Atopic dermatitis (AD) – treatment in Wrocław and Nysa

Atopic dermatitis is a chronic, inflammatory skin disease with a relapsing course in which the cardinal symptom is itching. It occurs in 15–20% of children and in 2–10% of adults, and an increase in incidence has been observed in industrialised countries in recent decades. In most patients the first symptoms appear before the age of 5.

Two coexisting mechanisms underlie the disease: damage to the epidermal barrier, associated among other things with disturbances in the structure of filaggrin, and an abnormal immune response of an inflammatory profile. A damaged barrier facilitates transepidermal water loss and the penetration of allergens and microorganisms, which sustains the inflammation. For that reason treatment covers both the restoration of the barrier and the suppression of the inflammation.

We hold dermatological consultations in Wrocław at ul. Barlickiego 31/1U and in Nysa. We see patients privately, without a referral. Reception: 573 290 488. 573 290 488.

The clinical picture according to age

The infant phase (up to the age of 2)

Erythematous and exudative lesions with a tendency to ooze and to form crusts cover the cheeks, the forehead and the scalp, with characteristic sparing of the area around the mouth and the nose. Subsequently the extensor surfaces of the limbs and the trunk are involved. The nappy area usually remains free of lesions.

The childhood phase (ages 2–12)

Lesions of a dry eczema character predominate, located in the elbow and knee flexures, on the wrists, the nape and the backs of the hands and feet. The skin becomes thickened, with accentuated markings, which follows from chronic scratching.

The adolescent and adult phase

Lesions cover the face, particularly the eyelids and the periorbital area, the neck, the upper chest and the hands. In some patients the disease takes the form of chronic hand eczema, which makes professional work difficult. In adults a nodular form resembling prurigo nodularis is also seen.

Accompanying symptoms

Itching – a symptom present in all patients, intensifying in the evening and at night and leading to sleep disturbance.
Dry skin – it persists also in periods without inflammatory lesions and requires constant care.
An additional skin fold beneath the lower eyelid and thinning of the lateral part of the eyebrow.
Accentuated markings of the skin of the hands and keratosis pilaris on the arms.
A tendency to recurrent skin infections, in particular staphylococcal and viral.

Diagnostic criteria

We make the diagnosis on the basis of the clinical picture and the history, without the need for confirmatory tests. The basis is the presence of itching coexisting with at least three of the following features:

skin lesions in a location typical for the age,
a chronic and relapsing course of the disease,
atopic diseases in the patient or in the immediate family, including bronchial asthma and allergic rhinitis,
generalised dryness of the skin,
the onset of symptoms before the age of 2.

Differential diagnosis

Disease	Distinguishing features
Seborrhoeic dermatitis	Greasy, yellowish scales in the seborrhoeic areas, less intense itching; in infants the nappy area is involved.
Psoriasis	Sharply demarcated lesions, silvery scale, location on the extensor surfaces, nail changes.
Scabies	Itching intensified at night, involvement of the interdigital spaces and the wrists, symptoms in other members of the household, the presence of burrows.
Contact eczema	Lesions limited to the site of contact with the causative agent; they resolve after it is eliminated.
Tinea of the glabrous skin	A ring-shaped lesion with an active border; the mycological examination is decisive.
Cutaneous T-cell lymphoma	Considered in adults with eczema resistant to treatment and with an atypical location; histopathological assessment is required.

Diagnostic procedure

During the visit we take a history covering the age at which the first symptoms appeared, the course of the disease, the treatment so far and the coexisting diseases. We assess the extent and the severity of the lesions, as well as the effect of the itching on sleep and on daytime functioning. We document the severity of the disease in a way that allows comparison at subsequent visits.

Allergy tests – the determination of specific IgE and skin prick tests are of limited value, because a positive result indicates sensitisation and not a causal relationship with the skin lesions. We perform them when a specific allergen is reasonably suspected.
Patch tests – considered in patients with hand eczema and when a superimposed contact eczema is suspected. The test is carried out in centres that perform contact allergy diagnosis.
Culture from the skin lesions – performed when a secondary bacterial infection is suspected, particularly with oozing and honey-yellow crusts.

Treatment of atopic dermatitis

Emollient therapy in atopic dermatitis – the basis of management

Emollients are used daily, also in periods without inflammatory lesions. In an adult the recommended quantity is 250–500 g a week, in a child 150–250 g a week. The preparation is applied to the skin within 3 minutes of bathing, onto a slightly moist surface. Regular care reduces the need for anti-inflammatory medicines and lengthens the periods of remission.

Topical anti-inflammatory treatment

Topical glucocorticosteroids – selected by potency according to the age of the patient and the location of the lesions. On the face, the neck and in the folds we use preparations of low potency and for a short time.
Calcineurin inhibitors – tacrolimus and pimecrolimus. They do not cause skin atrophy, so they are preferred in sensitive areas and in long-term treatment.
Proactive therapy – once a flare has been brought under control, the anti-inflammatory preparation is applied twice a week to the areas in which the lesions recur. This reduces the number of flares over a year.

