years of age. [14, 15]. Other advantages of Akriderm preparations for the topical treatment of atopic dermatitis include:

• convenient release form – 15 g and 30 g;
• reasonable price - the cost of a 30 g package is more profitable for the buyer compared to 15 g of a similar product; [16]
• over-the-counter status, which makes Akriderm preparations one of the most accessible means for treating manifestations of dermatitis.

Types of disease

Treatment of eyelid dermatitis should begin as soon as the disease is identified. There are three main types of disease:

1. Chronic dosage form - most often manifests itself against the background of taking antibiotics. It does not particularly matter whether the drug was taken orally or the ointment was applied to the skin of the eyelids. From the moment you start taking it, the skin begins to wrinkle, becomes thicker, and itching and redness may occur.
2. The medicinal form is a form of the disease that fully corresponds to drug dermatitis. But the speed of development of the disease is much greater: the full symptomatic picture is revealed in 5-6 hours.
3. Eczematous appearance - this form has the most pronounced symptomatic picture, but at the same time, a rare prevalence. The reason may be long-term use of certain types of drugs or the use of electrophoresis in the eye area. A distinctive feature of this form is local inflammation on the skin in the form of small blisters filled with liquid, accompanied by itching.

Diagnostics consists of a visual examination by a doctor of the affected skin of the eyelids and collection of information about what diseases the patient has suffered in the near future and what medications he has used.

Having made a diagnosis, the doctor determines the form of the disease, and, consequently, what treatment will be most effective in this case.