19663244-atopicdermatitis2

8/6/2019 19663244-atopicdermatitis2

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Atopic DermatitisAtopic Dermatitis

Dr. Maged ElDr. Maged El--Batawi, MD.Batawi, MD.

Professor of DermatologyProfessor of Dermatology

Cairo UniversityCairo University20042004


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What isWhat is atopicatopic dermatitis?dermatitis?

AA chronic relapsingchronic relapsing, intensely, intensely pruriticpruriticdermatitis,dermatitis,

with a characteristicwith a characteristic distributiondistributionpattern, inpattern, inanan atopicatopicindividual.individual.


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What isWhat is atopyatopy??

AnAn inheritedinheritedtendency to develop atendency to develop a

hypersensitivity response (hypersensitivity response (i.e.i.e. allergyallergy) to) tocertain environmental stimuli (certain environmental stimuli (i.e.i.e. allergensallergens),),

in presence of a characteristicin presence of a characteristic immunologicimmunologic

profileprofile..

AA = no,= no, topostopos= place= place

AtoposAtopos== out of placeout of place oror strangestrange


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Atopic DisordersAtopic Disorders

AsthmaAsthma

Allergic rhinitis (hay fever)Allergic rhinitis (hay fever)

Atopic dermatitisAtopic dermatitis

Allergic gastroenteritisAllergic gastroenteritisAllergic conjunctivitisAllergic conjunctivitis


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AetiologyAetiology

Genetic predisposition, inheritedGenetic predisposition, inherited

tendencytendency

Immunologic profileImmunologic profile

Environmental triggers (allergens)Environmental triggers (allergens)PathogenesisPathogenesis


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Immunologic Profile in AtopyImmunologic Profile in Atopy

ElevatedElevated totaltotalserum IgEserum IgE (RIST)(RIST)Elevated serumElevated serum allergenallergen--specificspecificIgEIgE(RAST)(RAST)

Frequent positiveFrequent positive prick testsprick teststo manyto manyenvironmental allergensenvironmental allergens

Eiosinophilia;Eiosinophilia; blood and tissue, MBPblood and tissue, MBP


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Immunologic Profile in Atopy (Immunologic Profile in Atopy (contcont))

Biphasic Th1/Th2 reversal response:Biphasic Th1/Th2 reversal response:

Th2 predominance in acute and subacute lesionsTh2 predominance in acute and subacute lesions(early phases)(early phases)

Elevated ILElevated IL--4, IL4, IL--5 and IL5 and IL--1313

RelativeRelative anergyanergy for eliciting allergic contact dermatitis (for eliciting allergic contact dermatitis (

Th1)Th1)Increased susceptibility to viral and fungual infections (Increased susceptibility to viral and fungual infections ( Th1)Th1)

Th1 responses predominate in chronic lesions (lateTh1 responses predominate in chronic lesions (late

phase)phase)Elevated InterferonElevated Interferon--

Reversal of DTH suppressionReversal of DTH suppression


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Environmental Trigger FactorsEnvironmental Trigger FactorsInhalantsInhalants

Dust mitesDust mites

Animal furs, danderAnimal furs, dander

PollensPollens

IngestantsIngestants

CowCow

s milks milk

Nuts; peanuts,Nuts; peanuts,

EggsEggs

ContactantsContactants

Wool fibersWool fibers Lipid solvents;Lipid solvents;

soaps, detergentssoaps, detergents

Chlorine inChlorine inswimming poolsswimming pools

Microbial agentsMicrobial agents StaphStaph. aureus (. aureus (superantigensuperantigen))

CandidaCandidaClimateClimate

Extremes of temperatureExtremes of temperature

DrynessDryness

Emotional stressEmotional stress


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PathogenesisPathogenesisHigh PDE activityHigh PDE activity cAMPcAMP

hyperreleasibility of mast cellshyperreleasibility of mast cells

FcFcRI gene abnormalityRI gene abnormality

Carriage of FcCarriage of FcRI on:RI on:

