dr. Archianda Arsad, SpKK

Department of Dermato-Venereology

Medical Faculty, North Sumatera University

Atopic dermatitis (AD) = Atopic eczemao A chronically relapsing skin diseaseo Occurs most commonly during early

infancy and childhoodo Frequently associate with elevated

serum IgE levelso A personal/family history of atopy(+)

• Prevalence 3x than 1960s

• Industrialized countries > agricultural countries

• Female : male = 1,3:1

• AD, associated with :

- small family size

- increased income and education

- migration rural urban

- use of antibiotic

Hereditary

(genetic)

Food & aero Allergy (hypersensitivity) Irritan

allergens Infection

Climate

Cellular

immunity ATOPIC DERMATITIS

defect Xerosis

Decrease

skin barrier

Psychological effect

• Strong maternal influence• Chromosome 5q31-33, contains a clustered

family of functionally related cytokine genes :- IL-3, IL-4, IL-5, IL-13 expressed- GM-CSF by Th2 cell- Differences in transcriptional activity of the IL-4 gene influence AD predisposition- A significant association between a specific polymorphism in the mast cell chymase gene and AD

Key cells in AD skin :

• Langerhans cells

• Lymphocyte cells

• Eosinophils

• Mast cells

• Increased synthesis of IgE

• Increased specific IgE to multiple allergens, including foods, aeroallergens, microorganism, bacterial toxins, autoallergens

• Increased expression of of CD23 (affinity IgE receptor) on B cells and monocytes

• Increased basophil histamine release

• Impaired delayed-type hypersensitivity response

• Eosinophilia• Increased secretion of IL-4, IL-5 dan IL-13 by

Th2 cells• Decreased secretion of IFN-γ by Th1 cells• Increased soluble IL-2 receptor levels• Elevated levels of monocyte CAMP-

phosphodiesterase with increased IL-10 and prostaglandin E2

• Epidermal lipid ↓• TEWL ↑• Skin capacitance↓

• Epidermal lipid ↓• TEWL ↑• Skin capacitance↓

Soap &detergen Decrease skin barrier functionDecrease skin barrier function

Allergen absorption ↑Microbial colonization ↑Treshold of pruritus ↓

Allergen absorption ↑Microbial colonization ↑Treshold of pruritus ↓

• Food infant and children :milk and eggs

adult : seafood and nuts

• Aeroallergens : dust mites, animal danders, molds, pollens.

• Temperature & humidity

• Intense perspiration

• Emotional stress

• Diagnostic criteria of AD : various

• The UK working party’s : proposed alternative system, the criteria of Hanifin & Rajka (1994)

• Diagnose of AD:

-Three or more of the major criteria

-Three or more of the minor criteria

• Pruritus

• Typical morphology & distribution

• Involvement during infancy & early childhood flexural

• Flexural dermatitis in adult

• Chronic or chronically relapsing dermatitis

• Personal or family history of atopy

• Xerosis• Skin infection• Hand/foot dermatitis• Ichthyosis/palmar hyperlinearity/keratosis

pilaris• Pityriasis alba• Nipple eczema• White dermatografism & delayed blanched

response

• Cheilitis

• Infra orbital fold

• Anterior subcapsular cataracts

• Orbital darkening

• Facial pallor

• Itchiness when sweating

• Perifollicular accentuation

• Food hypersensitivity

• Duration of AD influenced by environment and psychis factors

• Immediate skin test reactivity

• Elevated serum IgE

• Early age of AD

Hyperlinearity of palmaris

Dennie Morgan folds

1. Seborrhoic dermatitis2. Contact dermatitis3. Numular dermatitis4. Scabies5. Ichthyosis6. Psoriasis 7. Dermatitis herpetiformis8. Sezary syndrome9. Leterrer-Siwe disease

In infant

1. Wiskott-Aldrich syndrome

2. Hyper- IgE syndrome

• Education

• Appropriate skin hydration & use of emollient skin barrier repair measure

• Avoidance of irritants

• Identification & treatment of complication bacterial, viral of fungal infection

• Treatment of psychosocial aspect of disease

• Antipruritic intervention

1. Topical therapy

2. Systemic therapy

1. Cutaneus hydration

2. Topical glucocorticoid

3. Topical calcineurine inhibitor

(tacrolimus & pimocrolimus)

1. Tar preparation

2. Topical anti histamine : not recommended except : doxepine cream 5%

1. Systemic glucocorticoid

2. Anti histamine

3. Infection agent

4. Interferon

5. Cyclosporine

6. Phototherapy (UVB, UVA+UVB, PUVA)

• Many factor correlate with AD → difficult to predict prognosis

• The predictive factors correlate with a poor prognosis of AD :

1. Widespread AD in childhood2. Associated allergenic rhinitis & asthma3. Family history of AD in parents or sibling4. Early age at onset of AD5. Being an only children6. Very high serum IgE levels

• 30-35% infatile AD → asthma / hay fever

• Often develop non specific irritant hand dermatitis