ATOPIC DERMATITISATOPIC DERMATITIS

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M. Sjabaroeddin Loebis, Lily Irsa, Rita Evalina

Allergy Immunology Division

Pediatrics Departement

Medical Faculty Sumatera Utara University

Atopic dermatitisAtopic dermatitis

DefinitionDefinition

An inflammatory skin disorderAn inflammatory skin disorder

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An inflammatory skin disorderAn inflammatory skin disorder

characterized with : characterized with : erythema, edema,erythema, edema,

intense pruritus, exudation, crusting, intense pruritus, exudation, crusting, andand

scalingscaling..

Mechanisms of Eczema in

Children

1. ALLERGY

2. SKIN BARRIER DYSFUNCTIONS

3. CHRONIC INFECTION

4. AUTO-IMMUNITY (?)

= complex interplay according to pt. and age

Atopic dermatitis

1. SKIN DISORDER

2. ALLERGIC DISEASE2. ALLERGIC DISEASE

3. Combination ?

Pathophysiology of atopic dermatitis

Components of the skin immune system

- The static component

- The dynamic component

- Lessons from the genes

Mechanisms inducing the inflammation in skinMechanisms inducing the inflammation in skin

- The role of antigen presenting cells

Putative mechanisms underlying chronicity (AD at

the frontier between allergy and autoimmunity)

- Staph. aureus and IgE response

- Epidermal antigens or autoallergens ?

- Evidence for a lack of tolerance: the IDO-story

Onset of dermatities frequently coincidesOnset of dermatities frequently coincides

with the introduction of certain foods into thewith the introduction of certain foods into the

infant’s diet (especially:cow’s milk, wheat,infant’s diet (especially:cow’s milk, wheat,

soy, peanuts fish or eggs)soy, peanuts fish or eggs)

Diagnosis • Intense pruritus • Eosinophilia

• White dermographism

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• Intense pruritus• Family history of asthma, hay fever, atopic dermatitis

• elevated IgE• elevated antibodies to variety of foods & inhalants

• White dermographism

Clinical manifestations

� Affect: 2-10%

children

�Most begin in infancy

• Early lessions: erythematous, weepy patches on cheek, �Most begin in infancy

(the first 2-3 mo of life)

� 60% affected by 1 yr of age, 90% by 5 yr of age

patches on cheek, extend to : face, neck, wrists, hands, abdomen, extensor aspect of the extremities

Clinical Manifestation

Infantil form :begins at 2-3 month of age

face, sclap, extensor, surface of limb,

hand and sucked thumb, flexure folds

after 1 yr

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Children form: > 2 yr

Flexure folds, hand, food and periorbital

Adult form: > 20 yr

Lichenification, scaling.

DIAGNOSTIC CRITERIA DIAGNOSTIC CRITERIA OF AD (Hanifin & Rajka, 1980)OF AD (Hanifin & Rajka, 1980)

�� Must have 3 or more Must have 3 or more MAJORMAJOR features:features:

�� PruritusPruritus

�� Typical morphology and distribution Typical morphology and distribution

�� flexural lichenification in adult flexural lichenification in adult

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�� flexural lichenification in adult flexural lichenification in adult

�� facial and extensor involvement in infant and facial and extensor involvement in infant and

children children

�� Personal and family history of atopyPersonal and family history of atopy

�� Chronic and chronically relapsing course Chronic and chronically relapsing course

�� ANDAND

DIAGNOSTIC CRITERIA OF ADDIAGNOSTIC CRITERIA OF AD

(Hanifin & Rajka, 1980)(Hanifin & Rajka, 1980)

�� Must also have 3 or more Must also have 3 or more MINOR featuresMINOR features::

�� XerosisXerosis

�� Ichthyosis/palmar hyperlinearity/keratosis pilaris Ichthyosis/palmar hyperlinearity/keratosis pilaris

�� Immediate (type I) skin test reactivity Immediate (type I) skin test reactivity

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�� Immediate (type I) skin test reactivity Immediate (type I) skin test reactivity

�� Elevated serum IgEElevated serum IgE

�� Early age of onset dermatitisEarly age of onset dermatitis

DIAGNOSTIC CRITERIA

OF AD (Hanifin & Rajka, 1980)

�� MINOR featuresMINOR features ::

�� Tendency toward cutaneous infectionsTendency toward cutaneous infections

�� Tendency toward nonspecific hand & foot Tendency toward nonspecific hand & foot

dermatitisdermatitis

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dermatitisdermatitis

�� Nipple eczemaNipple eczema

�� CheilitisCheilitis

�� Recurrent conjunctivitisRecurrent conjunctivitis

�� DenniDenni--Morgan infraorbital foldMorgan infraorbital fold

�� MINOR featuresMINOR features

�� KeratoconusKeratoconus

�� Anterior subcapsular cataractAnterior subcapsular cataract

Orbital darkeningOrbital darkening

DIAGNOSTIC CRITERIA DIAGNOSTIC CRITERIA OF AD (Hanifin & Rajka, 1980)OF AD (Hanifin & Rajka, 1980)

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�� Orbital darkeningOrbital darkening

�� facial pallor/facial erythemafacial pallor/facial erythema

�� Pityriasis albaPityriasis alba

�� Sweating itchSweating itch

�� Intolerance to wool and lipid solventIntolerance to wool and lipid solvent

DIAGNOSTIC CRITERIA DIAGNOSTIC CRITERIA OF AD (Hanifin & Rajka, 1980)OF AD (Hanifin & Rajka, 1980)

�� MINOR featuresMINOR features::

�� Perifollicular accentuationPerifollicular accentuation

�� Food hypersensitivityFood hypersensitivity

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�� Course influenced by environmental/emotional Course influenced by environmental/emotional

factorsfactors

�� White dermagraphism/delayed blanchWhite dermagraphism/delayed blanch

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ComplicationsComplications

Secondary infection of the lession withSecondary infection of the lession with

bacterial, fungal, or viral.bacterial, fungal, or viral.

Treatment

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Treatment

• Avoid extreme temperature & humidity• Sweating leads to itching and aggravation of the disease

• Exposure to sunlight and salt water may beneficial

Treatment ……..

• Avoid the use of soap and detergent for the dry skin

• During acute flare-up, wet dressings (e.g. Burrow’s solution 1:20) → antipruritic & anti-inflammatory

• If infection is present (acute weeping or crusting)

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• If infection is present (acute weeping or crusting) → systemic antibiotic. Drug of choice : erythromycin or cephalexin (because of frequent resistance of penicillin by Staphylococcus aureus)

• Topical triamcinolone acetonide ointment, 0,1% is useful but best limited to 1-3 weeks at a time; after improvement

What improvements are needed?

� Ideally, a cure

Managing atopic eczema:

New opportunities

� Ideally, a cure

� The next best alternative is a treatment that is

safe and effective and adds a significant

dimension to existing therapies

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