Mast cellsMast cells immediate reactionimmediate reactionLangerhans cellsLangerhans cells late phase reactionlate phase reaction

Neuropeptide abnormalityNeuropeptide abnormality

Abnormal vascular responsesAbnormal vascular responses

IntenseIntense prurituspruritus


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Clinical PhasesClinical Phases

Infantile phaseInfantile phase

Childhood phaseChildhood phase

Adolescent and adulthood phaseAdolescent and adulthood phase


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Infantile phaseInfantile phase

2 months to 2 years2 months to 2 years Face, extensorsFace, extensors

Acute oozing lesionsAcute oozing lesions

Subacute crusted lesionsSubacute crusted lesions


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4 to 10 years4 to 10 years Less acute lesionsLess acute lesions

More dry subacute and lichenified lesionsMore dry subacute and lichenified lesions

FlexorsFlexors


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Adolescent and Adult phaseAdolescent and Adult phase

Early teens to early twentiesEarly teens to early twenties

Dry lichenified hyperpigmented plaquesDry lichenified hyperpigmented plaques

FlexorsFlexors


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Infantile EczemaInfantile Eczema


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Infantile EczemaInfantile Eczema


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LichenificationLichenification


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LichenificationLichenification


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Adulthood ADAdulthood AD


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Adulthood ADAdulthood AD


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Other Presentations of ADOther Presentations of AD Nummular dermatitisNummular dermatitis

Eyelid dermatitisEyelid dermatitis Ear dermatitis; postEar dermatitis; post--auricular fissuresauricular fissures

CheilitisCheilitis

Nipple dermatitisNipple dermatitis

Facial dermatitisFacial dermatitis

Hand dermatitisHand dermatitis Juvenile plantar dermatosisJuvenile plantar dermatosis


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Nummular dermatitisNummular dermatitis


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Nummular dermatitisNummular dermatitis


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Eyelid dermatitisEyelid dermatitis


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Ear lobe dermatitisEar lobe dermatitis


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SimpleSimple CheilitisCheilitis


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Angular cheilitisAngular cheilitis


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Nipple dermatitisNipple dermatitis


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Hand dermatitisHand dermatitis


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Juvenile plantar dermatosisJuvenile plantar dermatosis


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Associated FeaturesAssociated Features

Skin conditionsSkin conditions

Atopic stigmataAtopic stigmata

EyeEye


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Associated Features (1)Associated Features (1)CutaneousCutaneous

XerosisXerosis

IchthyosisIchthyosis

Pityriasis albaPityriasis alba

Keratosis pilarisKeratosis pilaris

Reticulate pigmentation of the neck (dirty neck)Reticulate pigmentation of the neck (dirty neck) KeratosisKeratosis punctatapunctata palmarispalmaris etet plantarisplantaris

Chapping of the digits (Chapping of the digits (pulpitispulpitis siccasicca))

PeriorbitalPeriorbital miliamilia

WhiteWhite dermographismdermographism Cholinergic urticariaCholinergic urticaria

Infections;Infections; StaphStaph. aureus, HSV (eczema. aureus, HSV (eczema herpeticumherpeticum))


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PupitisPupitis siccasicca


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StaphStaph. Infected AD. Infected AD


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EczemaEczema HerpeticumHerpeticum


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Associated features (2)Associated features (2)Atopic stigmata:Atopic stigmata:

Low hairlineLow hairlinePerinasalPerinasal pallor (headlight sign)pallor (headlight sign)

Darkening of orbital skin (allergic shiners)Darkening of orbital skin (allergic shiners)

HertogheHertoghess sign (thinning of outer eyebrows)sign (thinning of outer eyebrows)DennieDennie--Morgan foldMorgan fold

Anterior Neck foldAnterior Neck fold

HyperlinearityHyperlinearity of the palmsof the palms


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HertogheHertoghess signsign


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DenneDenne--Morgan linesMorgan lines


