Transcript of Childhood Atopic Dermatitis 2 * VERY! 10-20% of children in developed countries (Harper et al,2000)...
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- Childhood Atopic Dermatitis 2
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- * VERY! 10-20% of children in developed countries (Harper et
al,2000) * Incidence has trebled over the last 30 years (Harper et
al, 2000) * Positive correlations of eczema with higher social
classes and airpollution has been confirmed (Simpson, Hanifin,
2005) * 80% of children will develop eczema in 1st year * 50% of
children will clear by 2 years of age * 85% of children will clear
by 5 years of age * About 5% of children with eczema will continue
into adulthood How common is Atopic Eczema ? 3
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- Increased IgE production Specific IgE to multiple antigens
Increased basophil spontaneous histamine release Decreased CD8
suppressor/cytotoxic number and function Increased expression of CD
23 on mononuclear cells macrophage activation with increased
secretion of GM- CSF(IL-5), PGE 2 and IL-10 Decreased numbers of
IFN-gamma-secreting from Th 1-like cells 6
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- First appointment is important in managing the eczema
effectively and gain the trust of the patient and family * Family
history * Coexisting atopic disease * Immunization * Allergies,
tests, diet manipulation and adequacy * Growth * Previous
treatments used and outcomes * Most distressing element * Sleep
disturbance * Environmental aggravators, assess
heat/prickle/dryness * Effect on family life, school * Parents
expectations from treatment * YOUR expectation from treatment
Taking a good history 7
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- Infantile stage: ( 0-2 years ) tends to start around 3-6
months.Usually affects the face, wrists,nappy area and when severe
every part of the body.Often gets infected. Childhood stage:( 2-12
years ) the skin starts to become dry cracked and thickened.Usually
affects the elbows,back of knees,ankles and back of ears.Severe
thickening of the skin is very common in Afro-Caribbeans and
Asians. Adolescent and adult phase: (puberty onwards )
lichenification of the skin is very prominent now.Affects the
elbows,knees, neck and bottom of the eyes. STAGES of Atopic Eczema
PHASES 8
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- Serum IgE levels Skin prick tests(Allergy test) Skin patch
tests RAST(checks to see if the body is producing antibodies
against common things like house dustmite,pollens,cat and dog hair
and food substances) Skin biopsy INVESTIGATIONS 9
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- Must have:Major Features itchy skin family history of atopy
typical picture,( facial, flexures, lichenification) Plus three or
more of the following:Minor Features Xerosis/ichthyosis/hyper
linear palms, keratosis pilaris periaricular fissures,dennie-morgan
lines chronic scalp scaling,pityriasis alba,cataract Diagnostic
criteria 14
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- Pityriasis alba 15
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- Xerosis 16
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- Keratosis Pilaris 17
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- Ichthyosis 18
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- * Heat * Dry skin and environment * Prickle * Allergies *
Irritants * Infection * Saliva * Water What aggravates Atopic
Eczema? 21
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- * Too many clothes * Hot baths >29 degrees * Too many
blankets * Sport/running around * Hot cars * Heaters * Hot school
classrooms What makes eczema hot and itchy? 22
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- * Soap, use bath oils or washes * Air blowing heaters *
Swimming pools * Australia!!!! * Therefore apply moisturiser from
top to toe regularly and more often when flaring What makes eczema
dry and itchy? 23
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- This depends on Disease severity Age Compliance Efficacy Safety
data Treatment costs 24
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- Every day * avoid aggravators * moisturiser * bath oil Eczema
Treatments Topical Treatments Flaring Treatments * every day
treatments + * steroid ointments * wet dressings * cool compresses
* antibiotics 25
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- * Phototherapy(using ultraviolet rays UVA,nUVB) * Immunity
suppressing drugs(e.g.oral
steroids,azathioprine,ciclosporin,tacrolimus) * Diet and nutrition
(food allergy) * Alternative therapies (Chinese medicine herbalism)
Second line treatment(severe cases): All these require specialist
treatment in the Hospital. 26
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- Identify trigger factors Irritants soaps and detergents Contact
allergens Food allergens Inhalant allergens Skin infections Refer
for specialist advice when necessary 27
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- Tailor treatment to severity Start with emollients should be
used even when skin clear Mild disease emollients + mild steroid
creams 1% hydrocortisone Moderate disease emollients + moderate
steroid creams. Topical calcineurin inhibitors, bandages. Severe
disease potent steroid creams (short periods only) topical
calcineurin inhibitors, bandages, phototherapy, systemic therapy
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- Use topical antibiotics + steroid for localised infection for
no longer than 2 weeks Non-sedating antihistamines if eczema is
severe or severe itching or urticaria Sedating antihistamines
children aged > 6/12 during acute flares if sleep disturbance
for child or carers. Recognise indications for referral 29
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- Treat the AD! Oral antibiotics Cephalexin (50 mg/kg divided
BID-TID) Dicloxacillin Septra, clindamycin, doxycycline if
concerned about MRSA 31
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- Dilute bleach cup household bleach in half-full bathtub once to
twice weekly Dilute bleach + intranasal mupirocin improved AD
severity over 3 month study period Swimming in chlorinated pool may
have similar effect 32
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- Immediate (same day) if eczema herpeticum suspected Urgent
(within 2 weeks) If severe and not responded to optimal treatment
for 1 week Treatment of bacterial infected eczema has failed
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- Routine referral Diagnosis uncertain Eczema on face not
responded Eczema is associated with sever recurrent infections
Contact allergic eczema suspected Causing serious social or
psychological problems for child or carers Eczema not controlled to
the satisfaction of carers or child 34
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