Atopic dermatitis(Eczema)

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Dr Muhammad Raza PG Trainee MCPS

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Transcript of Atopic dermatitis(Eczema)

  • Dr Muhammad Raza

    PG Trainee MCPS

  • 1. To know about basic concept of atopic dermatitis.

    2. Signs and symptoms of the disease

    3. Etiology and pathogenesis.

    4. Diagnosis, management and referral of the disease.

    By the end of my presentation each participant should be able to:

  • Atopic Dermatitis(Eczema)

    Atopic dermatitis (eczema) is a condition that makes your skin cracked, swollen, red and itchy. It's common in children but can occur at any age.

    Atopic dermatitis is long lasting (chronic)and tends to flare periodically.

    It may be accompanied by asthma or hay fever

  • People with atopic dermatitis

    More than 50% develop asthma

    75% develop allergic rhinitis

  • Signs and symptoms

    Dry skin

    Itching , especially at night

    Red to brownish-gray patches, especially on the hands, feet,

    ankles, wrists, neck, upper chest, eyelids, inside the bend of the

    elbows and knees, and in infants, the face and scalp

    Small, raised bumps, which may leak fluid and crust

    over when scratched

    Thickened, cracked, scaly skin

    Raw, sensitive, swollen skin from scratching.

  • UK Diagnostic criteria

    Itchy skin and at least three of the

    followings:

    History of itch in skin creases or

    cheeks(if < 4yrs)

    Dry skin

    (Xeroderma)

    Visible flexural

    eczema(cheeks,fore

    head,outer limbs if

    < 4yrs

    History of

    asthma/hay fever(in

    1st-degree relatives

    if < 4yrs)

    Onset in first 2

    years of life

  • Infancy

    Often acute and involves the face and trunk

    sparing of napkin area

    Childhood

    Back of the knees, front of the elbows, wrists and

    ankles

    Adults

    Face and trunk, lichenification is common

    Distribution and character of rash

  • Typical AD for Infants and Toddlers

    Erythematous, ill-

    defined plaques on

    the lateral lower

    with overlying scale

    Erythematous, ill-

    defined plaques on

    the cheeks with

    overlying scale and

  • More Examples of Atopic Dermatitis

    Note the distribution of AD on face and extensor surfaces

  • Affects flexural areas of neck, elbows, knees,

    wrists, and ankles

    Antecubital fossa Lichenified, erythematous plaques behind the knees

  • Acute

    Redness and

    swelling,usually

    with ill defined

    margins

    Papules,vesicles

    and large blisters

    Exudation and

    cracking

    Chronic

    Usually less

    vesicular and

    exudative.

    Lichenification,

    secondary to

    rubbing and

    scratichng

    Fissures, scratch

    marks

    Continue.

  • EPIDEMIOLOGY

    Age Of Onset 60% develop in 2 months to 1 year of life. 30% are seen for the first time by age 5, and 10% develop AD between 6

    20 years of age. Rarely AD has an adult onset

    Gender Slightly More Common in males than females

  • The cause of AD is multifactorial and not completely understoodThe following factors are thought to play varying roles:

    Genetics

    Skin Barrier Dysfunction

    Impaired Immune Response

    Eliciting factors

    Exacerbating factors

  • Mutation in filaggrin gene(FLG), which encodes a

    protein that aggregates keratin filaments during

    terminal differentiation of the epidermis

    Filaggrin is an important component of barrier of

    the skin

    Filaggrin

  • Atopic Dermatitis: Cause

  • ELICITING FACTORS

    Inhalants Specific aeroallergens, especially dust mites and pollens.

    Microbial Agents Exotoxins of Staphylococcus aureus may act as super-antigents and stimulate the T cells and macrophages

    Auto-allergens IgE antibodies directed at human proteins cause release of auto-allergens from damaged tissue which trigger IgE or T cell responses.

    Foods Eggs, milk, soya-beans, fish and wheat

  • Exacerbating Factors

    Skin Barrier Disruption Increase transepidermal water loss by frequent bathing, handwashing and dehydration

    Infections S.aureus present in severe cases; rarely fungus (dermatophytosis, candidiasis)

    Season AD improves in summer, flares in winter

    Clothing Wool is an important trigger; wool clothing or blankets.

    Emotional Stress is an exacerbating factor in flares of the disease

  • Diagnosis

    Skin biopsy elevated

    numbers of a certain type of

    white blood cells

    (eosinophils) and elevated

    serum IgElevel)

    Skin scratch/prick

    test which involve

    scratching or pricking the skin with a needle that contains a

    small amount of a suspected

    allergen)

    Patch test is performed in

    suspected cases of contact allergic

    dermatitis

    Bacterial and viral

    swabs are useful in

    suspected secondary infections

    Total & specific IgE antibodies

    to determine specific

    environmental allergens.