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Associated Features (3)Associated Features (3)Eye complicationsEye complications

CataractCataract KeratoconusKeratoconus

AtopicAtopic keratoconjunctivitiskeratoconjunctivitis


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DiagnosisDiagnosisClinical criteriaClinical criteria

Major;Major; PruritusPruritus, Dermatitis, Atopy history, Dermatitis, Atopy history MinorMinor

Hypersensitivity to environmental factorsHypersensitivity to environmental factors

Dry skinDry skinDermatitis in specific areasDermatitis in specific areas

AssociatedAssociated Dermatologic conditionsDermatologic conditions

StigmataStigmata Eye conditionsEye conditions

IgE; (IgE; (RIST, RASTRIST, RAST))


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InvestigationsInvestigations Skin prick testSkin prick test

Total IgE (Total IgE (RISTRIST)) Specific IgE (Specific IgE (RASTRAST))

Eosinophilia;Eosinophilia; blood, lesionsblood, lesions

Th2 cytokine profile;Th2 cytokine profile; ILIL--4, IL4, IL--5, IL5, IL--1313

Reduced Th1 response;Reduced Th1 response; interferoninterferon--, DTH to, DTH tocontact allergenscontact allergens


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Skin Prick TestSkin Prick Test


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TreatmentTreatmentGeneralGeneral

Avoid any possible environmental trigger factors:Avoid any possible environmental trigger factors:

cowcows milk, nuts, eggs,s milk, nuts, eggs,

extremes of temperature and humidity, hot water showersextremes of temperature and humidity, hot water showers

over bathing, swimming pools, harsh soaps and detergentsover bathing, swimming pools, harsh soaps and detergents

wools, nonwools, non--absorbent or tight clothesabsorbent or tight clothesemotional stress, anxietyemotional stress, anxiety

Wear absorbent comfortable clothes (cotton)Wear absorbent comfortable clothes (cotton)

Avoid dryness of the skin, use emollientsAvoid dryness of the skin, use emollients

Elimination diets (doubtful benefit)Elimination diets (doubtful benefit)

Breast feedingBreast feeding


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TreatmentTreatmentTopicalTopical

Wet compresses for oozing lesions:Wet compresses for oozing lesions:

Aluminum acetate 5% (Aluminum acetate 5% (BurowBurowss solution) 20solution) 20--30 minutes,30 minutes,44--6 times daily6 times daily

Topical corticosteroidsTopical corticosteroids (problems!)(problems!)

Hydrating agents for dry skin:Hydrating agents for dry skin:10% urea in hydrophilic cream10% urea in hydrophilic cream

EucerinEucerin creamcream

Tar preparationsTar preparations

MacrolideMacrolide immunomodulatorsimmunomodulators::

TacrolimusTacrolimus 0.3% ointment0.3% ointment

AscomycinAscomycin macrolactammacrolactam derivatives (derivatives (PimecrolimusPimecrolimus 1%)1%)


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TreatmentTreatmentSystemicSystemic AntihistaminesAntihistamines

Sedating;Sedating; hydroxyzinehydroxyzine,, doxepindoxepin,,

AntistaphylococcalAntistaphylococcal antibioticsantibioticsPenicillinsPenicillins,, cephalosporinscephalosporins, erythromycin,, erythromycin,

Systemic corticosteroidsSystemic corticosteroids

Side effects!Side effects!

Only for acute flareOnly for acute flare--upsups Phototherapy;Phototherapy; PUVA, UVBPUVA, UVB

CyclosporineCyclosporine

Side effects!Side effects!

ExpensiveExpensive InterferonInterferon--;; Th1 promoterTh1 promoter

Papaverine;Papaverine; PDE inhibitorPDE inhibitor

Evening Primrose oil;Evening Primrose oil; --linoleniclinolenic acid, PG modulatoracid, PG modulator

19663244-atopicdermatitis2

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