Systemic treatment

In moderate and severe forms that do not respond to topical treatment, immunosuppressive medicines are used, above all ciclosporin A and methotrexate. Such treatment requires periodic monitoring of laboratory tests.

Modern treatment of the severe form of the disease covers monoclonal antibodies and oral Janus kinase inhibitors. In Poland these therapies are conducted within the drug programme of the National Health Fund, in designated centres. The task of the clinic is to assess the severity of the disease, to document the treatment so far and to refer the patient to such a centre.

Phototherapy

Irradiation with narrow-band UVB at a wavelength of 311 nm is an established method of treating chronic forms in people over the age of 12. The treatments are carried out in centres equipped with an irradiation cabin, in cycles usually covering 20–30 sessions.

Management of secondary infection

Oozing, honey-yellow crusts and a sudden deterioration of the skin indicate a bacterial superinfection, most often with Staphylococcus aureus. Disseminated vesicles and erosions with fever require urgent consultation, because they may correspond to a herpes simplex infection with a severe course.

Care of atopic skin

A bath lasting 5–10 minutes in water at 27–30°C, using cleansers without ionic detergents.
Drying the skin by gently applying a towel, without rubbing.
Applying an emollient within 3 minutes of the bath.
Clothing of cotton or silk, without wool or synthetic fabrics next to the skin.
Washing with fragrance-free products, with an additional rinse.
A temperature of 18–20°C in the bedroom and air humidity of 40–60%.
Short-cut nails and, in small children, also cotton gloves at night during periods of intense itching.

Factors that aggravate the symptoms

low air humidity during the heating season and rapid changes of temperature,
sweat and overheating, including clothing that is too warm,
detergents, solvents and prolonged contact with water,
chronic stress and lack of sleep,
respiratory infections,
in some patients selected foods, although elimination is carried out only after the connection with a flare has been confirmed, never preventively.

Contraindications and limitations

We do not recommend the long-term use of strong topical glucocorticosteroids, particularly on the face and in the skin folds. We also advise against elimination diets in children without a confirmed diagnosis of food allergy, because this carries a risk of nutritional deficiencies. Herbal preparations of undetermined composition and cosmetics containing fragrances may provoke a contact eczema superimposed on the underlying disease.

Prices

Medical visit – dermatological examination: 280–350 PLN
Consultation with a specialist online, with the possibility of issuing a prescription: 220 PLN
Examination of the skin for a fungal infection – collection of material and mycological examination: from 100 PLN

The full list is available on the page HappyDERM price list.

Frequently asked questions

Is atopic dermatitis an allergy?

Not in the colloquial sense of the word. It is an inflammatory skin disease associated with damage to the epidermal barrier and an abnormal immune response. Allergy coexists in some patients, but it is neither a condition of the diagnosis nor the only cause of flares.

Are emollients enough to control the disease?

Emollients are the basis of management and reduce the number of flares, but they do not abolish existing inflammation. During a flare anti-inflammatory treatment must be added, and the emollient is used alongside it.

Can a child with atopic dermatitis be vaccinated?

Yes. The disease is not a contraindication to protective vaccination. Vaccination is postponed only during a severe flare or an active skin infection, which the treating doctor determines.

Does atopic dermatitis pass with age?

In a substantial proportion of children the skin symptoms resolve or clearly diminish at school age. The tendency to dry skin and to irritation usually persists throughout life, however, which justifies continued care.

Are allergy tests necessary?

Not in every patient. We perform allergy tests when the history indicates a repeatable connection between the symptoms and a specific factor. Routinely performing broad allergy panels does not change management and is often a source of erroneous conclusions.

Are steroids applied to the skin safe?

Used as directed, for a limited time and in a preparation matched to the location, they are safe and effective. The risk of adverse effects is associated with the long-term use of strong preparations without medical supervision.

What should be brought to the consultation?

Please prepare a list of the preparations used so far together with their packaging, the results of earlier tests and information about coexisting diseases. Photographs of the lesions taken during a flare are also helpful.

Do you provide biologic treatment?

Biologic therapies and Janus kinase inhibitors are conducted within the drug programme in centres designated by the National Health Fund. At the clinic we assess the severity of the disease, document the course of the treatment so far and refer the patient to such a centre.

The doctors who see patients

Consultations in inflammatory skin diseases are provided by dr n. med. Małgorzata Micał-Strąk, lek. Ireneusz Pijanowski and lek. Dagmara Pawełczyk-Sicińska.

Booking a visit

An appointment for a consultation can be booked by telephone on 573 290 488. We also invite you to read the pages devoted to seborrhoeic dermatitis and psoriasis.

Telephone booking: 573 290 488. The contact details of all the clinics are available on the page contact.