    RAST

    (Radioallergosorbenttest may

    suggest dust mite allergy)

    Atopic dermatitis is typically diagnosed

    clinically by UK diagnostic criteria ,

    however further labs are helpful in

    diagnosing AD.

  • Management

    Primary preventionMoisturize your skin at least twice a day (Creams,

    ointments and lotions)

    Identify and avoid triggers that worsen the condition (sweat, stress, obesity, soaps, detergents, dust and pollen)

    Take shorter baths or showers (Limit your baths and showers to 10 to 15 minutes. And use warm, rather than hot, water)

  • Continue.

    Take a bleach bath (A diluted-bleach bath with household bleach for 10 minutes decreases bacteria on the skin and related infections)

    Use only gentle soaps (Choose mild soaps,Because deodorant soaps and antibacterial soaps can remove more natural oils and dry your

    skin.)

    Dry yourself carefully (After bathing gently pat your skin dry with a soft towel and apply moisturizer

    while your skin is still damp)

  • Atopic Dermatitis

    Irritants

    Wool Clothing

    Winter Chapping

    Excessive Heat

    Sweating

    Airborne allergens

    Food allergens

    Skin infections

    Stress

    Habitual scratching

    Supportive Care

  • Emollients (Moisturizers)

    (Alpha-Hydroxy acid) is made up of glycolic

    acid(8%) + lactic acid(12%) + Urea (6%).

    Vanicream,Eucerin,Lubiderm,Curel and vaseline

    petroleum jelly.

    Urea creams

    Oils

    Apply emollients once in a day after bathing

    and the times when the skin is usually dry.

    1st line treatment

    ( Emollients+ Topical steroids)

  • Topical steroids

    Hydrocortisone 1-2.5% applied to all skin

    Quite safe and often use for months

    Use intermittently on thin areas(face and

    Stronger potency topical steroids for non

    facial/genital regions.

    Avoid potent/ultrapotent topical steroid

    preparations on face,armpit,groins & bottom.

  • 2nd line treatment

    Topical immunosuppresants and topical calcineurin

    inhibitors like tacrolimus and pimecrolimus.

    Use when the continued use of topical steroids is

    ineffective or inadvisable

    3rd line treatment

    Phototherapy with ultraviolet (UV) light can be an effective treatment for severe atopic dermatitis.

    Combined UVA and UVB light have a more beneficial

    effect than UVA or UVB light alone. UV light may also

    help to prevent bacterial infections.

  • Systemic Treatment

    Antihistamines for itching

    Linoleic acid and linoleic gamma for pruritis

    Macrolide and cephalosporin for secondary bacterial infection

    Acyclovir for Herpeticumeczema

  • Advance Therapies

    Cyclosporine Methotrexate AzathioprineBiologics(Anti-

    IgE i-e omaltizumab)

  • Differential Diagnosis

    seborrheic dermatitis

    Scabies

    Drug reactions

    Psoriasis

    Allergic contact dermatitis

    Cutaneous T-cell lymphoma

    Lichen planus

    Palmoplanter pustulosis

  • Staph areus is most commonBacterial

    Herpes simplex virus cause a widespread severe eruption( eczema herpeticum)

    Papillomavirus and moluscum contagiosum.Viral

    Defective barrier functionIrritant reaction

    Loss of schooling and behavioural difficultiesSleep disturbance

    Eggs, cows milk, protein, fish, wheat and soya may cause an immediate urticarial eruption.Food allergy

    Complications of atopic eczema

  • When to Refer

    Patients should be referred to a

    dermatologist when:Patients have recurrent skin

    infections

    Patients have extensive and/or

    severe disease

    Herpeticum eczema

    Symptoms are poorly controlled

    with topical steroids

  • Resources

    http://www.nhs.uk/conditions/pregnancy-and-baby/pages/eczema-in-children.

    https://nationaleczema.org/eczema/child-eczema/

    https://www.allergyuk.org/atopic-dermatitis-and-eczema-in-children/atopic-dermatitis-eczema-in-children

    http://www.nhs.uk/conditions/pregnancy-and-baby/pages/eczema-in-childrenhttps://nationaleczema.org/eczema/child-eczema/https://www.allergyuk.org/atopic-dermatitis-and-eczema-in-children/atopic-dermatitis-eczema-in-children