Eczema or atopic dermatitis is a leading cause of distress and an important element in health care expenditures in the developed world because of its increasing prevalence and chronic disease course. Recent studies suggest that prenatal maternal distress (i.e. anxiety, depression), might increase the risk of allergic disease in children such as asthma and eczema.
A recent study published in the August 2016 issue of The Journal of Allergy and Clinical Immunology looked into a large birth cohort to see if prenatal maternal psychological stress increases the risk of atopic dermatitis (eczema). Depression, anxiety and distress was evaluated at 36 weeks gestation and eczema was evaluated by pediatric allergy specialists at 6 months, 1,2,3, and 4 years of age. Approximately 2500 mother-baby pairs were studied from Korea.
The results showed that prenatal depression and anxiety increased the risk of atopic dermatitis (eczema).
The mechanism proposed is that distress causes higher cortisol levels which disrupts the maternal-fetal hormonal balance, however the exact nature is unclear. The results though imply that the mechanism underlying the relationship between maternal stress and offspring’s atopic dermatitis (eczema) involves chronic stress, abnormal steroid levels and oxidative stress of the mother.
Atopic Dermatitis is a frustrating disease with no known cure at the present time. Standard treatments consist of;
Skin Hydration-Eczema is characterized by impaired skin barrier function, moisture application particularly after soaking in water can help retain water and improve barrier function. There is very little data comparing barrier creams with one another.
Topical Steroids-For non-mild atopic dermatitis, moisturizing alone may not be sufficient. Topical steroids can be applied one to two times daily to calm both itch and inflammation. They though must be used with caution in thin skin areas. Once improved, low potency steroids should be used to minimize side effects.
Topical Calcineurin Inhibitors-These represent another class of anti-inflammatory medications without the adverse side effect profile. Tacrolimus and pimecrolimus inhibit the activation of key cells in eczema. Common side effects are local burning of the skin, which wears off after a few days. These medications do not cause skin atrophy and are favored for facial use. Procactive therapy with twice weekly application has been shown to reduce flares. Despite the black box warnings, studies have shown since 2006 no increase in lymphomas.
Antihistamines-Studies have shown little effectiveness besides their high usage. This is the case because histamine is not the only mediator involved in pruritis. But patients with concomitant hives or allergies may find it beneficial.
Vitamin D-There is controversy about Vitamin D supplementation. Eczema is worse in the wintertime, leading some to believe this is due to Vitamin D deficiency because lack of sun exposure. This is a relatively benign therapy that may help some patients.
Treatment of Infections– Staphyloccus aureus has been know to play a significant role in eczema, causing infection and inflammation, even as a colonizer. They may be severe and recurrent. When an infection is present, a short course of oral antibiotics is warranted. Dilute bleach baths have been shown to reduce severity. Mixing 1/4 of plain household bleach in a 40 gallon bath and soaking twice weekly and lead to a dramatic improvement.
Wet Dressings-For difficult to manage patients, wet wraps in combo with topical steroids represent a powerful therapy. This entails soaking the skin, applying a topical steroid, and then applying a damp layer of gauze or clothing followed by a dry layer. Wet dressing appear to be safe for up to 14 days and actually decrease steroid usage.
Trigger Elimination-A range of trigger factors are soaps, chemical and fabrics. Other proteins can be dust mites. Food triggers are often suspected and up to 1/3 of patients with moderate to severe eczema have them. Testing for food allergy is recommended for children younger than 5 years old who have persistent eczema.
A new medication is on the horizon for atopic dermatitis, Dupilumab for Atopic Dermatitis, which has shown great results in preliminary studies.
In conclusion, prenatal maternal distress, including depression an anxiety, is associated with a higher risk of atopic dermatitis in offspring. Higher scores of maternal distress directly increased the probably of eczema development. Further studies should be designed to evaluate whether early interventions in mothers exhibiting prenatal distress prevent eczema development in offspring.